scholarly journals Evaluation of a Pulsed Xenon Ultraviolet Disinfection System for Reduction of Healthcare-Associated Pathogens in Hospital Rooms

2015 ◽  
Vol 36 (2) ◽  
pp. 192-197 ◽  
Author(s):  
Michelle M. Nerandzic ◽  
Priyaleela Thota ◽  
Thriveen Sankar C. ◽  
Annette Jencson ◽  
Jennifer L. Cadnum ◽  
...  
Keyword(s):  
Uv Irradiation ◽  
Organic Load ◽  
Short Exposure ◽  
Glass Slides ◽  
Before And After ◽  
Ultraviolet C ◽  
Pathogen Recovery ◽  
Healthcare Associated ◽  
The Impact ◽  
Uv C

OBJECTIVETo determine the effectiveness of a pulsed xenon ultraviolet (PX-UV) disinfection device for reduction in recovery of healthcare-associated pathogens.SETTINGTwo acute-care hospitals.METHODSWe examined the effectiveness of PX-UV for killing ofClostridium difficilespores, methicillin-resistantStaphylococcus aureus(MRSA), and vancomycin-resistantEnterococcus(VRE) on glass carriers and evaluated the impact of pathogen concentration, distance from the device, organic load, and shading from the direct field of radiation on killing efficacy. We compared the effectiveness of PX-UV and ultraviolet-C (UV-C) irradiation, each delivered for 10 minutes at 4 feet. In hospital rooms, the frequency of native pathogen contamination on high-touch surfaces was assessed before and after 10 minutes of PX-UV irradiation.RESULTSOn carriers, irradiation delivered for 10 minutes at 4 feet from the PX-UV device reduced recovery ofC. difficilespores, MRSA, and VRE by 0.55±0.34, 1.85±0.49, and 0.6±0.25 log10colony-forming units (CFU)/cm2, respectively. Increasing distance from the PX-UV device dramatically reduced killing efficacy, whereas pathogen concentration, organic load, and shading did not. Continuous UV-C achieved significantly greater log10CFU reductions than PX-UV irradiation on glass carriers. On frequently touched surfaces, PX-UV significantly reduced the frequency of positiveC. difficile, VRE, and MRSA culture results.CONCLUSIONSThe PX-UV device reduced recovery of MRSA,C. difficile, and VRE on glass carriers and on frequently touched surfaces in hospital rooms with a 10-minute UV exposure time. PX-UV was not more effective than continuous UV-C in reducing pathogen recovery on glass slides, suggesting that both forms of UV have some effectiveness at relatively short exposure times.Infect Control Hosp Epidemiol 2014;00(0): 1–6

scholarly journals Effectiveness of Ultraviolet-C Room Disinfection on Preventing Healthcare-Associated Clostridioides difficile Infection

2020 ◽  
Vol 41 (S1) ◽  
pp. s33-s33
Author(s):  
Michihiko Goto ◽  
Erin Balkenende ◽  
Gosia Clore ◽  
Rajeshwari Nair ◽  
Loretta Simbartl ◽  
...  
Keyword(s):  
Acute Care ◽  
Acute Care Hospitals ◽  
Incidence Rates ◽  
Positive Test ◽  
Negative Binomial Regression Model ◽  
Test Results ◽  
Clostridioides Difficile ◽  
Ultraviolet C ◽  
Healthcare Associated ◽  
Uv C

Background: Enhanced terminal room cleaning with ultraviolet C (UVC) disinfection has become more commonly used as a strategy to reduce the transmission of important nosocomial pathogens, including Clostridioides difficile, but the real-world effectiveness remains unclear. Objectives: We aimed to assess the association of UVC disinfection during terminal cleaning with the incidence of healthcare-associated C. difficile infection and positive test results for C. difficile within the nationwide Veterans Health Administration (VHA) System. Methods: Using a nationwide survey of VHA system acute-care hospitals, information on UV-C system utilization and date of implementation was obtained. Hospital-level incidence rates of clinically confirmed hospital-onset C. difficile infection (HO-CDI) and positive test results with recent healthcare exposures (both hospital-onset [HO-LabID] and community-onset healthcare-associated [CO-HA-LabID]) at acute-care units between January 2010 and December 2018 were obtained through routine surveillance with bed days of care (BDOC) as the denominator. We analyzed the association of UVC disinfection with incidence rates of HO-CDI, HO-Lab-ID, and CO-HA-LabID using a nonrandomized, stepped-wedge design, using negative binomial regression model with hospital-specific random intercept, the presence or absence of UVC disinfection use for each month, with baseline trend and seasonality as explanatory variables. Results: Among 143 VHA acute-care hospitals, 129 hospitals (90.2%) responded to the survey and were included in the analysis. UVC use was reported from 42 hospitals with various implementation start dates (range, June 2010 through June 2017). We identified 23,021 positive C. difficile test results (HO-Lab ID: 5,014) with 16,213 HO-CDI and 24,083,252 BDOC from the 129 hospitals during the study period. There were declining baseline trends nationwide (mean, −0.6% per month) for HO-CDI. The use of UV-C had no statistically significant association with incidence rates of HO-CDI (incidence rate ratio [IRR], 1.032; 95% CI, 0.963–1.106; P = .65) or incidence rates of healthcare-associated positive C. difficile test results (HO-Lab). Conclusions: In this large quasi-experimental analysis within the VHA System, the enhanced terminal room cleaning with UVC disinfection was not associated with the change in incidence rates of clinically confirmed hospital-onset CDI or positive test results with recent healthcare exposure. Further research is needed to understand reasons for lack of effectiveness, such as understanding barriers to utilization.Funding: NoneDisclosures: None

scholarly journals How Dead Wood in the Forest Decreases Relaxation? The Effects of Viewing of Dead Wood in the Forest Environment on Psychological Responses of Young Adults

Forests ◽  
2021 ◽  
Vol 12 (7) ◽  
pp. 871
Author(s):  
Emilia Janeczko ◽  
Ernest Bielinis ◽  
Ulfah Tiarasari ◽  
Małgorzata Woźnicka ◽  
Wojciech Kędziora ◽  
...  
Keyword(s):  
Young Adults ◽  
Dead Wood ◽  
Short Exposure ◽  
Managed Forests ◽  
Environment Impact ◽  
Forest Environment ◽  
Dead Trees ◽  
Before And After ◽  
Positive Feelings ◽  
The Impact

The intensity of the neutral environment impact on humans may be determined by specific features of space, including dead wood occurrence. Dead wood is claimed to be disliked by the public because it reduces the scenic beauty and recreational values of the forest. The attractiveness of a forest with dead wood may be determined by its variants. Much is known about the preference for landscape with dead wood, but there is little information available about how such a landscape affects a person’s mental relaxation, improves mood, increases positive feelings, levels of vitality, etc. Hence, the aim of our research was to investigate the psycho-logical relaxing effects of short 15-min exposures to natural and managed forests with dead wood. In the study, three areas within the Białowieża Primeval Forest were used to measure the impact of different types of forest with dead wood (A: forest reserve with dead wood subject to natural decomposition processes; B: managed forest with visible cut wood and stumps; C: man-aged forest with dead trees from bark beetle outbreak standing) on human psychological relaxation in a randomized experiment. The participants of the experiment were forty-one young adults aged 19–20. Each respondent experienced each type of forest at intervals visiting it. Four psychological questionnaires were used in the project (Profile of Mood States (POMS), Positive and Negative Affect Schedule (PANAS), Subjective Vitality Scale (SVS), and Restorative Outcome Scale (ROS)) before and after the short exposure to the forest were evaluated. The results show that a forest landscape with dead wood affects the human psyche, and the relaxing properties of such a landscape are better in a protected forest with natural, slow processes of tree dieback than those obtained in managed forests

scholarly journals 1215. Ultraviolet-C (UV-C) Monitoring Made Ridiculously Simple: UV-C Dose Indicators for Convenient Measurement of UV-C Dosing

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S437-S437
Author(s):  
Jennifer Cadnum ◽  
Annette Jencson ◽  
Sarah Redmond ◽  
Thriveen Sankar Chittoor Mana ◽  
Curtis Donskey
Keyword(s):  
Methicillin Resistant Staphylococcus Aureus ◽  
Fetal Calf Serum ◽  
Color Change ◽  
Calf Serum ◽  
Organic Load ◽  
Healthcare Facilities ◽  
Log Reduction ◽  
Ultraviolet C ◽  
Effective Doses ◽  
Uv C

Abstract Background Ultraviolet-C (UV-C) light is increasingly used as an adjunct to standard cleaning in healthcare facilities. However, most facilities do not have a means to measure UV-C to determine whether effective doses are being delivered. We tested the efficacy of 2 easy-to-use colorimetric indicators for monitoring UV-C dosing in comparison to log reductions in pathogens. Methods In a laboratory setting, we exposed methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile spores on steel disk carriers with or without an organic load (5% fetal calf serum) to UV-C for varying times resulting in fluence exposures ranging from 10,000 to 100,000 µJ/cm2. The UV-C indicators were placed adjacent to the carriers. Log reductions were calculated in comparison to untreated controls and the change in color of the indicators was correlated with dose and log reductions. Results The UV-C doses required to achieve a 3-log reduction in MRSA and C. difficile were 10,000 and 46,000 µJ/cm2, respectively. For both indicators, there was a visible color change from baseline at 10,000 µJ/cm2 and a definite final color change by 46,000 µJ/cm2 (Figure 1). Organic load had only a modest impact on UV-C efficacy. The indicators required only a few seconds to place and were easy to read (Figure 2). Conclusion UV-C doses of 10,000 and 46,000 µJ/cm2 were required to achieve 3 log reductions of MRSA and C. difficile spores, respectively. The colorimetric indicators provide an easy means to monitor UV-C dosing. Disclosures All authors: No reported disclosures.

scholarly journals Decontamination of Targeted Pathogens from Patient Rooms Using an Automated Ultraviolet-C-Emitting Device

2013 ◽  
Vol 34 (5) ◽  
pp. 466-471 ◽  
Author(s):  
Deverick J. Anderson ◽  
Maria F. Gergen ◽  
Emily Smathers ◽  
Daniel J. Sexton ◽  
Luke F. Chen ◽  
...  
Keyword(s):  
Tertiary Care ◽  
Environmental Services ◽  
Convenience Sample ◽  
Vancomycin Resistant Enterococci ◽  
Colony Forming Units ◽  
Before And After ◽  
Ultraviolet C ◽  
Vancomycin Resistant ◽  
Tertiary Care Hospitals ◽  
Uv C

Objective.To determine the effectiveness of an automated ultraviolet-C (UV-C) emitter against vancomycin-resistant enterococci (VRE),Clostridium difficile, andAcinetobacterspp. in patient rooms.Design.Prospective cohort study.Setting.Two tertiary care hospitals.Participants.Convenience sample of 39 patient rooms from which a patient infected or colonized with 1 of the 3 targeted pathogens had been discharged.Intervention.Environmental sites were cultured before and after use of an automated UV-C-emitting device in targeted rooms but before standard terminal room disinfection by environmental services.Results.In total, 142 samples were obtained from 27 rooms of patients who were colonized or infected with VRE, 77 samples were obtained from 10 rooms of patients withC. difficileinfection, and 10 samples were obtained from 2 rooms of patients with infections due toAcinetobacter. Use of an automated UV-C-emitting device led to a significant decrease in the total number of colony-forming units (CFUs) of any type of organism (1.07 log10reduction;P< .0001), CFUs of target pathogens (1.35 log10reduction;P< .0001), VRE CFUs (1.68 log10reduction;P< .0001), and C.difficileCFUs (1.16 log10reduction;P< .0001). CFUs ofAcinetobacteralso decreased (1.71 log10reduction), but the trend was not statistically significantP= .25). CFUs were reduced at all 9 of the environmental sites tested. Reductions similarly occurred in direct and indirect line of sight.Conclusions.Our data confirm that automated UV-C-emitting devices can decrease the bioburden of important pathogens in real-world settings such as hospital rooms.

scholarly journals Infection Prevention Performance among Hospital Staff during Vaginal Birth: Results from a Criterion-Based Audit at a Zonal Referral Hospital in Tanzania

2021 ◽  
Vol 5 (1) ◽  
pp. 36-43
Author(s):  
Lærke Vinberg Rasmussen ◽  
Enna Sengoka ◽  
Eusebius Maro ◽  
Godfrey Kisigo ◽  
Vibeke Rasch ◽  
...  
Keyword(s):  
Infection Prevention ◽  
Training Session ◽  
Vaginal Birth ◽  
Healthcare Associated Infections ◽  
Audit Process ◽  
Knowledge Test ◽  
Before And After ◽  
Labour Ward ◽  
Healthcare Associated ◽  
The Impact

Background: Healthcare associated infections is a global burden and is one of the main causes of maternal and neonatal morbidity and mortality during the time of labour when admitted to the hospital. Healthcare workers´ hands are in most cases the vehicle for transmission of microorganisms from patient to patient.Good hand hygiene practices at the bedside are a simple way of reducing healthcare associated infections. The objective was to assess the impact of a criterion-based audit on infection prevention performance and knowledge during vaginal delivery at a hospital in Tanzania. The quantitative findings were discussed with staff to identify barriers and solutions to quality improvement. Methods: A mixed-method uncontrolled, before and after intervention study by criterion-based audit was performed at the labour ward at Kilimanjaro Christian Medical Centre. Criteria for best practice were established together with key staff based on national and international guidelines. Sixty clean procedures during vaginal birth were observed and assessed by a structured checklist based on the audit criteria. Baseline findings were discussed with staff and an intervention performed including a short training and preparation of alcohol-based hand rub. Hereafter another 60 clean procedures were observed, and performance compared to the care before the intervention. Furthermore, a knowledge test was performed before and after the intervention. Results: Hand washing increased significantly after a procedure from 46.7% to 80% (RR=1.71 95% CI; 1.27 to 2.31), the use of alcohol-based hand rub before a procedure from 1.7% to 33.3% (p<0.001), and the use of alcohol-based hand rub after procedure from 0% to 30% (p<0.001). After the intervention the mean score for the knowledge test increased insignificantly from 59.3% to 65.3%, (mean difference = 6.1%, 95% CI; -4.69 to 16.88). Conclusion: The criterion-based audit process identified substandard care for infection prevention at the labour ward. An intervention of discussing baseline findings and a short training session and introducing alcohol-based hand rub resulted in improvements on infection prevention performance.

scholarly journals Comparison of the effectiveness of manual cleaning, hydrogen peroxide vapor and ultraviolet-c in disinfection of hospital equipment

2020 ◽  
Vol 39 (3) ◽  
pp. 66-84 ◽  
Author(s):  
Yosra Sedaghat ◽  
Seifollah Gholampour ◽  
Farhad Tabatabai Ghomshe
Keyword(s):  
Hydrogen Peroxide ◽  
Complete Coverage ◽  
Hospital Beds ◽  
Before And After ◽  
Ultraviolet C ◽  
Pressure Meter ◽  
Uv C ◽  
Hospital Equipment ◽  
Hydrogen Peroxide Vapor ◽  
Number Of Bacteria

Hospitals are the focus of many infections which cause the intensification of the patients’ illness and even their death. The number of bacteria on various hospital equipment was counted before and after being disinfected with manual cleaning (MC), hydrogen peroxide vapour (HPV) and ultraviolet-C (UV-C). The effectiveness of disinfection of hospital beds in intensive care unit (ICU) using the three methods MC, HPV and UV-C has been 66.67%, 100% and 50%, respectively. Hence, the effectiveness of HPV method in the disinfection of this unit has been higher than others. The effectiveness of otoscope disinfection in the ICU and blood pressure meter in the operating room with three methods of MC, HPV and UV-C has been 0%, 50% and 100%, respectively. So, for disinfecting these small outfits, UV-C method has proven to be the best one. In case of programming, the correct move of portable UV-Cs for complete coverage of massive equipment, disinfection with UV-C method may be considered more effective than other methods.

The impact of vancomycin-resistant Enterococcus (VRE) screening policy change on the incidence of healthcare-associated VRE bacteremia

2021 ◽  
pp. 1-6
Author(s):  
Sun Young Cho ◽  
Hye Mee Kim ◽  
Doo Ryeon Chung ◽  
Jong Rim Choi ◽  
Myeong-A Lee ◽  
...  
Keyword(s):  
Policy Change ◽  
Tertiary Care ◽  
High Risk Patient ◽  
Hospital Setting ◽  
Molecular Characteristics ◽  
Screening Policy ◽  
Before And After ◽  
Vancomycin Resistant ◽  
Healthcare Associated ◽  
The Impact

Abstract Objective: To evaluate the impact of a vancomycin-resistant Enterococcus (VRE) screening policy change on the incidence of healthcare-associated (HA)-VRE bacteremia in an endemic hospital setting. Design: A quasi-experimental before-and-after study. Setting: A 1,989-bed tertiary-care referral center in Seoul, Republic of Korea. Methods: Since May 2010, our hospital has diminished VRE screening for admitted patients transferred from other healthcare facilities. We assessed the impact of this policy change on the incidence of HA-VRE bacteremia using segmented autoregression analysis of interrupted time series from January 2006 to December 2014 at the hospital and unit levels. In addition, we compared the molecular characteristics of VRE blood isolates collected before and after the screening policy change using multilocus sequence typing and pulsed-field gel electrophoresis. Results: After the VRE screening policy change, the incidence of hospital-wide HA-VRE bacteremia increased, although no significant changes of level or slope were observed. In addition, a significant slope change in the incidence of HA-VRE bacteremia (change in slope, 0.007; 95% CI, 0.001–0.013; P = .02) was observed in the hemato-oncology department. Molecular analysis revealed that various VRE sequence types appeared after the policy change and that clonally related strains became more predominant (increasing from 26.1% to 59.3%). Conclusions: The incidence of HA-VRE bacteremia increased significantly after VRE screening policy change, and this increase was mainly driven by high-risk patient populations. When planning VRE control programs in hospitals, different approaches that consider risk for severe VRE infection in patients may be required.

Analysis of the role of copper impregnated composite hard surfaces, bed linens and patient gowns in reducing healthcare-associated infection rates

2018 ◽  
Vol 14 (1) ◽  
Author(s):  
Gene H Burke ◽  
Jacqueline P Butler
Keyword(s):  
Infection Risk ◽  
Healthcare Associated Infections ◽  
Drug Resistant ◽  
Infection Rates ◽  
Healthcare Associated Infection ◽  
Before And After ◽  
New Construction ◽  
Healthcare Associated ◽  
The Impact

The aim of this study was to evaluate the impact of copper-impregnated composite hard surfaces, bed linens and patient gowns on healthcare-associated infections (HAIs). We took in account potentially confounding factors of new construction and Det Norse Veritas Managing Infection Risk (DNV MIR) certification to mitigate risk of HAIs, multi drug resistant organisms (MDRO) and Clostridium difficile HAIs. The study was conducted in the acute care units from three hospitals within a regional healthcare system and these were assessed retrospectively. Facility 1 and Facility 2 shared the circumstance of new construction. Facility 1 and Facility 3 shared the processes of DNV-MIR. Only Facility 1 undertook the intervention of copper-impregnated hard surfaces, bed linens and patient gowns. We compared infection rates (IR) following their normalization per 10,000 patient hospitalization days before and after complete implementation of copper-impregnated composite hard surfaces, bed linens and patient gowns. Facility 1 had a 28% reduction in total C. difficile and MDRO IR, while Facilities 2 and 3 had 103% and 48% increases in total IR respectively. Although the rate changes per facility were not statistically significantly changed from baseline (p>0.05), there was consistent divergence between the IR at the copper enabled facility and the others. As this divergence occurred when other pertinent factors were constant between them, including new construction and new processes for mitigation of infection risks, these outcomes support the contention that copper-impregnated linens and composite hard surfaces were shown to reduce HAI rates.

scholarly journals Application of a Continuously Active Antimicrobial Surface Coating in Two Professional Sports Training Facilities

2020 ◽  
Vol 41 (S1) ◽  
pp. s440-s440
Author(s):  
Gavriel Grossman ◽  
Valerie Beck ◽  
Dan Watson ◽  
Ece Toklu ◽  
Maha El-Sayed
Keyword(s):  
Treatment Period ◽  
Surface Coating ◽  
Professional Sports ◽  
Surface Contamination ◽  
Sports Training ◽  
Before And After ◽  
Plate Counts ◽  
Healthcare Associated ◽  
Occupancy Rates ◽  
The Impact

Background: The role of surface contamination in infections is of interest in healthcare as well as other industries, especially where infections incur high cost. One such industry is professional sports, where infections pose significant risks to players and the organizations that employ them. Sports training facilities experience highly variable occupancy rates due to differing seasonal activities, presenting a measurement challenge because the relationship between occupancy and surface contamination is not well described. In a recent publication, a continuously active antimicrobial (CAA) surface coating demonstrated a reduction in bacterial bioburden in ICUs alongside a reduction in healthcare-associated infections (HAIs). Objective: We investigated the impact of a CAA surface coating on bioburden in 2 professional sports training facilities, despite changes in occupancy. Methods: A CAA surface coating was applied using an electrostatic sprayer to all surfaces in both facilities during a period of high-occupancy at facility A and during low occupancy at facility B. Surface cultures were taken using 3M Sponge-Sticks from lockers, gym equipment, and physiotherapy surfaces before treatment, 4–13 weeks after treatment at facility A and 4–23 weeks after treatment at facility B. Total aerobic bacteria counts were obtained by plating on tryptic soy agar, and geometric means of aerobic plate counts (APCs) were used to compare bioburden before and after treatment at both facilities and for an out-of-efficacy period at facility B (17–23 weeks). Occupancy rates were monitored as person days per week (pd/w) over the course of the study. Results: APC counts at facility A decreased 61% (585 CFU/100 cm2 to 226 CFU/100 cm2) from baseline to posttreatment, and occupancy remained constant (165 pd/w to 171 pd/w). At facility B, there was no significant change in APC (76 CFU/100 cm2 to 80 CFU/100 cm2), although occupancy increased >13,000% during the treatment period (3 pd/w to 386 pd/w). During the out-of-efficacy period at facility B, total bacteria increased 170% (217 CFU/100 cm2) compared to the treatment period, and the occupancy remained relatively constant (344 pd/w). Conclusions: Levels of bioburden were significantly influenced by the application of the CAA surface coating, especially considering the variation in occupancy in both facilities before, during, and after the efficacy period. Facility A saw a significant reduction in bioburden during the treatment period (P < .0001), and a significant increase was observed at facility B during the out-of-efficacy period (P < .0001) despite constant occupancy rates, demonstrating the ability of the surface coating to reduce bioburden levels despite large changes in occupancy.Funding: Allied BioScience, Inc, provided Funding: for this study.Disclosures: Gavri Grossman, Valerie Beck, and Daniel S Watson report salary from Allied BioScience.

scholarly journals Impact of a hospital-wide huddle on device utilisation and infection rates: a community hospital’s journey to zero

2020 ◽  
Vol 21 (6) ◽  
pp. 228-233
Author(s):  
Alfredo J Mena Lora ◽  
Mirza Ali ◽  
Candice Krill ◽  
Sherrie Spencer ◽  
Eden Takhsh ◽  
...  
Keyword(s):  
Infection Prevention ◽  
Cost Savings ◽  
Bloodstream Infections ◽  
Central Line ◽  
Culture Of Safety ◽  
Before And After ◽  
Quasi Experimental ◽  
Tract Infections ◽  
Healthcare Associated ◽  
The Impact

Background: Device utilisation ratios (DUR) correlate with device-associated complications and rates of infection. We implemented a hospital-wide Daily Interdisciplinary Safety Huddle (DISH) with infection control and device components. The aim of this study was to evaluate the impact of DISH on DURs and rates of infection for indwelling urinary catheters (IUC) and central venous catheters (CVC). Methods: A quasi-experimental study assessing DURs and rates of infection before and after implementation of DISH. At DISH, usage of IUC and CVC is reported by managers and the infection preventionist reviews indications and plans for removal. Data before and after implementation were compared. Paired T-test was used to assess for differences between both groups. Results: DISH was successfully implemented at a community hospital. The average DUR for IUC in intensive care unit (ICU) and non-ICU settings was reduced from 0.56 to 0.35 and 0.27 to 0.12, respectively. CVC DUR decreased from 0.29 to 0.26 in the ICU and 0.14 to 0.12 in non-ICU settings. Catheter-associated urinary tract infections (CAUTIs) decreased by 87% and central line-associated bloodstream infections (CLABSIs) by 96%. Conclusion: DISH was associated with hospital-wide reductions in DUR and device-associated healthcare-associated infections. Reduction of CLABSIs and CAUTIs had estimated cost savings of $688,050. The impact was more profound in non-ICU settings. To our knowledge, an infection prevention hospital-wide safety huddle has not been reported in the literature. DISH increased device removal, accountability and promoted a culture of safety.

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