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To determine the rate of healthcare personnel (HCP) glove or gown contamination with methicillin-resistant Staphylococcus aureus (MRSA) and to estimate which patient care interactions and HCP roles are associated with greater contamination.
Design:
Multicenter cohort study.
Setting:
Five Veterans Affairs medical centers in the United States.
Patients and participants:
Patients with a positive MRSA clinical or surveillance culture within the past 7 days were enrolled. Five HCP in the room were observed for each patient. After completion of tasks and prior to room exit, HCP gloves and gowns were cultured separately.
Results:
We enrolled 799 patients and obtained 3,832 glove and gown cultures. Contamination of HCP gloves or gown with MRSA occurred 713 of 3,832 (18.6%) of the time, while 589 of 3,832 (15.4%) of interactions resulted in contamination of gloves, and 319 of 3,831 (8.3%) of interactions resulted in contamination of gowns. The gloves and gowns of physical therapists and occupational therapists were most frequently contaminated. Any interactions that involved touching the patient resulted in glove or gown contamination in 622 of 2,901 (21.4%) of observations, while touching only the environment resulted contamination in 91 of 931 (9.8%) of observations. Rates of glove or gown contamination were similar in the intensive care unit (ICU) and non-ICU.
Conclusions:
Contamination of HCP gloves and gowns with MRSA occurs frequently when caring for Veteran patients particularly when there is direct patient contact. Hospitals may consider optimizing contact precautions by using fewer precautions for low-risk interactions and more precautions for high-risk interactions.
Background: Most people in the US lack access to infectious disease (ID) expertise, with 80% of counties lacking an ID physician. This is problematic as in-person ID consultation has been shown to improve clinical outcomes such as mortality with certain invasive infections, with Staphylococcus aureus bacteremia (SAB) as the paradigm. Telemedicine consultation has emerged as a tool to expand access in rural and underserved communities though its impact on clinical outcomes is less well established. This study characterizes the impact of a Tele-ID program in improving care for patients with SAB at a network of academic-affiliated rural hospitals that do not have access to in-person ID consultation. Methods: This was a retrospective cohort study of patients with SAB who were initially evaluated at 3 academic-affiliated rural hospitals between 7/1/22 and 6/30/24. A cohort of patients who received a Tele-ID consult was compared against a cohort that did not. The primary outcome was adherence to the standard of care for SAB, defined as documentation of clearance of blood cultures, receipt of an echocardiogram, and receipt of an appropriate course of antibiotics. Secondary outcomes included clinical outcomes such as mortality and readmission rates. Results: A total of 260 discrete episodes of SAB were screened for inclusion, with 122 episodes meeting inclusion criteria. Seventy five patients (61.5%) who received a Tele-ID consult were compared against 47 patients (38.5%) who did not. Patient characteristics were overall similar in these groups, though those receiving Tele-ID consultation were more likely to have end-stage renal disease (15% vs 0%, p < .01) and indwelling hardware (56% vs 21%, p < .01). Tele-ID consultation was associated with a higher likelihood of receiving standard of care for SAB (91% vs 15%, p < .01). This finding was consistent across all hospitals and among the individual components of the primary outcome. In addition, Tele-ID consultation was associated with significantly decreased SAB-related 30-day mortality (7 vs 24%, p < .01) and SAB-related 90-day mortality (8 vs 25%, p < .01). No significant difference was observed in rates of readmission or relapsed bacteremia. Conclusion: In this retrospective cohort study of 122 patients with SAB cared for in rural, academic-affiliated hospitals, Tele-ID consultation was associated with a significantly increased likelihood of receiving standard of care and decreased mortality. This data will inform policy at regional hospitals, such as supporting a mandatory ID consult for SAB and implementation of a SAB bundle.
In this chapter, we rely upon two experiments to demonstrate that the public withdraws acceptance of executive actions implemented through contravention – over the objection of a court – but only if that court has a high level of judicial independence. But, if executives contravene a low independence court, it is as if the court had not acted: there is no difference in the public’s level of acceptance. Additionally, we find no evidence in any of our quartet of countries that judicial approval improves the public’s acceptance of an executive’s policy. Contrary to fears that citizens may blindly follow courts and adjust their opinions based on a court’s ruling, we find no evidence that even widely-respected courts are able to increase citizens’ support for an executive action by endorsing it.
In this chapter, we examine how both variation in levels of judicial independence and in the partisanship of litigants affects citizens’ willingness to punish executives who ignore courts. We again test the partisanship-centered account against our theoretical framework. Leveraging the presence of abstract review in Germany, Poland, and Hungary, we demonstrate that judicial independence continues to be a prerequisite to judicial efficacy, even with the appearance of a discernible influence from partisanship. Our results in this chapter suggest that judicial review holds the promise – at least where courts have high levels of judicial independence – to constrain executives even in contexts where partisanship is heightened.
In this chapter, we examine the effects of judicial review across citizens. We find that, when courts enjoy high levels of judicial independence, their rulings’ efficacy is amplified among citizens who have a strong regard for the rule of law; when citizens have low levels of support for the rule of law, the effect of a court’s ruling is muted. For courts that lack judicial independence, even those citizens who hold the rule of law in the highest regard are unaffected by a court’s determination that that an executive’s behavior is unconstitutional. Additionally, we explain how the efficacy of judicial review varies based on the public’s approval of the executive whose policy the court reviews. Notably, we find that the public opinion constraint on executives comes from their supporters, not their opponents. These findings point to an important implication: political sympathy for the executive may not necessarily be the Achilles heel of judicial efficacy it is often portrayed to be.
This chapter ties together our theory and analyses to draw general conclusions and to chart the path for future research. We discuss the implications of our findings for the broad set of research areas we engage, including theories of judicial independence, models of executive unilateral action, and the relationship between the rule of law and democratic entrenchment. We highlight strengths and weaknesses of our findings and research design and suggest paths for other scholars to move this research forward. We see many additional opportunities to interrogate our theory and its implications in other places, on other issues, and in other settings to facilitate a broader understanding of when and how courts are efficacious.
This chapter presents our research design. First, in recognition of our theory’s emphasis on judicial independence, we select four cases – the United States, Germany, Hungary, and Poland – that vary in their levels of judicial independence but share important political, legal, and socio-economic characteristics. We use surveys of elites and the public to demonstrate that variation in judicial independence is observed by experts and citizens alike. Second, the chapter establishes the crucial role the COVID-19 pandemic plays in our research design. The global pandemic presented a unique and fleeting opportunity to probe citizens’ reactions to rule-of-law violations because it produced real threats to the rule of law in ways that were felt simultaneously and similarly around the world. Third, we discuss the benefits of using survey experiments for a study like ours. Finally, we introduce the four countries in detail, describing their general political characteristics, the institutional characteristics of their constitutional courts, and their handling of the pandemic.
Even where a public consensus exists about the appropriate bounds of constitutional action, citizens’ capacity to punish executive overreach is not guaranteed. People often lack information about possible constitutional transgressions, and imposing meaningful political penalties for overreach requires coordinated action among citizens. We argue that courts are key to overcoming these obstacles: under the right conditions, courts, through the use of judicial review, are uniquely positioned to alert the public of constitutional transgressions and thereby transform the public’s support for the rule of law into a guardrail against executive overreach. We suggest judicial independence enhances the ability of courts to signal that an executive has gone too far. By contrast, courts with low levels of judicial independence are impotent: their decisions are not credible enough to affect citizens’ attitudes. We also expect the rulings of independent courts to be most effective among citizens who have a high level of support for the rule of law and to persist even in the face of stark partisan polarization.
We open the book by discussing the rise of constitutional courts and judicial review, emphasizing their stated responsibility as guardians of the constitutional system. We discuss existing theories of judicial power and independence, highlighting the concept of judicial efficacy: the ability of courts to create political penalties for elites who fail to abide by the constitutional limits on their authority. We discuss different types of penalties courts might levy and explain why attitudinal costs – particularly a loss of public support – represent the cornerstone of judicial efficacy. We then provide a summary of our argument, contrasting our theory of judicial efficacy with existing accounts of judicial power and impact. The chapter concludes with a roadmap for the rest of the book and a summary of our key findings.
Does partisanship undermine the ability of courts to affect citizens’ attitudes? We introduce a dueling theoretical account to our own which suggests that citizens prioritize partisanship over constitutional rules when evaluating executive actions. We test these rival perspectives in Germany and the United States with a survey experiment that leverages the countries’ federal structures. We find that citizens of both countries are remarkably steadfast in their willingness to punish executives – including copartisans – for breaching constitutional limits and flouting court orders. Contrary to fears that partisanship is an overwhelmingly pernicious threat to the rule of law, we show that independent courts are resilient in their ability to cut through the binds of partisanship, to monitor executives, and coordinate public actions to reign in incumbent excess.