Journal Article > ResearchFull Text
Journal of the American Medical Association (JAMA). 2 August 2019; Volume 2 (Issue 8); DOI:10.1001/jamanetworkopen.2019.9118
Lenglet AD, van Deursen B, Viana R, Abubakar N, Hoare S, et al.
Journal of the American Medical Association (JAMA). 2 August 2019; Volume 2 (Issue 8); DOI:10.1001/jamanetworkopen.2019.9118
IMPORTANCE
Hand hygiene adherence monitoring and feedback can reduce health care-acquired infections in hospitals. Few low-cost hand hygiene adherence monitoring tools exist in low-resource settings.
OBJECTIVE
To pilot an open-source application for mobile devices and an interactive analytical dashboard for the collection and visualization of health care workers' hand hygiene adherence data.
DESIGN, SETTING, AND PARTICIPANTS
This prospective multicenter quality improvement study evaluated preintervention and postintervention adherence with the 5 Moments for Hand Hygiene, as suggested by the World Health Organization, among health care workers from April 23 to May 25, 2018. A novel data collection form, the Hand Hygiene Observation Tool, was developed in open-source software and used to measure adherence with hand hygiene guidelines among health care workers in the inpatient therapeutic feeding center and pediatric ward of Anka General Hospital, Anka, Nigeria, and the postoperative ward of Noma Children's Hospital, Sokoto, Nigeria. Qualitative data were analyzed throughout data collection and used for immediate feedback to staff. A more formal analysis of the data was conducted during October 2018.
EXPOSURES
Multimodal hand hygiene improvement strategy with increased availability and accessibility of alcohol-based hand sanitizer, staff training and education, and evaluation and feedback in near real-time.
MAIN OUTCOMES AND MEASURES
Hand hygiene adherence before and after the intervention in 3 hospital wards, stratified by health care worker role, ward, and moment of hand hygiene.
RESULTS
A total of 686 preintervention adherence observations and 673 postintervention adherence observations were conducted. After the intervention, overall hand hygiene adherence increased from 32.4% to 57.4%. Adherence increased in both wards in Anka General Hospital (inpatient therapeutic feeding center, 24.3% [54 of 222 moments] to 63.7% [163 of 256 moments]; P < .001; pediatric ward, 50.9% [132 of 259 moments] to 68.8% [135 of 196 moments]; P < .001). Adherence among nurses in Anka General Hospital also increased in both wards (inpatient therapeutic feeding center, 17.7% [28 of 158 moments] to 71.2% [79 of 111 moments]; P < .001; pediatric ward, 45.9% [68 of 148 moments] to 68.4% [78 of 114 moments]; P < .001). In Noma Children's Hospital, the overall adherence increased from 17.6% (36 of 205 moments) to 39.8% (88 of 221 moments) (P < .001). Adherence among nurses in Noma Children's Hospital increased from 11.5% (14 of 122 moments) to 61.4% (78 of 126 moments) (P < .001). Adherence among Noma Children's Hospital physicians decreased from 34.2% (13 of 38 moments) to 8.6% (7 of 81 moments). Lowest overall adherence after the intervention occurred before patient contact (53.1% [85 of 160 moments]), before aseptic procedure (58.3% [21 of 36 moments]), and after touching a patient's surroundings (47.1% [124 of 263 moments]).
CONCLUSIONS AND RELEVANCE
This study suggests that tools for the collection and rapid visualization of hand hygiene adherence data are feasible in low-resource settings. The novel tool used in this study may contribute to comprehensive infection prevention and control strategies and strengthening of hand hygiene behavior among all health care workers in health care facilities in humanitarian and low-resource settings.
Hand hygiene adherence monitoring and feedback can reduce health care-acquired infections in hospitals. Few low-cost hand hygiene adherence monitoring tools exist in low-resource settings.
OBJECTIVE
To pilot an open-source application for mobile devices and an interactive analytical dashboard for the collection and visualization of health care workers' hand hygiene adherence data.
DESIGN, SETTING, AND PARTICIPANTS
This prospective multicenter quality improvement study evaluated preintervention and postintervention adherence with the 5 Moments for Hand Hygiene, as suggested by the World Health Organization, among health care workers from April 23 to May 25, 2018. A novel data collection form, the Hand Hygiene Observation Tool, was developed in open-source software and used to measure adherence with hand hygiene guidelines among health care workers in the inpatient therapeutic feeding center and pediatric ward of Anka General Hospital, Anka, Nigeria, and the postoperative ward of Noma Children's Hospital, Sokoto, Nigeria. Qualitative data were analyzed throughout data collection and used for immediate feedback to staff. A more formal analysis of the data was conducted during October 2018.
EXPOSURES
Multimodal hand hygiene improvement strategy with increased availability and accessibility of alcohol-based hand sanitizer, staff training and education, and evaluation and feedback in near real-time.
MAIN OUTCOMES AND MEASURES
Hand hygiene adherence before and after the intervention in 3 hospital wards, stratified by health care worker role, ward, and moment of hand hygiene.
RESULTS
A total of 686 preintervention adherence observations and 673 postintervention adherence observations were conducted. After the intervention, overall hand hygiene adherence increased from 32.4% to 57.4%. Adherence increased in both wards in Anka General Hospital (inpatient therapeutic feeding center, 24.3% [54 of 222 moments] to 63.7% [163 of 256 moments]; P < .001; pediatric ward, 50.9% [132 of 259 moments] to 68.8% [135 of 196 moments]; P < .001). Adherence among nurses in Anka General Hospital also increased in both wards (inpatient therapeutic feeding center, 17.7% [28 of 158 moments] to 71.2% [79 of 111 moments]; P < .001; pediatric ward, 45.9% [68 of 148 moments] to 68.4% [78 of 114 moments]; P < .001). In Noma Children's Hospital, the overall adherence increased from 17.6% (36 of 205 moments) to 39.8% (88 of 221 moments) (P < .001). Adherence among nurses in Noma Children's Hospital increased from 11.5% (14 of 122 moments) to 61.4% (78 of 126 moments) (P < .001). Adherence among Noma Children's Hospital physicians decreased from 34.2% (13 of 38 moments) to 8.6% (7 of 81 moments). Lowest overall adherence after the intervention occurred before patient contact (53.1% [85 of 160 moments]), before aseptic procedure (58.3% [21 of 36 moments]), and after touching a patient's surroundings (47.1% [124 of 263 moments]).
CONCLUSIONS AND RELEVANCE
This study suggests that tools for the collection and rapid visualization of hand hygiene adherence data are feasible in low-resource settings. The novel tool used in this study may contribute to comprehensive infection prevention and control strategies and strengthening of hand hygiene behavior among all health care workers in health care facilities in humanitarian and low-resource settings.
Journal Article > ResearchFull Text
Infect Control Hosp Epidemiol. 30 August 2018; Volume 39; DOI:10.1017/ice.2018.213
Chaintarli K, Lenglet AD, Beauzile BD, Senat-Delva R, Mabou MM, et al.
Infect Control Hosp Epidemiol. 30 August 2018; Volume 39; DOI:10.1017/ice.2018.213
Patient colonization with extended-spectrum β-lactamase–producing gram-negative bacteria (ESBL-GNB) could serve as a
potential reservoir for transmission of multidrug-resistant (MDR)
bacteria in a hospital setting. Individuals colonized with ESBLEnterobacteriaceae are also known to be at a higher risk of ESBLGNB infection following their colonization.1 We encountered an
outbreak of MDR Klebsiella pneumoniae in the neonatal care unit
(NCU) of the Médecins Sans Frontiéres (MSF) obstetric emergency hospital in Port au Prince (CRUO), Haiti, between 2014
and 2015.2 As part of ongoing surveillance activities for MDR
bacteria and in an effort to better target infection, prevention,
and control (IPC) measures throughout the hospital, we conducted a point-prevalence survey to estimate the prevalence of
colonization with ESBL-GNB and to identify risk factors for
colonization with ESBL-GNB in women and neonates admitted
to this hospital.
potential reservoir for transmission of multidrug-resistant (MDR)
bacteria in a hospital setting. Individuals colonized with ESBLEnterobacteriaceae are also known to be at a higher risk of ESBLGNB infection following their colonization.1 We encountered an
outbreak of MDR Klebsiella pneumoniae in the neonatal care unit
(NCU) of the Médecins Sans Frontiéres (MSF) obstetric emergency hospital in Port au Prince (CRUO), Haiti, between 2014
and 2015.2 As part of ongoing surveillance activities for MDR
bacteria and in an effort to better target infection, prevention,
and control (IPC) measures throughout the hospital, we conducted a point-prevalence survey to estimate the prevalence of
colonization with ESBL-GNB and to identify risk factors for
colonization with ESBL-GNB in women and neonates admitted
to this hospital.
Journal Article > CommentaryFull Text
PLoS Negl Trop Dis. 25 July 2019 (Issue 7)
Azman AS, Ciglenecki I, Wamala JF, Lynch JA, Aggarwal R, et al.
PLoS Negl Trop Dis. 25 July 2019 (Issue 7)
Journal Article > CommentaryFull Text
PLOS Med. 6 September 2016; Volume 13 (Issue 9); e1002111.; DOI:10.1371/journal.pmed.1002111
Sheather J, Jobanputra K, Schopper D, Pringle J, Venis S, et al.
PLOS Med. 6 September 2016; Volume 13 (Issue 9); e1002111.; DOI:10.1371/journal.pmed.1002111
SUMMARY POINTS
• Humanitarian organisations often have to innovate to deliver health care and aid to populations in complex and volatile contexts.
• Innovation projects can involve ethical risks and have consequences for populations even if human participants are not directly involved. While high-level principles have been developed for humanitarian innovation, there is a lack of guidance for how these should be applied in practice.
• Médecins sans Frontières (MSF) has well-established research ethics frameworks, but application of such frameworks to innovation projects could stifle innovation by introducing regulation disproportionate to the risks involved. In addition, the dynamic processes of innovation do not fit within conventional ethics frameworks.
• MSF developed and is piloting an ethics framework for humanitarian innovation that is intended for self-guided use by innovators or project owners to enable them to identify and weigh the harms and benefits of such work and be attentive towards a plurality of ethical considerations.
• Humanitarian organisations often have to innovate to deliver health care and aid to populations in complex and volatile contexts.
• Innovation projects can involve ethical risks and have consequences for populations even if human participants are not directly involved. While high-level principles have been developed for humanitarian innovation, there is a lack of guidance for how these should be applied in practice.
• Médecins sans Frontières (MSF) has well-established research ethics frameworks, but application of such frameworks to innovation projects could stifle innovation by introducing regulation disproportionate to the risks involved. In addition, the dynamic processes of innovation do not fit within conventional ethics frameworks.
• MSF developed and is piloting an ethics framework for humanitarian innovation that is intended for self-guided use by innovators or project owners to enable them to identify and weigh the harms and benefits of such work and be attentive towards a plurality of ethical considerations.
Journal Article > ResearchFull Text
Crit Care. 3 May 2017; Volume 21 (Issue 1); 103.; DOI:10.1186/s13054-017-1679-0
Obonyo N, Brent B, Olupot-Olupot P, Boele van Hensbroek M, Kuipers I, et al.
Crit Care. 3 May 2017; Volume 21 (Issue 1); 103.; DOI:10.1186/s13054-017-1679-0
BACKGROUND
Fluid therapy in severely malnourished children is hypothesized to be deleterious owing to compromised cardiac function. We evaluated World Health Organization (WHO) fluid resuscitation guidelines for hypovolaemic shock using myocardial and haemodynamic function and safety endpoints.
METHODS
A prospective observational study of two sequential fluid management strategies was conducted at two East African hospitals. Eligible participants were severely malnourished children, aged 6-60 months, with hypovolaemic shock secondary to gastroenteritis. Group 1 received up to two boluses of 15 ml/kg/h of Ringer's lactate (RL) prior to rehydration as per WHO guidelines. Group 2 received rehydration only (10 ml/kg/h of RL) up to a maximum of 5 h. Comprehensive clinical, haemodynamic and echocardiographic data were collected from admission to day 28.
RESULTS
Twenty children were enrolled (11 in group 1 and 9 in group 2), including 15 children (75%) with kwashiorkor, 8 (40%) with elevated brain natriuretic peptide >300 pg/ml, and 9 (45%) with markedly elevated median systemic vascular resistance index (SVRI) >1600 dscm-5/m2 indicative of severe hypovolaemia. Echocardiographic evidence of fluid-responsiveness (FR) was heterogeneous in group 1, with both increased and decreased stroke volume and myocardial fractional shortening. In group 2, these variables were more homogenous and typical of FR. Median SVRI marginally decreased post fluid administration (both groups) but remained high at 24 h. Mortality at 48 h and to day 28, respectively, was 36% (4 deaths) and 81.8% (9 deaths) in group 1 and 44% (4 deaths) and 55.6% (5 deaths) in group 2. We observed no pulmonary oedema or congestive cardiac failure on or during admission; most deaths were unrelated to fluid interventions or echocardiographic findings of response to fluids.
CONCLUSION
Baseline and cardiac response to fluid resuscitation do not indicate an effect of compromised cardiac function on response to fluid loading or that fluid overload is common in severely malnourished children with hypovolaemic shock. Endocrine response to shock and persistently high SVRI post fluid-therapy resuscitation may indicate a need for further research investigating enhanced fluid volumes to adequately correct volume deficit. The adverse outcomes are concerning, but appear to be unrelated to immediate fluid management.
Fluid therapy in severely malnourished children is hypothesized to be deleterious owing to compromised cardiac function. We evaluated World Health Organization (WHO) fluid resuscitation guidelines for hypovolaemic shock using myocardial and haemodynamic function and safety endpoints.
METHODS
A prospective observational study of two sequential fluid management strategies was conducted at two East African hospitals. Eligible participants were severely malnourished children, aged 6-60 months, with hypovolaemic shock secondary to gastroenteritis. Group 1 received up to two boluses of 15 ml/kg/h of Ringer's lactate (RL) prior to rehydration as per WHO guidelines. Group 2 received rehydration only (10 ml/kg/h of RL) up to a maximum of 5 h. Comprehensive clinical, haemodynamic and echocardiographic data were collected from admission to day 28.
RESULTS
Twenty children were enrolled (11 in group 1 and 9 in group 2), including 15 children (75%) with kwashiorkor, 8 (40%) with elevated brain natriuretic peptide >300 pg/ml, and 9 (45%) with markedly elevated median systemic vascular resistance index (SVRI) >1600 dscm-5/m2 indicative of severe hypovolaemia. Echocardiographic evidence of fluid-responsiveness (FR) was heterogeneous in group 1, with both increased and decreased stroke volume and myocardial fractional shortening. In group 2, these variables were more homogenous and typical of FR. Median SVRI marginally decreased post fluid administration (both groups) but remained high at 24 h. Mortality at 48 h and to day 28, respectively, was 36% (4 deaths) and 81.8% (9 deaths) in group 1 and 44% (4 deaths) and 55.6% (5 deaths) in group 2. We observed no pulmonary oedema or congestive cardiac failure on or during admission; most deaths were unrelated to fluid interventions or echocardiographic findings of response to fluids.
CONCLUSION
Baseline and cardiac response to fluid resuscitation do not indicate an effect of compromised cardiac function on response to fluid loading or that fluid overload is common in severely malnourished children with hypovolaemic shock. Endocrine response to shock and persistently high SVRI post fluid-therapy resuscitation may indicate a need for further research investigating enhanced fluid volumes to adequately correct volume deficit. The adverse outcomes are concerning, but appear to be unrelated to immediate fluid management.
Journal Article > ResearchFull Text
Scand J Trauma Resusc Emerg Med. 27 June 2018; Volume 26 (Issue 1); DOI:10.1186/s13049-018-0517-y
Älgå ABK, Karlow Herzog K, Alrawashdeh M, Wong S, Khankeh H, et al.
Scand J Trauma Resusc Emerg Med. 27 June 2018; Volume 26 (Issue 1); DOI:10.1186/s13049-018-0517-y
Globally, armed conflict is a major contributor to mortality and morbidity. The treatment of war-associated injuries is largely experience-based. Evidence is weak due to difficulty in conducting medical research in war settings. A qualitative method could provide insight into the specific challenges associated with providing health care to injured civilians. The aim of this study was to explore the challenges hospital-based physicians encounter in war wound management, focusing on surgical intervention and antibiotic use.
Journal Article > ResearchFull Text
J Int AIDS Soc. 21 July 2017; Volume 20 (Issue Suppl 4); 21654.; DOI:10.7448/IAS.20.5.21654
Ssonko C, Gonzalez L, Mesic A, da Fonseca M, Achar J, et al.
J Int AIDS Soc. 21 July 2017; Volume 20 (Issue Suppl 4); 21654.; DOI:10.7448/IAS.20.5.21654
INTRODUCTION
Countries in the West and Central African regions struggle to offer quality HIV care at scale, despite HIV prevalence being relatively low. In these challenging operating environments, basic health care needs are multiple, systems are highly fragile and conflict disrupts health care. Médecins Sans Frontières (MSF) has been working to integrate HIV care in basic health services in such settings since 2000. We review the implementation of differentiated HIV care and treatment approaches in MSF-supported programmes in South Sudan (RoSS), Central African Republic (CAR) and Democratic Republic of Congo (DRC).
METHODS
A descriptive analysis from CAR, DRC and RoSS programmes reviewing methodology and strategies of HIV care integration between 2010 and 2015 was performed. We describe HIV care models integrated within the provision of general health care and highlight best practices and challenges.
RESULTS
Services included provision of general health care, with out-patient care (range between countries 43,343 and 287,163 consultations/year in 2015) and in-patient care (range 1076–16,595 in 2015). By the end of 2015 antiretroviral therapy (ART) initiations reached 12–255 patients/year. A total of 1101 and 1053 patients were on ART in CAR and DRC, respectively. In RoSS 186 patients were on ART when conflict recommenced late in 2013. While ART initiation and monitoring were mostly clinically driven in the early phase of the programmes, DRC implemented CD4 monitoring and progressively HIV viral load (VL) monitoring during study period. Attacks to health care facilities in CAR and RoSS disrupted service provision temporarily. Programmatic challenges include: competing health priorities influencing HIV care and need to integrate within general health services. Differentiated care approaches that support continuity of care in these programmes include simplification of medical protocols, multi-month ART prescriptions, and community strategies such as ART delivery groups, contingency plans and peer support activities.
CONCLUSIONS
The principles of differentiated HIV care for high-quality ART delivery can successfully be applied in challenging operating environments. However, success heavily depends on specific adaptations to each setting.
Countries in the West and Central African regions struggle to offer quality HIV care at scale, despite HIV prevalence being relatively low. In these challenging operating environments, basic health care needs are multiple, systems are highly fragile and conflict disrupts health care. Médecins Sans Frontières (MSF) has been working to integrate HIV care in basic health services in such settings since 2000. We review the implementation of differentiated HIV care and treatment approaches in MSF-supported programmes in South Sudan (RoSS), Central African Republic (CAR) and Democratic Republic of Congo (DRC).
METHODS
A descriptive analysis from CAR, DRC and RoSS programmes reviewing methodology and strategies of HIV care integration between 2010 and 2015 was performed. We describe HIV care models integrated within the provision of general health care and highlight best practices and challenges.
RESULTS
Services included provision of general health care, with out-patient care (range between countries 43,343 and 287,163 consultations/year in 2015) and in-patient care (range 1076–16,595 in 2015). By the end of 2015 antiretroviral therapy (ART) initiations reached 12–255 patients/year. A total of 1101 and 1053 patients were on ART in CAR and DRC, respectively. In RoSS 186 patients were on ART when conflict recommenced late in 2013. While ART initiation and monitoring were mostly clinically driven in the early phase of the programmes, DRC implemented CD4 monitoring and progressively HIV viral load (VL) monitoring during study period. Attacks to health care facilities in CAR and RoSS disrupted service provision temporarily. Programmatic challenges include: competing health priorities influencing HIV care and need to integrate within general health services. Differentiated care approaches that support continuity of care in these programmes include simplification of medical protocols, multi-month ART prescriptions, and community strategies such as ART delivery groups, contingency plans and peer support activities.
CONCLUSIONS
The principles of differentiated HIV care for high-quality ART delivery can successfully be applied in challenging operating environments. However, success heavily depends on specific adaptations to each setting.
Protocol > Research Protocol
JMIR Res Protoc. 26 November 2018; Volume 7 (Issue 11); e12334.; DOI:10.2196/12334
Alga A, Wong S, Haweizy R, Conneryd Lundgren K, von Schreeb J, et al.
JMIR Res Protoc. 26 November 2018; Volume 7 (Issue 11); e12334.; DOI:10.2196/12334
BACKGROUND
In armed conflict, injuries commonly affect the extremities and contamination with foreign material often increases the risk of infection. The use of negative-pressure wound therapy has been described in the treatment of acute conflict-related wounds, but reports are retrospective and with limited follow-up.
OBJECTIVE
The objective of this study is to investigate the effectiveness and safety of negative-pressure wound therapy use in the treatment of patients with conflict-related extremity wounds.
METHODS
This is a multisite, superiority, pragmatic randomized controlled trial. We are considering for inclusion patients 18 years of age and older who are presenting with a conflict-related extremity wound within 72 hours after injury. Patients are block randomly assigned to either negative-pressure wound therapy or standard treatment in a 1:1 ratio. The primary end point is wound closure by day 5. Secondary end points include length of stay, wound infection, sepsis, wound complications, death, and health-related quality of life. We will explore economic outcomes, including direct health care costs and cost effectiveness, in a substudy. Data are collected at baseline and at each dressing change, and participants are followed for up to 3 months. We will base the primary statistical analysis on intention-to-treat.
RESULTS
The trial is ongoing. Patient enrollment started in June 2015. We expect to publish findings from the trial by the end of 2019.
CONCLUSIONS
To the best of our knowledge, there has been no randomized trial of negative-pressure wound therapy in this context. We expect that our findings will increase the knowledge to establish best-treatment strategies.
In armed conflict, injuries commonly affect the extremities and contamination with foreign material often increases the risk of infection. The use of negative-pressure wound therapy has been described in the treatment of acute conflict-related wounds, but reports are retrospective and with limited follow-up.
OBJECTIVE
The objective of this study is to investigate the effectiveness and safety of negative-pressure wound therapy use in the treatment of patients with conflict-related extremity wounds.
METHODS
This is a multisite, superiority, pragmatic randomized controlled trial. We are considering for inclusion patients 18 years of age and older who are presenting with a conflict-related extremity wound within 72 hours after injury. Patients are block randomly assigned to either negative-pressure wound therapy or standard treatment in a 1:1 ratio. The primary end point is wound closure by day 5. Secondary end points include length of stay, wound infection, sepsis, wound complications, death, and health-related quality of life. We will explore economic outcomes, including direct health care costs and cost effectiveness, in a substudy. Data are collected at baseline and at each dressing change, and participants are followed for up to 3 months. We will base the primary statistical analysis on intention-to-treat.
RESULTS
The trial is ongoing. Patient enrollment started in June 2015. We expect to publish findings from the trial by the end of 2019.
CONCLUSIONS
To the best of our knowledge, there has been no randomized trial of negative-pressure wound therapy in this context. We expect that our findings will increase the knowledge to establish best-treatment strategies.
Journal Article > ResearchFull Text
BMC Infect Dis. 22 May 2018; Volume 18 (Issue 1); DOI:10.1186/s12879-018-3149-y
Alga A, Wong S, Shoaib M, Lundgren KC, Giske CG, et al.
BMC Infect Dis. 22 May 2018; Volume 18 (Issue 1); DOI:10.1186/s12879-018-3149-y
Armed conflicts are a major contributor to injury and death globally. Conflict-related injuries are associated with a high risk of wound infection, but it is unknown to what extent infection directly relates to sustainment of life and restoration of function. The aim of this study was to investigate the outcome and resource consumption among civilians receiving acute surgical treatment due to conflict-related injuries. Patients with and without wound infections were compared.
Journal Article > EditorialFull Text
Bull World Health Organ. 1 May 2017; Volume 95 (Issue 5); DOI:10.2471/BLT.17.194837
Brigden G, Castro JL, Ditiu L, Gray G, Hanna D, et al.
Bull World Health Organ. 1 May 2017; Volume 95 (Issue 5); DOI:10.2471/BLT.17.194837