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Background: The Health Services Provision Assessment in Ethiopia (SPA-ET) is a survey that generates data on the availability and quality of health services in Ethiopia. Despite the presence of integrated management of childhood illness guidelines in healthcare settings, there has been inadequate exploration or assessment of how effectively and consistently health professionals follow the guidelines., Objective: This study aims to identify factors influencing healthcare worker adherence to the integrated management of childhood illness guidelines to identify spatial clusters., Methods: The data for this study were gathered from the Service Provision Assessment (SPA) survey in Ethiopia, which was conducted nationwide from August 11, 2021, to February 4, 2022. It included a total of 788 health professionals who assessed sick children experiencing at least one of the three main childhood illness symptoms: fever, cough, or diarrhea. We employed STATA version 16 for data analysis, utilizing cross-tabulations to explore relationships between variables and logistic regression modeling to identify factors influencing adherence. To account for the hierarchical structure of the health survey data, we employed multilevel logistic regression. Model selection was based on comparison parameters including the Bayesian Information Criterion (BIC) and Akaike Information Criterion (AIC). We computed adjusted odds ratios with 95% confidence intervals, and statistical significance was determined at a significance level of p < 0.05., Results: The rate of adherence to the integrated management of childhood illness guideline was 33% (95% CI: 29.70%, 36.26%). The analysis revealed several factors influencing adherence to IMCI protocols. child's age (being ≥24 months) [aOR = 0.66, 95% CI: (0.45, 0.87)], facility type (health center) [aOR = 2.61, 95% CI: (1.84, 3.37)], place of residency (being rural) [aOR = 0.54, 95% CI: (0.38, 0.77)], and care provider's qualification (health officer) [aOR = 1.71, 95% CI: (1.18, 2.48)] were all statistically significant. Moreover, the primary cluster is situated in the west Oromia region, with a central focus at coordinates (7.982108 N, 36.203355 E) and extends to a radius of 78.28 km., Conclusion: This study confirms a low adherence rate (33%) among health professionals in Ethiopia to the IMCI guideline for assessing the three main symptoms of sick children. The study identified child's age, facility type, academic qualification, and place of residence as crucial factors correlated with adherence rate. Furthermore, 5 secondary clusters (hotspot areas) were identified using SaTScan software. To address the higher protocol refusal, interventional plan needs to be based on academic qualification of care provider, facility type, age of child and place of residency. Moreover, interventions to reduce non-adherence to IMCI guidelines should be location-tailored based on identified hotspot areas to restore guidelines adherence equality., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Tareke 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: Movement behavior features such as time use estimates, average acceleration and intensity gradient are crucial in understanding associations with cardiometabolic health. The aim of this study was to 1) compare movement behavior features processed by commonly used accelerometer metrics among adults (i.e. Euclidian Norm Minus One (ENMO), Mean Amplitude Deviation (MAD) and counts per minute (CPM)), 2) investigate the impact of accelerometer metrics on compliance with movement behavior guidelines, and 3) explore potential variations in the association between movement behavior features and cardiometabolic variables depending on the chosen metric., Methods: This cross-sectional study collected movement behavior features (Actigraph GT3X+) and cardiometabolic variables. Accelerometer data were analyzed by four metrics, i.e. ENMO, MAD, and CPM vertical axis and CPM vector magnitude (GGIR). Intraclass correlations and Bland‒Altman plots identified metric differences for time use in single movement behaviors (physical activity, sedentary behavior), average acceleration and intensity gradient. Regression models across the four metrics were used to explore differences in 24-hour movement behaviors (24h-MBs; compositional variable) as for exploration of associations with cardiometabolic variables., Results: Movement behavior data from 213 Belgian adults (mean age 45.8±10.8 years, 68.5% female) differed according to the metric used, with ENMO representing the most sedentary movement behavior profile and CPM vector magnitude representing the most active profile. Compliance rates for meeting integrated 24h-MBs guidelines varied from 0-25% depending on the metric used. Furthermore, the strength and direction of associations between movement behavior features and cardiometabolic variables (body mass index, waist circumference, fat% and HbA1c) differed by the choice of metric., Conclusion: The metric used during data processing markedly influenced cut-point dependent time use estimates and cut-point independent average acceleration and intensity gradient, impacting guideline compliance and associations with cardiometabolic variables. Consideration is necessary when comparing findings from accelerometry studies to inform public health guidelines., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Willems 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.)

Provider adherence to the integrated antenatal care (ANC) procedure is an important indicator of high-quality ANC. The procedure is intended to avoid missed opportunities to detect the risk of abnormalities in pregnancy. This study aims to assess the provider's adherence to integrated ANC in Basic Emergency Obstetric and Newborn Care (BEmONC) and non-BEmONC Primary Health Center (PHC). This study employed an explanatory sequential mixed-method design. The quantitative phase reviewed 149 medical records of pregnant women in the four PHCs in Semarang from January until February 2020. The findings were used to describe the provider's adherence to the integrated ANC and lead to the contributing factors which should be explored in the qualitative phase. The study involved four in-depth interviews with midwife coordinators in four PHCs. The Mann-Whitney and Chi-square test was employed to analyse the quantitative data, while the thematic analysis was undertaken on the qualitative data. The provider's adherence to the guideline did not differ between BEmONC and non-BEmONC PHC. The general physical examination of the patients (18.81%) and dentist visits (84.6%) were not done in either BEmONC or non-BEmONC PHC. Incomplete laboratory tests were haemoglobin (28.2%) and urine protein (38.9%). The barriers to adherence to the integrated ANC guideline were related to an imbalance of resources, role and responsibility issues among doctors and midwives, and policy issues. This study found low BEmONC nor non-BEmONC PHC adherence to the integrated ANC guideline. A Periodic evaluation of the implementation of integrated ANC to ensure its high-quality implementation in Indonesia is needed., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Yuliyanti 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.)

Objective: Physician adherence to evidence-based clinical practice parameters impacts outcomes of amyotrophic lateral sclerosis (ALS) patients. We sought to investigate compliance with the 2009 practice parameters for treatment of ALS patients in the United States, and sociodemographic and provider characteristics associated with adherence., Methods: In this population-based, retrospective cohort study of incident ALS patients in 2009-2014, we included all Medicare beneficiaries age ≥20 with ≥1 International Classification of Diseases, Ninth Revision, Clinical Modification ALS code (335.20) in 2009 and no prior years (N = 8,575). Variables of interest included race/ethnicity, sex, age, urban residence, Area Deprivation Index (ADI), and provider specialty (neurologist vs. non-neurologist). Outcomes were use of practice parameters, which included feeding tubes, non-invasive ventilation (NIV), riluzole, and receiving care from a neurologist., Results: Overall, 42.9% of patients with ALS received neurologist care. Black beneficiaries (odds ratio [OR] 0.56, 95% confidence interval [CI] 0.47-0.67), older beneficiaries (OR 0.964, 95% CI 0.961-0.968 per year), and those living in disadvantaged areas (OR 0.70, 95% CI 0.61-0.80) received less care from neurologists. Overall, only 26.7% of beneficiaries received a feeding tube, 19.2% NIV, and 15.3% riluzole. Neurologist-treated patients were more likely to receive interventions than other ALS patients: feeding tube (OR 2.80, 95% CI 2.52-3.11); NIV (OR 10.8, 95% CI 9.28-12.6); and riluzole (OR 7.67, 95% CI 6.13-9.58), after adjusting for sociodemographics. These associations remained marked and significant when we excluded ALS patients who subsequently received a code for other diseases that mimic ALS., Conclusions: ALS patients treated by neurologists received care consistent with practice parameters more often than those not treated by a neurologist. Black, older, and disadvantaged beneficiaries received less care consistent with the practice parameters., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Laurido-Soto 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.)

Tuberculosis and Human Immunodeficiency Virus are among the top ten causes of death globally. To prevent the spread of these infections, health workers and student nurses should comply to infection prevention and control measures called standard precautions. The aim of this study is to assess compliance of Eswatini university student nurses regarding standard precautions for preventing Tuberculosis and Human Immunodeficiency Virus. A non-experimental quantitative approach was used to conduct a survey on all senior student nurses of Eswatini University using questionnaires. IBM SPSS Statistics version 26 software was used to analyse the data. Results from this study showed that out of the 105 student nurses who were asked only 51.4% (n = 54) said they always used personal protective equipment. However, they did comply well on disposing sharps as 92.4% (n = 97) reported that they always used designated containers. There is a need for close supervision of student nurses in the clinical area. The researcher recommends that clinical facilitator should always accompany student nurses in the clinical area and that preceptors should be exempted from other nursing duties when there are student nurses in the hospitals so that they can mentor the students., Competing Interests: The authors have declared that no competing interests exist.

Background: Total hip and total knee replacement (THR/TKR) are common and effective surgeries to reduce the pain and disability associated with arthritis but are associated with small but significant risks of preventable complications such as surgical site infection (SSI) and venous-thrombo-embolism (VTE). This study aims to determine the degree to which hospital care was compliant with clinical guidelines for the prevention of SSI and VTE after THR/TKR; and whether non-compliant prophylaxis is associated with increased risk of complications., Methods and Findings: A prospective multi-centre cohort study was undertaken in consenting adults with osteoarthritis undergoing elective primary TKR/THR at one of 19 high-volume Australian public or private hospitals. Data were collected prior to surgery and for one-year post-surgery. Four adjusted logistic regression analyses were undertaken to explore associations between binary non-compliance and the risk of surgical complications: (1) composite (simultaneous) non-compliance with both (VTE and antibiotic) guidelines and composite complications [all-cause mortality, VTE, readmission/reoperation for joint-related reasons (one-year) and non-joint-related reasons (35-days)], (2) VTE non-compliance and VTE outcomes, (3) antibiotic non-compliance and any SSI, and (4) antibiotic non-compliance and deep SSI. Data were analysed for 1875 participants. Guideline non-compliance rates were high: 65% (VTE), 87% (antibiotics) and 95% (composite guideline). Composite non-compliance was not associated with composite complication (12.8% vs 8.3%, adjusted odds ratio [AOR] = 1.41, 95%CI 0.68-3.45, p = 0.40). Non-compliance with VTE guidelines was associated with VTE outcomes (5% vs 2.4%, AOR = 2.83, 95%CI 1.59-5.28,p < 0.001). Non-compliance with antibiotic guidelines was associated with any SSI (14.8% vs 6.1%, AOR = 1.98, 95%CI 1.17-3.62,p = 0.02) but not deep infection (3.7% vs 1.2%,AOR = 2.39, 95%CI 0.85-10.00, p = 0.15)., Conclusions: We found high rates of clinical variation and statistically significant associations between non-compliance with VTE and antibiotic guidelines and increased risk of VTE and SSI, respectively. Complications after THR/TKR surgery may be decreased by improving compliance with clinical guidelines., Competing Interests: JF is an unpaid member of the group that developed the NHMRC Guidelines for the prevention of VTE. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Background: Despite the development and enforcement of preventive guidelines by governments, COVID-19 continues to spread across nations, causing unprecedented economic losses and mortality. Public places remain hotspots for COVID-19 transmission due to large numbers of people present; however preventive measures are poorly enforced. Supermarkets are among the high-risk establishments due to the high interactions involved, which makes compliance with the COVID-19 preventive guidelines of paramount importance. However, until now, there has been limited evidence on compliance with the set COVID-19 prevention guidelines. Therefore, this study aimed to measure compliance with the COVID-19 prevention guidelines among supermarkets in Kampala Capital City and Mukono Municipality Uganda., Methods: A cross-sectional study was conducted among selected supermarkets in Kampala Capital City and Mukono Municipality in September 2020. A total of 229 supermarkets (195 in Kampala City and 34 in Mukono Municipality) were randomly selected for the study. Data were collected through structured observations on the status of compliance with COVID-19 prevention guidelines, and entered using the KoboCollect software, which was preinstalled on mobile devices (smart phones and tablets). Descriptive statistics were generated to measure compliance to the set COVID-19 Ministry of Health prevention guidelines using Stata 14 software., Results: Only 16.6% (38/229) of the supermarkets complied with the COVID-19 prevention and control guidelines. In line with the specific measures, almost all supermarkets 95.2% (218/229) had hand washing facilities placed at strategic points such as the entrance, and 59.8% (137/229) of the supermarkets surveyed regularly disinfected commonly touched surfaces. Only 40.6% and 30.6% of the supermarkets enforced mandatory hand washing and use of face masks respectively for all customers accessing the premises. Slightly more than half, 52.4% (120/229) of the supermarkets had someone or a team in charge of enforcing compliance to COVID-19 measures and more than half, 55.5% (127/229) of the supermarkets had not provided their staff with job-specific training/mentorship on infection prevention and control for COVID-19. Less than a third, 26.2% (60/229) of the supermarkets had an infrared temperature gun for screening every customer, and only 5.7% (13/229) of the supermarkets captured details of clients accessing the supermarket as a measure to ease follow-up., Conclusion: This study revealed low compliance with COVID-19 guidelines, which required mandatory preventive measures such as face masking, regular disinfection, social distancing, and hand hygiene. This study suggests the need for health authorities to strengthen enforcement of these guidelines, and to sensitise the supermarket managers on COVID-19 in order to increase the uptake of the different measures., Competing Interests: The authors declare that they have no competing interests.

Background: The immediate postpartum period is the most critical time for both the mother and the newborn. However, it is the most neglected part of the maternal continuum of care, and evidence in this regard was scarce in Ethiopia. Therefore, this study aimed to assess the healthcare provider's adherence to immediate postpartum care guidelines and associated factors in hospitals of Gondar province., Methods: A multicenter observational cross-sectional study was conducted among 406 healthcare providers from 15th November 2020 to 10th March 2021. Data were collected through face-to-face interviews and direct observation using a structured questionnaire and standardized checklist respectively. Data was entered into EPI INFO 7.1.2 and analyzed by SPSS version 25. Both bivariable and multivariable logistic regression analyses were carried out. The level of significance was declared based on the adjusted odds ratio (AOR) with a 95% confidence interval (CI) at a p-value of ≤ 0.05., Results: Overall, 42.4% (95% CI: 37.5, 47.2) of healthcare providers had complete adherence to immediate postpartum care guidelines. Having birth assistant (AOR = 1.87; 95% CI: 1.10, 9.67), being married (AOR = 1.59; 95% CI: 1.15, 3.31), availability of postpartum care guidelines at the maternity ward (AOR = 2.39; 95% CI: 1.44, 3.98), received basic emergency obstetric and newborn care (BEmONC) training (AOR = 2.1; 95% CI: 1.2, 3.6), monthly income of ≥ 10001 Ethiopian birr (AOR = 3.55; 95% CI: 1.30, 9.67), and work experience of ≥ 6 years (AOR = 0.15; 95% CI: 0.06, 0.38) were significantly associated with healthcare providers adherence to immediate postpartum care guidelines., Conclusion: This study indicated that health worker's adherence to immediate postpartum care guidelines was low. Hiring adequate health workers, availing postpartum guidelines at the maternity ward, improving the salary and education opportunities for healthcare workers of healthcare workers, and provision of BEmONC training will have a great role in improving healthcare provider's adherence to immediate postpartum care guidelines., Competing Interests: The authors have declared that no competing interests exist.

We aimed to apply the Systems Engineering Initiative for Patient Safety (SEIPS) model to increase effectiveness and sustainability of the World Health Organization's (WHOs) hand hygiene (HH) guidelines within healthcare systems. Our cross-sectional, mixed-methods study took place at Jimma University Medical Center (JUMC), a tertiary care hospital in Jimma, Ethiopia, between November 2018 and August 2020 and consisted of three phases: baseline assessment, intervention, and follow-up assessment. We conducted questionnaires addressing HH knowledge and attitudes, interviews to identify HH barriers and facilitators within the SEIPS framework, and observations at the WHO's 5 moments of HH amongst healthcare workers (HCWs) at JUMC. We then implemented HH interventions based on WHO guidelines and results from our baseline assessment. Follow-up HH observations were conducted months later during the Covid-19 pandemic. 250 HCWs completed questionnaires with an average knowledge score of 61.4% and attitude scores indicating agreement that HH promotes patient safety. Interview participants cited multiple barriers to HH including shortages and location of HH materials, inadequate training, minimal Infection Prevention Control team presence, and high workload. We found an overall baseline HH compliance rate of 9.4% and a follow-up compliance rate of 72.1%. Drastically higher follow-up compared to baseline compliance rates were likely impacted by our HH interventions and Covid-19. HCWs showed motivation for patient safety despite low HH knowledge. Utilizing the SEIPS model helped identify institution-specific barriers that informed targeted interventions beyond WHO guidelines aimed at increasing effectiveness and sustainability of HH efforts., Competing Interests: The authors have declared that no competing interests exist.

Background: Thrombophilia workup is typically inappropriate in the inpatient setting as testing may be skewed by anticoagulation, acute thrombosis, or acute illness., Objective: To determine adherence of inpatient thrombophilia testing with institutional guidelines., Patients and Methods: A retrospective study to evaluate thrombophilia testing practices of adult patients who were admitted to Lehigh Valley Hospital at Cedar Crest with either venous thromboembolism or ischemic stroke in 2019. Testing included inherited and acquired thrombophilia. Patient charts were individually reviewed for three measured outcomes: 1) the number of appropriate thrombophilia testing in the inpatient setting; 2) the indications used for thrombophilia testing; 3) the proportion of positive thrombophilia tests with change in clinical management., Results: 201 patients were included in our study. 26 patients (13%) were tested appropriately in accordance with institution guidelines and 175 (87%) patients were tested inappropriately. The most common reason for the inappropriate testing was testing during acute thrombosis. 28 of the 201 patients had positive thrombophilia tests, but the reviewers only noted 7 patients with change in clinical management-involving anticoagulation change., Conclusion: Our study revealed that a majority of inpatient thrombophilia testing did not follow institutional guidelines for appropriate testing and did not change patient management. These thrombophilia tests are often overutilized and have minimal clinical utility in the inpatient setting., Competing Interests: The authors have declared that no competing interests exist.

Background/aims: Maternal and infant morbidities associated with pregnant women with cardiac conditions are a global issue contingent upon appropriate care. This study aimed to describe the clinical variables and their association with the adherence scores to perinatal guidelines for pregnant women with cardiac conditions. The clinical variables included cardiac, perinatal, and neonatal outcomes and complications., Methods: Using a retrospective cross-sectional medical record audit, data were abstracted and categorised as cardiac, obstetric, and neonatal predictors. Linear regression modelling was used to find the mean difference (MD) in adherence scores for each predictor, including a 95% confidence interval (CI) and a significance value for all the three categories' clinical outcomes., Results: This maternal cohort's (n = 261) cardiac complications were primarily arrhythmias requiring treatment (29.9%), particularly SVT (28%), a new diagnosis of valvular heart disease and congenital heart disease (24%) and decompensated heart failure (HF) (16%). Women with HF had associated increased adherence scores (MD = 3.546, 95% CI: 1.689, 5.403) compared to those without HF. Elective LSCS mode of delivery was associated with a higher adherence score (MD = 5.197, 95% CI: 3.584, 6.811) than non-elective LSCS subgroups. Babies admitted to intensive /special care had greater adherence to the guidelines (MD = 3.581, 95% CI: 1.822, 5.340) than those not requiring the same care., Conclusions: Some pregnancy associated complications and morbidities were associated with higher adherence scores, reflecting that a diagnosis, identification of morbidities or risk factors, initiation of appropriate multidisciplinary involvement and adherence to guidelines were associated. Conversely, potentially avoidable major complications such as sepsis were associated with a low adherence score., Trial Registration: ACTRN12617000417381., Competing Interests: The authors have declared that no competing interests exist.

Introduction: Head injury, a common presentation to the emergency department (ED), is a substantial problem in developing countries like Nepal. The current national institute for health and clinical excellence (NICE) guideline revised in January 2014 focuses on effective clinical assessment and early management of head injuries according to their severity in all age groups. This study assessed the impact of implementing this guideline on the proportions of computed tomography (CT) head scans, guideline adherence, and confidence level of the attending physicians., Methods: We consecutively recruited 139 traumatic head injury (THI) patients in this prospective pre-post interventional study conducted in the ED of a tertiary care center. We implemented the NICE guideline into routine practice using multimodal intervention through physicians' education sessions, information sheets and guideline-dissemination. The pre and post-implementation CT head scan rates were compared. The post-implementation guideline adherence was assessed. Online Google form-questionnaires including 12 validated case scenarios were distributed to the attending physicians at the end of both phases to assess their confidence levels., Results: The implementation resulted in a statistically significant decrease in the proportion of CT head scan rates from 92.0% to 70.0% (p-value = 0.005). Following educational interventions, improved guideline adherence of 20.3 percentage points (p-value = 0.001) was observed. Nine ED attending physicians were enrolled in the study who showed statistically significant improvement in their confidence level following the intervention. The NICE guideline showed a sensitivity and specificity of 93.6% and 76.4% with 82.6% accuracy compared to that of clinical judgment (100%, 34.6%, and 58.1% respectively) in detecting intracranial lesions., Conclusion: The implementation was successful in satisfying the aim of the NICE guideline by decreasing the proportion of CT head scans, improving guideline adherence and increasing the confidence of the attending physicians., Competing Interests: The authors have declared that no competing interests exist.

Mask wearing has been advocated by public health officials as a way to reduce the spread of COVID-19. In the United States, policies on mask wearing have varied from state to state over the course of the pandemic. Even as more and more states encourage or even mandate mask wearing, many citizens still resist the notion. Our research examines mask wearing policy and adherence in association with COVID-19 case rates. We used state-level data on mask wearing policy for the general public and on proportion of residents who stated they always wear masks in public. For all 50 states and the District of Columbia (DC), these data were abstracted by month for April ─ September 2020 to measure their impact on COVID-19 rates in the subsequent month (May ─ October 2020). Monthly COVID-19 case rates (number of cases per capita over two weeks) >200 per 100,000 residents were considered high. Fourteen of the 15 states with no mask wearing policy for the general public through September reported a high COVID-19 rate. Of the 8 states with at least 75% mask adherence, none reported a high COVID-19 rate. States with the lowest levels of mask adherence were most likely to have high COVID-19 rates in the subsequent month, independent of mask policy or demographic factors. Mean COVID-19 rates for states with at least 75% mask adherence in the preceding month was 109.26 per 100,000 compared to 249.99 per 100,000 for those with less adherence. Our analysis suggests high adherence to mask wearing could be a key factor in reducing the spread of COVID-19. This association between high mask adherence and reduced COVID-19 rates should influence policy makers and public health officials to focus on ways to improve mask adherence across the population in order to mitigate the spread of COVID-19., Competing Interests: The authors have declared that no competing interests exist.

The outbreak of SARS-CoV-2 is thought to have originated in Wuhan, China in late 2019 and has since spread quickly around the world. To date, the virus has infected tens of millions of people worldwide, compelling governments to implement strict policies to counteract community spread. Federal, provincial, and municipal governments have employed various public health policies, including social distancing, mandatory mask wearing, and the closure of schools and businesses. However, the implementation of these policies can be difficult and costly, making it imperative that both policy makers and the citizenry understand their potential benefits and the risks of non-compliance. In this work, a mathematical model is developed to study the impact of social behaviour on the course of the pandemic in the province of Ontario. The approach is based upon a standard SEIRD model with a variable transmission rate that depends on the behaviour of the population. The model parameters, which characterize the disease dynamics, are estimated from Ontario COVID-19 epidemiological data using machine learning techniques. A key result of the model, following from the variable transmission rate, is the prediction of the occurrence of a second wave using the most current infection data and disease-specific traits. The qualitative behaviour of different future transmission-reduction strategies is examined, and the time-varying reproduction number is analyzed using existing epidemiological data and future projections. Importantly, the effective reproduction number, and thus the course of the pandemic, is found to be sensitive to the adherence to public health policies, illustrating the need for vigilance as the economy continues to reopen., Competing Interests: The authors have declared that no competing interests exist.

In the absence of vaccines or causal therapies, behavioral measures such as wearing face masks and maintaining social distance are central to fighting Covid-19. Yet, their benefits are often questioned by the population and the level of adherence to the measures is variable. We examined in representative samples across eight countries (N = 7,568) whether adherence reported around June 1, 2020 predicted the increase in Covid-19 mortality by August 31, 2020. Mortality increased 81.3% in low adherence countries (United States, Sweden, Poland, Russia), 8.4% in high adherence countries (Germany, France, Spain, United Kingdom). Across countries adherence and subsequent mortality increases correlated with r = -0.91. No African or South American countries were included in the present study, which limits the generalizability of the findings. While reported Covid-19 mortality is likely to be influenced by other factors, the almost tenfold difference in additional mortality is significant, and may inform decisions when choosing whether to prioritize individual liberty rights or health-protective measures., Competing Interests: The authors have declared that no competing interests exist.

Introduction: In 2016, under its new National Adherence Guidelines (AGL), South Africa formalized an existing model of fast-track HIV treatment initiation counselling (FTIC). Rollout of the AGL included an evaluation study at 24 clinics, with staggered AGL implementation. Using routinely collected data extracted as part of the evaluation study, we estimated and compared the costs of HIV care and treatment from the provider's perspective at the 12 clinics implementing the new, formalized model (AGL-FTIC) to costs at the 12 clinics continuing to implement some earlier, less formalized, model that likely varied across clinics (denoted here as early-FTIC)., Methods: This was a cost-outcome analysis using standard methods and a composite outcome defined as initiated antiretroviral therapy (ART) within 30 days of treatment eligibility and retained in care at 9 months. Using patient-level, bottom-up resource-utilization data and local unit costs, we estimated patient-level costs of care and treatment in 2017 U.S. dollars over the 9-month evaluation follow-up period for the two models of care. Resource use and costs, disaggregated by antiretroviral medications, laboratory tests, and clinic visits, are reported by model of care and stratified by the composite outcome., Results: A total of 350/343 patients in the early-FTIC/AGL-FTIC models of care are included in this analysis. Mean/median costs were similar for both models of care ($135/$153 for early-FTIC, $130/$151 for AGL-FTIC). For the subset achieving the composite outcome, resource use and therefore mean/median costs were similar but slightly higher, reflecting care consistent with treatment guidelines ($163/$166 for early-FTIC, $168/$170 for AGL-FTIC). Not surprisingly, costs for patients not achieving the composite outcome were substantially less, mainly because they only had two or fewer follow-up visits and, therefore, received substantially less ART than patients who achieved the composite outcome., Conclusion: The 2016 adherence guidelines clarified expectations for the content and timing of adherence counseling sessions in relation to ART initiation. Because clinics were already initiating patients on ART quickly by 2016, little room existed for the new model of fast-track initiation counseling to reduce the number of pre-ART clinic visits at the study sites and therefore to reduce costs of care and treatment., Trial Registration: Clinical Trial Number: NCT02536768., Competing Interests: The authors have declared that no competing interests exist.

Objective: To assess General Practitioner (GP) and pediatrician adherence to clinical practice guidelines (CPGs) for diagnosis, treatment and management of attention deficit hyperactivity disorder (ADHD)., Method: Medical records for 306 children aged ≤15 years from 46 GP clinics and 20 pediatric practices in Australia were reviewed against 34 indicators derived from CPG recommendations. At indicator level, adherence was estimated as the percentage of indicators with 'Yes' or 'No' responses for adherence, which were scored 'Yes'. This was done separately for GPs, pediatricians and overall; and weighted to adjust for sampling processes., Results: Adherence with guidelines was high at 83.6% (95% CI: 77.7-88.5) with pediatricians (90.1%; 95% CI: 73.0-98.1) higher than GPs (68.3%; 95% CI: 46.0-85.8; p = 0.02). Appropriate assessment for children presenting with signs or symptoms of ADHD was undertaken with 95.2% adherence (95% CI: 76.6-99.9), however ongoing reviews for children with ADHD prescribed stimulant medication was markedly lower for both pediatricians (51.1%; 95% CI: 9.6-91.4) and GPs (18.7%; 95% CI: 4.1-45.5)., Conclusion: Adherence to CPGs for ADHD by pediatricians was generally high. Adherence by GPs was lower across most domains; timely recognition of medication side effects is a particular area for improvement., Competing Interests: Dr Bronwyn Gould’s general practice in Paddington provided no funding to the study. The authors have declared that no competing interests exist, and that this does not alter our adherence to PLOS ONE policies on sharing data and materials.

Although strong evidence exists about the effectiveness of basic childbirth services in reducing maternal and newborn mortality, these services are not provided in every childbirth, even those at health facilities. The WHO Safe Childbirth Checklist (SCC) was developed as a job aide to remind health workers of evidenced-based practices to be provided at specific points in the childbirth process. The Zambian government requested context-specific evidence on the feasibility and outcomes associated with introducing the checklist and related mentorship. A study was conducted on use of the SCC in four facilities in Nchelenge District of Zambia. Observations of childbirth services were conducted just before and six months after the introduction of the intervention. Observers used a structured tool to record adherence to essential services indicated on the checklist. The primary outcome of interest was the change in the average proportion of essential childbirth practices completed. Feedback questionnaires were administered to health workers before and six months after the intervention. At baseline and endline, 108 and 148 pause points were observed, respectively. There was an increase from 57% to 76% of tasks performed (p = 0.04). Considering only these cases where necessary supplies were available, health workers completed 60% of associated tasks at baseline compared to 84% at endline (p<0.01). Some tasks, such as taking an infant's temperature and hand washing, were never or rarely performed at baseline. Feedback from the health workers indicated that nearly all health workers agreed or strongly agreed with positive statements about the intervention. The performance of health workers in Zambia in completing essential practices in childbirth was low at baseline but improvements were observed with the introduction of the SCC and mentorship. Our results suggest that such interventions could improve quality of care for facility-based childbirth. However, national-level commitment to ensuring availability of trained staff and supplies is essential for success. Trial registration Clinical Trials.gov (NCT03263182) Registered August 28, 2017 This study adheres to CONSORT guidelines., Competing Interests: The authors have declared that no competing interests exist.

Background: Mobilization of intensive care patients is a multi-professional task. Aim of this study was to explore how different professions working at Intensive Care Units (ICU) estimate the mobility capacity using the ICU Mobility Score in 10 different scenarios., Methods: Ten fictitious patient-scenarios and guideline-related knowledge were assessed using an online survey. Critical care team members in German-speaking countries were invited to participate. All datasets including professional data and at least one scenario were analyzed. Kruskal Wallis test was used for the individual scenarios, while a linear mixed-model was used over all responses., Results: In total, 515 of 788 (65%) participants could be evaluated. Physicians (p = 0.001) and nurses (p = 0.002) selected a lower ICU Mobility Score (-0.7 95% CI -1.1 to -0.3 and -0.4 95% CI -0.7 to -0.2, respectively) than physical therapists, while other specialists did not (p = 0.81). Participants who classified themselves as experts or could define early mobilization in accordance to the "S2e guideline: positioning and early mobilisation in prophylaxis or therapy of pulmonary disorders" correctly selected higher mobilization levels (0.2 95% CI 0.0 to 0.4, p = 0.049 and 0.3 95% CI 0.1 to 0.5, p = 0.002, respectively)., Conclusion: Different professions scored the mobilization capacity of patients differently, with nurses and physicians estimating significantly lower capacity than physical therapists. The exact knowledge of guidelines and recommendations, such as the definition of early mobilization, independently lead to a higher score. Interprofessional education, interprofessional rounds and mobilization activities could further enhance knowledge and practice of mobilization in the critical care team., Competing Interests: CH is self-employed and received honoraria for e.g. professional talks and consulting from different companies. For this Manuscript are no conflicts of interest to declare. PN reports no conflict of interest. MB received research support from MSD (Haar, Germany) not related to this manuscript, received honoraria from giving lectures from GE Healthcare (Helsinki, Finland), MSD (Haar, Germany), Grünenthal (Aachen, Germany). RD received honoraria for professional talks and consulting from different companies. For this Manuscript are no conflicts of interest to declare. SF reports no conflict of interest. AK received honoraria for professional talks and consulting from different companies. For this Manuscript are no conflicts of interest to declare. BU reports no conflict of interest. SJ Schaller reports grants and non-financial support from ESICM (Brussels, Belgium), Fresenius (Germany), Liberate Medical LLC (Crestwood, USA), STIMIT AG (Nidau, Switzerland), MSD (Haar, Germany) as well as from Technical University of Munich, Germany, from national (e.g. DGAI) and international (e.g. ESICM) medical societies (or their congress organizers) in the field of anesthesiology and intensive care, personal fees and non-financial support from Bavarian Medical Association, all outside the submitted work; SJS holds stocks in small amounts from Alphabeth Inc., Bayer AG, Rhön-Klinikum AG, and Siemens AG. These did not have any influence on this study. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Background: Peripheral intravenous catheters (PIVCs) are the most widely used invasive devices worldwide. Up to 42% of PIVCs are prematurely removed during intravenous therapy due to failure. To date, there have been few systematic attempts in European hospitals to measure adherence to recommendations to mitigate PIVC failures., Aim: To analyse the clinical outcomes from clinical practice guideline recommendations for PIVC care on different hospital types and environments., Methods: We conducted an observational study in three hospitals in Spain from December 2017 to April 2018. The adherence to recommendations was monitored via visual inspection in situ evaluations of all PIVCs inserted in adults admitted. Context and clinical characteristics were collected by an evaluation tool, analysing data descriptively., Results: 646 PIVCs inserted in 624 patients were monitored, which only 52.7% knew about their PIVC. Regarding PIVC insertion, 3.4% (22/646) patients had at least 2 PIVCs simultaneously. The majority of PIVCs were 20G (319/646; 49.4%) and were secured with transparent polyurethane dressing (605/646; 93.7%). Most PIVCs (357/646; 55.3%) had a free insertion site during the visual inspection at first sight. We identified 342/646 (53%) transparent dressings in optimal conditions (clean, dry, and intact dressing). PIVC dressings in medical wards were much more likely to be in intact conditions than those in surgical wards (234/399, 58.7% vs. 108/247, 43.7%). We identified 55/646 (8.5%) PIVCs without infusion in the last 24 hours and 58/646 (9.0%) PIVCs without infusion for more than 24 hours. Regarding PIVC failure, 74 (11.5%) adverse events were identified, all of them reflecting clinical manifestation of phlebitis., Conclusions: Our findings indicate that the clinical outcome indicators from CPG for PIVC care were moderate, highlighting differences between hospital environments and types. Also, we observed that nearly 50% of patients did not know what a PIVC is., Competing Interests: The authors declare that they have no competing interests.

Globally, little evidence exists on transmission patterns of COVID-19. Recommendations to prevent infection include appropriate and frequent handwashing plus physical and social distancing. We conducted an exploratory observational study to assess compliance with these recommendations in selected transportation stations in Ghana. A one-hour audit of 45 public transport stations in the Greater Accra region was carried out between 27th and 29th March 2020. Using an adapted World Health Organization (WHO) hand hygiene assessment scale, the availability and use of handwashing facilities, social distancing, and ongoing public education on COVID-19 prevention measures were assessed, weighted and scored to determine the level of compliance of stations. Compliance with recommendations was categorized as "inadequate" "basic", "intermediate" and "advanced", based on the overall score. Majority (80%) of stations in Accra have at least one Veronica Bucket with flowing water and soap, but the number of washing places at each station is not adequate. Only a small minority (18%) of stations were communicating the need to wash hands frequently and appropriately, and to practice social/physical distancing while at the station. In most stations (95%), hand washing practice was either not observed, or only infrequently. Almost all stations (93%) did not have alcohol-based hand sanitizers available for public use, while social distancing was rarely practiced (only 2%). In over 90% of the stations, face masks were either not worn or only worn by a few passengers. Compliance with COVID-19 prevention measures was inadequate in 13 stations, basic in 16 stations, intermediate in 7 stations, and advanced in 9 stations. Compliance with COVID-19 prevention measures in public transportation stations in the Greater Accra region remains a challenge. Awareness creation should aim to elevate COVID-19 risk perception of transportation operators and clients. Transport operators and stations need support and guidance to enforce hand washing and social distancing., Competing Interests: The authors have declared that no competing interests exist.

Objective: We conducted a quality improvement initiative to restrict fluoroquinolone prescribing on two inpatient units housing high-risk patients and applied a human factors approach to understanding the barriers and facilitators to success of this intervention by front-line providers., Methods: This was a mixed-methods, quasi-experimental study. This study was conducted on two inpatient units at a tertiary care academic medical center: the medical-surgical intensive care and abdominal solid organ transplant units. Unit-level data were collected retrospectively for 24 months pre- and post- fluoroquinolone restriction intervention, implemented in July 2016, for all admissions to the study units. Our restriction intervention required antimicrobial stewardship pre-approval for fluoroquinolone prescribing. We explored barriers and facilitators to optimal fluoroquinolone prescribing using semi-structured interviews attending, fellow and resident physicians, advanced practice providers and pharmacists on these units., Results: Hospital-onset C. difficile infection did not decrease significantly, but fluoroquinolone use declined significantly from 111.6 to 19.8 days of therapy per 1000 patient-days without negatively impacting length of stay, readmissions or mortality. Third generation cephalosporin and aminoglycoside use increased post-restriction. Providers identified our institution's strong antimicrobial stewardship program and pharmacy involvement in antimicrobial decision making as key facilitators of fluoroquinolone optimization and patient complexity, lack of provider education and organizational culture as barriers to optimal prescribing., Conclusions: Fluoroquinolones can be safely restricted even among high-risk patients without negatively impacting length of stay, readmissions or mortality. Our study provides a framework for successful antimicrobial stewardship interventions informed by perceptions of front line providers., Competing Interests: No authors have competing interests.

The Japanese government instituted countermeasures against COVID-19, a pneumonia caused by the new coronavirus, in January 2020. Seeking "people's behavioral changes," in which the government called on the public to take precautionary measures or exercise self-restraint, was one of the important strategies. The purpose of this study is to investigate how and from when Japanese citizens have changed their precautionary behavior under circumstances in which the government has only requested their cooperation. This study uses micro data from a cross-sectional survey conducted on an online platform of an online research company, based on quota sampling that is representative of the Japanese population. By the end of March 2020, a total of 11,342 respondents, aged from 20 to 64 years, were recruited. About 85 percent reported practising the social distancing measures recommended by the government including more females than males and more older than younger participants. Frequent handwashing is conducted by 86 percent of all participants, 92 percent of female, and 87.9 percent of over-40 participants. The most important event influencing these precautionary actions was the infection aboard the Diamond Princess cruise ship, which occurred in early February 2020 (23 percent). Information from the central and local governments, received by 60 percent of the participants, was deemed trustworthy by 50 percent. However, the results also showed that about 20 percent of the participants were reluctant to implement proper prevention measures. The statistical analysis indicated that the typical characteristics of those people were male, younger (under 30 years old), unmarried, from lower-income households, a drinking or smoking habit, and a higher extraversion score. To prevent the spread of infection in Japan, it is imperative to address these individuals and encourage their behavioural changes using various means to reach and influence them., Competing Interests: KM is a member of the Expert Meeting on the Control of Novel Coronavirus Infection. TM is a member of the Committee of Crisis Communication of the Science Council of Japan. KW is a member of the MHLW Headquarters for Novel Coronavirus Disease Control. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Background: The Brazilian Workers Food Program (WFP) is a public policy program of nutritional assistance to workers, with the main objective of improving nutritional conditions, which was implemented 40 years ago and serves over 21.4 million workers., Objectives: To compare the long-term change in anthropometric indicators of the nutritional status and dietary intake between workers of manufacturing industries adherent to and non-adherent to the WFP., Methods: A prospective cohort study, based on a combined stratified and multistage probability sampling, was carried out, with two waves with a 4-year interval. The change in body mass index (BMI), waist circumference (WC) and dietary intake at lunch by the 24-hour recall method were compared between groups with analysis of covariance., Results: A total of 273 workers in 16 industries from an initial cohort of 1069 workers in 26 industries of the State of Rio Grande do Norte in Brazil were evaluated in the two waves. The mean age was 37±10 years and 53.1% were male, with no differences between groups in age and sex distribution. BMI increased in both groups (0.44 kg/m2 in non-WFP, p = 0.003, and 0.56 kg/m2 in WFP, p = 0.0006) and WC increased in the WFP group (1.50 cm, p = 0.0006). BMI change over time did not show statistical differences between groups (p = 0.54) but WC had a greater increase in the WFP group (difference 1.37 cm, p = 0.047). There were no differences between groups in the change over time of the dietary intake., Conclusion: BMI and WC increased over time in manufacturing workers of industries both adherent and non-adherent to the WFP, but with a greater increase of WC in the WFP group. In order to achieve the objectives of the WFP, there will be a need for periodic evaluation and monitoring of nutritional indicators in these workers and implementation of monitoring and enforcement actions of the WFP., Competing Interests: The authors have declared that no competing interests exist.

Objective: To determine parental awareness of influenza vaccination recommendations for children and explore associations with awareness., Design: Cross-sectional survey., Setting/participants: South Australian parents with a telephone listing in the Electronic White Pages were randomly selected., Methods: Participants were interviewed using Computer Assisted Telephone Interviewing (CATI) during May-July 2016. Univariable and multivariable analyses explored characteristics associated with awareness; with the survey data weighted to reflect the population of SA and the probability of selection within a household., Results: Of 539 parents, 33% were aware of the recommendation that all children (<5 years) should receive the influenza vaccine annually with 51.9% aware that children with special risk medical conditions (SRMC) should also receive the vaccine annually. Characteristics strongly associated with parental awareness of the recommendation for children aged < 5 years were knowledge of recommendation for children with a SRMC (adjusted Odds Ratio [aOR] 10.46, CI 4.44-24.63) or living in a metropolitan area (aOR 2.91, CI 1.19-7.09). There was lack of awareness in those not working (aOR 0.13, CI 0.04-0.47), with trade level education (compared with high school) (aOR 0.25 CI, 0.09-0.71) and in those born in the UK or Ireland (aOR 0.19, CI 0.04-0.85). Awareness of the recommendation for children with SRMC to receive the vaccine was strongly associated with knowledge of the influenza recommendation for children <5 years (aOR 10.22, CI 4.39-23.77) or not being born in Australia [UK/ Ireland (aOR 7.63, CI 1.86-31.31); other (aOR 3.93, CI 0.94-16.42)]. The most influential cues to future receipt were a general practitioner (GP) recommendation (63.8%) and providing influenza vaccine free for all children (37.6%). More parents who delayed or excluded vaccines believed that their children's vaccinations (in general) were unnecessary, as other children were vaccinated (42.8%) compared to those with no or minor concerns (11.1%) (p<0.0001)., Conclusions: Parental awareness of children's influenza vaccine recommendations is low. Targeted communication strategies and resources are required to establish broader community awareness of recommendations. Healthcare provider endorsement of the vaccine remains key and health care professionals, particularly GPs and paediatric specialists should be encouraged to discuss influenza vaccine with parents at every opportunity. Many parents have vaccine concerns and addressing concerns across the spectrum of hesitancy is crucial., Competing Interests: JT and NC report no conflict. HM is an investigator on clinical trials of investigational vaccines sponsored by Industry. Her institution receives funding from Industry (GSK, Pfizer, Novavax) for Investigator led research. She does not receive any personal payments from Industry. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Despite the increase in the number of journals issuing data policies requiring authors to make data underlying reporting findings publicly available, authors do not always do so, and when they do, the data do not always meet standards of quality that allow others to verify or extend published results. This phenomenon suggests the need to consider the effectiveness of journal data policies to present and articulate transparency requirements, and how well they facilitate (or hinder) authors' ability to produce and provide access to data, code, and associated materials that meet quality standards for computational reproducibility. This article describes the results of a research study that examined the ability of journal-based data policies to: 1) effectively communicate transparency requirements to authors, and 2) enable authors to successfully meet policy requirements. To do this, we conducted a mixed-methods study that examined individual data policies alongside editors' and authors' interpretation of policy requirements to answer the following research questions. Survey responses from authors and editors along with results from a content analysis of data policies found discrepancies among editors' assertion of data policy requirements, authors' understanding of policy requirements, and the requirements stated in the policy language as written. We offer explanations for these discrepancies and offer recommendations for improving authors' understanding of policies and increasing the likelihood of policy compliance., Competing Interests: I have read the journal's policy and the authors of this manuscript have the following competing interests: TC and AG are employees of the Odum Institute Data Archive. TV was a member of the Dryad Digital Repository Board of Directors and participated in unpaid activities for Dryad during the research project period. EH is an employee of Dryad Digital Repository. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Food allergy is an emerging clinical condition in pediatrics, so recommendations on its management have been widely published. Studying pediatricians' adherence to these clinical practice guidelines (CPG) and understanding the reasons for their non-compliance can help to promote better management of this condition. A cross-sectional study was conducted by a survey among Brazilian pediatricians, randomly selected during the 38th Brazilian Congress of Pediatrics, which took place in October, 2017. A validated questionnaire with 16 questions addressing knowledge and practice on food allergy, as well as self-reported adherence to international guidelines was applied. Of the total of 415 pediatricians from all regions of the country who were surveyed, only 69 (16.7%) had a satisfactory adherence rate (≥80%). Adequate adherence to the guidelines was associated with the variables: 'evaluating more than 10 children with suspected cow's milk allergy (CMA) per month'; 'having read the Brazilian consensus'; or 'being aware of any international food allergy guideline'. In 8 of the 10 questions that assessed conscious adherence, a minority of those surveyed (20.3-42.3% variation) stated that they knew that their response was in line with the guidelines. This finding was statistically significant (p<0.05) in 7 of these 8 questions. The self-reported adherence of Brazilian pediatricians to international food allergy guidelines was low. Pediatricians who evaluated a higher number of children with suspected CMA or who were aware of the recommendations, had a higher rate of adherence. The results of the survey found that lack of resource was the major reported barrier to guideline adherence but lack of awareness must be a relevant non perceived barrier. This study shows the pediatricians´ self-reported adherence to food allergy guidelines in a widely overview for the first time in Brazil. More studies are necessary to investigate adherence to guidelines by pediatricians in other countries and to develop strategies to improve adherence., Competing Interests: Authors competing interests I have read the journal’s policy and the authors of this manuscript have the following competing interests: SCF Vieira - has attended a Danone Nutricia Symposium with reimbursement for expenses JM Franco - has attended a Danone Nutricia Symposium with reimbursement for expenses MLC Wayhs - has participated as a consultant or speaker for Abbott, Danone Nutricia, EMS and Merck, and has attended a Danone Nutricia Symposium with reimbursement for expenses MC Vieira - Has participated as a consultant and/or speaker for Aché Laboratories, Danone Nutricia and Nestle Nutrition Institute MB Morais - has participated as a consultant and/or speaker for Aché laboratories, Bago Laboratory, Biolab, Danone Nutricia, Merck and Nestlé Nutrition Institute. RQ Gurgel currently serve on the editorial board of the Plos One journal This does not alter our adherence to PLOS ONE policies on sharing data and materials

Background: Head injuries in children are a common and potentially devastating presentation. The CareTrack Kids (CTK) study assessed care of Australian children aged 0-15 years, in 2012 and 2013, to evaluate the proportion in line with guideline-based indicators for 17 common conditions. Overall adherence to guideline-based recommended practice occurred 59.8% of care encounters (95% CI: 57.5-62.0), and 78.3% (95% CI: 75.1-81.2) for head injury. This paper presents results for head injury, at indicator level., Methods: A modified version of the RAND-UCLA method of indicator development was used. Indicators, measurable components of a standard or guideline, were developed from international and national guidelines relating to head injury in children and were ratified by clinical experts using a Delphi process. Paediatric nurses extracted data from medical records from general practitioners (GPs), emergency departments (EDs) and inpatient wards in Queensland, New South Wales and South Australia, for children under 15 years receiving care in 2012-13. Our purpose was to estimate the percentage adherent for each indicator., Results: The medical records of 629 children with head injury were examined. Fifty-one percent of children were under 5 years old, with more males (61%) than females. Thirty-eight indicators were assessed. Avoidance of nasotracheal airways (100%; 95% CI: 99.4-100) or nasogastric tubes (99.7%; 95% CI: 98.5-100) for children with a head injury had the highest adherence. Indicators relating to primary and secondary assessment of head injuries were mostly adhered to. However, adherence to other indicators was poor (e.g., documentation of the past history of children (e.g., presence or absence of seizures) before the injury; 29.9% (95% CI: 24.5-35.7)), and for others was difficult to estimate with confidence due to small sample sizes (e.g., Children with a head injury who were intubated had PaO2 above 80mm Hg; 56.0% (95% CI: 28.6-80.9)). Indicators guiding clinical decision making regarding the need for CT scan had insufficient data to justify reporting., Conclusion: This study highlights that management of head injury in children mostly follows guidelines, but also flags some specific areas of inconsistency. Individual sites are encouraged to use these results to guide investigation of local practices and inform quality improvement endeavours., Competing Interests: The authors have declared that no competing interests exist.

Effective and safe practices during extracorporeal membrane oxygenation (ECMO) including infection precautions and securement of lines (cannulas and circuits) are critical to prevent life-threatening patient complications, yet little is known about the practices of bedside clinicians and data to support best practice is lacking. Therefore, the aim of this study was to identify and describe common line-related practices for patients supported by peripheral ECMO worldwide and to highlight any gaps for further investigation. An electronic survey was conducted to examine common line practices for patients managed on peripheral ECMO. Responses were obtained from 45 countries with the majority from the United States (n = 181) and United Kingdom (n = 32). Standardised infection precautions including hand hygiene, maximal barrier precautions and skin antisepsis were commonplace for cannulation. The most common antisepsis strategies included alcohol-based chlorhexidine gluconate (CHG) for cannula insertion (53%) and maintenance (54%), isopropyl alcohol on circuit access ports (39%), and CHG-impregnated dressings to cover insertion sites (36%). Adverse patient events due to line malposition or dislodgement were reported by 34% of respondents with most attributable to ineffective securement. Centres 'always' suturing peripheral cannula sites were more likely to experience a cannula adverse event than centres that 'never' sutured (35% [95% CI 30, 41] vs 0% [95% CI 0, 28]; Chi-square 4.40; p = 0.04) but this did not meet the a priori significance level of <0.01. An evidence-based guideline would be beneficial to improve ECMO line management according to 78% of respondents. Evidence gaps were identified for antiseptic agents, dressing products and regimens, securement methods, and needleless valves. Future research addressing these areas may provide opportunities for consensus guideline development and practice improvement., Competing Interests: I have read the journal's policy and the authors of this manuscript have the following competing interests. JFF acknowledges his membership of the International ECMO Network (ECMONet) research consortium who granted endorsement of the study, however, there has been no financial or other input by ECMONet that could have influenced the study outcome. All other authors have declared that no competing interests exist. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Background: The European Society of Breast Cancer Specialists (EUSOMA), which aims to standardize the quality of patient care in Europe, has defined quality indicators (QIs) for breast cancer (BC) care to assess compliance to current care standards. These QIs are a useful tool to evaluate care organizations. Only population-based studies are able to assess health system performance in "real-life" situations. This population-based study aimed to describe compliance with several EUSOMA QIs overall and according to patient and organizational factors in France., Methods: 1 560 adult women with primary invasive non-metastatic BC diagnosed in 2012 were randomly selected among all incident BC from 16 French geographical areas covered by cancer registries. Twelve EUSOMA QIs were selected regarding diagnosis, treatment and staging., Results: The minimum standard as proposed by EUSOMA was met for nine QIs related to pre-operative definitive diagnosis, multidisciplinary discussion and treatment (single surgery, breast conserving surgery (BCS) for small BC (<3cm), radiotherapy after BCS or mastectomy for regional BC (pN≥2a), hormonotherapy, adjuvant chemotherapy and trastuzumab). Low compliance was observed for sentinel lymph node biopsy (SLNB) and staging imaging. Adherence to guidelines was usually lower in older patients and in patients with comorbidities. Multidisciplinary discussion was positively related to adherence to guidelines for diagnosis, staging practices (SNLB, imaging) and systemic treatments. Compliance also varied by area of residence and by place of first treatment., Conclusion: This study provides the first current, comprehensive overview of BC quality care at a population level in France. The guidelines were correctly applied in percentage satisfying the EUSOMA standards for the diagnosis and treatment of BC, although staging practices (SLNB, imaging) can be improved. These results highlight the need for continuous measurement of adherence to guidelines to improve BC care., Competing Interests: The authors have declared that no competing interests exist.

Objective: The Japanese government has developed and promoted a national nutrient-based dietary guideline for preventing lifestyle-related chronic disease. However, its impact in a real-life setting has never been evaluated. We performed a critical appraisal of the guideline by examining the association between adherence to the guideline and lifestyle-related outcome indicators., Methods: This is a retrospective observational cross-sectional study using nationally representative data on health and nutrition characteristics from the 2016 National Health and Nutrition Survey of Japan. We considered 3,861 participants aged ≥20 years, with evidence of low health risks of diabetes, hypertension, hyperlipidemia, and obesity. Five health outcome indicators (hemoglobin A1c (HbA1c), systolic blood pressure, diastolic blood pressure, high-density lipoprotein cholesterol, and body mass index), were employed. A summary score was developed to reflect adherence to the recommended intake of seven nutrients defined by the guideline, including proteins, fat, saturated fatty acid, carbohydrate, dietary fiber, sodium, and potassium. Multivariate quartile regression approaches were employed to examine the association between the adherence score and the health outcome indicators, adjusting for the covariates., Results: Overall, the proportion of those who adhered to the guideline (adherence rate) for all seven nutrients was only 0.3%. There was considerable variation in the adherence rate between the different nutrients, from 24.2% to 61.8%. After adjustment for covariates, in most health outcome indicators, regardless of age category and quartile, there was no clear association between the guideline adherence score and indicators., Conclusions: There is plenty of scope for improving the guideline. Nutrient impact on health may not necessarily depend on the amount of each nutrient in the diet. The significance and contribution of synergies between nutrients and complex interactions within foods to health outcomes need to be explored in future guideline updates., Competing Interests: SN and KS report grants from Ajinomoto Co., Inc. and the Ministry of Education, Culture, Sports, Science and Technology of Japan. DY, SN, KK, ST, and KS declare no competing interests. KN, HU, and NH declare that they are employed by Ajinomoto Co., Inc. and have no other competing interests. This does not alter the authors' adherence to PLOS ONE policies on sharing data and materials. The study was approved by the appropriate ethics review board. We have read and understood your journal’s policies, and we believe that neither the manuscript nor the study violates any of these.

Background: The aims of the study were to assess the level of knowledge, the attitudes and the adherence to evidence-based recommendations for surgical site infection (SSI) prevention and to describe any influences that may motivate nurses to adopt evidence-based practices for SSI prevention., Methods: The present study was a national cross-sectional survey conducted from June to November 2017. For each hospital that agreed to participate, 30 nurses were randomly selected. The questionnaire was aimed at exploring socio-demographic and practice characteristics, knowledge of, attitudes toward, and reported practices regarding evidence-based procedures for SSI prevention., Results: Out of 55 hospitals that were contacted, 36 agreed to participate (a response rate of 65%). Of the original sample of 1313 nurses, a total of 1305 returned the questionnaire, a response rate of 99.4%. Regarding knowledge, only 53.8% knew that preoperative hair removal, if necessary, should take place shortly before surgery, and 28.9% of the sample did not know the right definition of "bundle". Over three quarters of participants stated that they always perform hand antisepsis before and after biological sample collection while 9.7% considered that wearing gloves during this practice is sufficient to prevent SSI. Furthermore, 91% of nurses reported that they always performed hand antisepsis before and after invasive procedures., Conclusion: The study findings highlight the areas that were most lacking in nurses' training and for which targeted activities are needed. These data could support healthcare managers to implement interventions focused at enabling adherence to effective prevention practices to reduce risk to all patients., Competing Interests: The authors have declared that no competing interests exist.

Background: Non-invasive testing is recommended as a basis to decide about the indication for invasive coronary angiography (ICA) in patients with suspected stenotic coronary artery disease (CAD). However, a recent study based on insurance claims data reported that one third of patients undergoing ICA in Switzerland did not have non-invasive testing beforehand. We aimed to re-evaluate the practice of testing prior to ICA in Switzerland by manual review of patient histories., Methods: Retrospective analysis of all 816 consecutive patients (age 67±9 years, 70% males) undergoing elective ICA solely for the evaluation of stenotic CAD during the year 2015 in a single center in Eastern Switzerland. The proportion of patients undergoing a non-invasive test was assessed, and predictors of the lack of such a test were determined., Results: 764/816 (94%) patients had a non-invasive test prior to ICA. The majority of patients (728/816; 89%) had an exercise stress test, one fifth (160/816; 20%) underwent a test other than an exercise stress test (6% scintigraphy, 4% stress echocardiography, 6% stress magnetic resonance imaging, 4% computed tomography coronary angiography), and 122/816 (15%) patients had two tests. The use of antianginal drugs other than beta-blockers [odds ratio 1.92 (95% confidence interval 1.01-3.66); p = 0.047] and a lower left ventricular ejection fraction [odds ratio 0.97 (95% confidence interval 0.94-0.99) per one % point increase; p = 0.005] were independent predictors of the lack of a non-invasive test. ICA revealed stenotic CAD in 72% of patients, and 54% of patients underwent revascularization. Patients with and without non-invasive tests did not differ with respect to ICA findings and management., Conclusions: The present analysis suggests that patients are appropriately selected for ICA based on clinical judgement and non-invasive testing in Switzerland. There is no evidence for an overuse of ICA., Competing Interests: The authors have declared that no competing interests exist.

Children attending kindergarten are at high risk for contracting infections, for which hand hygiene (HH) has been recognized as the most cost-effective prevention measure globally. Kindergarten teachers' HH behavior plays a vital role in encouraging favorable hygiene techniques and environment. This study aims to evaluate the effectiveness of a multimodal intervention at changing kindergarten teachers' HH behavior and social cognitive factors that influences HH behavior in China. The intervention named "Clean Hands, Happy Life" includes HH products with refills, reminders and cues for action, a kick-off event with awards, and training programs. We evaluated the intervention using a self-administrative questionnaire with a stratified random sample of 12 kindergartens. Two surveys was completed by 176 teachers at baseline and 185 after the 6-month intervention. Compared with the baseline scores, there was a significant improvement in the overall self-reported HH compliance of teachers (9.38 vs. 9.68 out of 10, p = 0.006), as well as teachers' perceived disease susceptibility, disease severity and behavioral control after the intervention (p<0.05). We found that teachers' HH compliance was likely to be higher among those who have better HH guideline awareness (β = 0.48, p<0.01) and perceived behavioral control (β = 0.26, p = 0.01), which explained 24.2% of the variance of self-reported compliance of teachers at baseline. The assessed intervention may provide Chinese kindergarten teachers with behavioral skills and cognitions that associated with the compliance of HH behavior. We thus recommend future intervention studies consider our HH behavior change techniques, address multiple social cognitive determinants of HH behavior and include the change of targeted influences in the impact evaluation., Competing Interests: The hand hygiene products used in this study were jointly sponsored by Essity Hygiene Corporate and Vinda China Group. This does not alter our adherence to PLOS ONE policies on sharing data and materials. There are no patents, products in development, or marketed products to declare.

Introduction: Despite the benefits of early antenatal care visits for early prevention, detection, and treatment of potential complications in pregnancy, a high level of provider adherence to first-visit antenatal care standards is needed. However, little information is available regarding provider adherence to antenatal care in Tanzania. This study was performed to assess provider adherence to first-visit antenatal care standards and to apply stratified analysis to identify associated factors in Tanzania., Methods: Data from the 2014-2015 Tanzania Service Provision Assessment Survey were used in this study. Provider adherence to first-visit antenatal care standards was measured using 10 domains: client history; aspects of prior pregnancies; danger signs of the current pregnancy; physical examination; routine tests; HIV testing and counseling; maintaining a healthy pregnancy; iron/folate supplements; tetanus toxoid vaccination, and preparation for delivery. A composite score was then created in which the highest quantile (corresponding to ≥60.5%) considered to provider adhering to first-visit antenatal care standards. Initially, a series of unadjusted logistic regression analyses according to the type of facility and managing authority were performed separately at each level (i.e., facility, provider, and client). Thereafter, all variables with P < 0.2 were fitted into the respective stratified multivariable logistic regression analysis using a 5% significance level., Results: A total of 1756 first-visit antenatal care consultations performed by 822 providers in 648 health facilities were analyzed. The overall median [Interquartile range, IQR] adherence to first-visit antenatal care was relatively low at 47.1% [35.7%-60.5%]. After adjusting for selected variables from each level in specific strata, at dispensary; female providers [AOR = 5.5; 95% CI, 1.8-16.4], at health centre; performance of quality assurance [AOR = 2.2; 95% CI, 1.3-3.9], at hospital; availability of routine tests [AOR = 2.5; 95% CI, 1.3-4.8] and basic medicine [AOR = 2.8; 95% CI, 1.4-5.7], at public facilities; availability of medicine [AOR = 1.8; 95% CI, 1.1-3.2] and receiving refresher training [AOR = 1.8; 95% CI, 1.1-3.1], and at private facility; receiving external fund from government [AOR = 3.0; 95% CI, 1.1-8.4] were significantly associated with better adherence to first-visit antenatal care standards., Conclusions: The study highlighted the important factors, including the provision of refresher training, regular distribution of basic medicines, and diagnostics equipment which may influence provider adherence to first-visit ANC standards., Competing Interests: The authors have declared that no competing interests exist.

Aim: To assess the adherence of physicians to the Medical-Care Guidelines for Malignant Breast Tumors in Mexico, before and after the allocation of federal subsidies from the Catastrophic Health Expenditure Fund (FPGC by its Spanish initials) to accredited hospitals, a strategy implemented with the view of offering free treatment to women with breast cancer (BC)., Material and Methods: Based on a cross-sectional design, we gathered information on 479 BC patients who had been attended to at in four FPGC-accredited hospitals. Analysis centered on those treated within either three years before or three years after the accreditation of their attending hospitals. The four hospitals analyzed were located in the North, South, West and Center of the country. Information on all medical procedures performed during treatment was drawn from hospital medical records. Information on the socio-demographic characteristics of the patients was obtained by means of face-to-face interviews conducted in their homes., Results: Adherence of physicians to the Guidelines grew by 12.8 percent (from 43.4 to 56.2 percent) after FPGC accreditation (p<0.001) and varied according to the clinical stage of the disease, with much lower levels of adherence observed in the advanced stages (p<0.05)., Conclusions: The FPGC strategy increased the adherence of physicians to the Medical-Care Guidelines for Malignant Breast Tumors in Mexico., Competing Interests: The authors have declared that no competing interests exist.

Background: The relationship between guideline adherence and outcomes in patients with acute myocardial infarction (AMI) has been widely investigated considering the emergency, acute, post-acute phases separately, but the effectiveness of the whole care process is not known., Aim: The study aim was to evaluate the effect of the multicomponent continuum of care on 1-year survival after AMI., Methods: We conducted a cohort study selecting all incident cases of AMI from health information systems during 2011-2014 in the Lazio region. Patients' clinical history was defined by retrieving previous hospitalizations and drugs prescriptions. For each subject the probability to reach the hospital and the conditional probabilities to survive to 30 days from admission and to 31-365 days post discharge were estimated through multivariate logistic models. The 1-year survival probability was calculated as the product of the three probabilities. Quality of care indicators were identified in terms of emergency timeliness (time between residence and the nearest hospital), hospital performance in treatment of acute phase (number/timeliness of PCI on STEMI) and drug therapy in post-acute phase (number of drugs among antiplatelet, β-blockers, ACE inhibitors/ARBs, statins). The 1-year survival Probability Ratio (PR) and its Bootstrap Confidence Intervals (BCI) between who were exposed to the highest level of quality of care (timeliness<10', hospitalization in high performance hospital, complete drug therapy) and who exposed to the worst (timeliness≥10', hospitalization in low performance hospital, suboptimal drug therapy) were calculated for a mean-severity patient and varying gender and age. PRs for patients with diabetes and COPD were also evaluated., Results: We identified 38,517 incident cases of AMI. The out-of-hospital mortality was 27.6%. Among the people arrived in hospital, 42.9% had a hospitalization for STEMI with 11.1% of mortality in acute phase and 5.4% in post-acute phase. For a mean-severity patient the PR was 1.19 (BCI 1.14-1.24). The ratio did not change by gender, while it moved from 1.06 (BCI 1.05-1.08) for age<65 years to 1.62 (BCI 1.45-1.80) for age >85 years. For patients with diabetes and COPD a slight increase in PRs was also observed., Conclusions: The 1-year survival probability post AMI depends strongly on the quality of the whole multicomponent continuum of care. Improving the performance in the different phases, taking into account the relationship among these, can lead to considerable saving of lives, in particular for the elderly and for subjects with chronic diseases., Competing Interests: The authors have declared that no competing interests exist.

Background: Chronic obstructive pulmonary disease (COPD) is one of the main reasons for healthcare appointments and use of healthcare resources. In recent years, clinics specializing in COPD have been developed to offer improved care and optimization of recourses for patients with high complexity and frequent decompensations. However, little is known about the clinical practice in this clinical model specializing in COPD. The objectives of this study were to assess the prevalence, characteristics of specialized COPD outpatient respiratory clinics and to evaluate clinical practice in this healthcare model., Methods: EPOCONSUL is a Spanish nationwide, observational, cross-sectional, clinical audit with prospective case recruitment including the clinical records for 4508 COPD cases from outpatient respiratory clinics over a 12-month period (May 2014-May 2015). The study evaluated clinical practice in 2378 cases from 28 hospitals with both general and specialized COPD outpatient respiratory clinics., Results: Only 28 (47.5%) centers had an outpatient clinic specializing in COPD, which was characterized by longer patient visits and a higher prevalence of written protocols compared to a general clinic. Patients treated in a specialized clinic had greater obstruction severity, a higher degree of dyspnea and also suffered from more comorbidities. The majority of patients at both types of clinic were classified as high risk (81.1% versus 83%, p = 0.384) according to GesEPOC criteria. Clinical control of COPD was more frequent at specialized clinics, with significant differences in non-severe patients (70.5% versus 56.1%, p < 0.001). Testing was done more frequently in specialized clinics, with better adherence to good clinical practice recommendations., Conclusion: A specialized COPD outpatient clinic is a healthcare model found in few pulmonology departments that treats more severe patients and those with increased comorbidities. The COPD patients treated in a specialized clinic had a better clinical control, as defined by impact and clinical stability. It is a healthcare model to offer improved care with a higher degree of adherence to guidelines., Competing Interests: This study was partly funded by Boehringer Ingelheim. Myriam Calle Rubio has received speaker fees from Boehringer Ingelheim, AstraZeneca, GlaxoSmithKline, Menarini, and Novartis and consulting fees from GlaxoSmith¬Kline, Gebro Pharma and Novartis. Juan José Soler-Cataluña has received speaker fees from AstraZeneca, Boehringer Ingelheim, Chiesi, Esteve, Ferrer, GSK, Menarini, Mundipharma, Novartis and and consulting fees from AstraZeneca, Boehringer Ingelheim, Chiesi, Esteve, GSK, Mundipharma and Novartis. Jose Luis Lopez Campos has received fees for giving conferences, scientific advising, participation in clinical studies or draft of publications for (alphabetical order): Almirall, AstraZeneca, Bayer, Boehringer Ingelheim, Cantabria Pharma, Chiesi, Esteve, Faes, Ferrer, Gebro Pharma, GlaxoSmithKline, Grifols, Menarini, MSD, Novartis, Pfizer, Rovi, Teva y Takeda. Bernardino Alcázar Navarrete reports personal fees from GSK, grants, personal fees and non-financial support from Novartis AG, personal fees and non-financial support from Boehringer Ingelheim, personal fees and non-financial support from Chiesi, grants, personal fees and nonfinancial support from Laboratorios Menarini, personal fees from Gebro, personal fees from Astra- Zeneca, outside the submitted work. None of these are related to this work. José Miguel Rodríguez González- Moro has received fees for giving conferences from Astra-Zeneca, GSK, Boehringer Ingelheim, Teva, Novartis and Chiesi. J.B. Soriano declares having received grants from 2014 to date from Linde via Hospital Universitario de La Princesa, and has participated in speaking activities, advisory committees and consultancies during the period 2014−2018 sponsored by Almirall, AstraZeneca, Boehringer Ingelheim, CHEST, Chiesi, ERS, Esteve, GEBRO, Grifols, GSK, Linde, Lipopharma, Mundipharma, Novartis, Pfizer, RiRL, Rovi, Sandoz, SEPAR and Takeda, outside the submitted work. Manuel E. Fuentes Ferrer does not have conflicts of interest Juan Luis Rodriguez Hermosa has received speaker fees from Boehringer Ingelheim and Gebro Pharma. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

As dog bite injuries are a considerable problem in modern society, in order to reduce such injuries, breed-specific legislation has been introduced in a number of countries. Whilst many studies have shown a lack of effect with such legislation, the commonly used methodology is known to be flawed. Therefore, the aim of this study is to investigate the effect of the Danish breed-specific legislation on the number of dog bite injuries using more credible methods. A time series intervention method was used on a detailed dataset from Odense University Hospital, Denmark, regarding dog bite injuries presented to the emergency department. The results indicate that banning certain breeds has a highly limited effect on the overall levels of dog bite injuries, and that an enforcement of the usage of muzzle and leash in public places for these breeds also has a limited effect. Despite using more credible and sound methods, this study supports previous studies showing that breed-specific legislation seems to have no effect on dog bite injuries. In order to minimise dog bite injuries in the future, it would seem that other interventions or non-breed-specific legislation should be considered as the primary option., Competing Interests: The authors have declared that no competing interests exist.

Background: Global action plans to tackle antimicrobial resistance (AMR) include implementation of antimicrobial stewardship (AMS), but few studies have directly addressed the challenges faced by low and middle-income countries (LMICs). Our aim was to explore healthcare providers' knowledge and perceptions on AMR, and barriers/facilitators to successful implementation of a pharmacist-led AMS intervention in a referral hospital in Ethiopia., Methods: Tikur Anbessa Specialized Hospital (TASH) is an 800-bed tertiary center in Addis Ababa, and the site of an ongoing 4-year study on AMR. Between May and July 2017, using a mixed approach of quantitative and qualitative methods, we performed a cross-sectional survey of pharmacists and physicians using a pre-tested questionnaire and semi-structured interviews of purposively selected respondents until thematic saturation. We analyzed differences in proportions of agreement between physicians and pharmacists using χ2 and fisher exact tests. Qualitative data was analyzed thematically., Findings: A total of 406 survey respondents (358 physicians, 48 pharmacists), and 35 key informants (21 physicians and 14 pharmacists) were enrolled. The majority of survey respondents (>90%) strongly agreed with statements regarding the global scope of AMR, the need for stewardship, surveillance and education, but their perceptions on factors contributing to AMR and their knowledge of institutional resistance profiles for common bacteria were less uniform. Close to 60% stated that a significant proportion of S. aureus infections were caused by methicillin-resistant strains (an incorrect statement), while only 48% thought a large proportion of gram-negative infections were caused by cephalosporin-resistant strains (a true statement). Differences were noted between physicians and pharmacists: more pharmacists agreed with statements on links between use of broad-spectrum antibiotics and AMR (p<0.022), but physicians were more aware that lack of diagnostic tests led to antibiotic overuse (p<0.01). More than cost, fear of treatment failure and of retribution from senior physicians were major drivers of antibiotic prescription behavior particularly among junior physicians. All respondents identified high turnover of pharmacists, poor communication between the laboratory, pharmacists and clinicians as potential challenges; but the existing hierarchical culture and academic setting were touted as opportunities to implement AMS in Ethiopia., Conclusions: This knowledge and perceptions survey identified specific educational priorities and implementation strategies for AMS in our setting. This is likely also true in other LMICs, where expertise and infrastructure may be lacking., Competing Interests: The authors have declared that no competing interests exist.

Background: Nucleic acid testing (NAT) for virus detection during blood screening has helped to prevent transfusion-transmitted infections worldwide. In northern Brazil, NAT was implemented in 2012 for HIV and HCV and more recently, in January 2015, the screening for HBV was included and currently used concomitant with serological tests (HBsAg and anti-HBc). This study aims to evaluate the prevalence and the incidence of HBV infection among voluntary blood donors at ten regional blood centers of HEMOPA Foundation in Pará state and to compare the residual risk of transfusion-transmitted HBV infection before and after the Brazilian HBV-NAT implementation., Methods: The prevalence (restricted to first time donors- FT) and seroconversion rate (restricted to repeat donors- RP) of HBV were calculated based on rates of confirmed positive samples. Residual risk was based on the incidence and window period (WP) model described by Schreiber and coauthors. Logistic and Poisson regression were used in the statistical analysis by SPSS v20.0. A p value <0.05 was considered statistically significant., Results: HBV prevalence in the periods before and after the implementation of HBV-NAT were 247 and 251 per 100,000 donations, respectively. Seroconversion rates were 114 and 122 per 100,000 donations in the two periods, respectively. The residual risk (RR) for HBV decreased significantly in the posterior period to the HBV-NAT implementation, when compared to RR before implementation, with a reduction of 1:144,92 to 1:294,11 donations (p <0,001)., Conclusions: The RR to HBV decreased after the implementation of HBV-NAT, increasing significantly the transfusional security in the North region of Brazil at HEMOPA Foundation., Competing Interests: The authors have declared that no competing interests exist.

Background: Quality of care is a difficult parameter to measure. With the introduction of digital algorithms based on the Integrated Management of Childhood Illness (IMCI), we are interested to understand if the adherence to the guidelines improved for a better quality of care for children under 5 years old., Methods: More than one year after the introduction of digital algorithms, we carried out two cross sectional studies to assess the improvements in comparison with the situation prior to the implementation of the project, in two Basic Health Centres in Kabul province. One survey was carried out inside the consultation room and was based on the direct observation of 181 consultations of children aged 2 months to 5 years old, using a checklist completed by a senior physicians. The second survey queried 181 caretakers of children outside the health facility for their opinion about the consultation carried out through the tablet and prescriptions and medications given., Results: We measured the quality of care as adherence to the IMCI's guidelines. The study evaluated the quality of the physical examination and the therapies prescribed with a special attention to antibiotic prescription. We noticed a dramatic improvement (p<0.05) of several indicators following the introduction of digital algorithms. The baseline physical examination was appropriate only for 23.8% [IC% 19.9-28.1] of the patients, 34.5% [IC% 30.0-39.2] received a correct treatment and 86.1% [IC% 82.4-89.2] received at least one antibiotic. With the introduction of digital algorithms, these indicators statistically improved respectively to 84.0% [IC% 77.9-88.6], >85% and less than 30%., Conclusions: Our findings suggest that digital algorithms improve quality of care by applying the guidelines more effectively. Our experience should encourage to test this tool in different settings and to scale up its use at province/state level., Competing Interests: The authors have declared that no competing interests exist.

Objectives: Clinical practice guidelines have the potential to improve care, but are often not optimally implemented. Improving guideline use in clinical practice may improve care. The objective of this study was to identify the barriers and facilitators (determinants) of guidelines use among neurologists and to propose a strategy to improve guideline implementation., Methods: This was a mixed-methods study design. A quantitative, population-based, cross-sectional survey of Canadian neurologists was conducted. Associations between guidelines use and determinants of guidelines use were examined. Focus groups and interviews were conducted using purposeful sampling of the population. Determinants of guideline use were mapped to interventions to establish a strategy for guideline implementation among neurologists., Results: 38.7% (n = 311) of neurologists responded to the survey. Typically, respondents had been practicing for 16.6 years and worked in an academic institution in an urban setting. Being male and having an academic affiliation was associated with guideline use. Determinants of guideline use differed between guideline users and non-users; non-users consistently rating determinants lower than users, especially applicability. Two focus groups and one interview (n = 11) identified six main themes of determinants of guideline use: Credibility, knowledge, applicability, resources, motivation, and target audience; which was congruent with the quantitative data. The proposed knowledge translation strategy contains three pillars: guidelines development, dissemination, and interventions., Conclusions: Several determinants of guideline use not commonly discussed in the literature were identified (applicability, target audience, credibility). The proposed implementation strategy is a valuable resource for guideline developers and policy/decision-makers to improve knowledge translation of guidelines among neurologists., Competing Interests: The authors have declared that no competing interests exist.

Aims of the Study: Despite the widespread existence of guidelines regarding undernutrition monitoring and reporting, there is scarce information whether they are followed. We aimed to evaluate the adherence to guidelines regarding undernutrition monitoring and reporting as well as their determinants in a university hospital., Methods: Retrospective analysis of discharged patients with data on Nutritional Risk Screening score (NRS-2002) from the department of internal medicine of the Lausanne University Hospital for years 2013-14. Adherence to the hospital monitoring guidelines, i.e.: 1) discharged patients with NRS-2002 score≥3 should have prealbumin levels measured, and 2) discharged patients with prealbumin levels<0.20 g/l should be rechecked 7 days afterwards, was assessed. Reporting of nutritionally 'at-risk' status in the discharge letter was also assessed. Multivariable logistic regression was used to examine potential determinants of adherence to guidelines., Results: Of the 2,539 discharged patients with NRS-2002 data, 1,605 (63.0%) were nutritionally 'at-risk'. Complete adherence to the monitoring guideline was observed in 238 (14.8%) of 'at-risk' patients. After multivariable analysis, adherence to the first step of monitoring guideline was associated with older age (≥ 80 years) [OR (95% CI): 2.03 (1.29-3.18)], high comorbidity index [1.36 (1.05-1.77)], and nutritional management [5.57 (4.38-7.07)]. Nutritional management was also associated with adherence to the second step of monitoring [3.98 (2.33-6.78)]. Adherence to the reporting guideline was observed in 343 (21.4%) of 'at-risk' patients. Multivariable analysis showed that adherence to the reporting guideline was associated with NRS-2002 score>4 [1.97 (1.47-2.64)], nutritional management [3.80 (2.85-5.07)], and adherence to the monitoring guideline [3.33 (2.35-4.71)]., Conclusions: Our results show a poor adherence to guidelines regarding undernutrition monitoring and reporting, possibly due to lack of training, staff, and time., Competing Interests: The authors have declared that no competing interests exist.

Introduction: Despite the importance of chemotherapy in the treatment of early stage triple negative breast cancer (TNBC), no one optimal regimen has been identified. We conducted a pilot trial comparing outcomes for the three most commonly used chemotherapy regimens to assess the feasibility of conducting a larger definitive trial., Methods: Using integrated consent, newly diagnosed TNBC patients were randomised to one of three standard regimens: dose-dense doxorubicin-cyclophosphamide then paclitaxel, doxorubicin-cyclophosphamide then weekly paclitaxel or 5-FU-epirubicin-cyclophosphamide then docetaxel. Feasibility endpoints included; physician engagement, accrual rates, physician compliance and patient satisfaction with the integrated consent model. Our anticipated pilot trial sample size was 35 randomised patients in one year., Results: Between August 30th, 2016 and January 31st 2017, 2 patients met eligibility and were randomised. A survey of 10 participating oncologists was performed to identify potential strategies to enhance accrual. Most investigators (9/10) believed that the best regimen for TNBC was unknown, and 4/10 felt this was a pressing clinical question. Physicians' responses suggested that poor accrual was due to: a lack of interest in some study arms as oncologists already had a preferred regimen (4/10) and concerns about trial demands in busy clinics (3/10). The pilot feasibility endpoints were not met and the study was closed., Conclusions: Despite initial interest in the trial question and multiple investigators agreeing to approach patients, this trial failed to meet feasibility endpoints. The reasons for poor accrual were multiple and require further evaluation if this important patient-centred question is to be answered., Trial Registration: ClinicalTrials.gov NCT02688803., Competing Interests: The authors have declared that no competing interests exist.

Background: In 2008, a bundle of care to prevent Surgical Site Infections (SSIs) was introduced in the Netherlands. The bundle consisted of four elements: antibiotic prophylaxis according to local guidelines, no hair removal, normothermia and 'hygiene discipline' in the operating room (i.e. number of door movements). Dutch hospitals were advised to implement the bundle and to measure the outcome. This study's goal was to assess how effective the bundle was in reducing SSI risk., Methods: Hospitals assessed whether their staff complied with each of the bundle elements and voluntary reported compliance data to the national SSI surveillance network (PREZIES). From PREZIES data, we selected data from 2009 to 2014 relating to 13 types of surgical procedures. We excluded surgeries with missing (non)compliance data, and calculated for each remaining surgery with reported (non)compliance data the level of compliance with the bundle (that is, being compliant with 0, 1, 2, 3, or 4 of the elements). Subsequently, we used this level of compliance to assess the effect of bundle compliance on the SSI risk, using multilevel logistic regression techniques., Results: 217 489 surgeries were included, of which 62 486 surgeries (29%) had complete bundle reporting. Within this group, the SSI risk was significantly lower for surgeries with complete bundle compliance compared to surgeries with lower compliance levels. Odds ratios ranged from 0.63 to 0.86 (risk reduction of 14% to 37%), while a 13% risk reduction was demonstrated for each point increase in compliance-level. Sensitivity analysis indicated that due to analysing reported bundles only, we probably underestimated the total effect of implementing the bundle., Conclusions: This study demonstrated that adhering to a surgical care bundle significantly reduced the risk of SSIs. Reporting of and compliance with the bundle compliance can, however, still be improved. Therefore an even greater effect might be achieved.

Background: The 2009 Institute of Medicine (IOM) guidelines for gestational weight gain (GWG) are intended for use among women in the United States. Little data are available on whether the 2009 IOM recommendations can be applied to Asian women. This study aimed to evaluate whether the recommendations are related to adverse pregnancy outcomes in Korean pregnant women., Methods and Findings: A retrospective cohort study was conducted for all singleton-pregnant women at a university hospital in Korea. After classifying the enrolled women into four Korean pre-pregnancy body mass index (BMI) categories, the risk of adverse pregnancy outcomes were analyzed for women who gained inadequate or excessive GWG based on 2009 IOM recommendations. Of 7,843 pregnancies, 64.0% of women had normal pre-pregnancy BMI and 42.7% achieved optimal GWG. Across all BMI categories, adverse pregnancies outcomes such as small for gestational age (SGA), large for gestational age (LGA), preterm birth, preeclampsia, and cesarean due to dystocia were significantly associated with GWG (all P ≤ 0.001).Women with normal BMI who gained inadequate weight were more likely to develop SGA and preterm birth and less likely to develop LGA (adjusted odds ratio (aOR) 2.21, 1.33, and 0.54, respectively). Whereas, women with normal BMI who gained excessive weight were more likely to develop LGA, preterm birth, preeclampsia, and cesarean section due to dystocia (aOR 2.10, 1.33, 1.37, and 1.37, respectively) and less likely to develop SGA (aOR 0.60)., Conclusions: It is tolerable for Korean women to follow recommended GWG from the 2009 IOM guidelines to decrease adverse pregnancy outcomes. This will be helpful for antenatal care on GWG not only for Korean pregnant women, but also other Asian women who have lower BMI criteria than Caucasian women.

Objectives: Antibiotic overprescribing in primary care has major impacts on the development of antibiotic resistance. The objective of this study is to provide insight in antibiotics prescriptions for patients suffering from cough, acute bronchitis or community acquired pneumonia in primary care., Methods: Data from 2009 to 2013 of electronic health records of 12,880 patients in Germany were obtained from a research database. The prescription of antibiotics for acute lower respiratory tract infections was compared to the national S3 guideline cough from the German Society of General Practitioners and Family Medicine., Results: Antibiotics were prescribed in 41% of consultations. General practitioners' decision of whether or not to prescribe an antibiotic was congruent with the guideline in 52% of consultations and the antibiotic choice congruence was 51% of antibiotic prescriptions. Hence, a congruent prescribing decision and a prescription of recommendation was found in only 25% of antibiotic prescriptions. Split by diagnosis we found that around three quarters of antibiotics prescribed for cough (73%) and acute bronchitis (78%) were not congruent to the guidelines. In contrast to that around one quarter of antibiotics prescribed for community acquired pneumonia (28%) were not congruent to the guidelines., Conclusions: Our results show that there is a big gap between guideline recommendation and actual prescribing, in the decision to prescribe and the choice of antibiotic agent. This gap could be closed by periodic quality circles on antibiotic prescribing for GPs.

Objectives: Guidelines for managing catheter-associated urinary tract infection (CAUTI) and asymptomatic bacteria (ASB) are poorly translated into routine care due in part to cognitive diagnostic errors. This study determines if the accuracy for CAUTI and ASB diagnosis and treatment improves after implementation of a fast and frugal algorithm compared with traditional education methods., Materials and Methods: A pre and post-intervention with contemporaneous comparison site involving inpatient and long term care wards at two regional Veterans Affairs Systems in United States. Participants included 216 internal medicine residents and 16 primary care clinicians. Intervention clinicians received training with a fast and frugal algorithm. Comparison site clinicians received guidelines education. Diagnosis and treatment accuracy compared with a criterion standard was assessed during similar three-month, pre- and post-intervention periods. Sensitivity, specificity, and likelihood ratios were compared for both periods at each site., Results: Bacteriuria management was evaluated against criterion standard in 196 cases pre-implementation and 117 cases post-implementation. Accuracy of bacteriuria management among intervention participants was significantly higher, post-implementation, than those at the comparison site (Intervention: positive likelihood ratio (LR+) = 8.5, specificity = 0.89, 95% confidence interval (CI) = 0.78-1.00; comparison: LR+ = 4.62, specificity (95%CI) = 0.79 (0.63-0.95). Further, improvements at the intervention site were statistically significant (pre-implementation: LR+ = 2.1, specificity (95%CI) = 0.60 (0.50-0.71); post-implementation: LR+ = 8.5, specificity (95%CI) = 0.89 (0.78-1.00). At both sites, there were similar improvements in negative LR from pre- to post-implementation: [Intervention site = 0.28 to 0.08; comparison site = 0.13 to 0.04]. Inappropriate management of ASB declined markedly from 32 (40%) to 3 (11%) cases at the intervention site., Conclusions: A fast and frugal algorithm improves diagnosis and treatment accuracy for CAUTI and reduces inappropriate treatment of ASB. Fast and frugal algorithms that realign diagnostic intuitions and treatment norms can enhance translation of evidence into practice.

The objective of this study was to assess whether the Brazilian Workers' Food Program (WFP) is associated with changes in the nutritional status of workers in the transformation industry. We conducted a cross-sectional, observational, comparative study, based on prospectively collected data from a combined stratified and two-stage probability sample of workers from 26 small and medium size companies, 13 adherent and 13 non-adherent to the WFP, in the food, mining and textile sectors. Study variables were body mass index (BMI), waist circumference (WC), and dietary intake at lunch obtained by 24-hour dietary recall. Data were analyzed with nested mixed effects linear regression with adjustment by subject variables. Sampling weights were applied in computing population parameters. The final sample consisted of 1069 workers, 541 from WFP-adherent and 528 from WFP non-adherent companies. The groups were different only in education level, income and in-house training. Workers in WFP-adherent companies have greater BMI (27.0 kg/m2 vs. 26.0 kg/m2, p = 0.002) and WC (87.9 cm vs. 86.5, p = 0.04), higher prevalence of excessive weight (62.6% vs. 55.5%, p<0.001) and of increased WC (49.1% vs. 39.9%). Workers of WFP companies have lower intake of saturated fat (-1.34 g, p<0.01) and sodium (-0.3 g, p<0.01) at lunch. In conclusion, this study showed that workers of companies adherent to the Brazilian WFP have greater rates of excessive weight and increased cardiovascular risk-a negative finding-as well as lower intake of sodium and saturated fat-a positive finding. Therefore, the WFP needs to be revisited and its aims redefined according to the current epidemiological status of the target population of the program., Competing Interests: The authors have declared that no competing interests exist.