Hospital setting
This study was undertaken in a general ICU (including ward 2A and 2B) with 32 beds (2A has 12 beds) at a university-affiliated hospital located in Shanghai, China. It is a tertiary hospital, which is divided into a north and south branch. The experiment was completed in ward 2B of the south branch only because the author (Fei Kaihong) is the head nurse of the south branch’s ICU (2B). Patients admitted to the ICU are assigned randomly to two wards. In 2B, there are 3 quadruple rooms (beds numbered from 11 to 14, 19 to 22, and 23 to 26), 2 double rooms (beds numbered 15, 16, 17, and 18), and 6 single rooms.
The exploratory experiment
From January 1, 2018, to December 31, 2019, the head nurse of the 2B ward applied an elementary predictive rule to prediscriminate the status of MDROs colonization/infection. There are eight relevant factors in the predictive rule. If one clause is met, HCWs judged that the patient has a very high risk for colonization/infection-supposing to have colonized/infected MDROs. The details of this rule are shown in table 1. If the status is assumed to be colonized/infected with MDROs, the HCWs strengthen their hand hygiene and wear isolation gowns before and after contacting the patient. If circumstances permit, everyone predicted to be positive with MDROs should be isolated into a single room or infected or colonized patients should be separated from other patients. This preintervention continues until the clinical culture results are acquired.
Table 1 An elementary predictive rule applied in ICU ward 2B
Clauses
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Antibiotic treatment before admission to the ICU
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Hospital stay longer than 2 weeks
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Underlying health problems and age older than 60
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Recent invasive procedures
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Treatment with immunosuppressive agents
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Known colonization with MDROs
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Sepsis or organ failure before ICU admission
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Abrupt admission to the ICU
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Data collection
Because this is a retrospective sharing of an ICU clinical practice, data were pulled from the hospital electronic file and CARSS retrospectively to assess the efficiency and benefit of this routine ICU care. Data included age, sex, ward (2A or 2B), hospitalization expenses (on April 1, 2020, 1 CNY=0.1408 $USD), admission date, discharge data, length of hospital stay, bed number, and status of MDRO colonization/infection based on screening results from January 1, 2018, to December 31, 2019. To analyze the length of the clinical culture testing, we exported the date of sample submission and the date of test result acquisition from January 1, 2018, to December 31, 2019, of the whole ICU.
Statistical analysis
Quantitative variables that are normally distributed are expressed as the means (standard deviations); otherwise, they are expressed as medians (interquartile ranges). Categorical variables are described by number (percentage). Before the statistics, for quantitative variables, histograms and the Shapiro-Wilk test were used to assess the normality of the distribution. Quantitative variables were examined using Student’s t-tests for normally distributed variables and the Wilcoxon rank-sum tests for nonnormally distributed variables. Chi-square tests were used for categorical variables. All reported P values are 2-tailed, with a P-value <0.05 considered statistically significant. Statistical analyses were performed using IBM SPSS, 25.0.
We compared differences between 2A and 2B. Variables included age, sex, hospitalization expenses, ICU length of stay, and status of MDROs colonization/infection. We examined age as a categorical variable. Age categories used were ≥65 years and <65 years. Hospitalization expenses were converted to US dollars (refer to the China-US exchange rate on April 1, 2020, 1CNY=0.1408 $). Hospitalization expenses were divided into two groups: ≥6500 $ and <6500 $. Because patients in the ICU normally had tens of days of admission length, 14 days served as a cutoff point. ICU length of stay was examined as a categorical variable too.
Ethical considerations
The study was approved by the Shanghai General Hospital Institutional Review Boards. Written informed consent was not required.