Search

Objective: We evaluated longitudinal rates, risk factors, and costs of superficial and deep incisional surgical-site infection (SSI) 6 months after primary total knee arthroplasty (pTKA) and revision total knee arthroplasty (rTKA). Methods: Patients were identified from January 1, 2016 through March 31, 2018, in the IBM MarketScan administrative claims databases. Kaplan-Meier survival curves evaluated time to SSI over 6 months. Cox proportional hazard models evaluated SSI risk factors. Generalized linear models estimated SSI costs up to 12 months. Results: Of the 26,097 pTKA patients analyzed (mean age, 61.6 years; SD, 9.2; 61.4% female; 60.4% commercial insurance), 0.65% (95% CI, 0.56%–0.75%) presented with a deep incisional SSI and 0.82% (95% CI, 0.71%–0.93%) with a superficial incisional SSI. Also, 3,663 patients who had rTKA (mean age, 60.9 years; SD, 10.1; 60.6% female; 53.0% commercial insurance), 10.44% (95% CI, 9.36%–11.51%) presented with a deep incisional SSI and 2.60% (95% CI, 2.07%–3.13%) presented with a superficial incisional SSI. Infections were associated with male sex and multiple patient comorbidities including chronic pulmonary disease, pulmonary circulatory disorders, fluid and electrolyte disorders, malnutrition, drug abuse, and depression. Adjusted average all-cause incremental commercial cost ranged from $14,298 to $29,176 and from $41,381 to 59,491 for superficial and deep incisional SSI, respectively. Conclusions: SSI occurred most frequently following rTKA and among patients with pulmonary comorbidities and depression. The incremental costs associated with SSI following TKA were substantial.

This chapter looks at the rules relating to legal professional privilege and, in outline, the doctrine of the privilege against self-incrimination. Under these provisions potentially relevant evidence may be excluded at trial. The role of legal professional privilege in protecting defendants in criminal trials is outlined and the absolutist stance of the courts discussed. The chapter outlines the various immunities which are embraced under the privilege against self-incrimination. Summarizing some recent case law, the chapter reflects on the extent to which the privilege may now extend to a broader set of circumstances than the earlier authorities suggested. For example, the privilege may not necessarily be unavailable against the use of compelled questions in an administrative enquiry.

This chapter focuses on the competence and compellability of witnesses in criminal and, in outline, in civil trials. It explains the main criminal law exceptions in relation to competence and universal compellability. It gives details on the complex and controversial position under s80 of the Police and Criminal Evidence Act (PACE) 1984. The chapter outlines the special measures directions (SMDs) available under the Youth Justice and Criminal Evidence Act (YJCAE) 1999 for vulnerable non-defendant witnesses in criminal trials. The more limited measures for vulnerable defendants are outlined, in particular the use of intermediaries. The chapter concludes with an outline of the Criminal Evidence (Witness Anonymity) Act 2008.

This chapter focuses on confessions and on the defendant’s pre-trial silence. It explains how a defendant may be convicted on the evidence of a confession alone. It analyses the definition of a confession as specified in s82(1) of the Police and Criminal Evidence Act 1984 (PACE), and how a confession proffered by the prosecution or by a co-defendant may be excluded by rule under PACE. The chapter also considers the preservation of the common law discretion to exclude confession evidence as well as the procedure for police interrogation of suspects under PACE. It examines recent case law on the significance of lack of access to legal advice of a suspect under interrogation. It concludes with an examination of how the jury at trial may draw an inference of guilt under ss34, 36, and 37 of the Criminal Justice and Public Order Act 1994 (CJPO), sections which have eroded the right to silence. The influence of the Strasbourg jurisprudence in this area is outlined.

This chapter examines a number of procedural matters in criminal trials. It first explains suspect evidence and the erosion of the rules on corroboration under the Criminal Justice and Public Order Act (CJPOA)1994. It then concentrates in some detail on identification evidence concerned with the Turnbull directions and the provisions of Code D Police and Criminal Evidence Act (PACE) 1984. The extent to which the defendant’s lies may constitute evidence of guilt is explained, along with a review of Lucas directions. It continues with a review of the various procedural aspects of examination and cross-examination. The chapter concludes with a discussion of the rules on cross-examination of complainants in sexual cases on their previous sexual history along with the case law under s41 Youth Justice and Criminal Evidence Act (YJCEA)1999.

This chapter, which focuses on hearsay evidence and its relationship to confessions, first considers the rule against hearsay and its application to out-of-court statements of witnesses in civil and criminal cases. It then looks at statements, both oral and written, and gestures, as well as the admissibility of hearsay in criminal proceedings under the Criminal Justice Act (CJA) 2003 and, in outline, in civil proceedings under the Civil Evidence Act (CEA) 1995. The survival of some common law rules on hearsay is discussed. The chapter also explains the legal distinction between first-hand (what X told Y) and multiple hearsay (what X told Y who told Z). It concludes by discussing the landmark decisions under Art 6(3)(d) of the European Convention on Human Rights (ECHR).

Fifty years of evolution in infection prevention and control programs have involved significant accomplishments related to clinical practices, methodologies, and technology. However, regulatory mandates, and resource and research limitations, coupled with emerging infection threats such as the COVID-19 pandemic, present considerable challenges for infection preventionists. This article provides guidance and recommendations in 14 key areas. These interventions should be considered for implementation by United States health care facilities in the near future.

Background Colorectal surgical procedures place substantial burden on health care systems because of the high complication risk, of surgical site infections in particular. The risk of surgical site infection after colorectal surgery is one of the highest of any surgical specialty. Objective The purpose of this study was to determine the incidence, cost of infections after colorectal surgery, and potential economic benefit of using antimicrobial wound closure to improve patient outcomes. Design Retrospective observational cohort analysis and probabilistic cost analysis were performed. Settings The analysis utilized a database for colorectal patients in the United States between 2014 and 2018. Patients A total of 107,665 patients who underwent colorectal surgery were included in the analysis. Main outcome measures Rate of infection was together with identified between 3 and 180 days postoperatively, infection risk factors, infection costs over 24 months postoperatively by payer type (commercial payers and Medicare), and potential costs avoided per patient by using an evidence-based innovative wound closure technology. Results Surgical site infections were diagnosed postoperatively in 23.9% of patients (4.0% superficial incisional and 19.9% deep incisional/organ space). Risk factors significantly increased risk of deep incisional/organ-space infection and included several patient comorbidities, age, payer type, and admission type. After 12 months, adjusted increased costs associated with infections ranged from $36,429 to $144,809 for commercial payers and $17,551 to $102,280 for Medicare, depending on surgical site infection type. Adjusted incremental costs continued to increase over a 24-month study period for both payers. Use of antimicrobial wound closure for colorectal surgery is projected to significantly reduce median payer costs by $809 to $1170 per patient compared with traditional wound closure. Limitations The inherent biases associated with retrospective databases limited this study. Conclusions Surgical site infection cost burden was found to be higher than previously reported, with payer costs escalating over a 24-month postoperative period. Cost analysis results for adopting antimicrobial wound closure aligns with previous evidence-based studies, suggesting a fiscal benefit for its use as a component of a comprehensive evidence-based surgical care bundle for reducing the risk of infection. See Video Abstract at http://links.lww.com/DCR/B358. EVALUACION DEL RIESGO Y LA CARGA ECONOMICA DE LA INFECCION DEL SITIO QUIRURGICO DESPUES DE UNA CIRUGIA COLORRECTAL UTILIZANDO UNA BASE DE DATOS LONGITUDINAL DE EE.UU.: ?EXISTE UN PAPEL PARA LA TECNOLOGIA INNOVADORA DE CIERRE DE HERIDAS ANTIMICROBIANAS PARA REDUCIR EL RIESGO DE INFECCION?: Los procedimientos quirurgicos colorrectales suponen una carga considerable para los sistemas de salud debido al alto riesgo de complicaciones, particularmente las infecciones del sitio quirurgico. El riesgo de infeccion posoperatoria del sitio quirurgico colorrectal es uno de los mas altos de cualquier especialidad quirurgica.El proposito de este estudio fue determinar la incidencia, el costo de las infecciones despues de la cirugia colorrectal y el beneficio economico potencial del uso del cierre de la herida con antimicrobianos para mejorar los resultados de los pacientes.Analisis retrospectivo de cohorte observacional y analisis de costo probabilistico.El analisis utilizo la base de datos para pacientes colorrectales en los Estados Unidos entre 2014 y 2018.Un total de 107,665 pacientes sometidos a cirugia colorrectal.Se identifico una tasa de infeccion entre 3 y 180 dias despues de la operacion, los factores de riesgo de infeccion, los costos de infeccion durante 24 meses posteriores a la operacion por tipo de pagador (pagadores comerciales y Medicare), y los costos potenciales evitados por paciente utilizando una tecnologia innovadora de cierre de heridas basada en evidencias.Infecciones del sitio quirurgico, diagnosticadas postoperatoriamente en el 23,9% de los pacientes (4,0% incisional superficial y 19,9% incisional profunda / espacio organico). Los factores de riesgo aumentaron significativamente el riesgo de infeccion profunda por incision / espacio organico e incluyeron comorbilidades selectivas del paciente, edad, tipo de pagador y tipo de admision. Despues de 12 meses, el aumento de los costos asociados con las infecciones vario de $ 36,429 a $ 144,809 para los pagadores comerciales y de $ 17,551 a $ 102,280 para Medicare, segun el tipo de infeccion del sitio quirurgico. Los costos incrementales ajustados continuaron aumentando durante un periodo de estudio de 24 meses para ambos pagadores. Se preve que el uso del cierre antimicrobiano de la herida para la cirugia colorrectal reducira significativamente los costos medios del pagador en $ 809- $ 1,170 por paciente en comparacion con el cierre tradicional de la herida.Los sesgos inherentes asociados a las bases de datos retrospectivas limitaron este estudio.Se encontro que la carga del costo de la infeccion del sitio quirurgico es mayor que la reportada previamente, y los costos del pagador aumentaron durante un periodo postoperatorio de 24 meses. Los resultados del analisis de costos para la adopcion del cierre de heridas antimicrobianas se alinean con estudios previos basados en evidencia, lo que sugiere un beneficio fiscal para su uso como componente de un paquete integral de atencion quirurgica basada en evidencia para reducir el riesgo de infeccion. Consulte Video Resumen en http://links.lww.com/DCR/B358.

The conventional view of 'Duncan v Cammell Laird' was succinctly expressed by Wade and Forsyth. "The case", they wrole: "is a good example of the most genuine type where it seems plain that the interests of litigants must be sacrificed in order to preserve secrets of state." To Zuckerman Duncan was "the most outstanding" example of a rare number of cases genuinely involving national security. These, along with almost all other commentators, argue that national security considerations meant that the 1942 decision was on its facts pretty well inevitable and probably correct. This article suggests thal the view that the plaintiffs had to take second place to the greater good of keeping Germany in ignorance of British naval secrets perpetuates a myth. This myth was fostered by civil sewice lawyers in the interesis of litigation management by the Crown. The case papers tell a different story.

Surgical site infection posthysterectomy has significant impact on patient morbidity, mortality, and health care costs. This study evaluates incidence, risk factors, and total payer costs of surgical site infection after hysterectomy in commercial, Medicare, and Medicaid populations using a nationwide claims database.IBM MarketScan databases identified women having hysterectomy between 2014 and 2018. Deep-incisional/organ space (DI/OS) and superficial infections were identified over 6 months postoperatively with risk factors and direct infection-associated payments by insurance type over a 24-month postoperative period.Analysis identified 141,869 women; 7.8% Medicaid, 5.8% Medicare, and 3.9% commercially insured women developed deep-incisional/organ space surgical site infection, whereas 3.9% Medicaid, 3.2% Medicare, and 2.1% commercially insured women developed superficial infection within 6 months of index procedure. Deep-incisional/organ space risk factors were open approach (hazard ratio, 1.6; 95% confidence interval, 1.5-1.8) and payer type (Medicaid versus commercial [hazard ratio, 1.4; 95% confidence interval, 1.3-1.5]); superficial risk factors were payer type (Medicaid versus commercial [hazard ratio, 1.4; 95% confidence interval, 1.3-1.6]) and solid tumor without metastasis (hazard ratio, 1.4; 95% confidence interval, 1.3-1.6). Highest payments occurred with Medicare ($44,436, 95% confidence interval: $33,967-$56,422) followed by commercial ($27,140, 95% confidence interval: $25,990-$28,317) and Medicaid patients ($17,265, 95% confidence interval: $15,247-$19,426) for deep-incisional/organ space infection at 24-month posthysterectomy.Real-world cost of managing superficial, deep-incisional/organ space infection after hysterectomy was significantly higher than previously reported. Surgical approach, payer type, and comorbid risk factors contributed to increased risk of infection and economic burden. Medicaid patients experienced the highest risk of infection, followed by Medicare patients. The study suggests adoption of a robust evidence-based surgical care bundle to mitigate risk of surgical site infection and economic burden is warranted.

Background:. The U.S. Patient Protection and Affordable Care Act created the Hospital Readmissions Reduction Program (HRRP) and the Hospital-Acquired Condition Reduction Program (HACRP). Under these programs, hospitals face reimbursement reductions for having high rates of readmission and hospital-acquired conditions. This study investigated whether readmission following total joint arthroplasty (TJA) under the HRRP was associated with reimbursement penalties under the HACRP. Methods:. Hospital-level data on hospital-acquired conditions, readmissions, and financial penalties were obtained from Definitive Healthcare. Outcomes included receipt of an HACRP penalty and the associated losses in revenue in 2018. Logistic regression and linear regression models were used to determine whether the all-cause, 30-day readmission rate following TJA was associated with the receipt or magnitude of an HACRP penalty. Results:. Among 2,135 private, acute care hospitals, 477 (22.3%) received an HACRP penalty. After controlling for other patient and hospital characteristics, hospitals with a 30-day readmission rate of >3% after TJA had over twice the odds of receiving an HACRP penalty (odds ratio, 2.20; p = 0.043). In addition, hospitals with a readmission rate of >3% after TJA incurred $77,519 more in revenue losses due to HACRP penalties (p = 0.011). These effects were magnified in higher-volume hospitals. Conclusions:. Acute care hospitals in the United States with higher 30-day readmission rates following TJA are more likely to be penalized and to have greater revenue losses under the HACRP than hospitals with lower readmission rates after TJA. This strengthens the incentive to invest in the prevention of readmissions after TJA, for example, through greater efforts to reduce surgical site infections and other modifiable risk factors.

The global push to combat the problem of antimicrobial resistance has led to the development of antimicrobial stewardship programs (ASPs), which were recently mandated by The Joint Commission and the Centers for Medicare and Medicaid Services. However, the use of topical antibiotics in the open surgical wound is often not monitored by these programs nor is it subject to any evidence-based standardization of care. Survey results indicate that the practice of using topical antibiotics intraoperatively, in both irrigation fluids and powders, is widespread. Given the risks inherent in their use and the lack of evidence supporting it, the practice should be monitored as a core part of ASPs, and alternative agents, such as antiseptics, should be considered.

Environmental disinfection has become the new frontier in the ongoing battle to reduce the risk of health care-associated infections. Evidence demonstrating the persistent contamination of environmental surfaces despite traditional cleaning and disinfection methods has led to the widespread acceptance that there is both a need for reassessing traditional cleaning protocols and for using secondary disinfection technologies. Ultraviolet-C (UV-C) disinfection is one type of no-touch technology shown to be a successful adjunct to manual cleaning in reducing environmental bioburden. The dilemma for the infection preventionist, however, is how to choose the system best suited for their facility among the many UV-C surface disinfection delivery systems available and how to build a case for acquisition to present to the hospital administration/C-suite. This article proposes an approach to these dilemmas based in part on the experience of 2 health care networks.

Background Clostridioides difficile (CDiff) is a common bacterium in 2-5% in the human gut and can develop into a serious gastrointestinal infection after exposure to antibiotic therapy, an unhealthy diet, extended hospitalization and stay in a long-term care facility. Educating the public and children about preventing CDiff is important and engaging children early on is vital to the future of preventing CDiff. CDiff Foundation Junior Infection Fighter Program was introduced to families and their children in fall 2019. Methods The volunteer program was developed for children and teens ages 7 to 14, with the support of their parents/legal guardian. Two events were held in October and December with 8 children in Pennsylvania and 23 children in Michigan. A survey was given to the 23 students, in the age groups 5 to 13 in the second program. Results Students older than 8 years were knowledgeable and responded correctly 100% of the time in pretest and posttest. On average, all students in the age group 5 and older were correct 100% of time to know that bacterial and virus are germs, drinking plenty of water and exercising is important for good health. Knowledge gaps were predominant in the area of dental hygiene, students did not understand the importance of flossing in the age group of 5 to 7. Only 65% students were correct in their pretest survey on dental hygiene questions, post survey there was a 17% improvement in their understanding. 18% of the students thought that sharing cups does not spread germs, postsurvey there was a 4% improvement in their understanding. Conclusions Multi-faceted patient and family program offered by the C Diff Foundation builds awareness and advocacy for C. diff. infection prevention, treatments, clinical trials, antibiotic-resistance, and environmental safety worldwide. Children are our future and it is important that they are informed about infection prevention.

This chapter, which focuses on the admissibility and evidential worth of character evidence, explains the definition of bad character under the Criminal Justice Act 2003 (CJA). It examines how bad character evidence of the defendant may be admitted through one of the ‘gateways’ under the Act. It reviews the evidential worth of the character evidence if admitted and explains the difference between propensity and credibility. The law on the admissibility of the bad character of non-defendant witnesses is explained and the reasons for a more protective stance highlighted. The chapter concludes with a review of the admissibility of good character evidence, governed by the common law.

This chapter focuses on the competence and compellability of witnesses in criminal and, in outline, in civil trials. It explains the main criminal law exceptions in relation to competence and universal compellability. It gives details on the complex and controversial position under section 80 of the Police and Criminal Evidence Act 1984. The chapter outlines the Special Measures Directions (SMD) available under the Youth Justice and Criminal Evidence Act 1999 for vulnerable non-defendant witnesses in criminal trials and the more limited measures for vulnerable defendants. It concludes with an outline of the Criminal Evidence (Witness Anonymity) Act 2008.

This chapter looks at the rules relating to legal professional privilege and, in outline, the doctrine of the privilege against self-incrimination. Under these provisions potentially relevant evidence may be excluded at trial. The role of legal professional privilege in protecting defendants in criminal trials is outlined and the absolutist stance of the courts discussed. The chapter outlines the various immunities which are embraced under the privilege against self-incrimination.

This chapter focuses on the burden of proof and presumption of innocence in criminal and civil cases under Article 6 of the European Convention on Human Rights (ECHR). It considers the influence of the UK’s Human Rights Act 1998 (HRA) on the allocation of the burden of proof and compares legal/persuasive burden of proof with the evidential burden. It contains a detailed examSination of the case law under this Act and the criteria developed to assess where reverse burdens should apply. It draws on academic commentary in making this analysis. It also looks at situations where the legal and the evidential burden may be split. The leading cases on the standard of proof in civil cases are reviewed.

This chapter first explains exclusion of evidence on the grounds of the public interest immunity (PII) doctrine in relation to the public interest in non-disclosure of documents. The chapter examines areas of public interest that are covered by possible PII claims. These include national security, defence and foreign policy, protection of children, the identity of police informers, and confidential records held by public bodies. The difference between PII and closed material procedures (CMPs) is outlined. The chapter, concentrating on civil cases, lists the landmarks in the evolution of the common law doctrine. It considers the extent which it has been influenced by the Strasbourg jurisprudence. Attention is given to the role of national security matters in the evolution of the law.

This chapter focuses on prosecution evidence that is relevant but improperly obtained and consequently may be excluded by judicial discretion. It looks at the exclusionary discretion contained within s78 of the UK’s Police and Criminal Evidence Act 1984 (PACE) and explains how common law and statutory exclusionary discretion may be exercised in relation to other areas of evidence, such as character evidence and hearsay evidence, as well as confessions. The chapter also looks at the most common areas of exclusion, other than confession evidence, including breach or evasion of legislation such as PACE and the Codes of Practice. Police undercover activity is examined. Consideration is given to when a stay of prosecution might be the appropriate procedure. Finally, it discusses the relevant principles of Art 6 of the European Convention on Human Rights (ECHR) that are enshrined in s78 of PACE.

Cross-contamination from inanimate surfaces can play a significant role in intensive care unit (ICU)-acquired colonization and infection. This study assessed an innovative isopropyl alcohol/organofunctional silane solution (IOS) to reduce microbial contamination on inert surfaces in a medical ICU.Baseline adenosine triphosphate bioluminescence testing (ABT)-measurements (N = 200) were obtained on designated inert ICU surfaces followed by IOS treatment. At 1 and 6 weeks, selective surfaces were randomized to either IOS-treated or nontreated controls for comparison using ABT (N = 400) and RODAC colony counts (N = 400). An ABT value of ≤45 relative light units (RLU) was designated as "clean," whereas45 was assessed as "dirty."Mean RLU baseline values ranged from 870.3 (computer keyboard) to 201.6 (bed table), and 97.5% of surfaces were assessed as "dirty." At 6 weeks, the mean RLU of surfaces treated with IOS ranged from 31.7 (physician workstation) to 51.5 (telephone handpiece), whereas values on comparative control surfaces were 717.3 and 643.7, respectively (P.001). Some 95.5% of RODAC cultures from IOS-treated sites at 6 weeks were negative, whereas 90.5% of nontreated sites were culture-positive, yielding multiple isolates including multidrug-resistant gram-positive and gram-negative bacteria.IOS-treated surfaces recorded significantly lower RLU and RODAC colony counts compared with controls (P.001). A single application of IOS resulted in a persistent antimicrobial activity on inert ICU surfaces over the 6-week study interval.

Efforts to reduce the incidence of hospital-acquired infection (HAI) remain a significant focus for health care facilities, particularly in this era of drug-resistant organisms. With as many as 1 in every 25 hospitalized patients acquiring an infection, the need to minimize the risk of HAIs is widely recognized as critical. Advances in the fields of biomedical technology, microbiology, pharmacology, and infection control and prevention, among others, have played a tremendous role in these efforts. However, evidence suggests that a key element in this battle against HAIs is missing: collaboration and communication between these groups in health care facilities-particularly in microbiology and infection prevention. The need for collaboration between infection preventionists (IPs) and laboratorians has been addressed in the literature; however, a survey conducted by the APIC and the American Society for Microbiology demonstrated that both IPs and laboratorians feel they lack the tools to engage in this collaboration. This article addresses strategies for a working partnership between IPs and laboratorians and reports 3 case studies on successful collaborations at major medical centers.

Staphylococcus aureus has been recognized as a major microbial pathogen for over 100 y, having the capacity to produce a variety of suppurative and toxigenic disease processes. Many of these infections are life-threatening, with particularly enhanced virulence in hospitalized patients with selective risk factors. Strains of methicillin-resistant Staphylococcus aureus (MRSA) have rapidly spread throughout the healthcare environment such that approximately 20% of S. aureus isolates recovered from surgical site infections are methicillin-resistant, (although this is now reducing following national screening and suppression programs and high impact interventions).Widespread nasal screening to identify MRSA colonization in surgical patients prior to admission are controversial, but selective, evidence-based studies have documented a reduction of surgical site infection (SSI) after screening and suppression.Culture methods used to identify MRSA colonization involve selective, differential, or chromogenic media. These methods are the least expensive, but turnaround time is 24-48 h. Although real-time polymerase chain reaction (RT-PCR) technology provides rapid turnaround (1-2 h) with exceptional testing accuracy, the costs can range from three to 10 times more than conventional culture methodology. Topical mupirocin, with or without pre-operative chlorhexidine showers or skin wipes, is the current "gold-standard" for nasal decolonization, but inappropriate use of mupirocin is associated with increasing staphylococcal resistance.Selection of an effective active universal or targeted surveillance strategy should be based upon the relative risk of MSSA or MRSA surgical site infection in patients undergoing orthopedic or cardiothoracic device related surgical procedures.

Background A growing body of research has demonstrated that manual cleaning and disinfection of the operating room (OR) is suboptimal. Residual environmental contamination may pose an infection risk to the surgical wound. This study evaluates the impact of a visible-light continuous environmental disinfection (CED) system on microbial surface contamination and surgical site infections (SSI) in an OR. Methods Samples from 25 surfaces within 2 contiguous ORs sharing an air supply were obtained after manual cleaning on multiple days before and after a visible-light CED system installation in 1 of the ORs. Samples were incubated and enumerated as total colony-forming units. SSIs in both ORs, and a distant OR, were tracked for 1 year prior to and 1 year after the visible-light CED system installation. Results There was an 81% (P = .017) and 49% (P = .015) reduction in total colony-forming units after the visible-light CED system installation in the OR in which the system was installed, and in the contiguous OR, respectively. In the OR with the visible-light CED system, SSIs decreased from 1.4% in the year prior to installation to 0.4% following installation (P = .029). Conclusions A visible-light CED system, used in conjunction with manual cleaning, resulted in significant reductions in both microbial surface contamination and SSIs in the OR.

A surgical site infection (SSI) can occur at several anatomic sites related to a surgical procedure: Superficial or deep incisional or organ/space. The SSIs are the leading cause of health-care-associated infection (HAI) in industrialized Western nations. Patients in whom an SSI develops require longer hospitalization, incur significantly greater treatment costs and reduction in quality of life, and after selective surgical procedures experience higher mortality rates. Effective infection prevention and control requires the concept of the SSI care bundle, which is composed of a defined number of evidence-based interventional strategies, because of the many risk factors that can contribute to the development of an SSI. Intra-operative irrigation has been a mainstay of surgical practice for well over 100 years, but lacks standardization and compelling evidence-based data to validate its efficacy. In an era of antibiotic stewardship, with a widespread prevalence of bacterial resistance to multiple antibiotic agents, there has emerged an interest in using intra-operative antiseptic irrigation to reduce microbial contamination in the surgical site before closure and possibly reduce the need for antibiotic agents. This approach has gained added appeal in an era of biomedical device implantation, especially with the recognition that most, if not all, device-related infections are associated with biofilm formation. This review focuses on the limited, evidence-based rationale for the use of antiseptic agents as an effective risk reduction strategy for prevention of SSIs.

The Concentrate Questions and Answers series offers the best preparation for tackling exam questions and coursework. Each book includes typical questions, bullet-pointed answer plans and suggested answers, author commentary and illustrative diagrams and flow charts. Concentrate Q&A Evidence offers expert advice on what to expect from your Evidence exam, how best to prepare and guidance on what examiners are really looking for. Written by experienced examiners, it provides clear commentary with each question and answer and bullet points and diagram answer plans plus tips to make your answer really stand out from the crowd and further reading suggestions at the end of every chapter. The book should help the reader identify typical law exam questions, structure a first-class answer, avoid common mistakes, show the examiner what the reader knows and find relevant further reading. After an introduction, the book covers burden and standard of proof, presumptions, competence and compellability, Special Measures Directions, character evidence, hearsay, confessions, the defendant’s silence, improperly obtained evidence, supporting evidence, identification expert opinion, issues in the course of trial, privilege, public policy and mixed questions. The final chapter gives guidance on assessed coursework. The book is suitable for undergraduate law students taking optional modules in Evidence.

The Concentrate Questions and Answers series offers the best preparation for tackling exam questions. Each book includes typical questions, bullet-pointed answer plans and suggested answers, author commentary and illustrative diagrams and flow charts. This chapter discusses supporting evidence, which is variously referred to in textbooks as hazardous evidence, supporting evidence or safeguards against unreliability and error. Supporting evidence encompasses types of evidence that might intrinsically be of questionable reliability and, therefore, require supportive evidence. Key areas are disputed identification and lies told by the defendant. It is important to be familiar with the two distinct ways that the reliability of identification evidence is enhanced: first, the judge should issue the Turnbull guidelines; and, secondly, Code D of the Codes of Practice of the Police and Criminal Evidence Act 1984 should be followed in relation to identification procedures.

The Concentrate Questions and Answers series offers the best preparation for tackling exam questions. Each book includes typical questions, bullet-pointed answer plans and suggested answers, author commentary and illustrative diagrams and flow charts. This chapter focuses on the rule against hearsay, which is, historically, one of the great exclusionary rules underlying the law of evidence. In 1997 the Law Commission recommended that hearsay evidence be put on a clearer statutory footing in criminal trials. This eventually led to wholesale reform in the Criminal Justice Act (CJA) 2003, which preserves the rule but increases the number of exceptions and safeguards, providing a comprehensive regime for hearsay. The chapter provides an overview of the changes to hearsay introduced by the CJA 2003.

The Concentrate Questions and Answers series offers the best preparation for tackling exam questions. Each book includes typical questions, bullet-pointed answer plans and suggested answers, author commentary and illustrative diagrams and flow charts. This book is a supplementary aid to coursework preparation and particularly to revision for examinations and coursework. It does not present model answers to be slavishly imitated but, rather, examples to help the student understand the topic and see how it might be approached. The examinee’s objective is to accumulate in the time allowed as many marks as possible, a goal that needs to be broken down into three stages: namely, planning, execution and review. These days law examinations can take different forms, including seen questions, open book exams and so on. To take account of this, the book includes essay answers that are closer to more fully researched pieces than to the answers in a traditional unseen examination.

The Concentrate Questions and Answers series offers the best preparation for tackling exam questions. Each book includes typical questions, bullet-pointed answer plans and suggested answers, author commentary and diagrams and flow charts. This chapter concerns a complex question in criminal evidence: situations where defendants may adduce evidence of good character to suggest lack of guilt and support credibility, and those where prosecution counsel or counsel for the co-defendant may cross-examine them on previous ‘reprehensible’ behaviour. The exclusionary rule was fundamental to the English legal system and founded on the principle that the defendant should have a fair trial. The Criminal Justice Act (CJA) 2003 made comprehensive changes to the rules of admissibility of evidence of bad character of the defendant and witnesses providing that ‘the common law rules governing the admissibility of evidence of bad character in criminal proceedings are abolished’. There is now a presumption of admissibility of that evidence.

The Concentrate Questions and Answers series offers the best preparation for tackling exam questions. Each book includes typical questions, bullet-pointed answer plans and suggested answers, author commentary and diagrams and flow charts. This chapter covers evidence excluded for policy or public interest considerations: public interest immunity (PII). A party, witness or non-participant in proceedings may refuse to disclose information, papers or answer questions, even though such material may be highly relevant and reliable. If PII applies, neither party has access to the evidence. For privilege, the areas most likely to occur in Evidence courses are privilege against self-incrimination and legal professional privilege. The former includes the right to silence of the defendant. The privilege against self-incrimination is generally upheld by common law and by implication by Art. 6 of the European Convention on Human Rights (ECHR). Legal professional privilege is a common law exclusionary rule principle that applies in civil and criminal proceedings.

The Concentrate Questions and Answers series offers the best preparation for tackling exam questions. Each book includes typical questions, bullet-pointed answer plans and suggested answers, author commentary and illustrative diagrams and flow charts. This chapter covers witnesses, who are a principal source of evidence, and the rules relating to their attendance. All witnesses with relevant information are assumed to be competent to give evidence and usually compellable to give evidence, as the court may summon them to attend. Interests of the witness are secondary to the need of the court to have all necessary information. Some witnesses who are competent may claim a privilege not to give evidence, including defendants on their own behalf. Other exceptions comprise spouses or civil partners testifying for the prosecution. This is based on the concept that compulsion may lead to marital discord. The chapter also includes a review of Special Measures Directions for vulnerable witnesses.

The Concentrate Questions and Answers series offers the best preparation for tackling exam questions. Each book includes typical questions, bullet-pointed answer plans and suggested answers, author commentary and diagrams and flow charts. This chapter explores an area of evidence law dominated by expert witness evidence and the extent to which flawed testimony leads to miscarriages of justice. Expert evidence is now commonplace in criminal and civil trials, and the courts and Parliament have developed procedures to ensure that it is of high quality. These are an eclectic mix of common law and statute and their development reflects the importance of scientific expertise. It is necessary to be familiar with the differences between expert and non-expert opinion evidence and on when and in what circumstances both types are admissible and questions that can be asked of the expert whilst giving evidence. The approach depends on whether the question relates to civil or criminal trials

The Concentrate Questions and Answers series offers the best preparation for tackling exam questions. Each book includes typical questions, bullet-pointed answer plans and suggested answers, author commentary and diagrams and flow charts. This chapter describes how examination questions frequently cover several issues. It is impossible to cover each area in the same depth as single-issue questions so it is important to take time listing matters that raise points of law, then specifying the appropriate statute or case law, and finally applying the law to the given facts. A well-crafted question will not contain redundant information, so be prepared to comment on all parts of it. These questions do not ask for an evaluation or criticism of the law as it is, but for identification of legal issues in the narrative given and application of the law to each. It may be appropriate to refer to academic commentary, particularly in new areas of law.

The Concentrate Questions and Answers series offers the best preparation for tackling exam questions. Each book includes typical questions, bullet-pointed answer plans and suggested answers, author commentary and diagrams and flow charts. This chapter covers three areas: confessions, silence of the accused and judicial discretion to exclude improperly obtained prosecution evidence. It explains how the most persuasive, sometimes only, evidence available to the prosecution is a pre-trial confession. While confessions have long been accepted as evidence of guilt, they have also posed risks of unreliability and violation of individual autonomy. Defendants may not be making a true confession or may have been obtained as a result of pressure. Permissible inferences from a pre-trial failure to respond to questions has the crucial difference that such failure alone cannot found a conviction. English law has previously been unwilling to acknowledge the case for excluding evidence which involves the police acting improperly or even illegally.

The Concentrate Questions and Answers series offers the best preparation for tackling exam questions. Each book includes typical questions, bullet-pointed answer plans and suggested answers, author commentary and illustrative diagrams and flow charts. This chapter discusses the allocation of the burden of proof in civil and criminal trials, depending on who should bear the risk. In criminal trials the ‘presumption of innocence’ means that the burden is on the prosecution, unless reversed by express or implied statutory provision. The law of evidence safeguards what in some jurisdictions is a civil right backed by the constitution. It is important to understand the difference between the legal and evidential burden and the occasions where they are separately allocated. Tricky areas are where there is a divorce of the legal and evidential burden, primarily in situations where the prosecution cannot expect to put up evidence to anticipate every specific defence the accused may present.

The current practice of perioperative hair removal reflects research-driven changes designed to minimize the risk of surgical wound infection. An aspect of the practice which has received less scrutiny is the clean-up of the clipped hair. This process is critical. The loose fibers represent a potential infection risk because of the micro-organisms they can carry, but their clean-up can pose a logistical problem because of the time required to remove them. Research has demonstrated that the most commonly employed means of clean-up, the use of adhesive tape or sticky mitts, can be both ineffective and time-consuming in addition to posing an infection risk from cross-contamination. Recently published research evaluating surgical clippers fitted with a vacuum-assisted hair collection device highlights the potential for significant practice improvement in the perioperative hair removal clean-up process. These improvements include not only further mitigation of potential infection risk but also substantial OR time and cost savings.

Efforts to reduce health care–associated infections (HAIs) have grown in both scale and sophistication over the past few decades; however, the increasing threat of antimicrobial resistance and the impact of new legislation regarding HAIs on health care economics make the fight against them all the more urgent. On-demand polymerase chain reaction (PCR) technology has proven to be a highly effective weapon in this fight, offering the ability to accurately and efficiently identify disease-causing pathogens such that targeted and directed therapy can be initiated at the point of care. As a result, on-demand PCR technology has far-reaching influences on HAI rates, health care outcomes, hospital length of stay, isolation days, patient satisfaction, antibiotic stewardship, and health care economics. The basics of on-demand PCR technology and its potential to impact health care have not been widely incorporated into health care education and enrichment programs for many of those involved in infection control and prevention, however. This article serves as a primer on on-demand PCR technology and its ramifications.

any health care facilities have incorporated an antiseptic skin cleansing protocol, often referred to as preoperative bathing and cleansing, to reduce the endogenous microbial burden on the skin of patients undergoing elective surgery, with the aim of reducing the risk of surgical site infections (SSIs). According to a recent study by Injean et al, 91% of all facilities that perform coronary artery bypass surgery in California have a standardized preoperative bathing and cleansing protocol for patients. Historically, this practice has been endorsed by national and international organizations, such as the Hospital Infection Control Practice Advisory Committee and the Centers for Disease Control and Prevention, the Association for Professionals in Infection Control and Epidemiology (APIC), AORN, the Institute for Healthcare Improvement (IHI), and the National Institute for Health and Care Excellence (NICE), which recommend bathing and/or cleansing with an antiseptic agent before surgery as a component of a broader strategy to reduce SSIs. The 2008 Society for Healthcare Epidemiology of America (SHEA)/ Infectious Diseases Society of America (IDSA)/Surgical Infection Society (SIS) strategies to prevent SSIs in acute care hospitals declined to recommend a specific application policy regarding selection of an antiseptic agent for preoperative bathing but acknowledged that the (maximal) antiseptic benefits of chlorhexidine gluconate (CHG) are dependent on achieving adequate skin surface concentrations.

Drawing predominantly on Cabinet and departmental papers in the National Archives, the article reviews ministers’ and civil servants’ changing perceptions of the objectives of higher education in the decades between the Macmillan and Thatcher administrations. It gives an overview of two major reports, the 1963 Robbins Report on Higher Education and the 1971 Ormrod Report on Legal Education and suggests that some unresolved dichotomies are contained within their predominantly humanistic philosophy. It concludes with an examination of the launch of the Thatcher administration's embrace of an overtly market-based ideology in the early 1980s. A key document is a report prepared in 1983 for Prime Minister Thatcher by the Cabinet Office's Think Tank, the Central Policy Review Staff (CPRS). The Report on Higher Education is in a series of files titled ‘Responsiveness of Higher Education to Market Forces and Employment Needs'. The commissioning of the Report, newly released under the thirty year rule, sug...

Each Concentrate revision guide is packed with essential information, key cases, revision tips, exam Q&As, and more. Concentrates show you what to expect in a law exam, what examiners are looking for, and how to achieve extra marks. Evidence Concentrate is supported by extensive online resources to take your learning further. It has been written by experts and covers all the key topics so you can approach your exams with confidence. The clear, succinct coverage enables you to quickly grasp the fundamental principles of this area of law and helps you to succeed in exams. This guide has been rigorously reviewed and is endorsed by students and lecturers for level of coverage, accuracy, and exam advice. It is clear, concise, and easy to use, helping you get the most out of your revision. After an introduction, the book covers principles and key concepts; burden of proof and presumptions; confessions and the defendant’s silence; improperly obtained evidence, other than confessions; character evidence; hearsay evidence; competence and compellability, special measures; issues in the course of trial; opinion evidence; public interest immunity and disclosure; and privilege. New to this, the fifth edition, is an increased number of Diagrams and Tables to aid learning and to explain the key concepts of each chapter, see for example the Tables on judicial directions on good character in Chapter 5.

This chapter looks at the rules relating to legal professional privilege and, in outline, the doctrine of the privilege against self-incrimination. Under these provisions potentially relevant evidence may be excluded at trial. The role of legal professional privilege in protecting defendants in criminal trials is outlined and the absolutist stance of the courts discussed. The chapter outlines the various immunities which are embraced under the privilege against self-incrimination. The differences between public interest immunity and legal professional privilege are outlined. The chapter contains a number of Figures and Tables to help students understand this complex area. The reason for the limited range of privileges in English Evidence law is explained.

Pathogens are inherently present in thesurgical setting, and several significant health careeassociated pathogens can be transferred from pa-tient to patient, from health care worker to patientor vice versa, and from surfaces to patients orhealth care workers and cause surgical site in-fections (SSIs). These pathogens (eg, methicillin-resistant Staphylococcus aureus [MRSA], S aureus,vancomycin-resistant enterococci, Acinetobacterspecies) may survive on environmental surfaces forweeks or months.

In a recent study, the influential theorist of higher education Ronald Barnett suggests that one way for academics to address the pressures on their professional lives is to embrace a multidimensional concept of working time. Drawing on the analysis of space by the French philosopher/sociologist Henri Lefebvre, Barnett advocates conceiving academic practice as a continuum of interrelated strands rather than a set of discrete packages of activity subject to bureaucratic domination. This paper examines whether this approach can reassert agency on the part of academics and provide a site for resistance to the obsession on the part of managers and policy makers with outputs and the quantification of working hours. It sets Barnett's analysis in the context of other empirical studies in higher education literature on the management and allocation of workloads, particularly on tensions arising from conflicting demands of research and teaching. It also examines synergies between Barnett and other scholarship on the professional lives of law academics on the part of Bradney, Collier and Cownie. The paper concludes that a Lefebvrean analysis of how time and space are constituted by human activity provides a rigorous theoretical framework within which to reconstitute the coherence in academic practice which is sought by many in higher education.

The Concentrate Questions and Answers series offers the best preparation for tackling exam questions. Each book includes typical questions, bullet-pointed answer plans and suggested answers, author commentary and illustrative diagrams and flow charts. This chapter focuses on the rule against hearsay, which is, historically, one of the great exclusionary rules underlying the law of evidence. In 1997 the Law Commission recommended that hearsay evidence be put on a clearer statutory footing in criminal trials. This eventually led to wholesale reform in the Criminal Justice Act (CJA) 2003, which preserves the rule but increases the number of exceptions and safeguards, providing a comprehensive regime for hearsay. The chapter provides an overview of the changes to hearsay introduced by the CJA 2003.