bluuebunny/crossref_metadata_2025_split huggingface dataset:
Incidence and Risk Factors for Surgical Site Infection Following Coronary Artery Bypass Graft Procedures
Authors: van den Berg Polly , Wright Sharon , Feeser Baevin 
Published: November 2021

Background: Deep and organ-space surgical site infections (SSIs) are serious complications of coronary artery bypass graft (CABG) procedures. It is unclear whether the use of bilateral versus single internal mammary artery (BIMA vs SIMA) and surgical approach to internal mammary artery (IMA) harvest (pedicled vs skeletonized) are independent risk factors for SSI. The use of BIMA grafting redirects blood flow away from the sternum to the heart and may increase SSI risk due to lower tissue perfusion. A skeletonized approach to graft harvest, wherein the IMA is dissected free of surrounding tissue to preserve collateral sternal blood flow, may decrease SSI risk as compared to a pedicled approach in which the IMA is mobilized within a tissue pedicle. We describe the incidence and potential risk factors for post-CABG SSI in an academic tertiary-care center performing ~500 IMA procedures annually. Methods: Data were abstracted on adult patients who underwent a CABG procedure using at least 1 IMA graft between July 2017 and June 2020. Additional data on potential risk factors for SSI were obtained electronically from hospital data marts and the Division of Cardiac Surgery database, including demographics, comorbidities, number of arterial grafts, surgical approach, surgeon, and discharge location. Using standard NHSN definitions, infection control practitioners identified post-CABG deep and organ-space SSIs. Patient and procedure characteristics were evaluated as potential risk factors for deep and organ-space SSI using the Fisher exact test. Results: Of 1,591 CABG procedures performed during the study period, 1,244 (78.2%) were performed using a SIMA technique and 347 (21.8%) were performed using a BIMA technique. The overall post-CABG SSI incidence was 1.2 per 100 procedures, with 1.0 SSIs per 100 SIMA procedures and 1.7 SSIs per 100 BIMA procedures. Table 1 demonstrates an increase over time in proportion of CABG procedures performed using SIMA and skeletonized IMA grafts. We also observed a decrease in overall SSI incidence over this period. See Table 2 for univariate predictors of post-CABG SSI. Conclusions: Female sex, BMI ≥40, age ≥75 years, diabetes, and discharge to a rehabilitation setting were associated with development of post-CABG SSI. Although the overall incidence of deep and organ-space SSI in our cohort was very low, making it difficult to draw conclusions about potentially modifiable risk factors, an increase in the use of SIMA and skeletonized grafts appears to be accompanied by a decrease in SSI incidence. More data from our institution and others are needed to determine the significance of this trend.Funding: NoDisclosures: None
Does a Starting Positive End-Expiratory Pressure of 8 cm H2O Decrease the Probability of a Ventilator-Associated Event?
Authors: Barnett William , Holtzapple Zachary , Assaly Ragheb 
Published: November 2021

Background: Mechanical ventilation is commonly seen in critical ill patients. The vulnerability of these patients is high, and a wide range of associated conditions can stem from this intervention. To objectively identify nosocomial respiratory conditions and provide conformed surveillance definitions of these events, the Centers for Disease Control and Prevention (CDC) established the ventilator-associated event (VAE) criteria. They denote 3 categories of increasing progression in mechanically ventilated patients from a ventilator-associated condition (VAC) to an infection-related ventilator-associated complication (IVAC) and finally to a possible ventilator-associated pneumonia (PVAP). Manipulation of ventilator settings, such as starting on higher values to not trigger VAC criteria, has been criticized by some experts as not only ‘gaming the system,’ but potentially harming patients. In October 2018, our institution began a baseline of 8 cm H2O as the starting positive end-expiratory pressure (PEEP) protocol for mechanical ventilation but exempting neurosurgical patients. We sought to determine whether an 8 PEEP protocol is an effective strategy for reducing VAEs in our institution. Methods: We retrospectively examined patient data at our institution from January 2014 through February 2020. VAEs were separated by VAC only and IVAC positive (+), which are a combination of IVACs and PVAPs. Using the days between VAEs, a daily event probability can be calculated based on the geometric distribution. Furthermore, as VAEs occur, the likelihood of the event can be assessed as expected or unexpected using a strict probability limit of 0.99865 to reduce type 1 errors. Results: In total, 307 patients were identified in our hospital’s VAE surveillance. Of those, 180 met CDC-defined VAC-only criteria, and 127 patients met IVAC+ definitions. After implementation of an 8-PEEP protocol, the daily event probability for VACs decreased from 0.083 to 0.047. The last event occurred 162 days after the previous VAC, which was unexpected, because the probability of occurrence extended beyond the probability limit. With regard to IVAC+ events, the daily event probability decreased from 0.057 to 0.039 without significant reduction in the IVAC+ rate. Conclusions: Although a change in the VAC-only rate occurred, signified by a longer time between events, it took more than a year to achieve in our institution. Additionally, we did not see a reduction in the IVAC+ rate. These findings suggest that an 8-PEEP protocol may be able to reduce VAEs due to noninfectious etiologies, such as congestive heart failure and atelectasis.Funding: NoDisclosure: None
High-Level Disinfection in Ambulatory Care: Overcoming the Barriers of a Decentralized System through Auditing and Education
Authors: Saenz Sonja Rivera 
Published: November 2021

Background: High-level disinfection (HLD) of semicritical instruments in a multispecialty ambulatory care network has the potential for increased risk due to the decentralized instrument reprocessing and lack of a sterile processing department. Attention to HLD practices is an important part of device-borne outbreak prevention. Method: An HLD database was developed to identify specific departments and locations where HLD occurred across a 30-medical practice ambulatory care network in eastern Massachusetts, which included otolaryngology, urology, endoscopy, and obstetrics/gynecology departments. Based on qualitative feedback from managers and reprocessing staff, this database centralized information that included the supply inventory including manufacturer and model information, HLD methodology, standard work, and listing of competency evaluations. The infection control team then led audits to directly observe compliance with instrument reprocessing and a monthly-driven HLD calendar was developed to enforce annual competencies. Result: The results of the audits demonstrated variability across departments with gaps in precleaning, transportation of used instruments, the dilution of enzymatic cleaner, and maintenance of quality control logs. Given the uniqueness of shape and size of various ambulatory locations, proper storage and separation between clean and dirty spaces were common pitfalls. Auditing also revealed different levels of staff understanding of standard work and variable inventory management. Centralized education sessions held jointly by the infection control team and various manufacturers for the reprocessing staff helped to create and reinforce best practices. Conclusion: Decentralized HLD that occurs across multiple ambulatory care sites led to gaps in instrument reprocessing and unique challenges due to variable geography of sites, physical space constraints, and an independent approach to procuring medical supplies. Through the auditing and feedback of all areas that perform HLD, an effective and sustainable strategy was created to ensure practice improvement. Streamlining standard work, seeking direct input from frontline staff, and collective educational events were critical to our success in the ambulatory setting.Funding: NoDisclosures: None
Coronavirus Disease 2019 (COVID-19) Admission Screening at a Tertiary-Care Center, Iowa 2020
Authors: Alsuhaibani Mohammed , Kobayashi Takaaki , Trannel Alexandra , Holley Stephanie , Abosi Oluchi , Jenn Kyle , Meacham Holly , Sheeler Lorinda , Etienne William , Dains Angie , Kukla Mary , Ward Emily , Ford Bradley , Edmond Michael , Wellington Melanie , Diekema Daniel , Salinas Jorge 
Published: November 2021

Background: Hospitalized patients may unknowingly carry severe acute respiratory coronavirus virus 2 (SARS-CoV-2), even if they are admitted for other reasons. Because SARS-CoV-2 may remain positive by reverse-transcriptase polymerase chain reaction (RT-PCR) for months after infection, patients with a positive result may not necessarily be infectious. We aimed to determine the frequency of SARS-CoV-2 infections in patients admitted for reasons unrelated to coronavirus disease 2019 (COVID-19). Methods: The University of Iowa Hospitals and Clinics is an 811-bed tertiary-care center. We use a nasopharyngeal SARS-CoV-2 RT-PCR to screen admitted patients without signs or symptoms compatible with COVID-19. Patients with positive tests undergo a repeat test to assess cycle threshold (Ct) value kinetics. We reviewed records for patients with positive RT-PCR screening admitted during July–October 2020. We used a combination of history, serologies, and RT-PCR Ct values to assess and qualify likelihood of infectiousness: (1) likely infectious, if Ct values were <29, or (2) likely not infectious, if 1 or both samples had Cts <30 with or without a positive SARS-CoV-2 antinucleocapsid IgG/IgM test or history of a positive result in the past 90 days. Contact tracing was only conducted for patients likely to be infectious. We describe the isolation duration and contact tracing data. Results: In total, 6,447 patients were tested on hospital admission for any reason (persons under investigation or admitted for reasons other than COVID-19). Of these, 240 (4%) had positive results, but 65 (27%) of these were admitted for reasons other than COVID-19. In total, 55 patients had Ct values available and were included in this analysis. The median age was 56 years (range, 0–91), 28 (51%) were male, and 12 (5%) were children. The most frequent admission syndromes were neurological (36%), gastrointestinal (16%), and trauma (16%). Our assessment revealed 23 likely infections (42%; 14 definite, 9 possible) and 32 cases likely not infectious (58%). The mean Ct for patients who were likely infectious was 22; it was 34 for patients who were likely not infectious. Mean duration of in-hospital isolation was 6 days for those who were likely infectious and 2 days for those who were likely not infectious. We detected 8 individuals (1 healthcare worker and 7 patients) who were exposed to a likely infectious patient. Conclusions: SARS-CoV-2 infection in patients hospitalized for other reasons was infrequent. An assessment of the likelihood of infectiousness including history, RT-PCR Cts, and serology may help prioritize patients in need of isolation and contact investigations.Funding: NoDisclosures: None
Appropriateness of Antibiotic Duration at the Time of Hospital Discharge
Authors: Sedlock Carly , Gallagher Jason , Cavaretta Marissa , Haines Alexander , Nguyen Kevin , Agarwal Neelesh 
Published: November 2021

Background: Antimicrobial stewardship initiatives usually occur in the inpatient setting, and they are often lacking at transitions of care (TOC), including hospital discharge. We assessed the appropriateness of antibiotic treatment duration at the time of discharge from our institution. Methods: This retrospective chart review included 300 adult patients discharged on oral antibiotics for acute infections during a 3-month period in 2019. The primary outcome was the duration of antibiotic therapy (DOT). To assess appropriateness, we compared the prescribed DOT (1) to that recommended by clinical guidelines, (2) to the minimum supported by clinical trials, and (3) to the period beyond the point of clinical stability, defined as normal vital signs with improvement in symptoms present from diagnosis. Each indication and antibiotic was assessed using standards appropriate for the combination. Results: Results are shown in Tables 1 and 2 and Figure 1. Conclusions: Antibiotics were often given longer than necessary on hospital discharge. In this study, patients received a median 2 days of excess antibiotics compared to recommended guidelines and 6 days after reaching clinical stability. A pilot TOC stewardship program was initiated to address this problem.Funding: NoDisclosures: None
How the COVID-19 Pandemic Affected Antimicrobial Prescribing Practices at a Tertiary-Care Healthcare System in Detroit, Michigan
Authors: Beatriz Cruz Angela , LeRose Jennifer , Sandhu Avnish , Chopra Teena 
Published: November 2021

Background: Inappropriate antimicrobial use continues to threaten modern medicine. The ongoing pandemic likely exacerbated this problem because COVID-19 presents similarly to bacterial pneumonia, confusion exists regarding treatment guidelines, and testing turnaround times (TATs) are slow. Our primary object was to quantify antimicrobial use changes during the pandemic to rates before the crisis. A subanalysis within the COVID-19 cohort was completed based on SARS-CoV-2 status. Methods: The pre–COVID-19 period was January–May 2019 and the COVID-19 period was January–May 2020. Subanalyses were used to explore differences in antibiotics use between persons not under investigation (non-PUIs), SARS-CoV-2–negative PUIs, and SARS-CoV-2–positive PUIs. Non-PUI patients were those without respiratory symptoms and/or fever. The χ2 and Wilcoxon signed rank-sum tests were used for analysis. Results: During the 2019 and 2020 study periods, 7,909 and 7,283 patients received >1 antimicrobial, respectively (Figure 1). Overall, antibiotic therapy per 1,000 patient days increased from 633.1 before COVID-19 to 678.5 during COVID-19, a 7.2% increase (Table 1). Notably, broad-spectrum respiratory antibiotics demonstrated a significant increase between pre–COVID-19 and COVID-19 cohorts (p < 0.001). Of the 7,283 patients within the COVID-19 cohort, 34.7% (n = 2,532) were PUI and 13.8% (n = 1,002) of these patients tested SARS-CoV-2 positive. Again, broad-spectrum respiratory antibiotics use was significantly increased for COVID-19 patients (p < 0.001). Of note, the proportion of patients receiving respiratory antibiotics steadily decreased over time (R2 = 0.99). Conclusions: There was a significant increase in antibiotic use during the COVID-19 pandemic. Encouragingly, antimicrobial use decreased over time, likely due to (1) faster TATs, (2) real-time education to clinicians and subsequent de-escalation of unnecessary antimicrobials, and (3) development of treatment guidelines as new research emerged.Funding: NoDisclosures: None
Prospective Audit for Antimicrobial Use and Stewardship Practices in Intensive Care Unit at a Tertiary-Care Center in India
Authors: Singh Parul , Mathur Purva , Walia Kamini , Trikha Anjan 
Published: November 2021

Background: Antimicrobial decision making in the ICU is challenging. Injudicious use of antimicrobials contributes to the development of resistant pathogens and drug-related adverse events. However, inadequate antimicrobial therapy is associated with mortality in critically ill patients. Antimicrobial stewardship programs are increasingly being implemented to improve prescribing. Methods: This prospective study was conducted over 11 months, during which the pharmacist used a standardized survey form to collect data on antibiotic use. Evaluation of antimicrobial use and stewardship practices in a 12-bed polytrauma ICU and a 20-bed neurosurgery ICU of the 248-bed AIIMS Trauma Center in Delhi, India. Antimicrobial consumption was measured using WHO-recommended defined daily dose (DDD) of given antimicrobials and days of therapy (DOT). Results: Antibiotics were ranked by frequency of use over the 11-month period based on empirical therapy and culture-based therapy. The 11-month DDD and DOT averages when empiric antibiotics were used were 532 of 1,000 patient days and 484 per 1,000 patient days, respectively (Figure 1). When cultures were available, DDD was 486 per 1,000 patient days and DOT was 442 per 1,000 patient days (Figure). Conclusions: The quantity and frequency of antibiotics used in the ICUs allowed the AMSP to identify areas to optimize antibiotic use such as educational initiatives, early specimen collection, and audit and feedback opportunities.Funding: NoDisclosures: None
Building a PPE Monitor Team as Part of a Comprehensive COVID-19 Prevention Strategy
Authors: Summerlin-Long Shelley , Brewer Brooke , Selimos Amy , Buchanan Mark , Clark Christa , Croyle Karen , Culbreth Cynthia , Del Monte Pam , DiBiase Lauren , Hendrickson Lori , Miller Pam , Schnell Natalie , Schultz Katherine , Stancill Lisa , Teal Lisa , Weber David , Sickbert-Bennett Emily 
Published: November 2021

Background: The use of personal protective equipment (PPE) is a critical intervention in preventing the spread of transmission-based infections in healthcare settings. However, contamination of the skin and clothing of healthcare personnel (HCP) frequently occurs during the doffing of PPE. In fact, nearly 40% of HCP make errors while doffing their PPE, causing them to contaminate themselves. PPE monitors are staff that help to promote their colleagues’ safety by guiding them through the PPE donning and doffing processes. With the advent of the COVID-19 pandemic in early 2020, the UNC Medical Center chose to incorporate PPE monitors as part of its comprehensive COVID-19 prevention strategy, using them in inpatient areas (including COVID-19 containment units and all other units with known or suspected SARS-CoV-2–positive patients), procedural areas, and outpatient clinics. Methods: Infection prevention and nursing developed a PPE monitoring team using redeployed staff from outpatient clinics and inpatient areas temporarily closed because of the pandemic. Employee training took place online and included fundamentals of disease transmission, hand hygiene basics, COVID-19 policies and signage, and videos on proper donning and doffing, including coaching tips. The monitors’ first shifts were supervised by experienced monitors to continue in-place training. Employees had competency sheets signed off by a supervisor. Results: The Medical Center’s nursing house supervisors took over management and deployment of the PPE monitoring team, and infection prevention staff continued to train new members. Eventually, as closed clinics and areas reopened and these PPE monitors returned to their regular positions, areas used their own staff to perform the role of PPE monitor. In the fall of 2020, a facility-wide survey was sent to all inpatient staff to assess their perceptions of the Medical Center’s efforts to protect them from acquiring COVID-19. It included a question asking how much staff agreed or disagreed that PPE monitors “play an important role in keeping our staff who care for COVID-19 patients safe.” Of the 626 staff who answered this question, 67.6% agreed or strongly agreed that PPE monitors played an important role in keeping staff safe. Thus far, there has been no direct transmission or clusters of COVID-19 involving HCP in COVID-19 containment units with PPE monitors. Conclusions: PPE monitors are an important part of a comprehensive COVID-19 prevention strategy. In early 2021, the UNC Medical Center posted and hired paid PPE monitor positions to continue this critical work in a sustainable way.Funding: NoDisclosures: None
Risk Factors for In-Hospital Mortality from COVID-19 Among Nursing Home Patients—An Urban Center Experience
Authors: Vahia Amit , Sharma Mamta , Johnson Leonard , Bhargava Ashish , Saravolatz Louis , Szpunar Susan 
Published: November 2021

Background: As the COVID-19 pandemic continues, special attention is focused on high-risk patients. In this study, we assessed the risk factors for COVID-19 mortality in nursing home patients. Methods: In this retrospective cohort study, we reviewed the electronic medical records of SARS-COV-2 PCR–positive nursing-home patients between March 8 and June 14, 2020. The primary outcome was in-hospital mortality. Risk factors were compared between those who were discharged or died using the Student t test, the Mann-Whitney U test, χ2 analysis, and logistic regression. Results: Among 169 hospitalized nursing-home patients, the case fatality rate was 43.2%. The mean age was 72.3 ± 13.8 years; 92 patients (54.4%) were male; and 112 patients (66.3%) were black. Within the first day of hospitalization, 83 (49%) patients developed fever. On admission, 24 (14.2%) patients were hypotensive. Leukopenia, lymphopenia, and thrombocytopenia were present in 20 (12%), 91 (53%), and 40 (23.7%) patients, respectively. Among the inflammatory markers, elevations in CRP and ferritin levels occurred in 79% and 24%, respectively. Intensive care admission was needed for 40 patients (23.7%). Septic shock occurred in 25 patients (14.8%). Patients over the age of 70 were more likely to die than younger patients (OR, 2.2; 95% CI, 1.2– 4.1; P = .20). Patients with a fever on admission were more likely to die than those who were afebrile (OR, 2.03; 95% CI, 1.08–3.8; P = .03). Also, 66.7% hypotensive patients died compared to 39.3% normotensive patients (OR, 3.1; 95% CI, 1.2–7.7 P = .01). Intubated patients died more often than those not intubated, 78.4% versus 33.3%, respectively (OR=7.3, p < 0.001, CI 3.1, 17.2) Factors significantly associated with death included higher mean qSofa (p < 0.001), higher median Charlson scores (0.02), thrombocytopenia (p = 0.04) and lymphocytopenia (0.04). From multivariable logistic regression, independent factors associated with death were Charlson score (OR=1.2, p=0.05), qSofa (OR=2.0, p=0.004), thrombocytopenia (OR = 3.0, p = 0.01) and BMI less than 25 (OR = 3.5, p=0.002). Conclusions: Our multivariable analysis revealed that patients with a greater burden of comorbidities, lower BMI, higher qSOFA sepsis score, and thrombocytopenia had a higher risk of death, perhaps because of severe infection despite a robust immune response.Funding: NoDisclosures: None
Luminescence dating of a late Middle Pleistocene glacial advance in eastern England
Authors: Gibbard Philip L. , Bateman Mark D. , Leathard Jane , West R.G. 
Published: November 2021

Abstract
Previous investigation of isolated landforms, on the eastern margin of the East Anglian Fenland, England, has demonstrated that they represent an ice-marginal delta and alluvial fan complex deposited at the margin of an ice lobe that entered the Fenland during the ‘Tottenhill glaciation’ (termed the ‘Skertchly Line’). They have been attributed, based on regional correlations, to a glaciation during the Late Wolstonian (i.e. Late Saalian) Substage (Drenthe Stadial, early Marine Isotope Stage (MIS) 6). This paper aimed to test this correlation by directly optically luminescence dating, for the first time, sediments found within the Skertchly Line at Shouldham Thorpe, Norfolk, and Maidscross Hill, Suffolk, together with those in associated kame terrace deposits at Watlington, Norfolk. Ages ranged from 244 ± 10 ka to 12.8 ± 0.46 ka, all the results being younger than MIS 8 with some clearly showing the landforms have been subsequently subjected to periglacial processes, particularly during the Late Devensian Substage (∼MIS 2). Most of the remainder fall within the range 169–212 ka and could be assigned to MIS 6, thus confirming the previously proposed age of the glaciation. The local and regional implications of these conclusions are discussed, the maximum ice limit being linked to that of the Amersfoort–Nijmegen glaciotectonic ridge limit in the central Netherlands.