bluuebunny/crossref_metadata_2025_split huggingface dataset:
Utilizing Telemedicine During Outbreak Events to Reduce Exposure Risk
Authors: Bisht Anjali , Weinstein Stacey , Uslan Daniel 
Published: November 2020

Background: As of October 2019, the United States has seen the greatest number of annual measles cases reported since 1992, of which 2 outbreaks originated in Los Angeles County, California. Media reports and public awareness during outbreak events can result in large numbers of worried well patients or patients with outbreak mimics seeking medical attention. In densely populated cities, utilizing alternative approaches to in-person physician appointments can be beneficial to decrease both the overburden of healthcare resources as well as the spread of potential virus. During these measles outbreaks, we employed the use of telemedicine visits to facilitate triage and determination of in-person examination and testing needs. Methods: During the measles outbreak periods, patients who contacted the patient call center at our institution requesting an appointment for fever, rash, or expressing concerns for acute measles infection were instead routed for a telemedicine visit with a physician. All patients were all seen by the same physician, who was trained in internal medicine and pediatrics. During the telemedicine visit, patients were assessed for signs and symptoms consistent with acute measles based on CDC definition. If there was high enough clinical suspicion to warrant testing for measles, infection prevention coordinated logistics with clinic staff, including ensuring the use of appropriate personal protective equipment (PPE), end-of-day appointment scheduling, and appropriate diagnostic testing. Results: During this outbreak timeline, 7 patients were seen through telemedicine visits with ages ranging 13 months to 49 years. Also, 6 patients were scheduled due to a chief complaint of acute rash and 1 was due to a potential exposure to measles. Of 7 patients, 4 had received 1 dose of the MMR vaccine, and the remaining 3 were immune, unvaccinated, or had unknown immunity. The unvaccinated patient was further tested for measles but was IgM negative. Of those with chief complaint of rash, the diagnosis was determined to be some form of nonmeasles viral exanthem, allergic dermatitis/eczema, or hives. The exposed patient was deemed to be asymptomatic. Conclusions: During an outbreak, patients presenting to clinics with suspected measles symptoms can cause tremendous disruption, including concerns about exposure of staff and patients, need for contact tracing, and anxiety. Utilizing telemedicine appointments aided the management of patients during this outbreak by shifting physician evaluation outside the clinic. When evaluating suspect measles cases during an outbreak with patients who do not require further levels of care, telemedicine can prove to be useful in reducing the burden of potential exposure to others in the community and to the healthcare system.Funding: NoneDisclosures: None
Qualitative Visual Assessment of Hand Hygiene Product Effectiveness
Authors: Czaplicki Mary , Attar Shorook , Green Kristen , Leslie Rachel 
Published: November 2020

Background: Effective hand hygiene (HH) is an essential preventative measure for the reduction of hospital-acquired infections (HAIs). Commonly used HH products include alcohol-based hand rubs (ABHRs), antimicrobial soaps, and nonantimicrobial soaps. In vivo clinical studies have demonstrated that levels of bacterial reduction can vary based on the HH product type, formulation, and dose. It has been reported that ABHRs provide the greatest reduction in bacteria, followed by antimicrobial soaps. Objective: We examined the effects of products representative of 3 HH categories on artificially soiled hands, using a hand-stamp procedure. The hand-stamp images provide a clear visualization of product effectiveness and can be used as an educational tool to promote the importance of proper hand hygiene using different product formats. Method: Three commercially available formulations were evaluated in this study, a mild nonantimicrobial soap, an antimicrobial soap containing chloroxylenol (PCMX), and an ABHR containing 70% v/v ethanol. Prior to the hand stamp procedure, the participant’s hands were prewashed with 5 mL of a nonantimicrobial soap and dried. An inoculum of Serratia marcescens containing ∼1 × 109CFU/mL was prepared as described in ASTM E2755. A 0.2-mL aliquot of the inoculum was dispensed onto the palm of the subject’s hand and spread by rubbing over the entire surface of both hands. Following a 30-second dry time, one of the subject’s hands was gently pressed onto the surface of a large petri dish containing tryptic soy agar to obtain a baseline image. Following the baseline sample, 1 pump of the selected test product (∼0.9 mL for soap or 1.1 mL for ABHR) was applied to the participant’s hands. For soap applications, hands were vigorously rubbed for 30 seconds followed by a 30-second water rinse. For ABHR, product was rubbed by the user until dry. The hand-stamp procedure was repeated following product application using the participant’s other hand. Results: Clear qualitative reductions in bacteria were observed with each of the HH interventions. The greatest reduction was observed following the application of ABHR. Antimicrobial soap was less effective than ABHR but more effective than nonantimicrobial soap. Conclusions: The qualitative visual model demonstrates the effectiveness of various HH interventions and correlates with log reductions observed in traditional efficacy test methods. Future efforts should explore hand-stamp repeatability and image utilization to support HH improvement efforts in healthcare systems.Funding: GOJO Industries provided support for this study.Disclosures: Mary Rose Czaplicki reports salary from GOJO Industries.
The Effect of Automated Hand Hygiene Monitoring Systems and Other Complementary Behavior-Change Strategies on Performance
Authors: Arbogast James , Moore Lori , DiGiorgio Megan , Boyce John , Parker Albert 
Published: November 2020

Background:
Technology and interest for use of automated hand hygiene monitoring systems (AHHMS) as a tool to help improve healthcare personnel hand hygiene has been advancing for the last decade. Emerging evidence indicates that the use of AHHMS plus complementary strategies improves hand hygiene (HH) performance rates and outcomes (eg, healthcare-associated infections). The WHO HH guideline “Multimodal Strategy” teaches the importance of multiple components as necessary to build and sustain HH compliance. Few published data compare the impact of different complementary behavioral strategies in combination with AHHMS on results. Methods: We utilized data from 1 AHHMS that records alcohol-based hand rub and soap dispensing and room entries and exits to provide group HH performance rates. Data were collected from 58 units in 10 hospitals in North America from July 2014 through August 2019. Hospitals were stratified into 4 categories based on their approach to hospital-initiated unit-level interventions and AHHMS vendor support (Table 1). Baseline data were defined for each unit as the initial 1–2 months of execution, before complementary strategies were initiated. Statistical analysis was performed on the annual number of dispenses and opportunities with a mixed-effects Poisson regression with random effects for facility, unit and year and fixed effects for intervention type and unit type. Interactions were not included in the model based on interaction plots and significance tests. Poisson assumptions were verified with Pearson residual plots. Results: HH performance rates overall and compared to the baseline are shown in Table 2. More than 8 million opportunities were achieved in all 58 units combined. An intervention strategy with multiple complementary components (ie, clinical support provided by the AHHMS vendor plus hospital-initiated unit level interventions) yielded significantly better HH performance than all other categories (>20% increase, P < .00001). Somewhat surprisingly, vendor clinical support or hospital-initiated, unit-level interventions alone with the AHHMS yielded a slight decrease in HH performance relative to AHHMS only (P < .00001). Conclusions: AHHMS is a useful tool in understanding HH performance and identifying unit-based initiatives that need attention. Implementation of an AHHMS by itself or with limited complementary behavior-change strategies does not drive improvement. Support provided by the vendor and hospital-initiated, complementary strategies were not sufficient additions to the AHHMS individually, but in combination they resulted in the greatest improvements in HH performance. These findings illustrate the value of a partnership between the hospital and the AHHMS vendor.Funding: GOJO Industries, Inc., provided support for this study.Disclosures: James W. Arbogast, Lori D. Moore and Megan DiGiorgio report salary from GOJO Industries.
Characterization of Ceftazidime-Avibactam-Resistant Carbapenem-Resistant Enterobacteriaceae, United States, 2015–2017
Authors: Ansari Uzma , Reses Hannah E. , Grass Julian , Nadle Joelle , Bower Chris , Jacob Jesse , Vaeth Elisabeth , Witwer Medora , Hancock Emily , Dale Suzanne , Dumyati Ghinwa , Beldavs Zintars , Muleta Daniel , Duffy Nadezhda , See Isaac , Lutgring Joseph 
Published: November 2020

Background: Carbapenem-resistant Enterobacteriaceae (CRE) are a major public health problem. Ceftazidime-avibactam (CZA) is a treatment option for CRE approved in 2015; however, it does not have activity against isolates with metallo-β-lactamases (MBLs). Emerging resistance to CZA is a cause for concern. Our objective was to describe the microbiologic and epidemiologic characteristics of CZA-resistant (CZA-R) CRE. Methods: From 2015 to 2017, 9 states participated in laboratory- and population-based surveillance for carbapenem-resistant Escherichia coli, Klebsiella pneumoniae, K. oxytoca, K. aerogenes, and Enterobacter cloacae complex isolates from a normally sterile site or urine. A convenience sample of isolates from this surveillance were sent to the CDC for antimicrobial susceptibility testing (AST) using reference broth microdilution (BMD) including an MBL screen, species confirmation with MALDI-TOF, and real-time PCR to detect blaKPC, blaNDM, and blaOXA-48–like genes. Additional AST by BMD was performed on CZA-R isolates using meropenem-vaborbactam (MEV), imipenem-relebactam (IMR), plazomicin (PLZ), and eravacycline (ERV). Epidemiologic data were obtained from a medical record review. Community-associated cases were defined as having no healthcare exposures in the year prior to culture, no devices in place 2 days prior to culture, and culture collected before calendar day 3 after hospital admission. Data were analyzed in 3 groups: CRE that were CZA-susceptible (CZA-S), CZA-R that were due to blaNDM, and CZA-R without blaNDM. Results: Among 606 confirmed CRE tested with CZA, 33 (5.4%) were CZA-R. Of the CZA-R isolates, 16 (48.5%) harbored a blaNDM gene, of which 2 coharbored blaNDM and blaOXA-48-like genes; 9 (27.3%) harbored only a blaKPC gene. Of the 17 CZA-R isolates without blaNDM, all were MBL screen negative. CZA-R due to blaNDM were more frequently community-associated (43.8%) than CZA-S or CZA-R without blaNDM (11.0% and 5.9%, respectively); a higher percentage of CZA-R cases due to blaNDM also had recent international travel (25%) compared to the other groups (1.8% and 5.9%, respectively). CZA-R without blaNDM were more susceptible to MEV (76%), IMR (71%), PLZ (88%), and ERV (65%) compared to CZA-R due to blaNDM (19%, 6%, 56%, and 44%, respectively). Conclusions: The emergence of CZA-R isolates without blaNDM are concerning; however, these isolates are more susceptible to newer antimicrobials than those with blaNDM. In addition to high rates of resistance to newer antimicrobials, isolates with blaNDM are more frequently community-associated than other CRE. This underscores the need for more aggressive measures to stop the spread of CRE.Funding: NoneDisclosures: None
Implementation of a Female External Urinary Catheter Reduces Indwelling Urinary Catheter Use and Catheter-Associated Urinary Tract Infections
Authors: Gentile Paul , Jacob Jesse , Ashraf Shanza 
Published: November 2020

Background: Using alternatives to indwelling urinary catheters plays a vital role in reducing catheter-associated urinary tract infections (CAUTIs). We assessed the impact of introducing female external catheters on urinary catheter utilization and CAUTIs. Methods: In a 500-bed academic medical center, female external catheters were implemented on October 1, 2017, with use encouraged for eligible females with urinary incontinence but not meeting other standard indications for urinary catheters. Nurses were educated and trained on female external catheter application and maintenance, and infection prevention staff performed surveillance case reviews with nursing and medical staff. We determined the number of catheter days for both devices based on nursing documentation of device insertion or application, maintenance, and removal. We used the CAUTI and DUR (device utilization ratio) definitions from the CDC NHSN. Our primary outcomes were changes in DUR for both devices 21 months before and 24 months after the intervention in both intensive care units (ICUs) and non-ICU wards. We used a generalized least-squares model to account for temporal autocorrelation and compare the trends before and after the intervention. Our secondary outcome was a reduction in CAUTIs, comparing females to males. Results: In total, there were 346,213 patient days in 35 months. The mean rate of patient days per month increased from 7,436.4 to 7,601.9 after the implementation of female external catheters, with higher catheter days for both urinary catheters (18,040 vs 19,625) and female external catheters (22 vs 12,675). After the intervention, the DUR for female external catheters increased (0 vs 0.07; P < .001) and for urinary catheters the DUR decreased (0.12 vs 0.10; P < .001) (Fig. 1). A reduction in urinary catheter DUR was observed in ICUs (0.29 vs 0.27; P < .001) but not wards (0.08 vs 0.08; P = NS) (Fig. 2). Of the 39 CAUTIs, there was no significant overall change in the rate per 1,000 catheter days (1.22 vs 0.87; P = .27). In females (n = 20 CAUTI), there was a 61% reduction in the CAUTI rate per 1,000 catheter days (0.78 vs 0.31; P = .02), but no significant change in the rate in males (0.44 vs 0.56; P = .64). The CAUTI rate per 1,000 catheter days among females decreased in the ICUs (1.14 vs 0.31; P = .04) but not in wards (0.6 vs 0.33; P = .96). Conclusions: In a setting with a baseline low UC DUR, successful implementation of female external catheters further modestly reduced UC DUR and was associated with a 61% decrease in CAUTI among females in the ICU but not in wards. Further interventions to better identify appropriate patients for female external catheters may improve patient safety and prevent patient harm.Funding: NoneDisclosures: None
Infection Preventionist Run Clostridioides difficile Testing Diagnostic Stewardship Protocol- Experience From a Rural Community Hospital
Authors: Tirupathi Raghavendra , Freshman Ruth , Montoy Norma J , Gross Melissa 
Published: November 2020

Background: Distinguishing active Clostridioides difficile infection (CDI) from asymptomatic colonization remains a challenging task in the era of PCR testing. Inappropriate testing leads to overtesting and overdiagnosis, inadvertent treatment, and isolation in addition to laboratory identified (LabID) events, leading to increased incidence to hospital-onset CDI (HO-CDI). The institution has a nurse-driven C. difficile test ordering protocol, and we noted a significant increase in the HO-CDI incidence in 2017 due to inappropriate testing, with rates as high as 0.94 per 1,000 patient days. Methods: In September 2017, a multidisciplinary team reviewed and initiated algorithm-based testing with mandatory audit and review by infection preventionists (IPs) under the guidance of an ID physician of all ordered tests. They reviewed the adequacy and legitimacy of order for multiple parameters, including minimum 3 loose stools in 24 hours, use of laxatives in last 24 hours, consistency of the sample, presence of at least 1 clinical parameters (ie, fever, abdominal pain, leukocytosis, sepsis, or septic shock), recent or concomitant antibiotic use, recent PCR testing in the last 14 days, and chart review for medical and/or surgical history. The IPs served as the gatekeepers to testing and rejected the samples that were deemed inappropriate. Ambiguous cases were discussed with the ID specialist. On the microscope lab side, all specimens sent were batched to be run twice a day at 8:30 a.m. and 2:30 p.m., and testing was performed only on the samples cleared by infection preventionists. Results: The number of PCR tests completed in the comparison quarter of 2016 was 220, which decreased to 157 tests in 2017 with a reduction of 28%. After a full year of implementation of the diagnostic stewardship protocol, the number of completed PCR tests decreased to 626 from 940 PCR tests in 2016, with an overall 34% decrease in testing. In the year following the implementation of diagnostic stewardship, HO-CDI decreased from 60 events in 2017 to 43 events in 2018, with a reduction of 28%. Subsequently, HO-CDI further decreased in 2019 from 43 to 28, with a reduction of 35%. Since the implementation of the project in 2017, HO-CDIs have decreased by 54% overall. The reduction in 314 C. difficile PCR tests in the first year led to a savings of $8,300 in laboratory testing supplies. The reduction of HO CDI by 17 led to cost avoidance of $293,420. Conclusions: Our experience shows that the IP-run diagnostic stewardship program was highly successful in streamlining testing, with cost savings on several fronts.Funding: NoneDisclosures: NoneDisclosures:Commercial Company : If I am presenting research funded by a commercial company, the information presented will be based on generally accepted scientific principals and methods, and will not promote the commercial interest of the funding company.DisagreeRaghavendra Tirupathi
Data Mining to Guide a Program to Prevent Infection Related Readmissions From Skilled Nursing Facilities
Authors: Stachel Anna , Klock Julie , Ding Dan , Lighter Jennifer , Daniel Kwesi , Waldron Levi 
Published: November 2020

Background: Readmissions to hospitals are common, costly and often preventable, notably readmissions due to infections. A 30-day readmission analysis following hospital discharges, found much of the variation in Medicare spending between hospitals was related to readmissions and skilled nursing facility (SNF) care. Although some readmissions of patients with advanced disease are not preventable, efforts to decrease readmission are most effectively directed towards those patients with intermediate levels of a specific risk. A prediction model to identify patients at highest (or intermediate) risk of infection readmission will help healthcare administrators and providers to allocate appropriate resources. Hospitals should use electronic health record (EHR) data with modern data mining techniques to create more curated, sophisticated models as part of a comprehensive transitional care program. We propose using the risk estimates of a validated prediction model to notify stakeholders and develop readmission rate reports by SNF or discharging physician. Methods: We applied machine learning (ML) methods to predict the risk of 30-day readmission due to sepsis and pneumonia of patients discharged to SNF. We used our EHR data during 2012–2017 to train and data from 2018 to validate. We applied ML algorithms to data including logistic regression, random forest, gradient boosting trees, and support vector machine. Data from EDW and EPIC clarity tables were extracted and managed using SAS Base 9.4 and Enterprise Miner 14.3 (SAS Institute, Cary, NC). We assessed the discrimination and calibration to select the most effective prediction model. Using the resulted risk estimates, we created a notification system and reports for key stakeholders. Results: Figures 1 and 2 show the discrimination and calibration results of the final selected gradient boosting model (GBM). For predicting unplanned readmissions with sepsis and with pneumonia within 30 days after discharge to SNF, the c-statistic for final GBM model with 140 features was 0.69 (95% CI 0.65-0.73) and 73 features was 0.71 (95% CI 0.66-0.75), respectively. Table 1 lists features important to the validation set of the prediction model. We used estimates from these models to develop a daily email notification of patients discharged to SNF stratified into a low, medium, and high risk group for sepsis and pneumonia. We additionally created reports with case-mix adjustments to benchmark SNFs and discharging physicians to monitor and understand performance. Conclusions: Hospitals should leverage the plethora of data found in EHRs to curate readmission prediction models, and promote collaboration among transitional care teams and IPC to ultimately reduce readmissions due to sepsis and pneumonia.Funding: NoneDisclosures: None
Mitigating Hospital-Onset Clostridioides difficile: Evaluation of a Standardized Environmental Hygiene Program in Eight Hospitals
Authors: Carling Philip , O'Hara Lyndsay , Harris Anthony , Olmsted Russell 
Published: November 2020

Background: Despite ongoing efforts over the past 3 decades, hospital-onset Clostridioides difficile infection (HO-CDI) continues to challenge interventions aimed at its prevention and control. We describe the impact of a model environmental services (EVS) program on the incidence of HO-CDI across 8 hospitals that are part of a nationwide integrated health system. Methods: Eight acute-care hospitals with 44–532 beds (mean, 263 beds) in 6 states with stable endemic HO-CDI incidence densities independently implemented identical sporicidal environmental hygiene interventions in 2017. The program combined the use of a hydrogen peroxide/peroxyacetic acid surface disinfectant for all patient-zone hygienic cleaning combined with a structured model EVS cleaning program that included optimized cleaning and disinfection technique, staff training, and auditing with objective performance feedback, which aligned with 2008 HICPAC/CDC categories I and II as well as 2010 CDC Guidance Level II monitoring program recommendations. After a 3-month phase-in, we compared NHSN-reported LabID HO-CDI SIRs for 18 months before and 12 months after implementation of the program. Results were not shared between sites and data were not collated by the authors until a year after the postintervention results were initially available. Multiple possible confounding factors were evaluated and determined not to have identifiably affected the outcome. Results: Mean preintervention HO-CDI SIRs over the 18 months measured ranged from 0.5 to 1.4 (mean, 1.0 for the group). Following the wash-in period, SIRs decreased precipitously in all sites to a mean of 0.42 for the group by the end of 12 months of the intervention. (P < .0001) (Fig. 1). Individual site improvement ranged from 20% to 92% (mean, 57%) (Fig. 2.) Conclusions: Overall, HO-CDI SIRs decreased almost 60% in the study hospitals following daily sporicidal disinfection cleaning of all patient-zone surfaces in association with ongoing programmatic optimization of cleaning practice. As predicted by earlier single-site studies reporting a favorable impact of sporicidal disinfectant cleaning in outbreak settings, this multisite quasi-experimental study has illustrated the substantial potential impact of hospital-wide sporicidal disinfection integrated with objectively sustained optimized thoroughness of cleaning to decrease the incidence of HO-CDI.Funding: NoneDisclosures: None