bluuebunny/crossref_metadata_2025 huggingface dataset:
Model Input and Optimization: Improving the Speed and Accuracy of Our COVID-19 Hospitalization Forecasts
Authors: Rhea Sarah , Hadley Emily , Jones Kasey , Preiss Alexander , Stoner Marie , Kery Caroline , Baumgartner Peter , Giarrocco Alex
Published: November 2021

Background: During the COVID-19 pandemic, public-health decision makers have increasingly relied on hospitalization forecasts that are routinely provided, accurate, and based on timely input data to inform pandemic planning. In North Carolina, we adapted an existing agent-based model (ABM) to produce 30-day hospitalization forecasts of COVID-19 and non–COVID-19 hospitalizations for use by public-health decision makers. We sought to continually improve model speed and accuracy during forecasting. Methods: The geospatially explicit ABM included movement of agents (ie, patients) among 104 short-term acute-care hospitals, 10 long-term acute-care hospitals, 421 licensed nursing homes, and the community in North Carolina. Agents were based on a synthetic population of North Carolina residents (ie, >10.4 million agents). We assigned SARS-CoV-2 infections to agents according to county-level susceptible, exposed, infectious, recovered (SEIR) models informed by reported COVID-19 cases by county. Agents’ COVID-19 severity and probability of hospitalization were determined using agent-specific characteristics (eg, age, comorbidities). During May 2020–December 2020, we produced weekly 30-day forecasts of intensive care unit (ICU) and non-ICU bed occupancy for COVID-19 agents and non–COVID-19 agents statewide and by region under a range of SARS-CoV-2 effective reproduction numbers. During the reporting period, we identified optimizations for faster results turnaround. We evaluated the incorporation of real-time hospital-level occupancy data at model initialization on forecast accuracy using mean absolute percent error (MAPE). Results: During May 2020–December 2020, we provided 31 weekly reports of 30-day hospitalization forecasts with a 1-day turnaround time. Reports included (1) raw and smoothed 7-day average values for 42 model output variables; (2) static visuals of ICU and non-ICU bed demand and capacity; and (3) an interactive Tableau workbook of hospital demand variables. Identifying code efficiencies reduced a single model runtime from ~100 seconds to 28 seconds. The use of cloud computing reduced simulation runtime from ~20 hours to 15 minutes. Across forecasts, the average MAPEs were 21.6% and 7.1% for ICU and non-ICU bed demand, respectively. By incorporating hospital-level occupancy data, we reduced the average MAPE to 6.5% for ICU bed demand and 3.9% for non-ICU bed demand, indicating improved accuracy. Conclusions: We adapted an ABM and continually improved it during COVID-19 forecasting by optimizing code and computing resources and including real-time hospital-level occupancy data. Planned SEIR model updates for enhanced forecasts include the addition of compartments for undocumented infections and recoveries as well as permission of reinfection from recovered compartments.

Funding: No

Disclosures: None
Retrospective Study on Personal Protective Equipment During Pandemic Link to Outbreak of Carbpenem-Resistant Enterobacteriace
Authors: Evans Kenisha , LeRose Jennifer , Beatriz Cruz Angela , Jabbo Lavina , Chopra Teena
Published: November 2021

Background: In 2019, according to the Centers for Disease Control and Prevention, carbapenem-resistant Enterobacteriaceae (CRE), had cost the lives of >35,000 patients, particularly the most virulent plasmid-mediated New Delhi metallo-β-lactamase (NDM). Although healthcare systems normally have strict surveillance and infection control measures for CRE, the rapid emergence of novel SAR-CoV-2 and COVID-19 led to a shortage of personal protective equipment (PPE) and medical supplies. As a result, routine infection practices, such as contact precautions, were violated. Studies have shown this depletion and shift in resources compromised the control of infections such CRE leading to rising horizontal transmission. Method: A retrospective study was conducted at a tertiary healthcare system in Detroit, Michigan, to determine the impact of PPE shortages during the COVID-19 pandemic on NDM infection rates. The following periods were established during 2020 based on PPE availability: (1) pre-PPE shortage (January–June), (2) PPE shortage (July–October), and (3) post-PPE shortage (November–December). Rates of NDM per 10,000 patient days were compared between periods using the Wilcoxon signed rank-sum test. Isolates were confirmed resistant by NDM by molecular typing performed by the Michigan State Health Department. Patient characteristics were gathered by medical chart review and patient interviews by telephone. Results: Overall, the average rate of NDM infections was 1.82 ±1.5 per 10,000 patient days. Rates during the PPE shortage were significantly higher, averaging 3.6 ±1.1 cases per 10,000 patient days (P = .02). During this time, several infections occurred within patients on the same unit and/or patients with same treating team, suggesting possible horizontal transmission. Once PPE stock was replenished and isolation practices were reinstated, NDM infection rates decreased to 0.77 ±1.1 per 10,000 patient days. Conclusion: Control of CRE requires strategic planning with active surveillance, antimicrobial constructs, and infection control measures. The study illustrates that in times of crisis, such as the COVID-19 pandemic, the burden of effective infection control requires much more multidisciplinary efforts to prevent unintentional lapses in patient safety. A swift response by the state and local health departments at a tertiary-care healthcare center conveyed a positive mitigation of the highest clinical threats and decreased horizontal transmission of disease.

Funding: No

Disclosures: None
Assessing Robustness of Antimicrobial Stewardship in Colorado Hospitals and Barriers to Improvement
Authors: Dodson Daniel , Kronman Matthew , Parker Sarah , Czaja Christopher
Published: November 2021

Background: Adherence to core elements of antimicrobial stewardship programs (ASPs) is increasing nationally but the robustness of programs and inclusion of pediatrics is poorly understood. We describe the details of ASP in Colorado hospitals and identify steps by which academic centers and public health departments can assist community ASPs. Methods: We invited ASP leaders at the 102 acute-care hospitals (ACHs) and critical-access hospitals (CAHs) in Colorado to participate in a web-based survey regarding their ASPs. Questions related to adherence to Centers for Disease Control and Prevention (CDC) core elements, barriers to improvement, desired resources, and extension to pediatrics. Enrollment began in August 2020. Hospital types were compared using the Fisher exact test. Results: As of January 1, 2021, 31 hospitals (30% of targeted hospitals) completed the web-based survey including 19 ACH and 12 CAH. Hospitals were distributed across the state. Median number of beds was 52 (range, 11–680). Of the responding hospitals, 87% were adherent to all CDC core elements. However, if action was defined as prospective audit and feedback or prior authorization, tracking was defined as measuring antibiotic use in days of therapy (DOT) or defined daily dose (DDD) quarterly, and reporting was defined as providing unit- or provider-specific antibiotic use reports annually. Overall adherence fell to 35% including 81% for action, 58% for tracking, and 58% for reporting. CAHs were less likely to adhere to these strict criteria than ACHs (Figure 1). In the 27 hospitals (87% of hospitals) caring for pediatric patients, adherence to a strict action for at least 1 pediatric population was 59%. Reported barriers to improved ASP were available time and personnel, information technology support, perceived concerns about provider attitudes, and education gaps (Figure 2). CAHs were less likely to use the NHSN antibiotic use or resistance modules or have a data analyst than ACHs (Figure 3). Pediatric pharmacy expertise and guidelines were often not available in hospitals caring for pediatric patients. Desired ASP resources included assistance with data analysis, access to stewardship expertise and education, and treatment guidelines, including for pediatrics. Conclusions: Adherence to CDC core elements of an ASP was excellent but fell dramatically when stricter criteria were used and was worse in pediatric patients. Academic centers and public health departments can assist community hospitals by providing educational resources, assistance in analyzing data including using the NHSN ED: /AR modules, and ASP expertise and clinical care guidelines including those for pediatrics.

Funding: No

Disclosures: None
Interrupted Time-Series Analysis to Evaluate the Impact of a Behavioral Change Outpatient Antibiotic Stewardship Intervention
Authors: Morgan Brittany , May Larissa , Bettencourt Haylee
Published: November 2021

Background: The Centers for Disease Control and Prevention (CDC) estimates that outpatient settings account for 85%–90% of antibiotic prescriptions in the United States, and ~30% of those prescriptions are unnecessary. One of the most common examples of inappropriate prescribing is for viral upper respiratory infections (URIs). Up to 50% of prescriptions written for URIs are deemed inappropriate, making it an important focus for Antibiotic Stewardship programs. In this study, we evaluated the effect of a behaviorally enhanced quality improvement intervention in reducing inappropriate antibiotic prescribing for viral URIs. Methods: A quasi-experimental study assessed the effects of an Antibiotic Stewardship intervention on antibiotic prescribing for viral URIs. The outcome of interest was a change in the number of antibiotics prescribed at each participating clinic over a 1-year preimplementation period and a 2-year postimplementation period. Time trends were analyzed using segmented regression analysis, and a stepped wedge design was used to account for intervention roll-out across clinics. Results: From 2017 to 2020, there were 63,028 patient visits in 21 clinic locations. Antibiotics were prescribed an average of 11.5% and 5.8% of visits during the pre- and postimplementation periods, respectively. The most frequently prescribed antibiotic over the study period was azithromycin (n = 3,551), followed by amoxicillin (n = 924). Overall, the intervention was associated with a 46% reduction in antibiotic prescriptions or 0.54 times (P = .001) as many inappropriate antibiotics prescribed as before the intervention. There was no significant change in the month-to-month trend in inappropriate prescriptions after the intervention was implemented (P = .87). Conclusions: Our study demonstrates that a behaviorally enhanced quality improvement intervention to reduce inappropriate prescribing for URI in ambulatory care encounters was successful in reducing potentially inappropriate prescriptions for presumed viral respiratory infections.

Funding: No

Disclosures: None
Suspected COVID-19 Reinfections at a Tertiary Care Center, Iowa 2020
Authors: Kobayashi Takaaki , Alsuhaibani Mohammed , Ortiz Miguel , Imborek Katherine , Holley Stephanie , Trannel Alexandra , Marra Alexandre , Etienne William , Jenn Kyle , Abosi Oluchi , Meacham Holly , Sheeler Lorinda , Dains Angie , Kukla Mary , McCray Paul , Perlman Stanley , Ford Bradley , Diekema Daniel , Wellington Melanie , Pezzulo Alejandro , Salinas Jorge
Published: November 2021

Background: Coronavirus disease 2019 (COVID-19) is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). SARS-CoV-2 RNA can be detected by real-time reverse-transcription polymerase chain reaction (RT-PCR) for several weeks after infection. Discerning persistent RT-PCR positivity versus reinfection is challenging and the frequency of COVID-19 reinfections is unknown. We aimed to determine the frequency of clinically suspected reinfection in our center and confirm reinfection using viral whole-genome sequencing (WGS). Methods: The University of Iowa Hospitals and Clinics (UIHC) is an 811-bed academic medical center. Patients with respiratory complaints undergo COVID-19 RT-PCR using nasopharyngeal swabs. The RT-PCR (TaqPath COVID-19 Combo kit) uses 3 targets (ORF1ab, S gene, and N gene). We identified patients with previous laboratory-confirmed COVID-19 who sought care for new respiratory complaints and underwent a repeated SARS-CoV-2 test at least 45 days from their first positive test. We then identified patients with median RT-PCR cycle threshold (Ct) values. Results: During the study period, 13,603 patients had a SARS-CoV-2– positive RT-PCR. Of these, 296 (2.2%) had a clinical visit for new onset of symptoms and a repeated RT-PCR assay >45 days from the first test. Moreover, 29 patients (9.8%) had a positive RT-PCR assay in the repeated testing. Ct values were available for samples from 25 patients; 7 (28%) had Ct values. Conclusions: In patients with a recent history of COVID-19 infection, repeated testing for respiratory symptoms was infrequent. Some had a SARS-CoV-2–positive RT-PCR assay on repeated testing, but only 1 in 4 had Ct values suggestive of a reinfection. We confirmed 1 case of reinfection using WGS.

Funding: No

Disclosures: None
Identification of Risk Factors for Invasive Extraintestinal Pathogenic Escherichia coli (ExPEC) Disease
Authors: Clarke Erik , Geurtsen Jeroen , Spiessens Bart , Chehoud Christel
Published: November 2021

Background: A pathogenic group of invasive extraintestinal pathogenic (ExPEC) Escherichia coli possess the ability to infect normally sterile body sites and cause severe invasive ExPEC disease (IED). ExPEC is a leading cause of bacteremia and sepsis worldwide and is associated with older age and multidrug-resistant infections. Janssen Vaccines & Prevention is developing a novel multivalent glycoconjugate vaccine to prevent IED. We aimed to use an unbiased approach, with no prespecified potential risk factors, using machine-learning models, to screen for and identify IED risk factors for further validation. Methods: We used a patient-level prediction study design to model the probability of a patient developing IED within 14 days to 1 year from a given date based on their prior 2 years of health records. We used the Optum EHR database (~98 million subjects) in the common data model (CDM) format, with health features encoded in the following categories: conditions, procedures, drugs, healthcare visits, recent laboratory measurements, and age and gender. A gradient boosting model (XGBoost) was used with Shapley additive explanation (SHAP) values to identify which features were most important to the model’s decisions and to characterize precisely the relationship between features and outcomes (binary or continuous). Results: Study participants were aged ≥60 years at index with no previously recorded IED. Of ~6,500,000 cases included, ~8,000 had IED during the prediction window. We found that having ≥1 urinary tract infection (UTI) in the retrospective period increased the model’s probability of predicting IED for that patient, with more frequent or more recent UTIs increasing IED prediction chance (Figure 1). Higher age linearly increased the model’s likelihood of predicting that a patient would develop IED. The model also identified ≥1 inpatient or ER visit and laboratory values indicative of renal or immune dysfunction to be correlated with increased IED risk. This methodology is a generalizable approach to screening for potential risk factors for an outcome using EHR databases; it requires little to no prespecification of the health factors or precise relationship between the factors and outcome. Conclusions: Using a new, impartial methodology (with no prespecification), older age and a history of UTIs were key predictive features for IED, factors previously identified through traditional analysis, confirming the validity of the methodology. Novel features, including recent hospitalization, were shown to increase IED risk relative to existing criteria. Our findings may be used to inform the clinical development of preventive strategies.

Funding: Janssen Research and Development

Disclosures: None
A Cluster of Coronavirus Disease 2019 (COVID-19) Cases on an Inpatient Hospital Unit Involving Multiple Modes of Transmission
Authors: Witherspoon Kelsey , Haden Michael , Smyer Justin , Flaherty Jennifer , Smith Heather , Colburn Nora , Liscynesky Christina , Allen James , Day Shandra
Published: November 2021

Background: The Ohio State University Wexner Medical Center identified a cluster of coronavirus disease 2019 (COVID-19) cases on an inpatient geriatric stroke care unit involving both patients and staff. The period of suspected severe acute respiratory coronavirus virus 2 (SARS-CoV-2) transmission and exposure on the unit was December 20, 2020, to January 1, 2021, with some patients and staff developing symptoms and testing positive within the 14 days thereafter. Methods: An epidemiologic investigation was conducted via chart review, staff interviews, and contact tracing to identify potential patient and staff linkages. All staff who worked on the unit were offered testing regardless of the presence of symptoms as well as all patients admitted during the outbreak period. Results: In total, 6 patients likely acquired COVID-19 in the hospital (HCA). An additional 6 patients admitted to the unit during the outbreak period subsequently tested positive but had other possible exposures outside the hospital (Fig. 1). One patient failed to undergo COVID-19 testing on admission but tested positive early in the cluster and is suspected to have contributed to patient to employee transmission. Moreover, 32 employees who worked on the unit in some capacity during this period tested positive, many of whom became symptomatic during their shifts. In addition, 18 employees elected for asymptomatic testing with 3 testing positive; these were included in the total. Some staff also identified potential community exposures. Additionally, staff reported an employee who was working while symptomatic with inconsistent mask use (index employee) early in the outbreak period. The index employee likely contributed to employee transmission but had no direct patient contact. Our epidemiologic investigation ultimately identified 12 employees felt to be linked to transmission based on significant, direct patient care provided to the patients within the outbreak period (Fig. 1). In addition, 3 employees had an exposure outside the hospital indicating likely community transmission. Conclusions: Transmission was felt to be multidirectional and included employee-to-employee, employee-to-patient, and patient-to-employee transmission in the setting of widespread community transmission. Interventions to stop transmission included widespread staff testing, staff auditing regarding temperature and symptom monitoring, and re-education on infection prevention practices. Particular focus was placed on appropriate PPE use including masking and eye protection, hand hygiene, and cleaning and disinfection practices throughout the unit. SARS-CoV-2 admission testing and limited visitation remain important strategies to minimize transmission in the hospital.

Funding: No

Disclosures: None
Adherence to Antibiotic Stewardship Program Associated with Shorter Course of Treatment and Fewer Adverse Events
Authors: Mulligan Patrick , Shah Nirav , Acree Mary , Grant Jennfer , Ravichandran Urmila , Ismail Nader
Published: November 2021

Group Name: NorthShore University HealthSystem

Background: Prolonged antibiotic use has been attributed to an increased incidence of adverse drug events (ADEs). Cessation of unnecessary antibiotics would decrease length of treatment and may help prevent these adverse events. We evaluated whether an antibiotic stewardship intervention aimed at stopping unnecessary antibiotic usage would both shorten the duration of treatment and reduce ADEs. Methods: At NorthShore University HealthSystem, a 4-hospital, 832-bed system, we identified patients who were started on empiric antibiotics during a hospital admission between May 2, 2016, and June 30, 2018. Within 24 hours of antibiotic initiation, an infectious disease (ID) physician reviewed each patient chart. If the patient was unlikely to have a symptomatic bacterial infection, the ID physician left a note in the electronic medical record (EMR) recommending antibiotic cessation. Two physician reviewers retrospectively reviewed whether the treatment team accepted these recommendations and assessed potential ADEs for 30 days after the recommendation through inpatient and outpatient notes in the EMR. These ADEs were defined using previously published criteria. If the 2 reviewers disagreed on the presence of an ADE, an ID physician acted as the tie breaker. We compared the number of antibiotic days and the number of ADEs between cases in which the recommendations were followed and cases in which they were not. Results: We reviewed 168 cases: 78 (46.43%) followed recommendations and 90 (53.57%) did not. There were no significant differences in baseline patient characteristics between the 2 groups. There was a significant difference in total ADEs between the 2 groups: in 6 cases (7.69%) the recommendations were followed, and 21 (23.33%) they were not followed (P = .011). There was also a significant difference in antibiotic days between cases in which recommendations were followed (1.40 days) versus those in which they were not followed (1.99 days) (p < 0.001). Conclusions: Antibiotic-associated adverse events can cause harm to patients and increase healthcare costs, particularly when used for patients who are unlikely to have a bacterial infection. An antibiotic stewardship program to identify patients in an EMR who are unlikely to benefit from antibiotic use can decrease the length of total antibiotic usage and help prevent adverse events.

Funding: No

Disclosures: None
Automation of Healthcare-Associated Infections (HAIs) Areas for Opportunity Through the Use of Technology
Authors: Pearson Meri
Published: November 2021

Background: A large healthcare system in Georgia implemented an enhanced electronic infection surveillance system that is incorporated into the electronic medical record (EMR). Prior to the implementation of this electronic infection surveillance system, the infection prevention (IP) team performed healthcare-associated infection (HAI) surveillance through a locally created system that did not interface with their EMR. Each HAI identified undergoes a robust analysis for opportunities depending on the infection type by manual abstraction from the EMR, which is stored in a spreadsheet. One disadvantage of this spreadsheet is that only 1 person can enter data at a time. The coronavirus disease 2019 (COVID-19) pandemic has presented many challenges for healthcare facilities including shifting resources from HAI prevention programs. These programs include the investigations performed to identify risk factors that can aid in preventing future infections. Due to the necessity to increase efficiency in the current pandemic, the IP team proposed using technology to automate our HAI investigation process. Method: The IP team and the business intelligence (BI) team met to determine whether data completed in the electronic infection surveillance system could flow into an interactive data visualization software that is currently used for other HAI prevention dashboards. The existing spreadsheet was reviewed to select variables essential for HAI investigations and for which the data existed in the EMR. The BI team worked to find the correct data tables within the EMR so that the data could automatically refresh daily in the data visualization software. Result: The BI team was able to correctly identify variables used in the previously manual HAI investigation process within the EMR to interface with the data visualization software. This automation of investigations allows quick analysis of trends and areas of opportunity to prevent future HAIs. Conclusion: This utilization of technology can be applied to other healthcare facilities with similar software systems to streamline IP workflows. The automation of quickly and efficiently recognizing areas of opportunity allows IPs more time to facilitate the prevention of HAIs in other ways.

Funding: No

Disclosures: None
Antimicrobial Stewardship Standards and Patient Safety: A Case Study in Blood Culture Contamination
Authors: Schaefer Connie
Published: November 2021

Background: Blood culture is a crucial diagnostic tool for healthcare systems, but false-positive results drain clinical resources, imperil patients with an increased length of stay (and associated hospital-acquired infection risk), and undermine global health initiatives when broad-spectrum antibiotics are administered unnecessarily. Considering emerging technologies that mitigate human error factors, we questioned historically acceptable rates of blood culture contamination, which prompted a need to promote and trial these technologies further. In a 3-month trial, 3 emergency departments in a midwestern healthcare system utilized an initial specimen diversion device (ISDD) to draw blood cultures to bring their blood culture contamination rate (4.4% prior to intervention) below the 3% benchmark recommended by the Clinical & Laboratory Standards Institute. Methods: All emergency department nursing staff received operational training on the ISDD for blood culture sample acquisition. From June through August 2019, 1,847 blood cultures were drawn via the ISDD, and 862 were drawn via the standard method. Results: In total, 16 contamination events occurred when utilizing the ISDD (0.9%) and 37 contamination events occurred when utilizing the standard method (4.3%). ISDD utilization resulted in an 80% reduction in blood culture contamination from the rate of 4.4% rate held prior to intervention. Conclusions: A midwestern healthcare system experienced a dramatic reduction in blood culture contamination across 3 emergency departments while pilot testing an ISDD, conserving laboratory and therapeutic resources while minimizing patient exposure to unnecessary risks and procedures. If the results obtained here were sustained and the ISDD utilized for all blood culture draws, nearly 400 contamination events could be avoided annually in this system. Reducing unnecessary antibiotic use in this manner will lower rates of associated adverse events such as acute kidney injury and allergic reaction, which are possible topics for further investigation. The COVID-19 pandemic has recently highlighted both the importance of keeping hospital beds available and the rampant carelessness with which broad-spectrum antibiotics are administered (escalating the threat posed by multidrug-resistant organisms). As more ambitious healthcare benchmarks become attainable, promoting and adhering to higher standards for patient care will be critical to furthering an antimicrobial stewardship agenda and to reducing treatment inequity in the field.

Funding: No

Disclosures: None
Clostridioides difficile Is Not Difficult to Predict in Hospital Settings
Authors: Alexander Kinta , Petersen Frances , Brown Sean
Published: November 2021

Background:Clostridioides difficile is a gram-positive bacteria that is the most common cause of hospital-associated infectious diarrhea among traditional and nontraditional high-risk populations. Excess healthcare costs associate with C. difficile infection (CDI) prevalence, morbidity, and mortality is shown to economically impact the US healthcare system with at least an additional $1 billion in annual cost. Exposure to antimicrobial agents resulted in increased risk for hospital-onset CDI (HO-CDI) at an inner-city hospital during 2010 and 2011. Methods: A retrospective case-control study of all persons with HO-CDI in the MICU was conducted at an inner-city hospital between January 1, 2010, and December 31, 2011. A patient was considered to have developed HO-CDI if diarrhea developed after 72 hours of admission into the MICU and a confirmed laboratory stool specimen for Clostridioides difficile infection (CDI) was obtained. A non–HO-CDI person was randomly selected using “risk set sampling.” After the application of inclusion and exclusion criteria, 88 cases were eligible for the study. Of these cases, 29 met the definition for HO-CDI, and 59 met the definition for non–HO-CDI. The relationship between antimicrobial use and the development of HO-CDI in patients in the MICU at an inner-city hospital was investigated using a logistic regression model in which the variable of total antibiotics was used as a possible predictor for predicting a positive HO-CDI. Results: Logistic regression was utilized to determine the relationships between selected study variables and presence or absence of HO-CDI. Total antibiotics was significantly related to HO-CDI. The results of this analysis showed that total antibiotics was a significant predictor for HO-CDI. The total value of the coefficient B for this predictor was 0.47, and the exponentiated value (exp[B]) of this coefficient was 1.60 (95% CI, 1.08–2.35). In this sample, patients who had 1 or more antibiotics were at a 60% greater risk of having a positive HO-CDI culture. There was a significant association between the use of metronidazole and HO-CDI (p < .001). Conclusions: Antimicrobial stewardship is an integral part of patient safety. The findings from this study were instrumental in the implementation of a fledging antimicrobial stewardship program and the use of evidence-based practices at this inner-city hospital.

Funding: No

Disclosures: None
Inequities in CLABSI Rates in a Children’s Hospital by Race, Ethnicity, and Language Preference
Authors: McGrath Caitlin , Kronman Matthew , Zerr Danielle , Bettinger Brendan , Coker Tumaini , Bell Shaquita
Published: November 2021

Background: Systemic racism results in health inequities based on patient race, ethnicity, and language preference. Whether these inequities exist in pediatric central-line–associated bloodstream infections (CLABSIs) is unknown. Methods: This retrospective cohort study included patients with central lines hospitalized from October 2012 to June 2019 at our tertiary-care children’s hospital. Self-reported race, ethnicity, language preference, demographic, and clinical factors were extracted from the electronic health record. The primary outcome was non–mucosal barrier injury (non-MBI) CLABSI episodes as defined by the NHSN. CLABSI rates between groups were compared using χ2 tests and Cox proportional hazard regression. We adjusted for care unit, age, immunosuppressed status, diapered status, central-line type, line insertion within 7 days, daily CLABSI maintenance bundle compliance, number of blood draws and IV medication doses, and need for total parental nutrition, extracorporeal membrane oxygenation, and renal replacement therapy. In mid-2019, we engaged stakeholders in each care unit to describe preliminary findings and to identify and address potential drivers of observed inequities. Results: We included 337 non-MBI CLABSI events over 230,699 central-line days (CLDs). The overall non-MBI CLABSI rate during the study period was 1.46 per 1,000 CLDs. Unadjusted CLABSI rates for black or African American (henceforth, “black”), Hispanic, non-Hispanic white, and Asian (the 4 largest race or ethnicity groups by CLDs) patients were 2.74, 1.53, 1.42, 1.24 per 1,000 CLDs, respectively (P < .001) (Table 1). Unadjusted CLABSI rates for patients with limited-English proficiency (LEP) and English-language preference were 1.98 and 1.38 per 1,000 CLDs, respectively (P = .014). After adjusting for covariates, the hazard ratio (HR) point estimate for CLABSI rate remained higher for black patients (HR, 1.50; 95% CI, 0.99–2.28) and patients with LEP (HR, 1.33; 95% CI, 0.87–2.05), compared to the reference group based on largest CLD. The differences in CLABSI rate by race or ethnicity and language were more pronounced in 2 of our 6 care units. Stakeholder engagement and analysis of hospital data revealed opportunities on those units for improved (1) interpreter utilization and (2) line maintenance observation practices by race/ethnicity and language preference (data not shown). These findings and CLABSI rates over time by race/ethnicity and language preference (Figures 1 and 2) were shared with frontline staff. Conclusions: In our children’s hospital, CLABSI rates differed based on patients’ self-reported race, ethnicity, and language preference, despite controlling for factors commonly associated with CLABSI. Identifying inequities in CLABSI rates and mitigating their determinants are both essential to the goal of achieving equitable care.

Funding: No

Disclosures: None
Using a Quality-Driven Approach to Maintain an N-95 Respirator Supply During a Pandemic-Driven Global Shortage
Authors: Selimos Amy , Buchanan Mark , DiBiase Lauren , Dean Stephen , Boone Pat , Shaheen Nicholas , Sickbert-Bennett Vavalle Emily , Willis Beth
Published: November 2021

Background: Reports of hospitals overwhelmed by COVID-19 patients created severe shortages of personal protective equipment (PPE). In this large academic medical system, we used a systematic team approach to proactively maintain an adequate PPE supply. The team consisted of staff from multiple departments including infection prevention, environmental health and safety, operational efficiency, and supply chain. The healthcare system solicited donations of PPE, and our team was tasked with developing a sustainable method to provide healthcare workers with safe and effective N-95 respirators. Respirators are normally fitted to our 6,000+ healthcare workers through a fit-testing process using 4 models of N-95s. We received >60 models, many in small quantities, posing a new level of complexity that prevented use of our typical fit-testing method. Methods: Donated respirators were manually verified on the CDC/NIOSH website to validate approval or approved alternative. A categorization system was developed, and respirators were sorted based on quality, style, and condition. User seal checks replaced qualitative fit testing due to the uncertain and quickly changing respirator supply. Staff were educated about the importance of performing a seal check to evaluate respirator fit and were provided instructions for what to do if they failed a seal check. We performed limited quantitative fit testing on a small group previously fit tested to 1 of the 4 models of N-95s normally stocked to identify the most effective alternative respirators to serve as substitute N-95s. Results: We were able to provide staff with new N-95s and delay the release of reprocessed N-95s. Overall, 18 models of respirators were tested on staff for filtration effectiveness and fit. We deemed 61% masks to be of last resort, and these were not released. We determined that 39% were acceptable as an alternative for at least 1 of our usual respirator models. However, only 3 models (17%) available in small quantities fit wearers whose size was in shortest supply. This scarcity led to the evaluation and purchase of a new respirator prototype for small N-95 wearers, which was an important success of our team’s work and for staff safety. Conclusions: Collaboration between teams from a variety of backgrounds, using both qualitative and quantitative data, resulted in a sustainable method for receiving, sorting, and evaluating donated N-95 respirators, ensuring the delivery of a steady supply of effective N-95 respirators to our staff. This quality-driven approach was an efficient and effective strategy to maintain our N-95 respirator supply during a pandemic driven global shortage.

Funding: No

Disclosures: None
Cost of Personal Protective Equipment During the First Wave of COVID-19
Authors: Mena Lora Alfredo , Ali Mirza , Spencer Sherrie , Takhsh Eden , Krill Candice , Bleasdale Susan
Published: November 2021

Background: As the world prepared for and responded to the COVID-19 pandemic in early 2020, a rapid increase in demand for personal protective equipment (PPE) led to severe shortages worldwide. Acquisition of PPE in the general market was an integral part of pandemic response, along with the safeguarding of hospital supplies. We seek to quantify the difference in cost per unit (CPU) of PPE during the first wave of COVID-19 compared to prepandemic prices. Methods: We performed a retrospective review of market prices for PPE during the first surge of the pandemic in Chicago. Cost of PPE was tabulated and compared with prepandemic prices. The maximum cost per unit (CPU) of PPE was tabulated for each week, and the average cost throughout the pandemic was calculated. Disposable gowns, washable gowns, N95 respirators, face masks, and gloves were included in our analysis. Results: PPE prices were significantly higher during the pandemic compared to prepandemic prices (Figure 1). Disposable gown CPU peaked at $12 during the first week of March, 13.7 times higher than prepandemic prices, and the average gown CPU was 7.5 times higher than prepandemic prices. N95 respirators had a peak CPU of $12, and average CPU was 8 times higher than prepandemic prices. Face-mask CPU peaked at $0.55, 11 times higher, and averaged 9 times higher the regular price. Gloves averaged 2.5 times higher than the prepandemic CPU. Conclusions: Market prices for PPE were significantly elevated during the first weeks of the pandemic and remained high throughout the first wave of COVID-19. Multiple factors likely contributed to high prices, including demand shock, disrupted supply chains, and a rush to acquisition by healthcare systems and the general population alike. The impact of COVID-19 on prices highlights the importance of supply chains and national stockpiles for pandemic preparedness.

Funding: No

Disclosures: None
COVID-19 Outbreak in a Hemodialysis Center Using Universal Masking and Eye Protection
Authors: Sifri Costi , Buckner Joan , Shelton Cady
Published: November 2021

Background: Up to half of all new SARS-CoV-2 infections are acquired from presymptomatic or asymptomatic individuals. Hemodialysis patients and healthcare providers (HCPs) may be at increased risk for COVID-19 due to the need for extended close contact. Universal masking and eye protection are strategies used to reduce SARS-CoV-2 exposure, particularly from presymptomatic or asymptomatic individuals. We describe an outbreak of COVID-19 in an outpatient hemodialysis center despite universal masking and universal HCP eye protection. Methods: An COVID-19 outbreak investigation was performed in a hemodialysis center where universal masking was in use by all HCPs and patients and universal eye protection (goggles, safety glasses) was in use by all HCPs when directly encountering patients. After a cluster of cases was identified in early November 2020, all patients and HCPs were tested for SARS-CoV-2 by real-time reverse transcription polymerase chain reaction (RT-PCR) when symptomatic and weekly until the conclusion of the outbreak. Results: From November 12, 2020, through December 7, 2020, 14 (23.3%) of 60 patients and 9 (28.1%) of 32 HCPs tested positive for SARS-CoV-2 by RT-PCR (Figure 1). The median ages of the patients and HCPs were 64 years (range, 42–87) and 42 years (range, 29–68), respectively. Also, 5 (5.4%) individuals (3 patients and 2 HCPs) were asymptomatic at the time of testing. Furthermore, 7 (7.6%) individuals (5 patients and 2 HPCs) were hospitalized; 2 patients and no HCPs died. No lapses in universal masking or, for HCPs, eye protection prior to or during the outbreak were identified during the investigation. All HCPs and patients wore medical-grade face masks that were discarded at the end of the day; HCPs wore safety glasses or goggles during patient interactions. Although audits of face mask and eye protection compliance were not performed, independent interviews supported high HCP and patient adherence prior to the outbreak. Neither the staff nor patients shared meals at or outside the hemodialysis center. Most patients and HCPs shared the same hemodialysis shift, suggesting the presence of an index case; however, a source case could not be identified despite an extensive investigation. Conclusions: Universal masking and eye protection have been shown to reduce transmission of SARS-CoV-2 from presymptomatic or asymptomatic individuals in the healthcare setting. This report suggests that such measures cannot prevent all outbreaks. We speculate that certain factors associated with hemodialysis care, such as prolonged close patient–HCP contact, may have facilitated this outbreak. Whether nonadherence to universal masking and eye protection or failure of empiric droplet precautions contributed to this outbreak remains unknown.

Funding: No

Disclosures: None
Whole-Genome Sequencing: The Key to Unlocking a Nosocomial Outbreak of Coronavirus Disease 2019 (COVID-19)
Authors: Gottlieb Lindsey , Sordillo Emilia , van Bakel Harm , Smith Barbara , Camins Bernard , Alsamarai Sarah , Simon Viviana , Kim Kilyoub
Published: November 2021

Background: Accurately tracing nosocomial transmission of coronavirus disease 2019 (COVID-19) is critical to developing effective infection prevention policies. Given the high prevalence and variable incubation period of SARS-CoV-2 infection, the utility of traditional contact tracing is limited. We describe a nosocomial outbreak in which whole-genome sequencing (WGS) was pivotal to identifying the primary case. Methods: This study was conducted at a New York City academic hospital. The index case was identified on August 13, 2020, and the last case on September 9, 2020. Hospital policy required all inpatients to be screened for COVID-19 on admission by SARS-CoV-2 molecular amplification testing. All healthcare workers (HCWs) were required to wear masks and eye protection for patient care. After a patient (patient 1), who tested SARS-CoV-2 negative on admission, was positive on preprocedure screening on hospital day 9, contact tracing was initiated. Two patients (patients 2 and 3) and 13 HCWs with high-risk exposures (HREs) to patient 1 were quarantined and referred for testing. Additional surveillance testing was performed on 18 inpatients and 84 HCWs on the affected unit. Patients 2 and 3 and 3 HCWs (HCW-1, -2, and -3), only 1 of whom had a high-risk exposure to patient 1, tested positive. WGS was performed to further investigate this outbreak. Results: The outbreak variant (clade 20A) was found in samples from 6 patients and 2 HCWs. Patients 2 and 3 were roommates of patient 1 in the 2 days before patient 1’s positive test, and they did not consistently wear masks in the room. HCW-1 placed a peripheral IV in patient 1 the day before patient 1’s positive test without wearing eye protection. Four additional cases in this cluster (patients 4–6 and HCW-4) were identified by surveillance WGS of positive tests. A review indicated that patient 1 was located ~3 m (~10 feet) away from patient 4 in the emergency department (ED) for 6 hours on hospital day 1, when the admission SARS-CoV-2 test from patient 4 was not positive. No epidemiologic link was found to patient 5 or 6 or HCW-4. The specimen from HCW-2 was inadequate for WGS. The specimen from HCW-3 was not linked to this cluster. Conclusions: This complex nosocomial outbreak highlights the importance of WGS in understanding transmission events. Patient 4 was not identified by traditional contact tracing but was linked to patient 1 and was recognized as the primary case through WGS, having likely infected patient 1 in the ED. Based on these findings, we focused our corrective actions on more promptly isolating suspected COVID-19 cases in the ED, increasing inpatient masking, and improving HCW adherence to universal eye protection.

Funding: No

Disclosures: None
Thinking Otherwise: Bringing Young People into Pediatric Concussion Clinical and Research Practice
Authors: Mah Katie , Gladstone Brenda , Cameron Deb , Reed Nick
Published: November 2021

Background:

As rates of pediatric concussion have steadily risen, and concerns regarding its consequences have emerged, pediatric concussion has received increased attention in research and clinical spheres. Accordingly, there has been a commitment to determine how best to prevent and manage this injury that so commonly affects young people. Despite this increased attention, and proliferation of research, pediatric concussion as a concept has rarely, if ever, been taken up and questioned. That is, little attention has been directed toward understanding what concussion ‘is’, or how young people are regarded in relation to it. As a result, pediatric concussion is understood in decidedly narrow terms, constructed as such by a biomedical way of knowing.

Aim:

We aim to demonstrate how conceptualizing concussion, and young people, ‘otherwise’, enabled the co-production of a more nuanced and complex understanding of the experience of pediatric concussion from the perspective of young people.

Approach:

Drawing on an illustrative case example from a critical qualitative arts-based study, we demonstrate how bringing young people into research as ‘knowers’ enabled us to generate much-needed knowledge about concussion in young people.

Implications:

The critical thinking put forward in this paper suggests a different approach to pediatric concussion, which is shared in the form of implications for clinical and research practice.
From Nobility and Excellence to Generosity and Rights: Sophia's Defenses of Women (1739–40)
Authors: Broad Jacqueline
Published: November 2021

This article examines two early modern feminist works, Woman Not Inferior to Man (1739) and Woman's Superior Excellence Over Man (1740), written by “Sophia, A Person of Quality.” Scholars once dismissed these texts as plagiarisms or semi-translations of François Poulain de la Barre's De l’égalité des deux sexes (1673). More recently, however, Guyonne Leduc has drawn attention to the original aspects of these treatises by highlighting Sophia's significant variations on Poulain's vocabulary (Leduc 2010; 2012; 2015). In this article, I take Leduc's analysis a step further by demonstrating that Sophia's variations amount to unique and distinctive arguments for the restoration of women's rights, based on both the natural equality and the moral superiority of women compared to men. I argue that Sophia goes beyond Poulain's Cartesian insights to mount a critique of male tyranny characterized as a lack of generosity toward women. My contention is that Sophia's texts represent a culmination in a line of reasoning that extends from the querelle des femmes of the Renaissance to Poulain's Cartesian feminism of the seventeenth century, through to arguments for women's rights in the eighteenth century. Her works thus warrant greater recognition as significant turning points in the history of feminist thought.
Asymptotics of streamwise Reynolds stress in wall turbulence
Authors: Monkewitz Peter A.
Published: November 2021

The scaling of different features of streamwise normal stress profiles$\langle uu\rangle ^+(y^+)$in turbulent wall-bounded flows is the subject of a long-running debate. Particular points of contention are the scaling of the ‘inner’ and ‘outer’ peaks of$\langle uu\rangle ^+$at$y^+\approxeq ~15$and$y^+ ={O}(10^3)$, respectively, their infinite Reynolds number limit, and the rate of logarithmic decay in the outer part of the flow. Inspired by the thought-provoking paper of Chen & Sreenivasan (J. Fluid Mech., vol. 908, 2021, p. R3), two terms of an inner asymptotic expansion of$\langle uu\rangle ^+$in the small parameter$Re_{\tau }^{-1/4}$are constructed from a set of direct numerical simulations (DNS) of channel flow. This inner expansion is for the first time matched through an overlap layer to an outer expansion, which not only fits the same set of channel DNS within 1.5 % of the peak stress, but also provides a good match of laboratory data in pipes and the near-wall part of boundary layers, up to the highest$Re_{\tau }$values of$10^5$. The salient features of the new composite expansion are first, an inner$\langle uu\rangle ^+$peak, which saturates at 11.3 and decreases as$Re_{\tau }^{-1/4}$. This inner peak is followed by a short ‘wall log law’ with a slope that becomes positive for$Re_{\tau }$beyond${O}(10^4)$, leading up to an outer peak, followed by the logarithmic overlap layer with a negative slope going continuously to zero for$Re_{\tau }\to \infty$.