bluuebunny/crossref_metadata_2025_split huggingface dataset:
100% Single-Patient Rooms and Environmental Contamination With Highly Resistant Microorganisms: The MOVE Study
Authors: van der Schoor Adriënne S. , Voor in ‘t holt Anne F. , Severin Juliëtte A. , Gommers Diederik , Bruno Marco J. , Hendriks Joke M. , Vos Margreet C. 
Published: November 2020

Background: Studies have shown that patients colonized with highly resistant microorganisms (HRMO) contaminate the hospital environment, and that transmission from contaminated environments to patients occurs. In May 2018, the Erasmus MC University Medical Center, Rotterdam, moved from a hospital with mostly multiple-occupancy rooms to a new hospital with 100% single-patient rooms with private bathrooms. This move provided the unique opportunity to determine environmental contamination before the new hospital was open for admissions and thereafter and to compare the environmental contamination to the number of patients colonized with HRMO. Method: Environmental sampling took place twice in the old building and 12 times in the new building, from 2 weeks before to 15 months after relocating patients. At each moment, ~306 samples were taken from 13 locations (eg, nightstands, sinks) in 40 patient rooms. Samples were screened for Staphylococcus aureus (methicillin-susceptible [MSSA] and methicillin resistant [MRSA]) and highly resistant Pseudomonas aeruginosa, Acinetobacter baumannii, Enterococcus faecium, and Enterobacteriales. During the study period, January 1, 2018, until August 31, 2019, all clinical samples positive for HRMO were included. Results: Environmental sampling revealed that 29 of 724 (4.0%) locations were positive for HRMO in the old building, whereas 4 of 3,358 (0.1%) samples in the new building were positive for HRMO (P < .001). In the old building, 14 of 29 locations were positive for extended-spectrum β-lactamase (ESBL)–producing bacteria and 15 were positive for carbapenemase-producing bacteria. In the new building, 3 of 4 positive samples were positive for vancomycin-resistant E. faecium (VRE), 1 was positive for ESBL-producing K. pneumoniae. For both HRMO, no carriers were detected. In the old building, 145 of 12,256 adult patients (1.2%) had clinical samples positive for HRMO, compared to 561 of 38,397 (1.5%) in the new building, a small but significant increase (P = .02). Conclusions: The transition from mainly 2- and 4-person rooms to 100% single-patient rooms resulted in a significant decrease in environmental contamination, even though the number of patients colonized with HRMO slightly increased. No molecular typing to determine transfer from environment to patients and vice versa has yet been performed. Future sampling is needed to determine whether the low environmental contamination is a long-term effect of the transition to single rooms.Funding: NoneDisclosures: None
A Decade in Trying to Increase Hand Hygiene—Finally Success
Authors: Huddleston Linda , Bennett Sheila , Hermann Christopher 
Published: November 2020

Background: Over the past 10 years, a rural health system has tried 10 different interventions to reduce hospital-associated infections (HAIs), and only 1 intervention has led to a reduction in HAIs. Reducing HAIs is a goal of nearly all hospitals, and improper hand hygiene is widely accepted as the main cause of HAIs. Even so, improving hand hygiene compliance is a challenge. Methods: Our facility implemented a two-phase longitudinal study to utilize an electronic hand hygiene reminder system to reduce HAIs. In the first phase, we implemented an intervention in 2 high-risk clinical units. The second phase of the study consisted of expanding the system to 3 additional clinical areas that had a lower incidence of HAIs. The hand hygiene baseline was established at 45% for these units prior to the voice reminder being turned on. Results: The system gathered baseline data prior to being turned on, and our average hand hygiene compliance rate was 49%. Once the voice reminder was turned on, hand hygiene improved nearly 35% within 6 months. During the first phase, there was a statistically significant 62% reduction in the average number of HAIs (catheter associated urinary tract infections (CAUTI), central-line–acquired bloodstream infections (CLABSIs), methicillin-resistant Staphylococcus aureus (MRSA), multidrug-resistant organisms (MDROs), and Clostridiodes difficile experienced in the preliminary units, comparing 12 months prior to 12 months after turning on the voice reminder. In the second phase, hand hygiene compliance increased to >65% in the following 6 months. During the second phase, all HAIs fell by a statistically significant 60%. This was determined by comparing the HAI rates 6 months prior to the voice reminder being turned on to 6 months after the voice reminder was turned on. Conclusions: The HAI data from both phases were aggregated, and there was a statistically significant reduction in MDROs by 90%, CAUTIs by 60%, and C. difficile by 64%. This resulted in annual savings >$1 million in direct costs of nonreimbursed HAIs.Funding: NoneDisclosures: None
A Randomized Assessment of a Laxative-Based Clostridioides difficile Diagnostic Stewardship Intervention
Authors: Lau Chelsea E. , Morse Rena G. , Sifri Costi , Madden Gregory 
Published: November 2020

Background:Clostridiodes difficile is the leading healthcare-associated pathogen, with significant morbidity associated with acute C. difficile infection (CDI). However, polymerase chain reaction stool testing is unable to differentiate colonization from infection, leading to frequent overdiagnosis, unnecessary iatrogenesis, and additional costs. As a result, IDSA guidelines do not recommend C. difficile testing in patients with diarrheal symptoms attributed to other causes, including laxatives. Our group has previously investigated the use of a computerized clinical decision support (CCDS) tool to reduce inappropriate C. difficile testing in a single tertiary-care health system, with a subsequent 41% reduction in testing. We investigated the reduction in proportion of inappropriately completed tests with the randomized addition of a laxative alert to our existing CCDS. Methods: An existing electronic medical record-based CCDS tool was augmented by the addition of an automatic alert that notified the user if a patient received any of a set of identified laxative medications within 48 hours. During the 78-day pilot period, users encountered the existing CCDS or the CCDS with laxative alert (CCDS-LA), randomized by patient identification number. A proportional χ2 analysis was used to compare the proportion of aborted to completed tests among patients who met laxative criteria in the CCDS versus CCDS-LA groups. Results: In total, 187 test orders were attempted during the pilot period in 119 patients meeting the laxative alert criteria, with 43.3% order attempts randomized to the existing CCDS and 56.7% to the CCDS-LA. Of order attempts via the CCDS-LA, 50.0% were completed, compared to 64.2% of orders completed via the existing CCDS (22.1% relative reduction in test completion; P = .0525). Conclusions: We demonstrated substantially fewer completed C. difficile tests among patients receiving laxatives who were randomized to modified laxative-alert CCDS. Although our result did not reach statistical significance, the trend toward reduced inappropriate testing prompted the CCDS-LA alert to be adopted hospital-wide following completion of the test period. Further analyses of the pre- and postintervention periods are required to determine whether this intervention significantly impacts testing rates over time, as well as to determine the durability and safety of the CCDS-LA. Additional analyses are also needed to assess the impacts on hospital-onset CDI rate and the associated costs.Funding: NoneDisclosures: None
A Single Case Outbreak of Nipah Encephalitis From India in May–June 2019
Authors: Warrier Anup , Wilson Arun 
Published: November 2020

Background: Nipah encephalitis outbreaks mostly involve multiple patients. We report a case of Nipah virus encephalitis (NVE), which had no documented secondary cases in spite of many having prolonged and close contact with the patient. Methods: A 21-year-old male was admitted with NVE on May 30, 2019. Before the confirmatory report, there was close contact with multiple healthcare workers (HCWs), defined as exposure for >1 hour to the patient or his immediate environment and/or exposure to body fluids. We conducted extensive contact tracing of all HCWs who had come into close contact with the proven NVE case from the time of admission to the time of discharge. This contact tracing included those who had nursed him before the diagnosis with usual standard precautions and those who had nursed him after the diagnosis with full PPE. These HCWs were reviewed daily for fever and respiratory symptoms. All those who developed these symptoms within the 3 weeks of exposure where tested for NEV with a throat swab using RT-PCR. This testing was conducted twice over 3 days to confirm negative results. For the close family contacts that were asymptomatic, both throat swab and serum for Nipah IgM were tested. Results: In total, 169 HCW contacts were identified at our hospital. Of these, 94 were at high risk according the predetermined criteria and others were low-risk contacts. Moreover, 7 HCWs developed fever and respiratory symptoms within the defined surveillance period; 5 had symptoms before the diagnosis (using only standard precautions) and 2 were in contact with full PPE after the diagnosis. All of these symptomatic contacts were tested for NEV (throat swab and serology), and all were negative. The family members of the patient (his mother and aunt) who had cared for him throughout his illness period of 12 days before the diagnosis were also tested and were seronegative for NEV. Conclusions: This NEV case had very low transmission capability; even close family members who cared for him for 12 days without any precautions and had exposure to urine (which was positive for NEV) did not contract the disease. The absence of overt respiratory involvement and young age of the affected patient could have contributed to low transmissibility both prior to hospitalization and during the hospitalization.Funding: NoneDisclosures: None
A Statistically Significant Reduction in Hospital Onset Clostridioides difficile Events Using a Learning Collaborative Model
Authors: Louis Tracy , Hyde Sandi 
Published: November 2020

Background: Evidence-based best practices are available for the reduction and prevention of Clostridioides difficile infection (CDI). Often, these practices are not consistently followed in many inpatient care settings. A learning collaborative model resulted in a cost neutral, rapid, sustainable, statistically significant reduction in CDI events across an 88-hospital campus system without requiring hospitals to standardize laboratory methods, increase spending or increase staffing. Methods: In March 2018, a healthcare system with 88 critical access and community hospital campuses across 29 states participated in a harms-reduction learning collaborative. The collaborative format included educational webinars, gap analyses, action plans, and coaching calls facilitated by subject matter experts (SMEs). A collaborative cohort of 11 hospitals (55% rural*) was identified as having significant opportunity for improvement. These facilities participated in 3 monthly coaching calls. The coaching calls supported peer-to-peer sharing of practices and discussions of challenges and successes, and educational materials and presentations were provided by SMEs in pharmacy and infection prevention. Results: Statistically significant changes for the 88-hospital system as a whole: (1) 2018 compared to 2017: P < .001 (statistically significant); (2) 1H2018 compared to 2H2018 (before-and-after collaborative): P = .001; (3) 2019 compared to 2018: P < .001 (statistically significant). Statistically significant changes for the collaborative cohort: (1) 2018 compared to 2017: P < .001; (2) 1H2018 compared to 2H2018 (before-and-after collaborative): P = .002; and (3) 2019 compared to 2018: P < .001. We used 2-proportion, 2-tailed z-test for our analysis. Conclusions: Utilizing a learning collaborative model that included webinars, gap analyses, and interactive coaching calls, a cohort of 11 hospitals was able to induce rapid improvements to adherence of evidence-based practices resulting in a rapid, sustained, statistically significant improvement for both the cohort hospitals and the healthcare system.*2018 American community survey, US Census.Funding: NoneDisclosures: None
Achieving a Sustained Decrease in Facility-wide C. difficile Incidence in an Acute-Care Hospital in New York City
Authors: Moss Marie , Javaid Waleed , Ehni Jordan , Camins Bernard , Barnett Barbara 
Published: November 2020

Background: Mount Sinai Beth Israel is a 350-bed, acute-care hospital located on Manhattan’s Lower East Side. In 2014, the hospital had reached a high (9.8 cases per 10,000 patient days ) hospital-onset (HO) C. difficile rate. By 2015, this rate had decreased to 5.6 cases per 10,000 patient days because of compliance with established C.difficile bundle practices performed by nursing and environmental services. Despite these interventions, HO C. difficile events continued to occur. We realized that more had to be done to gain control over our rates. To determine areas for further improvement, infection prevention held an RCA meeting for every positive hospital-onset result. We discovered from these RCAs that many C. difficile tests were ordered without a valid indication. We believed that measures could be taken to ensure that only C. difficile tests with a valid indication would be ordered. Methods: We used the Plan-Do-Study-Act (PDSA) model to look at what changes could be made to reduce our rate and to sustain this reduction. Multidisciplinary meetings of leaders and frontline staff were held to determine why patients were being tested for C. difficile. The following indications were revealed: repeat tests for same patient to “catch” a positive result after the first test was negative; inclusion as part of patient “pan-culturing”; testing patients who had diarrhea after receiving laxatives; and C. difficile cultures for patients who were asymptomatic. Starting in 2016, 3 consecutive interventions were implemented in fairly rapid succession. First, a C. difficile testing algorithm was developed. Second, a C. difficile test order protocol with a “hard stop” to prevent inappropriate indications was placed in the EMR. Last, a multidisciplinary form, called the C. difficile Team Huddle Form, was created for use by all members of the patient’s team. This form gave MDs, RNs, and PCAs a framework to decide together whether the test was indicated for the patient. If the team agreed to test, the ID physician on service was called for approval. Results: These 3 interventions yielded a sustained and statistically significant decrease (P = 0.0007) in the facility-wide hospital-onset C. difficile from a preintervention rate of 5.6 cases per 10,000 patient days in 2015 to 0.4 in 2019. Conclusions: Multidisciplinary use of the C. difficile testing interventions led to further reduction of the hospital-onset C. difficile infection rate. To sustain this rate reduction over time, infection prevention specialists must work with providers and frontline staff on an ongoing basis.Funding: NoneDisclosures: None
Administrative Coding Methods Impact Surgical Site Infection Rates
Authors: Alsuhaibani Mohammed , Alzunitan Mohammed , Jenn Kyle , Diekema Daniel , Edmond Michael , Kukla Mary , Holley Stephanie , Meacham Holly , Abosi Oluchi , Salinas Jorge 
Published: November 2020

Background: Surveillance for surgical site infections (SSI) is recommended by the CDC. Currently, colon and abdominal hysterectomy SSI rates are publicly available and impact hospital reimbursement. However, the CDC NHSN allows surgical procedures to be abstracted based on International Classification of Diseases, Tenth Revision (ICD-10) or current procedural terminology (CPT) codes. We assessed the impact of using ICD and/or CPT codes on the number of cases abstracted and SSI rates. Methods: We retrieved administrative codes (ICD and/or CPT) for procedures performed at the University of Iowa Hospitals & Clinics over 1 year: October 2018–September 2019. We included 10 procedure types: colon, hysterectomy, cesarean section, breast, cardiac, craniotomy, spinal fusion, laminectomy, hip prosthesis, and knee prosthesis surgeries. We then calculated the number of procedures that would be abstracted if we used different permutations in administration codes: (1) ICD codes only, (2) CPT codes only, (3) both ICD and CPT codes, and (4) at least 1 code from either ICD or CPT. We then calculated the impact on SSI rates based on any of the 4 coding permutations. Results: In total, 9,583 surgical procedures and 180 SSIs were detected during the study period using the fourth method (ICD or CPT codes). Denominators varied according to procedure type and coding method used. The number of procedures abstracted for breast surgery had a >10-fold difference if reported based on ICD only versus ICD or CPT codes (104 vs 1,109). Hip prosthesis had the lowest variation (638 vs 767). For SSI rates, cesarean section showed almost a 3-fold increment (2.6% when using ICD only to 7.32% with both ICD & CPT), whereas abdominal hysterectomy showed nearly a 2-fold increase (1.14% when using CPT only to 2.22% with both ICD & CPT codes). However, SSI rates remained fairly similar for craniotomy (0.14% absolute difference), hip prosthesis (0.24% absolute difference), and colon (0.09% absolute difference) despite differences in the number of abstracted procedures and coding methods. Conclusions: Denominators and SSI rates vary depending on the coding method used. Variations in the number of procedures abstracted and their subsequent impact on SSI rates were not predictable. Variations in coding methods used by hospitals could impact interhospital comparisons and benchmarking, potentially leading to disparities in public reporting and hospital penalties.Funding: NoneDisclosures: None
Antimicrobial-Resistant Organism Outbreak in a Skilled Nursing Facility in Pennsylvania, 2019
Authors: Paoline Julie , Masters Michel , Cheriyan Feba , Kinsey Cara Bicking 
Published: November 2020

Background: In April 2019, the Montgomery County Office of Public Health (MCOPH) was notified by the Pennsylvania Department of Health (PADOH) of a tier 2 carbapenemase mechanism in a resident of a Pennsylvania skilled nursing facility that was detected through targeted surveillance. Production of the New Delhi metallo-β-lactamase (NDM) carbapenemase was detected using polymerase chain reaction (PCR). The initial follow-up revealed that the patient resided at a 148-bed skilled nursing facility that specializes in spinal cord injury, neurological diseases, ventilator dependence, and pulmonary diseases. MCOPH and PADOH initiated an investigation to identify additional cases and prevent transmission. Methods: Over a series of 9 point-prevalence surveys, we collected 518 specimens for colonization screening. Screening was conducted on the wing of the index case and was later expanded to include the entire unit (n = 90), after evidence of transmission was noted. Perirectal swabs were submitted to the regional antibiotic resistance laboratory for testing using the Cepheid GeneXpert Carba-R assay. Together with screening, MCOPH and PADOH conducted a series of on-site visits involving the completion of the CDC infection control assessment and response (ICAR) tool and direct care observations, including 409 hand hygiene observations. Results: In addition to NDM, Klebsiella pneumoniae carbapenemase (KPC) and Verona integron-encoded metallo-β-lactamase (VIM) were also detected. ICAR results and direct care observations revealed numerous deficiencies in the domains of hand hygiene, personal protective equipment, and environmental cleaning. In addition to 2 cases of carbapenemase-producing organisms (CPO) being detected through clinical specimens, an additional 27 CPO cases were identified through screening coordinated by public health. This large, multimechanism outbreak is attributed to a combination of intrafacility transmission and imported cases. Based on these findings, recommendations for infection prevention and control were provided on site and in writing. Our continued work with this facility lead to improvements in infection control, including a HH success rate improvement of 53%. Conclusions: Novel or targeted multidrug-resistant organisms are effectively contained when healthcare facilities and state and local public health work together to reduce transmission to baseline and to improve infection control practices.Funding: NoneDisclosures: None
Application of an Outpatient CLABSI Surveillance Definition: Results and Lessons From 7 Infusion Clinics
Authors: Williamson Keenan , Nix Chad Douglas , Hale Molly 
Published: November 2020

Background: The NHSN does not have a published surveillance definition for central-line–associated bloodstream infections (CLABSIs) related to healthcare in ambulatory settings. With the increasing reliance on services involving central-line care in the ambulatory setting, there is opportunity to improve healthcare performance by developing standardized surveillance. Methods: Chart review was performed on 320 patients who had a visit at an infusion clinic and a positive blood culture in 2018. A qualifying infusion clinic visit involved accessing of the central line during the encounter. Ambulatory-associated cases were defined as having a qualifying infusion clinic encounter within 7 days prior to blood culture collection. Cases were excluded if the patient’s central line had been accessed in an inpatient setting between the positive blood culture and infusion clinic visit. All other criteria were based on the NHSN inpatient CLABSI case definition. Results: Application of the proposed surveillance definition revealed 17 of 320 (5.3%) patients who met criteria for an ambulatory CLABSI. All 16 patients who met criteria (94%) had an inpatient hospital stay within 7 days of the qualifying infusion clinic encounter, for an average of 8.8 hospital days (range, 2–20). Positive blood cultures were collected on average 3.2 days after the patient’s qualifying infusion clinic encounter (range, 0–7). Moreover, 20 causative organisms were identified: 6 common commensals, 2 Staphylococcus aureus, and 12 gram-negative bacteria. Also, positive blood cultures for 7 patients (41%) were collected in ambulatory clinics. Patients reported symptom onset on average 1.2 days prior to telling a healthcare professional (range, 0–5) and an average of 2 days from their last qualifying infusion clinic visit (range, 0–6). In addition, 1 patient (6%) met for a site-specific infection outside of the defined window period during their subsequent admission. Conclusions: Application of the surveillance definition resulted in the identification of 17 CLABSIs. These results highlight important limitations in ambulatory CLABSI surveillance: Patients who access emergency services closer to their residence may have had their bloodstream infection (BSI) identified elsewhere. Ensuring comprehensive interfacility communication would increase the value of an institution’s surveillance. Additionally, ambulatory surveillance for BSI should include all possible collection locations. Although subject to recall bias, the event date could be based on symptom onset to allow for variation in healthcare-seeking behavior. In the ambulatory setting, because diagnostics are not readily available, delayed diagnosis of site-specific infections could result in an inflated ambulatory CLABSI rate.Funding: NoneDisclosures: None