scholarly journals From Little Things Big Things Grow: The Development of an Auditing Program to Assess the Quality of Antimicrobial Prescribing

2020 ◽  
Vol 41 (S1) ◽  
pp. s237-s237
Author(s):  
Rodney James ◽  
Caroline Chen ◽  
Kirsty Buising ◽  
Karin Thursky ◽  
Courtney Ierano
Keyword(s):  
Antimicrobial Prophylaxis ◽  
Inappropriate Prescribing ◽  
Indigenous Communities ◽  
Aged Care ◽  
Care Homes ◽  
Qualitative Assessment ◽  
Audit Tool ◽  
Accreditation Standard ◽  
Antimicrobial Prescribing ◽  
Wide Range

Background: An important aspect of antimicrobial stewardship is the qualitative assessment of antimicrobial prescribing. Owing to lack of standardized tools and resources required to design, conduct and analyze qualitative audits, these assessments are rarely performed. Objective: We designed an audit tool that was appropriate for all Australian hospital types, suited to local user requirements and including an assessment of the appropriateness of antimicrobial prescribing. Methods: In 2011, a pilot survey was conducted in 32 Australian hospitals to assess the usability and generalizability of a qualitative audit tool. The tool was revised to reflect the respondents’ feedback. A second study was performed in 2012 in 85 hospitals. In 2013, following further feedback and refinement, an online auditing tool, the Hospital National Antimicrobial Prescribing Survey (NAPS), was developed. Early audits demonstrated that surgical prophylaxis had the highest rates of inappropriate prescribing. In 2016, the Surgical NAPS was developed to further investigate reasons for this, and the NAPS program was further expanded to audit antimicrobial prescribing practices in Australian aged-care homes (ie, the Aged Care NAPS). Results: Between January 1, 2013, and November 12, 2019, 523 Australian public and private hospitals (53.8%) utilized the Hospital NAPS; 215 (22.1%) have utilized the Surgical NAPS; and 774 of Australian aged-care homes (29.0%) have utilized the Aged Care NAPS. National reporting has identified key target areas for quality improvement initiatives at both local and national levels. The following initiatives have been outlined in 14 public reports: improved documentation; prolonged antimicrobial prophylaxis; compliance with prescribing guidelines; appropriateness of prescribing; access to evidence-based guidelines; and improved microbiology sampling. Conclusions: By utilizing the Plan-Do-Study-Act cycle for healthcare improvement and by involving end users in the design and evaluation, we have created a practical and relevant auditing program to assess both quantitative and qualitative aspects of antimicrobial prescribing in a wide range of settings. This voluntary program is now endorsed by the National Strategy for Antimicrobial Resistance Surveillance, partners with the Antimicrobial Use and Resistance in Australian Surveillance System, and is utilized by facilities to meet mandatory national accreditation standard requirements. With the success of the NAPS program in Australia, it has now been implemented in New Zealand, Canada, Malaysia, Fiji, and Bhutan, with plans for other countries to implement the program soon. Current research is being conducted to expand the program to include audits for family physicians, veterinarians, and remote indigenous communities, and for antifungal use.Disclosures: NoneFunding: None

scholarly journals Skin and soft tissue infections and current antimicrobial prescribing practices in Australian aged care residents

2019 ◽  
Vol 147 ◽  
Author(s):  
N. J. Bennett ◽  
N. Imam ◽  
R. J. Ingram ◽  
R. S. James ◽  
K. L. Buising ◽  
...  
Keyword(s):  
Soft Tissue ◽  
Negative Binomial ◽  
Inappropriate Prescribing ◽  
Aged Care ◽  
Soft Tissue Infections ◽  
Prescribing Practices ◽  
Antimicrobial Prescribing ◽  
Care Facilities ◽  
Stop Date ◽  
Aged Care Facilities

AbstractTo determine the burden of skin and soft tissue infections (SSTI), the nature of antimicrobial prescribing and factors contributing to inappropriate prescribing for SSTIs in Australian aged care facilities, SSTI and antimicrobial prescribing data were collected via a standardised national survey. The proportion of residents prescribed ⩾1 antimicrobial for presumed SSTI and the proportion whose infections met McGeer et al. surveillance definitions were determined. Antimicrobial choice was compared to national prescribing guidelines and prescription duration analysed using a negative binomial mixed-effects regression model. Of 12 319 surveyed residents, 452 (3.7%) were prescribed an antimicrobial for a SSTI and 29% of these residents had confirmed infection. Topical clotrimazole was most frequently prescribed, often for unspecified indications. Where an indication was documented, antimicrobial choice was generally aligned with recommendations. Duration of prescribing (in days) was associated with use of an agent for prophylaxis (rate ratio (RR) 1.63, 95% confidence interval (CI) 1.08–2.52), PRN orders (RR 2.10, 95% CI 1.42–3.11) and prescription of a topical agent (RR 1.47, 95% CI 1.08–2.02), while documentation of a review or stop date was associated with reduced duration of prescribing (RR 0.33, 95% CI 0.25–0.43). Antimicrobial prescribing for SSTI is frequent in aged care facilities in Australia. Methods to enhance appropriate prescribing, including clinician documentation, are required.

scholarly journals Factors associated with antimicrobial choice for surgical prophylaxis in Australia

2020 ◽  
Vol 2 (3) ◽  
Author(s):  
Courtney Ierano ◽  
Karin Thursky ◽  
Trisha Peel ◽  
Sonia Koning ◽  
Rod James ◽  
...  
Keyword(s):  
Broad Spectrum ◽  
Antimicrobial Prophylaxis ◽  
Generation Cephalosporin ◽  
Fourth Generation ◽  
Prosthetic Material ◽  
Prescribing Practices ◽  
Inappropriate Use ◽  
Antimicrobial Prescribing ◽  
Wide Range ◽  
Marginal Means

Abstract Background Cefazolin is the most commonly recommended antimicrobial for surgical antimicrobial prophylaxis (SAP). However, the Australian Surgical National Antimicrobial Prescribing Survey revealed a wide range of antimicrobials prescribed for SAP. Inappropriate use of broad-spectrum antimicrobials is associated with increased patient harm and is a posited driver for antimicrobial resistance. Objectives To describe patient, hospital and surgical factors that are associated with appropriateness of the top five prescribed antimicrobials/antimicrobial classes for procedural SAP. Methods All procedures audited from 18 April 2016 to 15 April 2019 in the Surgical National Antimicrobial Prescribing Survey were included in the analysis. Estimated marginal means analyses accounted for a range of variables and calculated a rate of adjusted appropriateness (AA). Subanalyses of the top five audited antimicrobials/antimicrobial classes identified associations between variables and appropriateness. Results A total of 12 419 surgical episodes with 14 150 prescribed initial procedural doses were included for analysis. When procedural SAP was prescribed, appropriateness was low (57.7%). Allergy status, surgical procedure group and the presence of prosthetic material were positively associated with cefazolin and aminoglycoside appropriateness (P < 0.05). There were no significant positive associations with glycopeptides and third/fourth-generation cephalosporins. The use of broad-spectrum antimicrobials was the most common reason for inappropriate choice (67.9% of metronidazole to 83.3% of third/fourth-generation cephalosporin prescriptions). Conclusions Various factors influence appropriateness of procedural SAP choice. Identification of these factors provides targets for antimicrobial stewardship interventions, e.g. procedures where surgeons are regularly prescribing broad-spectrum SAP. These can be tailored to address local hospital prescribing practices.

Creating the Wind

2020 ◽  
Vol 2 (4) ◽  
pp. 14-31
Author(s):  
Élodie Dupey García
Keyword(s):  
Indigenous Communities ◽  
The Body ◽  
Historical Sources ◽  
Natural Behavior ◽  
Sensory Experiences ◽  
Identity And Agency ◽  
Wide Range ◽  
Late Postclassic ◽  
Comparative Examination ◽  
Meteorological Phenomenon

This article explores how the Nahua of late Postclassic Mesoamerica (1200–1521 CE) created living and material embodiments of their wind god constructed on the basis of sensory experiences that shaped their conception of this divinized meteorological phenomenon. In this process, they employed chromatic and design devices, based on a wide range of natural elements, to add several layers of meaning to the human, painted, and sculpted supports dressed in the god’s insignia. Through a comparative examination of pre-Columbian visual production—especially codices and sculptures—historical sources mainly written in Nahuatl during the viceregal period, and ethnographic data on indigenous communities in modern Mexico, my analysis targets the body paint and shell jewelry of the anthropomorphic “images” of the wind god, along with the Feathered Serpent and the monkey-inspired embodiments of the deity. This study identifies the centrality of other human senses beyond sight in the conception of the wind god and the making of its earthly manifestations. Constructing these deity “images” was tantamount to creating the wind because they were intended to be visual replicas of the wind’s natural behavior. At the same time, they referred to the identity and agency of the wind god in myths and rituals.

scholarly journals “A good death but there was all this tension around”- perspectives of residential managers on the experience of delivering end of life care for people living with dementia

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Jessica A. L. Borbasi ◽  
Allison Tong ◽  
Alison Ritchie ◽  
Christopher J. Poulos ◽  
Josephine M. Clayton
Keyword(s):  
End Of Life ◽  
End Of Life Care ◽  
Aged Care ◽  
Care Staff ◽  
Care Homes ◽  
Residential Aged Care ◽  
Life Care ◽  
Advanced Dementia ◽  
Front Line ◽  
Care Managers

Abstract Background End of life care for residents with advanced dementia in the aged care setting is complex. There is prolonged and progressive cognitive decline, uncertain disease trajectory, significant symptom burden and infrequent access to specialist palliative care. Residential aged care managers offer a unique perspective in understanding the experience of providing end of life care for residents with advanced dementia. They bring insight from the coalface to the broader policy context. The aim of this study was to describe the experience and perspectives of residential aged care managers on providing end of life care for residents living with dementia. Methods Focus groups and semi-structured interviews were conducted with residential or care managers from various care homes from one dementia specific aged care organisation in Australia. A comprehensive sampling strategy was used in participating care homes. Transcripts were analysed using thematic analysis. Results 20 residential or care managers from 11 aged care homes in two states of Australia participated in two focus groups (total 16 participants) or individual interviews (4 participants). Six themes were identified: laying the ground work to establish what families understand about dementia, playing the peacemaker in the face of unrealistic family demands and expectations, chipping away at denial and cultivating a path towards acceptance of death, recruiting general practitioners as allies, supporting and strengthening the front line, and dedication to optimal care is relentless but rewarding. Conclusion Aged care manager participants described provision of end of life dementia care as a rewarding but sometimes fraught experience requiring persistent personalisation of care and communication to enable family acceptance of the resident’s terminal condition. The findings suggest that continuous front line aged care staff skill development, iterative family discussions, and partnership building between aged care staff and general practitioners, are all required to promote optimal end of life dementia care in residential aged care settings.

scholarly journals Antimicrobial stewardship in rural and remote primary health care: a narrative review

2021 ◽  
Vol 10 (1) ◽  
Author(s):  
Jun Wern Yau ◽  
Sze Mun Thor ◽  
Danny Tsai ◽  
Tobias Speare ◽  
Chris Rissel
Keyword(s):  
Health Care ◽  
Primary Health Care ◽  
Antimicrobial Resistance ◽  
Antimicrobial Stewardship ◽  
Inappropriate Prescribing ◽  
Narrative Review ◽  
Rural And Remote ◽  
Antimicrobial Prescribing ◽  
Primary Health ◽  
Resistance Rates

Abstract Background Antimicrobial resistance is an emerging problem worldwide and poses a significant threat to human health. Antimicrobial stewardship programmes are being implemented in health systems globally, primarily in hospitals, to address the growing threat of antimicrobial resistance. Despite the significance of primary health care services in providing health care to communities, antimicrobial stewardship programmes are not well established in this sector, especially in rural and remote settings. This narrative review aims to identify in rural and remote primary health care settings the (1) correlation of antimicrobial resistance with antibiotic prescribing and volume of antibiotic use, (2) appropriateness of antimicrobial prescribing, (3) risk factors associated with inappropriate use/prescribing of antibiotics, and (4) effective antimicrobial stewardship strategies. Methods The international literature was searched for English only articles between 2000 and 2020 using specified keywords. Seven electronic databases were searched: Scopus, Cochrane, Embase, CINAHL, PubMed, Ovid Medline and Ovid Emcare. Publication screening and analysis were conducted using Joanna Briggs Institute systematic review tools. Results Fifty-one eligible articles were identified. Inappropriate and excessive antimicrobial prescribing and use directly led to increases in antimicrobial resistance. Increasing rurality of practice is associated with disproportionally higher rates of inappropriate prescribing compared to those in metropolitan areas. Physician knowledge, attitude and behaviour play important roles in mediating antimicrobial prescribing, with strong intrinsic and extrinsic influences including patient factors. Antimicrobial stewardship strategies in rural and remote primary health care settings focus on health care provider and patient education, clinician support systems, utility of antimicrobial resistance surveillance, and policy changes. Results of these interventions were generally positive with decreased antimicrobial resistance rates and improved appropriateness of antimicrobial prescribing. Conclusions Inappropriate prescribing and excessive use of antimicrobials are an important contributor to the increasing resistance towards antimicrobial agents particularly in rural and remote primary health care. Antimicrobial stewardship programmes in the form of education, clinical support, surveillance, and policies have been mostly successful in reducing prescribing rates and inappropriate prescriptions. The narrative review highlighted the need for longer interventions to assess changes in antimicrobial resistance rates. The review also identified a lack of differentiation between rural and remote contexts and Indigenous health was inadequately addressed. Future research should have a greater focus on effective interventional components and patient perspectives.

Qualitative assessment of air pollution in the working area of energy-intensive materials production by nanoscale aerosols with a solid dispersed phase

2021 ◽  
Vol 61 (12) ◽  
pp. 828-832
Author(s):  
Boris N. Filatov ◽  
Natalya I. Latyshevskaya ◽  
Natalya V. Krylova ◽  
Irina K. Gorkina ◽  
Yulya I. Velikorodnaya ◽  
...  
Keyword(s):  
Air Pollution ◽  
Mass Concentration ◽  
Solid Phase ◽  
Qualitative Assessment ◽  
Dust Particles ◽  
Dispersed Phase ◽  
Forced Circulation ◽  
Aluminum Powders ◽  
Nanoscale Particles ◽  
Wide Range

The presence of grinding, mixing, and fractionation of solid components of formulations leads to the formation of aerosols in the air of the working area with a wide range of dispersion of the solid phase - all this characterizes the organization of technological processes for the production of energy-intensive materials. The study aims to give a qualitative assessment of possible air pollution of the working area of energy-intensive materials production by nanoscale aerosols with a solid dispersed phase. The researchers carried out the sampling of the working area air and flushes from solid horizontal surfaces to produce energy-intensive materials. We carried out the sampling by forced circulation of the test air through the absorption devices of Polezhaev. Scientists used Triton TX-114 solution with a mass concentration of 2.0 mg/dm3 as an absorption medium. The researchers performed flushing from surfaces using cloth tampons moistened with Triton TX-114 solution with a mass concentration of 2.0 mg/dm3. We determined the particle sizes in the samples using NanotracULTRA (Microtrac). Scientists found aluminum and nitrocellulose particles with sizes from 36 to 102 nm in the air of the working area and flushes from horizontal surfaces. The study of the fractional composition of RDX and aluminum powders of the ASD-1 brand showed the presence of nanoscale particles in them. Nanoscale dust particles pollute the air of the working area and solid horizontal surfaces at certain stages of the production of energy-intensive materials. There are nanoscale particles in the composition of powders of some standard components of formulations. Flushes from solid horizontal surfaces are an adequate qualitative indicator of the presence of nanoaerosols in the air of the working area.

Distribution of Wave Impact Forces From Breaking and Non-Breaking Waves

2009 ◽  
Author(s):  
Anne M. Fullerton ◽  
Thomas C. Fu ◽  
Edward S. Ammeen
Keyword(s):  
Free Surface ◽  
Wave Height ◽  
Breaking Waves ◽  
Qualitative Assessment ◽  
Total Force ◽  
Impact Loads ◽  
Wave Impact ◽  
Data Set ◽  
Wave Characteristics ◽  
Wide Range

Impact loads from waves on vessels and coastal structures are highly complex and may involve wave breaking, making these changes difficult to estimate numerically or empirically. Results from previous experiments have shown a wide range of forces and pressures measured from breaking and non-breaking waves, with no clear trend between wave characteristics and the localized forces and pressures that they generate. In 2008, a canonical breaking wave impact data set was obtained at the Naval Surface Warfare Center, Carderock Division, by measuring the distribution of impact pressures of incident non-breaking and breaking waves on one face of a cube. The effects of wave height, wavelength, face orientation, face angle, and submergence depth were investigated. A limited number of runs were made at low forward speeds, ranging from about 0.5 to 2 knots (0.26 to 1.03 m/s). The measurement cube was outfitted with a removable instrumented plate measuring 1 ft2 (0.09 m2), and the wave heights tested ranged from 8–14 inches (20.3 to 35.6 cm). The instrumented plate had 9 slam panels of varying sizes made from polyvinyl chloride (PVC) and 11 pressure gages; this data was collected at 5 kHz to capture the dynamic response of the gages and panels and fully resolve the shapes of the impacts. A Kistler gage was used to measure the total force averaged over the cube face. A bottom mounted acoustic Doppler current profiler (ADCP) was used to obtain measurements of velocity through the water column to provide incoming velocity boundary conditions. A Light Detecting and Ranging (LiDAR) system was also used above the basin to obtain a surface mapping of the free surface over a distance of approximately 15 feet (4.6 m). Additional point measurements of the free surface were made using acoustic distance sensors. Standard and high-speed video cameras were used to capture a qualitative assessment of the impacts. Impact loads on the plate tend to increase with wave height, as well as with plate inclination toward incoming waves. Further trends of the pressures and forces with wave characteristics, cube orientation, draft and face angle are investigated and presented in this paper, and are also compared with previous test results.

Anthropogenic climate change detected in natural and human systems of the world’s mountains

2021 ◽  
Author(s):  
Christian Huggel ◽  
Simon K. Allen ◽  
Indra D. Bhatt ◽  
Rithodi Chakraborty ◽  
Fabian Drenkhan ◽  
...  
Keyword(s):  
Climate Change ◽  
Water Resources ◽  
Climate Change Impacts ◽  
Indigenous Communities ◽  
Anthropogenic Climate Change ◽  
Future Climate Change ◽  
Mountain Regions ◽  
Wide Range ◽  
Mountain Systems ◽  
Human Systems

<p>Mountains cover about a quarter of the Earth’s land surface and are home to or serve a substantial fraction of the global population with essential ecosystem services, in particular water, food, energy, and recreation. While mountain systems are expected to be highly exposed to climate change, we currently lack a comprehensive global picture of the extent to which environmental and human systems in mountain regions have been affected by recent anthropogenic climate change.</p><p>Here we undertake an unprecedented effort to detect observed impacts of climate change in mountains regions across all continents. We follow the approach implemented in the IPCC 5<sup>th</sup> Assessment Report (AR5) and follow-up research where we consider whether a natural or human system has changed beyond its baseline behavior in the absence of climate change, and then attribute the observed change to different drivers, including anthropogenic climate change. We apply an extensive review of peer-reviewed and grey literature and identify more than 300 samples of impacts (aggregate and case studies). We show that a wide range of natural and human systems in mountains have been affected by climate change, including the cryosphere, the water cycle and water resources, terrestrial and aquatic ecosystems, energy production, infrastructure, agriculture, health, migration, tourism, community and cultural values and disasters. Our assessment documents that climate change impacts are observed in mountain regions on all continents. However, the explicit distinction of different drivers contributing to or determining an observed change is often highly challenging; particularly due to widespread data scarcity in mountain regions. In that context, we were also able to document a high amount of impacts in previously under-reported continents such as Africa and South America. In particular, we have been able to include a substantial number of place-based insights from local/indigenous communities representing important alternative worldviews.</p><p>The role of human influence in observed climate changes is evaluated using data from multiple gridded observational climate products and global climate models. We find that anthropogenic climate change has a clear and discernable fingerprint in changing natural and human mountain systems across the globe. In the cryosphere, ecosystems, water resources and tourism the contribution of anthropogenic climate change to observed changes is significant, showing the sensitivity of these systems to current and future climate change. Furthermore, our analysis reveals the need to consider the plurality of knowledge systems through which climate change impacts are being understood in mountain regions. Such attempts at inclusivity, which addresses issues of representation and justice, should be deemed necessary in exploring climate change impacts.</p>

Agroforestry: The North American Perspective

2021 ◽  
Author(s):  
Sarah T. Lovell ◽  
Harold E. "Gene" Garrett
Keyword(s):  
Alley Cropping ◽  
Indigenous Communities ◽  
Environmental Benefits ◽  
Forest Understory ◽  
Herbaceous Plants ◽  
Ecological Knowledge ◽  
Specialty Crops ◽  
Wide Range ◽  
Trees And Shrubs ◽  
Edible Products

Agroforestry has a long, rich history that is rooted in activities practiced by indigenous communities around the world. Native peoples were known to gather fruits, nuts, and understory herbs from the forest, based on their deep ecological knowledge of the natural system, and they often cultivated preferred species. For modern applications, agroforestry can be defined as the intentional integration of trees and shrubs with crops or livestock to create a multifunctional system with a wide range of benefits. In temperate regions, agroforestry is characterized by six key practices: (1) alley cropping—planting rows of trees with a companion crop grown between the rows; (2) forest farming—growing high-value specialty crops in the shaded forest understory; (3) riparian buffers—protecting water resources such as streams with a zone of trees, shrubs, and herbaceous plants; (4) silvopasture—combining trees, forage, and livestock for multiple products; (5) windbreaks—planting rows of trees and shrubs to protect crops or livestock from wind and to reduce soil erosion; and (6) urban food forests—integrating trees, shrubs, and herbaceous plants that provide edible products for the good of the community. The environmental benefits of agroforestry have been widely studied and continue to be a source of great interest. Most recently, the potential for agroforestry to contribute to climate change adaption and mitigation is being explored. While the science of agroforestry has been influenced to a great extent by the field of ecology and related disciplines, social science dimensions are increasingly captured through the study of adoption behaviors, preferences, and cultural benefits. The investigation of the role of economic and policy drivers is critical to understanding strategies to motivate landowners to adopt these practices at a level that would expand agroforestry into the mainstream. Landscape-level planning and design could provide a vision and a pathway for a broader transformation to a system that encourages perennial habitats including specialty crops that supply edible products. Such a strategy could place agroforestry more directly into the growing call to support regional food systems and positive human health outcomes. This article focuses on the trends and directions in agroforestry research primarily in North America, with emphasis on developments in the early 21st century.

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