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INTRODUCTION: Efforts to improve teamwork in health care have received considerable attention. The current systematic review was conducted to identify recent studies that implemented practices to improve teamwork and were associated with positive improvements on the job. METHODS: Electronic searches of 2 databases (i.e., CINAHL and MEDLINE) were conducted to identify relevant articles published between 2008 and 2018. RESULTS: Twenty articles were selected for inclusion in this review. The studies most often used quasiexperimental designs and interventions were applied in a variety of hospital settings including labor and delivery, operating rooms, and emergency departments. Across studies, measures assessing teamwork skills on the job were most often collected and showed sustained improvements up to 12 months. Moreover, evidence of improved clinical processes (e.g., compliance with guidelines and efficiency) and increased patient safety (e.g., reduction in adverse events) was found in both studies of team training interventions, as well as in those that introduced performance support tools (e.g., checklist). CONCLUSIONS: The results of the current review are consistent with previous research and add to the evidence base on the practices to improve teamwork within hospital settings. Although efforts to improve teamwork have spread to other health care settings such as office-based care, published studies are lagging behind.

Introduction The aim of this systematic review was to determine the impact of automated patient monitoring systems (PMSs) on sepsis recognition and outcomes. Methods Systematic searches were conducted using CINAHL, MEDLINE, and Cochrane, for articles published from 2008 through 2018. English-language, peer-reviewed articles that reported the impact of PMS on sepsis care were included. For selected articles, the authors abstracted information, with the study designed to be compliant with Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Results Nineteen articles were identified for inclusion: 4 systematic reviews and 15 individual studies. Study design and quality varied, with some randomized controlled trials and quasiexperimental studies, as well as many observational studies. Study results for outcome measures (e.g., mortality, intensive care unit [ICU] length of stay, ICU transfer) were mixed, with more than half of the studies showing a significant improvement in at least one measure. Evidence for process measure (e.g., time to antibiotic administration, lactate measurement, etc.) improvement was of moderate strength across multiple types of hospital units, and evidence was most consistent outside the ICU. Conclusions Automated sepsis PMSs have the potential to improve sepsis recognition and outcomes, but current evidence is mixed on their effectiveness. More high-quality studies are needed to understand the effects of PMSs on important sepsis-related process and outcome measures in different hospital units.

OBJECTIVE: The aim of this systematic review was to examine the most effective and feasible methods for environmental cleaning and decontamination to prevent Clostridioides difficile infection (CDI) in health care settings. METHODS: A systematic search of the databases CINAHL and MEDLINE was conducted from 2008 to 2018 for English language articles with search terms including "Clostridium difficile," and related medical subject headings, in combination with terms like "disinfection," "decontamination," and "no-touch decontamination." RESULTS: Twelve studies and 2 systematic reviews were selected for inclusion in this review. The studies were primarily in hospitals (10/12) and used a before-after approach. The studied interventions included cleaning and decontamination with a chlorine-based agent (i.e., bleach; 2 studies), standard cleaning plus the use of hydrogen peroxide decontamination (3 studies), and standard bleach cleaning plus the use of ultraviolet light decontamination (6 studies), and there was 1 study about launderable bed covers. The interventions ranged in frequency, duration, and the area selected for cleaning and decontamination (e.g., all patient rooms versus only CDI patients' rooms). Studies showed significant reductions in CDI associated with use of bleach (versus quaternary ammonium compound) and hydrogen peroxide decontamination after standard bleach cleaning (versus bleach cleaning alone). Four of 6 studies found significant reductions in CDI after the implementation of ultraviolet light decontamination after standard bleach cleaning. CONCLUSIONS: The studied practices for environmental cleaning and decontamination were associated with significant decreases in facility-level CDI rates in most of the reviewed studies; however, study quality was low. Implementation challenges are worthy of further examination.

Objective The aim of the study was to summarize the latest evidence for patient bathing with a 2% to 4% chlorhexidine gluconate solution to reduce multidrug-resistant organism (MDRO) transmission and infection. Methods We searched 3 databases (CINAHL, MEDLINE, and Cochrane) for a combination of the key words "chlorhexidine bathing" and MeSH terms "cross-infection prevention," "drug resistance, multiple, bacterial," and "drug resistance, microbial." Articles from January 1, 2008, to December 31, 2018, were included, as well as any key articles published after December 31. Results Our findings focused on health care-associated infections (HAIs) and 3 categories of MDROs: methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), and carbapenem-resistant Enterobacteriaceae (CRE). Chlorhexidine bathing reduces MRSA acquisition and carriage, but not all studies found significant reductions in MRSA infections. Several studies found that chlorhexidine bathing reduced VRE acquisition and carriage, and one study showed lower VRE infections in the bathing group. Two studies found that bathing reduced CRE carriage (no studies examined CRE infections). Two very large studies (more than 140,000 total patients) found bathing significantly reduced HAIs, but these reductions may be smaller when HAIs are already well controlled by other means. Conclusions There is a high level of evidence supporting chlorhexidine bathing to reduce MDRO acquisition; less evidence is available on reducing infections. Chlorhexidine bathing is low cost to implement, and adverse events are rare and resolve when chlorhexidine use is stopped. There is evidence of chlorhexidine resistance, but not at concentrations in typical use. Further research is needed on chlorhexidine bathing's impact on outcomes, such as mortality and length of stay.

The Socio-Technical Probabilistic Risk Assessment, a proactive risk assessment tool imported from high-risk industries, was used to identify risks for surgical site infections (SSIs) associated with the ambulatory surgery center setting and to guide improvement efforts. This study had 2 primary objectives: (1) to identify the critical risk factors associated with SSIs resulting from procedures performed at ambulatory surgery centers and (2) to design an intervention to mitigate the probability of SSI for the highest risk factors identified. Inputs included quantitative and qualitative data sources from the evidence-based literature and from health care providers. The Socio-Technical Probabilistic Risk Assessment ranked the failure points (events) on the basis of their contribution to an SSI. The event, entitled “Failure to protect the patient effectively,” which included several failure points, was the most critical unique event with the highest contribution to SSI risk. A total of 51.87% of SSIs in this setting were caused by this failure. Consequently, we proposed an intervention aimed at all 5 major components of this failure. The intervention targets improvements in skin preparation; proper administration of antibiotics; staff training in infection control principles, including practices for the prevention of glove punctures; and procedures to ensure the removal of watches, jewelry, and artificial nails.

Background.Antibiograms have effectively improved antibiotic prescribing in acute-care settings; however, their effectiveness in skilled nursing facilities (SNFs) is currently unknown.Objective.To develop SNF-specific antibiograms and identify opportunities to improve antibiotic prescribing.Design and Setting.Cross-sectional and pretest-posttest study among residents of 3 Maryland SNFs.Methods.Antibiograms were created using clinical culture data from a 6-month period in each SNF. We also used admission clinical culture data from the acute care facility primarily associated with each SNF for transferred residents. We manually collected all data from medical charts, and antibiograms were created using WHONET software. We then used a pretest-posttest study to evaluate the effectiveness of an antibiogram on changing antibiotic prescribing practices in a single SNF. Appropriate empirical antibiotic therapy was defined as an empirical antibiotic choice that sufficiently covered the infecting organism, considering antibiotic susceptibilities.Results.We reviewed 839 patient charts from SNF and acute care facilities. During the initial assessment period, 85% of initial antibiotic use in the SNFs was empirical, and thus only 15% of initial antibiotics were based on culture results. Fluoroquinolones were the most frequently used empirical antibiotics, accounting for 54.5% of initial prescribing instances. Among patients with available culture data, only 35% of empirical antibiotic prescribing was determined to be appropriate. In the single SNF in which we evaluated antibiogram effectiveness, prevalence of appropriate antibiotic prescribing increased from 32% to 45% after antibiogram implementation; however, this was not statistically significant (P = .32).Conclusions.Implementation of antibiograms may be effective in improving empirical antibiotic prescribing in SNFs.

Study objective Duration of a stay in an emergency department (ED) is considered a measure of quality, but current measures average lengths of stay across all conditions. Previous research on ED length of stay has been limited to a single condition or a few hospitals. We use a census of one state's data to measure length of ED stays by patients' conditions and dispositions and explore differences between means and medians as quality metrics. Methods The data source was the Healthcare Cost and Utilization Project 2011 State Emergency Department Databases and State Inpatient Databases for Florida. Florida is unique in collecting ED length of stay for both released and admitted patients. Clinical Classifications Software was used to group visits based on first-listed International Classification of Disease, Ninth Edition, Clinical Modification , diagnoses. Results For the 10 most common diagnoses, patients with relatively minor injuries typically required the shortest mean stay (3 hours or less); conditions resulting in admission or transfer tended to be more serious, resulting in longer stays. Patients requiring the longest stays, by disposition, had discharge diagnoses of nonspecific chest pain (mean 7.4 hours among discharged patients), urinary tract infections (4.8 hours among admissions), and schizophrenia (9.6 hours among transfers) among the top 10 diagnoses. Conclusion Emergency department length of stay as a measure of ED quality should take into account the considerable variation by condition and disposition of the patient. Emergency department length of stay measurement could be improved in the United States by standardizing its definition; distinguishing visits involving treatment, observation, and boarding; and incorporating more distributional information.