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The aim of this study is to analyse the changing patterns in the transmission of COVID-19 in relation to changes in Vietnamese governmental policies, based on epidemiological data and policy actions in a large Vietnamese province, Bac Ninh, in 2021. Data on confirmed cases from January to December 2021 were collected, together with policy documents. There were three distinct periods of the COVID-19 pandemic in Bac Ninh province during 2021. During the first period, referred to as the ‘Zero-COVID’ period (01/04–07/04/2021), there was a low population vaccination rate, with less than 25% of the population receiving its first vaccine dose. Measures implemented during this period focused on domestic movement restrictions, mask mandates, and screening efforts to control the spread of the virus. The subsequent period, referred to as the ‘Transition’ period (07/05–10/22/2021), witnessed a significant increase in population vaccination coverage, with 80% of the population receiving their first vaccine dose. During this period, several days passed without any reported COVID-19 cases in the community. The local government implemented measures to manage domestic actions and reduce the time spent in quarantine, and encouraged home quarantining for the close contacts of cases with COVID-19. Finally, the ‘New-normal’ stage (10/23–12/31/2021), during which the population vaccination coverage with a second vaccine dose increased to 70%, and most of the mandates for the prevention and control of COVID-19 were reduced. In conclusion, this study highlights the importance of governmental policies in managing and controlling the transmission of COVID-19 and provides insights for developing realistic and context-specific strategies in similar settings.
Objectives:Candida auris was first detected in Japan in 2009 and has been reported in >47 countries, typically causing outbreaks in healthcare settings. According to the US Centers for Disease Control and Prevention, this pathogen causes death in more than one-third of infected patients. This study describes characteristics of healthcare-associated infections (HAIs) related to C. auris and infection prevention and control (IPC) measures applied to control transmission in Cho Ray Hospital, a tertiary-care, referral, general hospital in southern Vietnam. Methods: We reviewed medical records of all patients with HAIs caused by C. auris at Cho Ray Hospital between April 2020 and March 2021, as well as the IPC measures applied for these patients. Results: Overall, 5 HAI cases caused by C. auris were identified in 5 patients, including 2 catheter-associated urinary tract infections, 2 ventilator-associated pneumonia cases, and 1 surgical site infection. These cases were sporadically detected in 4 different clinical departments; 2 cases occurred in the respiratory department in April and August 2020. The average age of the patients was 63, and 4 of 5 patients were male. The average hospital stay was 27.2 days; 4 patients died and 1 was discharged. IPC interventions were implemented to immediately respond to C. auris infection cases, including isolating the patients, applying standard and transmission-based precautions, supplying adequate personal protective equipment, cleaning environment surfaces and medical equipment in the patient’s room, and marking isolation areas with signage. No additional cases of C. auris infection were detected in the affected units. Conclusions:C. auris can spread in healthcare settings via contact with contaminated equipment and surfaces or from person to person, causing outbreaks in hospitals and leading to severe illness and high mortality for patients. Prompt application of appropriate IPC measures effectively helped prevent additional cases of C. auris in our hospital.
Objectives: SARS-CoV-2 is a novel and highly infectious virus. An effective response requires rapid training of healthcare workers (HCWs). We measured the change in knowledge related to COVID-19 and associated factors before and after training of HCWs in Vietnam. Methods: A quasi-experimental design was used to evaluate HCW knowledge related to prevention and control of SARS-CoV-2 before and after attending a 2-day training-of-trainers course. Between June and September 2020, 963 HCWs from 194 hospitals in 21 provinces received the training. HCW knowledge was assessed using a 20-item questionnaire consisting of multiple-choice questions at the beginning and closing of the training course. A participant received 1 point for each correct answer. He or she was considered to have improved knowledge the posttest score was higher than the pretest score with a score ≥15 on the posttest. We applied the McNemar test and logistic regression model to test the level of association between demographic factors and change in knowledge of COVID-19. Results: Overall, 100% of HCWs completed both the pretest and posttest. At baseline, only 14.7% scored ≥15. Following the training, 78.4% scored ≥15 and 64.3% had improved knowledge according to the predetermined definition. Questions related to the order of PPE donning and doffing and respiratory specimen collection procedures were identified as having the greatest improvement (44.6% and 60.7%, respectively). Being female (OR, 1.5; 95% CI, 1.1–2.0), having a postgraduate degree (OR, 2.5; 95% CI, 1.4–4.4), working in a nonmanager position (OR, 1.5; 95% CI, 1.1–2.1), previous contact with a COVID-19 patient (OR, 1.5; 95% CI, 1.1–2.0), and working in northern Vietnam (OR, 2.0; 95% CI, 1.4–2.6), were associated with greater knowledge improvement. Conclusions: Most HCWs demonstrated improved knowledge of COVID-19 prevention and control after attending the training. Particular groups may benefit from additional training: those who are male, leaders and managers, those who hold an undergraduate degree, and those who work in the southern provinces.
Background: Catheter-associated urinary tract infections (CAUTIs) are among the most prevalent healthcare-associated infections (HAIs) globally, contributing to increased morbidity, prolonged hospital stays, and increased healthcare costs. Interventions that support prompt removal of the urinary catheter are evidence-based actions to effectively reduce CAUTI rates.1Objective: At the National Hospital of Tropical Disease (NHTD), catheter removal interventions in the intensive care unit (ICU) were implemented using quality improvement (QI) methodology to reduce CAUTI incidence and urinary catheter device utilization. Methods: Training was performed for ICU clinical staff with knowledge checks before and after the program. A bedside visual reminder of CAUTI risk and checklist to assess catheter need were implemented. Weekly compliance of provided visual reminders and checklists were measured using a simple audit tool. Device utilization ratios (DURs, ratios of device days to patient days), and CAUTI incidence rates (per 1,000 device days) were collected at baseline (July–September 2018) and quarterly thereafter until June 2019. Statistical significance was determined by an independent t test. Results: In the first quarter (October–December 2018), the CAUTI incidence rate decreased from 8.9 to 1.3 per 1,000 device days (P = .036). The ICU staff trained in CAUTI prevention, mean knowledge scores before and after training increased from 68% to 87%. The DUR decreased slightly from 0.59 to 0.55 after the first-quarter training then steadily increased in the following quarter (0.60; January–March 2019) and after the intervention (0.54; April–June 2019). CAUTI incidence rates also increased but were still lower than at baseline: 4.8 and 6.3 per 1,000 days of device use. Compliance of reminders was 51% during the first quarter, increased slightly in the second quarter 62%, then decreased to 40% during the last quarter. The nurses’ adherence to the daily checklist remained stable (>75%). Conclusions: This CAUTI prevention project was the first use of quality improvement methodology to implement change at NHTD. A trend decrease in CAUTI was observed, though a greater decrease occurred at the beginning of the intervention. Limited compliance of daily reminders is likely reflected in no statistically significant decrease in DUR. Possibly, this quality improvement project raised awareness among clinicians to improve general CAUTI prevention practices in the ICU without decreasing DUR. Given limited compliance with reminder and checklists, the intervention will be revised during the next PDSA cycle to improve adherence.
1Meddings J, Rogers MA, Krein SL, Fakih MG, Olmsted RN, Saint S. Reducing unnecessary urinary catheter use and other strategies to prevent catheter-associated urinary tract infection: an integrative review. BMJ Qual Saf 2014;23:277–289.
Background: Central-line–associated bloodstream infections (CLABSIs) increase the length of hospital stay, healthcare costs, and patient mortality. Objective: We conducted a quality improvement (QI) approach with plan-do-study-act (PDSA) cycle to strengthen adherence to a central-line (CL) maintenance bundle and to reduce CLABSI rate in a surgical intensive care unit (ICU) of children’s hospital 1 (CH1). Methods: The baseline CLABSI rate per 1,000 CL days and the ratio of CL days to patient days (device utilization ration; DUR) were captured for 12 months preceding the intervention. Baseline process indicators were captured for 2 months preceding implementation, including hand hygiene adherence, sterile technique for dressing change and CL access, CL hub cleaning, dating of CL components and daily chlorhexidine bathing. A multimodal intervention of clinician training, bedside checklist, and poster reminders of best practices was implemented. Process and outcome measures were monitored over 12 months of implementation. Z-test was used to calculate statistical significance before and after intervention. Results: Among 46 clinical ICU staff trained on a CLABSI maintenance bundle, mean pre- and posttest knowledge scores increased from 63% to 86%. Staff adherence to each CL care bundle element improved significantly (P < .001) and sustainably over the intervention period: hand hygiene adherence increased from 54% to 82%; sterile technique for dressing increased from 60% to 94%; sterile technique for CL access increased from 51% to 97%; hub scrubbing increased from 52% to 93%; dating of CL elements increased from 63% to 85%; daily chlorhexidine bathing increased from 52% to 87%. During the first 9 months, the CLABSI rate and the DUR decreased from 5.8 to 3.7 and from 0.43 to 0.41, respectively. In the following 2 months, the CLABSI rate increased to 12.7 while bundle adherence remained high. A root-cause analysis identified inadequate environmental hygiene and use of multidose saline bottles for multiple patients as potential factors. A PDSA cycle to improve these elements (enhanced cleaning; single-patient saline bottles) led to a decrease in the CLABSI rate from 12.7 to 3.0 after these efforts. Conclusions: This is the first time CH1 has used quality improvement methodology to implement an HAI prevention enhancement, which proved effective at creating and sustaining adherence to a multimodal CL maintenance bundle and an overall decrease in CLABSI rates. A 2-month increase in CLABSI rates highlights the unique challenges faced in low-resource settings and demonstrates the need for IPC elements not captured in a typical CLABSI prevention bundle. The quality improvement methodology provided a structured approach to implementing change. This methodology will be used for additional patient safety improvements at CH1 and other Viet Nam hospitals interested in CLABSI prevention.
Guidelines recommend empowering patients and families to remind healthcare workers (HCWs) to perform hand hygiene (HH). The effectiveness of empowerment tools for patients and their families in Southeast Asia is unknown.
We performed a prospective study in a pediatric intensive care unit (PICU) of a Vietnamese pediatric referral hospital. With family and HCW input, we developed a visual tool for families to prompt HCW HH. We used direct observation to collect baseline HH data. We then enrolled families to receive the visual tool and education on its use while continuing prospective collection of HH data. Multivariable logistic regression was used to identify independent predictors of HH in baseline and implementation periods.
In total, 2,014 baseline and 2,498 implementation-period HH opportunities were observed. During the implementation period, 73 families were enrolled. Overall, HCW HH was 46% preimplementation, which increased to 73% in the implementation period (P < .001). The lowest HH adherence in both periods occurred after HCW contact with patient surroundings: 16% at baseline increased to 24% after implementation. In multivariable analyses, the odds of HCW HH during the implementation period were significantly higher than baseline (adjusted odds ratio [aOR], 2.94; 95% confidence interval [CI], 2.54–3.41; P < .001) after adjusting for observation room, HCW type, time of observation (weekday business hours vs evening or weekend), and HH moment.
The introduction of a visual empowerment tool was associated with significant improvement in HH adherence among HCWs in a Vietnamese PICU. Future research should explore acceptability and barriers to use of similar tools in low- and middle-income settings.
We investigate the Sandpile Model and Chip Firing Game and an extension of these models
on cycle graphs. The extended model consists of allowing a negative number of chips at
each vertex. We give the characterization of reachable configurations and of fixed points
of each model. At the end, we give explicit formula for the number of their fixed
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