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Background Oral case presentations – structured verbal reports of clinical cases – are fundamental to patient care and learner education. Despite their continued importance in a modernized medical landscape, their structure has remained largely unchanged since the 1960s, based on the traditional Subjective, Objective, Assessment, Plan (SOAP) format developed for medical records. We developed a problem-based alternative known as Events, Assessment, Plan (EAP) to understand the perceived efficacy of EAP compared to SOAP among learners. Methods We surveyed (Qualtrics, via email) all third- and fourth-year medical students and internal medicine residents at a large, academic, tertiary care hospital and associated Veterans Affairs medical center. The primary outcome was trainee preference in oral case presentation format. The secondary outcome was comparing EAP and SOAP on 10 functionality domains assessed via a 5-point Likert scale. We used descriptive statistics (proportion and mean) to describe the results. Results The response rate was 21% (118/563). Of the 59 respondents with exposure to both the EAP and SOAP formats, 69% (n = 41) preferred the EAP format as compared to 19% (n = 11) who preferred SOAP (p Conclusions Our findings suggest that trainees prefer the EAP format over SOAP and that EAP may facilitate clearer and more efficient communication on rounds, which in turn may enhance patient care and learner education. A broader, multi-center study of the EAP oral case presentation will help to better understand preferences, outcomes, and barriers to implementation.

Background Community-acquired pneumonia (CAP) is a common cause for hospitalization and antibiotic overuse. We aimed to improve antibiotic duration for CAP across 41 hospitals participating in the Michigan Hospital Medicine Safety Consortium (HMS). Methods This prospective collaborative quality initiative included patients hospitalized with uncomplicated CAP who qualified for a 5-day antibiotic duration. Between 23 February 2017 and 5 February 2020, HMS targeted appropriate 5-day antibiotic treatment through benchmarking, sharing best practices, and pay-for-performance incentives. Changes in outcomes, including appropriate receipt of 5 ± 1–day antibiotic treatment and 30-day postdischarge composite adverse events (ie, deaths, readmissions, urgent visits, and antibiotic-associated adverse events), were assessed over time (per 3-month quarter), using logistic regression and controlling for hospital clustering. Results A total of 41 hospitals and 6553 patients were included. The percentage of patients treated with an appropriate 5 ± 1–day duration increased from 22.1% (predicted probability, 20.9% [95% confidence interval: 17.2%–25.0%]) to 45.9% (predicted probability, 43.9% [36.8%–51.2%]; adjusted odds ratio [aOR] per quarter, 1.10 [1.07–1.14]). Thirty-day composite adverse events occurred in 18.5% of patients (1166 of 6319) and decreased over time (aOR per quarter, 0.98 [95% confidence interval: .96–.99]) owing to a decrease in antibiotic-associated adverse events (aOR per quarter, 0.91 [.87–.95]). Conclusions Across diverse hospitals, HMS participation was associated with more appropriate use of short-course therapy and fewer adverse events in hospitalized patients with uncomplicated CAP. Establishment of national or regional collaborative quality initiatives with data collection and benchmarking, sharing of best practices, and pay-for-performance incentives may improve antibiotic use and outcomes for patients hospitalized with uncomplicated CAP.

Background Up to one-third of hospitalized patients treated for urinary tract infection (UTI) have asymptomatic bacteriuria (ASB). Both diagnostic (avoiding inappropriate urine cultures) and antibiotic stewardship (reducing unnecessary antibiotic use in asymptomatic patients) have been proposed to reduce unnecessary antibiotic use for ASB. However, it's unclear which method is most effective. Methods The Michigan Hospital Medicine Safety Consortium aimed to improve antibiotic use and outcomes of hospitalized patients with a positive urine culture between 7/1/2017—3/31/2020 (see Table 1 for patient characteristics) by benchmarking performance across 46 Michigan hospitals, sharing best practices, and implementing pay-for-performance metrics related to unnecessary treatment of ASB (see Figure 1). Using logistic regression models controlling for hospital clustering, we assessed change over time in percentage of hospitalized patients treated for UTI who had ASB (i.e., had no documented signs or symptoms of UTI) and hospital characteristics associated with baseline or change in unnecessary antibiotic prescribing. We then estimated the percentage of avoided ASB treatment attributable to diagnostic (decrease in urine cultures ordered on asymptomatic patients) vs. antibiotic stewardship (decrease duration or avoidance of antibiotic treatment). Results Across 46 hospitals, there were 15,493 patients with a positive urine culture. Of 13,805 patients treated for a UTI, 23.2% (3,197) had ASB. The percentage of patients treated for UTI who had ASB declined over time from 29.0% (95% CI: 26.1%, 32.0%) to 16.9% (95% CI: 14.2%, 20.1%; aOR 0.94 per quarter, 95% CI: 0.92-0.96; Figure 1) with hospitals not belonging to a larger healthcare system having the largest decrease over time (Table 2). Neither the proportion of patients with ASB who were treated with antibiotics (P=0.07) nor the duration of therapy for ASB changed over time (P=0.09); thus, nearly all avoided antibiotic therapy for ASB appeared due to diagnostic stewardship. Conclusions Across 46 hospitals, there was a decrease over time in unnecessary treatment for ASB with independent hospitals improving most. Diagnostic stewardship appeared responsible for nearly all improvement. Disclosures Payal K. Patel, MD, MPH, Qiagen: Honoraria.

Background In 10/2019, revised ATS/IDSA community-acquired pneumonia (CAP) guidelines removed healthcare-associated pneumonia (HCAP), expanding patients eligible for a 5-day antibiotic course. Using data from 46 hospitals in the Michigan Hospital Medicine Safety Consortium, we quantified the impact of removing HCAP on antibiotic duration for CAP. Methods From 11/2017 to 1/2022, data were abstracted from medical records of adult non-ICU medical patients admitted with pneumonia. Our primary outcome was percentage of patients who received 5-days of antibiotics out of those who, under the new CAP guidelines would be eligible for 5-days (including patients defined as HCAP prior to the 2019 guideline) [Table 1]. We evaluated using Chi-square, if the effect of the guidelines differed for patients defined as CAP based on the 2007 CAP guideline (pCAP) vs. HCAP. To assess the effect of the new guideline on 5-day therapy, we used segmented logistic regression accounting for hospital level clustering to look at changes at baseline and overtime before and after 10/2019. Results When applying the 2019 CAP definition to 34,810 patients admitted with pneumonia over the entire period, 41.2% (N=14,358) of patients were eligible for 5-day duration. Applying pre-2019 categorization to the entire period, 46.4% of pCAP (N=10,565/22,757) and 31.5% of HCAP (N=3793/12,053) were eligible for 5-day duration. Of those 5-day eligible, 34.4% (N=4,936) received 5 days (pCAP 35.5% N=3750; HCAP 31.2% N=1186, P< .001). Before 10/2019, 29.5% (N=2,018) of patients with pCAP who were eligible received 5 days vs 23.6% (N=548) of HCAP (P< .001). Post 10/2019, 46.5% (N=1,732) of patients with pCAP eligible received 5 days vs 43.5% (N=638) of HCAP (P=0.049). The improvement rate in 5-day therapy decreased after 10/2019, with similar decrements for both pCAP and HCAP [Figure 1]. Conclusion Among patients hospitalized with pneumonia, two thirds received an excess antibiotic duration, with similar proportions for pCAP and HCAP. Prior to the new guidelines, the 5-day treatment rate was improving for HCAP and pCAP. However, the rate of improvement decreased after 10/2019 for both pCAP and HCAP, suggesting the 2019 guidelines did not have an added effect on improving antibiotic duration. Disclosures Valerie Vaughn, MD, MSc, Thermo Fisher Scientific: Honoraria.

Background A recent randomized trial, the MICHELLE trial, demonstrated improved posthospital outcomes with a 35‐day course of prophylactic rivaroxaban for patients hospitalized with COVID‐19 at high risk of venous thromboembolism. We explored how often these findings may apply to an unselected clinical population of patients hospitalized with COVID‐19. Methods and Results Using a 35‐hospital retrospective cohort of patients hospitalized between March 7, 2020, and January 23, 2021, with COVID‐19 (MI‐COVID19 database), we quantified the percentage of hospitalized patients with COVID‐19 who would be eligible for rivaroxaban at discharge per MICHELLE trial criteria and report clinical event rates. The main clinical outcome was derived from the MICHELLE trial and included a composite of symptomatic venous thromboembolism, pulmonary embolus‐related death, nonhemorrhagic stroke, and cardiovascular death at 35 days. Multiple sensitivity analyses tested different eligibility and exclusion criteria definitions to determine the effect on eligibility for postdischarge anticoagulation prophylaxis. Of 2016 patients hospitalized with COVID‐19 who survived to discharge and did not have another indication for anticoagulation, 25.9% (n=523) would be eligible for postdischarge thromboprophylaxis per the MICHELLE trial criteria (range, 2.9%–39.4% on sensitivity analysis). Of the 416 who had discharge anticoagulant data collected, only 13.2% (55/416) were actually prescribed a new anticoagulant at discharge. Of patients eligible for rivaroxaban per the MICHELLE trial, the composite clinical outcome occurred in 1.2% (6/519); similar outcome rates were 5.7% and 0.63% in the MICHELLE trial's control (no anticoagulation) and intervention (rivaroxaban) groups, respectively. Symptomatic venous thromboembolism events and all‐cause mortality were 6.2% (32/519) and 5.66% in the MI‐COVID19 and MICHELLE trial control cohorts, respectively. Conclusions Across 35 hospitals in Michigan, ≈1 in 4 patients hospitalized with COVID‐19 would qualify for posthospital thromboprophylaxis. With only 13% of patients actually receiving postdischarge prophylaxis, there is a potential opportunity for improvement in care.

Background Healthcare-associated infection (HAI) is a common and largely preventable cause of morbidity and mortality. The COVID-19 pandemic has presented unprecedented challenges to health systems. We conducted a national survey to ascertain hospital characteristics and the use of HAI prevention measures in Israel. Methods We e-mailed surveys to infection prevention and control (IPC) leads of acute care hospitals in Israel. The survey included questions about the use of practices to prevent catheter-associated urinary tract infection (CAUTI), central line-associated bloodstream infection (CLABSI), ventilator-associated pneumonia (VAP), and Clostridioides difficile infection (CDI). The survey also assessed COVID-19 impact and healthcare worker well-being. Results IPC leads from 15 of 24 invited hospitals (63%) completed the survey. Only one-third of respondents reported strong support for IPC from hospital leadership. Although several prevention practices were used by all hospitals (e.g., maximum sterile barrier precautions for CLABSI and real-time assessment of environmental cleaning for CDI), use of other practices was suboptimal—particularly for CAUTI and VAP. COVID-19 had a profound impact on Israeli hospitals, with all hospitals reporting opening of new units to care for COVID patients and most reporting moderate to extreme financial hardship. All hospitals reported highly successful plans to vaccinate all staff and felt confident that the vaccine is safe and effective. Conclusion We provide a status report of the IPC characteristics and practices Israeli hospitals are currently using to prevent HAIs during the COVID-19 era. While many globally accepted IPC practices are widely implemented, opportunities to increase the use of certain IPC practices in Israeli hospitals exist.

Background As the COVID-19 pandemic evolves, it is critical to understand characteristics that have allowed US healthcare systems, including the Veterans Affairs (VA) and non-federal hospitals, to mount an effective response in the setting of limited resources and unpredictable clinical demands generated by this system shock. Objective To compare the impact of and response to resource shortages to both VA and non-federal healthcare systems during the COVID-19 pandemic. Design Cross-sectional national survey administered April 2021 through May 2022. Participants Lead infection preventionists from VA and non-federal hospitals across the US. Main Measures Surveys collected hospital demographic factors along with 11 questions aimed at assessing the effectiveness of the hospital’s COVID response. Key Results The response rate was 56% (71/127) from VA and 47% (415/881) from non-federal hospitals. Compared to VA hospitals, non-federal hospitals had a larger average number of acute care (214 vs. 103 beds, ppp=.03) and more frequently opened new units to care specifically for COVID patients (71% vs. 49%, pp=.001) and financial hardships stemming from the pandemic (58% vs. 7%, p Conclusions In our survey-based national study, lead infection preventionists noted several distinct advantages in VA versus non-federal hospitals in their ability to expand bed capacity, retain staff, mitigate supply shortages, and avoid financial hardship. While these benefits appear to be inherent to the VA’s structure, non-federal hospitals can adapt their infrastructure to better weather future system shocks.

Background:We sought to determine the incidence of community-onset and hospital-acquired coinfection in patients hospitalized with coronavirus disease 2019 (COVID-19) and to evaluate associated predictors and outcomes.Methods:In this multicenter retrospective cohort study of patients hospitalized for COVID-19 from March 2020 to August 2020 across 38 Michigan hospitals, we assessed prevalence, predictors, and outcomes of community-onset and hospital-acquired coinfections. In-hospital and 60-day mortality, readmission, discharge to long-term care facility (LTCF), and mechanical ventilation duration were assessed for patients with versus without coinfection.Results:Of 2,205 patients with COVID-19, 141 (6.4%) had a coinfection: 3.0% community onset and 3.4% hospital acquired. Of patients without coinfection, 64.9% received antibiotics. Community-onset coinfection predictors included admission from an LTCF (OR, 3.98; 95% CI, 2.34–6.76; P < .001) and admission to intensive care (OR, 4.34; 95% CI, 2.87–6.55; P < .001). Hospital-acquired coinfection predictors included fever (OR, 2.46; 95% CI, 1.15–5.27; P = .02) and advanced respiratory support (OR, 40.72; 95% CI, 13.49–122.93; P < .001). Patients with (vs without) community-onset coinfection had longer mechanical ventilation (OR, 3.31; 95% CI, 1.67–6.56; P = .001) and higher in-hospital mortality (OR, 1.90; 95% CI, 1.06–3.40; P = .03) and 60-day mortality (OR, 1.86; 95% CI, 1.05–3.29; P = .03). Patients with (vs without) hospital-acquired coinfection had higher discharge to LTCF (OR, 8.48; 95% CI, 3.30–21.76; P < .001), in-hospital mortality (OR, 4.17; 95% CI, 2.37–7.33; P ≤ .001), and 60-day mortality (OR, 3.66; 95% CI, 2.11–6.33; P ≤ .001).Conclusion:Despite community-onset and hospital-acquired coinfection being uncommon, most patients hospitalized with COVID-19 received antibiotics. Admission from LTCF and to ICU were associated with increased risk of community-onset coinfection. Future studies should prospectively validate predictors of COVID-19 coinfection to facilitate the reduction of antibiotic use.

Purpose Leadership development may be a key strategy to enhance job satisfaction, reduce burnout and improve patient safety in health-care systems. This study aims to assess feasibility of a leadership development series in an effort to invigorate a collaborative culture, create peer networks and elevate autonomy in daily work. Design/methodology/approach The authors implemented a collectivistic leadership development series titled Fueling Leadership in Yourself. The series was designed for all types of health-care workers in the medicine service at a tertiary referral center for veterans. Two series of leadership development sessions with varied experiential learning methods were facilitated by content experts. Subjects focused on leadership approaches and attributes applicable to all roles within a health-care system. The authors collected participant perceptions using pre- and post-series surveys. Primary outcomes were understanding and applicability of leadership concepts, employee engagement in leadership, satisfaction with training and work environment and qualitative reflections. Findings A total of 26 respondents (of 38 participants) from 8 departments and several role types increased their knowledge of leadership techniques, were highly satisfied with and would recommend the series and found leadership principles applicable to their daily work. Participants continued to use skills years after the series. Practical implications Short, intermittent, collectivistic leadership development sessions appear effective in expanding knowledge, satisfaction and skills used in daily practice for a diverse group of health-care workers. Originality/value Novel programmatic aspects included inviting all types of health-care workers, practicing universally applicable content and using a variety of active, experiential learning methods.

Background Indwelling urinary catheters are commonly used in hospitalized patients, which can lead to the development of urinary catheter complications, including catheter-associated urinary tract infection (CAUTI). Limited reports on the appropriateness of urinary catheter use exist in Japan. This study investigated the prevalence and appropriateness of indwelling urinary catheters, and the incidence of CAUTI in non-intensive care unit (non-ICU) wards in Japanese hospitals. Methods This prospective observational study was conducted in 7 non-ICU wards from 6 hospitals in Japan from October 2017 to June 2018. At each hospital the study teams evaluated urinary catheter prevalence through in-person bedside evaluation for at least 5 days of each week for 3 months. Catheter associated urinary tract infection (CAUTI) incidence and appropriateness of catheter use was collected via chart review. Results We assessed 710 catheter-days over 5528 patient-days. The mean prevalence of indwelling urinary catheter use in participating wards was 13% (range: 5% to 19%), while the mean incidence of CAUTI was 9.86 per 1000 catheter-days (range: 0 to 33.90). Approximately 66% of the urinary catheter days assessed had an appropriate indication for use (range: 17% to 81%). A physician's order for catheter placement was present in only 10% of catheterized patients. Conclusion This multicenter study provides epidemiological information about the appropriate use of urinary catheters in Japanese non-ICU wards. A multimodal intervention may help improve the appropriate use of urinary catheters.

Background Antibiotics are commonly prescribed to patients as they leave the hospital. We aimed to create a comprehensive metric to characterize antibiotic overuse after discharge among hospitalized patients treated for pneumonia or urinary tract infection (UTI), and to determine whether overuse varied across hospitals and conditions. Methods In a retrospective cohort study of hospitalized patients treated for pneumonia or UTI in 46 hospitals between 1 July 2017–30 July 2019, we quantified the proportion of patients discharged with antibiotic overuse, defined as unnecessary antibiotic use, excess antibiotic duration, or suboptimal fluoroquinolone use. Using linear regression, we assessed hospital-level associations between antibiotic overuse after discharge in patients treated for pneumonia versus a UTI. Results Of 21 825 patients treated for infection (12 445 with pneumonia; 9380 with a UTI), nearly half (49.1%) had antibiotic overuse after discharge (56.9% with pneumonia; 38.7% with a UTI). For pneumonia, 63.1% of overuse days after discharge were due to excess duration; for UTIs, 43.9% were due to treatment of asymptomatic bacteriuria. The percentage of patients discharged with antibiotic overuse varied 5-fold among hospitals (from 15.9% [95% confidence interval, 8.7%–24.6%] to 80.6% [95% confidence interval, 69.4%–88.1%]) and was strongly correlated between conditions (regression coefficient = 0.85; P < .001). Conclusions Antibiotic overuse after discharge was common and varied widely between hospitals. Antibiotic overuse after discharge was associated between conditions, suggesting that the prescribing culture, physician behavior, or organizational processes contribute to overprescribing at discharge. Multifaceted efforts focusing on all 3 types of overuse and multiple conditions should be considered to improve antibiotic prescribing at discharge., Of 21 825 hospitalized patients with pneumonia or urinary tract infection in 46 hospitals, half (49.1%) had antibiotic overuse after discharge. Overuse varied 5-fold among hospitals (15.9%–80.6%) and was correlated between conditions. To improve prescribing, stewardship should include care transitions.

BACKGROUND: Hand hygiene is key to preventing healthcare-associated infection and the spread of respiratory viruses like the novel coronavirus that causes COVID-19. Unfortunately, hand hygiene adherence of healthcare workers (HCWs) in Japan is suboptimal according to previous studies. OBJECTIVES: Our objectives were to evaluate hand hygiene adherence among physicians and nurses before touching hospitalized patients and to evaluate changes in hand hygiene adherence after a multimodal intervention was implemented. DESIGN, SETTING, AND PARTICIPANTS: We conducted a pre- and postintervention study with HCWs at four tertiary hospitals in Niigata, Japan. Hand hygiene observations were conducted from June to August 2018 (preintervention) and February to March 2019 (postintervention). INTERVENTION: The multimodal hand hygiene intervention recommended by the World Health Organization was tailored to each hospital and implemented from September 2018 to February 2019. MAIN OUTCOMES AND MEASURES: We observed hand hygiene adherence before touching patients in each hospital and compared rates before and after intervention. Intervention components were also evaluated. RESULTS: There were 2,018 patient observations preintervention and 1,630 postintervention. Overall, hand hygiene adherence improved from 453 of 2,018 preintervention observations (22.4%) to 548 of 1,630 postintervention observations (33.6%; P < .001). Rates improved more among nurses (13.9 percentage points) than among doctors (5.7 percentage points). Improvement varied among the hospitals: Hospital B (18.4 percentage points) was highest, followed by Hospitals D (11.4 percentage points), C (11.3 percentage points), and Hospital A (6.5 percentage points). CONCLUSIONS: A multimodal intervention improved hand hygiene adherence rates in physicians and nurses in Niigata, Japan; however, further improvement is necessary. Given the current suboptimal hand hygiene adherence rates in Japanese hospitals, the spread of COVID-19 within the hospital setting is a concern.

We assessed infection prevention in Swiss hospitals via a national survey focusing on infection prevention practices prior to a large national infection prevention initiative. Of the 59 hospitals that responded (77%), 98% had infection prevention teams and 40% very good or excellent leadership support. However, a minority of hospitals used recommended infection prevention practices and surveillance systems regularly.

Purpose The purpose of this paper is to retrace past developments that occurred in the Alaskan and Canadian North as of result of the Second World War and illustrate the ramifications of these events in the Canadian and American political landscapes as it pertains to warfare tourism. The paper also intends to initiate a discussion on how certain narratives pertaining to warfare tourism are promoted, while others are overlooked. Design/methodology/approach This paper analyses the political, economic, socio-cultural and technological factors that resulted in tourism growth or the lack thereof in the Canadian and American Norths. Findings Warfare tourism, like most types of tourism, is expected to grow. Through this growth comes opportunities to expand and integrate the discussion pertaining to warfare tourism in the Canadian and American Norths while also providing a starting point for discussion about potential solutions to address warfare tourism and cultural dissonance. Research limitations/implications This viewpoint is dependent on literature reviews. Practical implications The relationship between Indigenous peoples and other marginalized populations in the Second World War and warfare tourism is a relatively new research area. For warfare tourism to become integrated into tourism policies and developments, a willingness to address cultural dissonance and integrate populations formerly marginalized in the Second World War will be required. This paper examines how northern and other marginalized voices can be integrated in future commemoration and interpretation strategies. Social implications The paper provides an opportunity to examine the growth and healing that can result from warfare tourism. Originality/value This interdisciplinary collaboration conducted by a military historian, a northern historian and a tourism research researcher provides one of the first examinations of the impacts of the Second World War in North America, and the relevance of these impacts to the interpretation of warfare tourism in Canada.

Objectives Most older adults have multimorbidity that impairs physical functioning, but it is difficult to quantify using claims data. We previously developed and validated a multimorbidity-weighted index (MWI) that embeds physical functioning through disease weightings. We mapped these conditions to International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes and compared them with existing indices. Design Population-based prospective cohort. Setting Respondents to the 2006-2016 waves of the Health and Retirement Study (HRS) with linked Medicare claims data and continuous enrollment in 2006. Participants Community-dwelling Medicare-eligible HRS participants (N = 9923; mean age = 75.5 ± 8.5 y). Measurements Individuals were followed for future physical functioning (2006-2014) and mortality (2007-2016). MWI conditions were mapped to ICD-9-CM codes to produce an ICD-coded MWI (MWI-ICD). We compared MWI-ICD, simple disease count, Charlson, Elixhauser, and the health-related quality of life comorbidity index (HRQOL-CI) through distributions, hazard ratios for mortality, and relationships with future physical functioning. Results MWI-ICD exhibited the broadest distribution and most unique values (5891). Left censoring was most pronounced for Charlson (34.3% score = 0) and Elixhauser (13.1% score = 0) vs MWI (5.0% score = 0). Hazard ratios and concordance (C)-statistics for mortality across extreme quartiles were similar for MWI-ICD, Elixhauser, and Charlson but lower for disease count and the HRQOL-CI. For physical functioning, MWI-ICD yielded the greatest contrast across extreme quartiles and overall coefficient of determination (R2 ). Conclusion MWI-ICD was significantly associated with mortality and future physical functioning and comparable with established metrics for mortality prediction although not weighted to mortality. MWI-ICD successfully captures diseases accumulation and functioning in claims data. J Am Geriatr Soc 68:999-1006, 2020.

ObjectiveThe patient–physician relationship impacts patients’ experiences and health outcomes. Physician attire is a form of nonverbal communication that influences this relationship. Prior studies examining attire preferences suffered from heterogeneous measurement and limited context. We thus performed a multicentre, cross-sectional study using a standardised survey instrument to compare patient preferences for physician dress in international settings.Setting20 hospitals and healthcare practices in Italy, Japan, Switzerland and the USA.ParticipantsConvenience sample of 9171 adult patients receiving care in academic hospitals, general medicine clinics, specialty clinics and ophthalmology practices.Primary and secondary outcome measuresThe survey was randomised and included photographs of a male or female physician dressed in assorted forms of attire. The primary outcome measure was attire preference, comprised of composite ratings across five domains: how knowledgeable, trustworthy, caring and approachable the physician appeared, and how comfortable the respondent felt. Secondary outcome measures included variation in preferences by country, physician type and respondent characteristics.ResultsThe highest rated forms of attire differed by country, although each most preferred attire with white coat. Low ratings were conferred on attire extremes (casual and business suit). Preferences were more uniform for certain physician types. For example, among all respondents, scrubs garnered the highest rating for emergency department physicians (44.2%) and surgeons (42.4%). However, attire preferences diverged for primary care and hospital physicians. All types of formal attire were more strongly preferred in the USA than elsewhere. Respondent age influenced preferences in Japan and the USA only.ConclusionsPatients across a myriad of geographies, settings and demographics harbour specific preferences for physician attire. Some preferences are nearly universal, whereas others vary substantially. As a one-size-fits-all dress policy is unlikely to reflect patient desires and expectations, a tailored approach should be sought that attempts to match attire to clinical context.

Objective: Clostridioides difficile infection (CDI) can be prevented through infection prevention practices and antibiotic stewardship. Diagnostic stewardship (ie, strategies to improve use of microbiological testing) can also improve antibiotic use. However, little is known about the use of such practices in US hospitals, especially after multidisciplinary stewardship programs became a requirement for US hospital accreditation in 2017. Thus, we surveyed US hospitals to assess antibiotic stewardship program composition, practices related to CDI, and diagnostic stewardship. Methods: Surveys were mailed to infection preventionists at 900 randomly sampled US hospitals between May and October 2017. Hospitals were surveyed on antibiotic stewardship programs; CDI prevention, treatment, and testing practices; and diagnostic stewardship strategies. Responses were compared by hospital bed size using weighted logistic regression. Results: Overall, 528 surveys were completed (59% response rate). Almost all (95%) responding hospitals had an antibiotic stewardship program. Smaller hospitals were less likely to have stewardship team members with infectious diseases (ID) training, and only 41% of hospitals met The Joint Commission accreditation standards for multidisciplinary teams. Guideline-recommended CDI prevention practices were common. Smaller hospitals were less likely to use high-tech disinfection devices, fecal microbiota transplantation, or diagnostic stewardship strategies. Conclusions: Following changes in accreditation standards, nearly all US hospitals now have an antibiotic stewardship program. However, many hospitals, especially smaller hospitals, appear to struggle with access to ID expertise and with deploying diagnostic stewardship strategies. CDI prevention could be enhanced through diagnostic stewardship and by emphasizing the role of non–ID-trained pharmacists and clinicians in antibiotic stewardship.

Background Strategies to optimize antibiotic prescribing at discharge are not well understood. Methods In fall 2019, we surveyed 39 Michigan hospitals on their antibiotic stewardship strategies. The association of reported strategies with discharge antibiotic overuse (unnecessary, excess, suboptimal fluoroquinolones) for community-acquired pneumonia (CAP) and urinary tract infection (UTI) was evaluated in 2 ways: (1) all strategies assumed equal weight and (2) strategies were weighted based on the ROAD (Reducing Overuse of Antibiotics at Discharge) Home Framework (ie, Tier 1—Critical infrastructure, Tier 2—Broad inpatient interventions, Tier 3—Discharge-specific strategies) with Tier 3 strategies receiving the highest weight. Results Between 1 July 2017 and 30 July 2019, 39 hospitals with 20 444 patients (56.5% CAP; 43.5% UTI) were included. Survey response was 100%. Hospitals reported a median (interquartile range [IQR]) 12 (9–14) of 34 possible stewardship strategies. On analyses of individual stewardship strategies, the Tier 3 intervention, review of antibiotics prior to discharge, was the only strategy consistently associated with lower antibiotic overuse at discharge (adjusted incident rate ratio [aIRR] 0.543, 95% confidence interval [CI]: .335–.878). On multivariable analysis, weighting by ROAD Home tier predicted antibiotic overuse at discharge for both CAP and UTI. For diseases combined, having more weighted strategies was associated with lower antibiotic overuse at discharge (aIRR 0.957, 95% CI: .927–.987, per weighted intervention); discharge-specific stewardship strategies were associated with a 12.4% relative decrease in antibiotic overuse days at discharge. Conclusions The more stewardship strategies a hospital reported, the lower its antibiotic overuse at discharge. However, Tier 3, or discharge-specific strategies, appeared to have the largest effect on antibiotic prescribing at discharge.

We assessed the long-term sustainability of a quality improvement intervention to reduce urethral catheter use at a Veterans Affairs (VA) hospital. During the 8 years after the initial intervention, point-prevalence surveillance showed that urethral catheter use continued to decrease (OR, 0.91; 95% CI, 0.86–0.97; P = .003) and that appropriateness of catheter use remained unchanged.

Background Antibiotic overuse at hospital discharge is common and harmful; however, methods to improve prescribing during care transitions have been understudied. We aimed to pilot a pharmacist-facilitated antibiotic timeout prior to discharge. Methods From May 2019 to October 2019, we conducted a single-center, controlled pilot study of a pharmacist-facilitated antibiotic timeout prior to discharge. The timeout addressed key elements of stewardship (e.g., duration) and was designed and implemented using iterative cycles with rapid feedback. We evaluated implementation outcomes related to feasibility, including usability, adherence, and acceptability, using mixed methods. Pre vs. post intervention antibiotic use at discharge in intervention vs. control groups was assessed using logistic regression models controlling for patient characteristics. Results Pharmacists conducted 288 antibiotic timeouts. Timeouts were feasible (mean 2.5 minutes per timeout) and acceptable (85% [40/48] of hospitalists believed timeouts improved prescribing). Pharmacists recommended an antibiotic change in 25% (73/288) of timeouts with 70% (51/73) of recommended changes accepted by hospitalists. Barriers to adherence included unanticipated and weekend discharges. Compared to control services, there were no differences in antibiotic use after discharge during the intervention. Conclusions A pharmacist-facilitated antibiotic timeout at discharge was feasible and holds promise as a method to improve antibiotic use at discharge.

Objectives We examined the association between multimorbidity and social participation and whether purpose in life and life satisfaction moderate this relationship. Methods Participants were 12,825 Health and Retirement Study adults. We used multiple linear regression to examine the association between a cumulative-updated multimorbidity-weighted index (MWI) and social participation. Results Among adults with average purpose in life or life satisfaction, MWI was associated with lower social participation. For those with above average purpose in life, each 1-point increase in MWI was associated with a 0.11-point (95% confidence interval [CI]: [0.07, 0.14]) better social participation score. Participants with above average life satisfaction experienced a 0.04-point (95% CI: [0.02, 0.07]) better social participation score with each 1-point increase in MWI. Discussion Multimorbidity was associated with worse social participation, but this was reversed by above average purpose in life and life satisfaction. Interventions that improve well-being should be assessed to enhance social participation among older adults with any degree of multimorbidity.

Background: Nearly half of hospitalized patients with bacteriuria or treated for pneumonia receive unnecessary antibiotics (noninfectious or nonbacterial syndrome such as asymptomatic bacteriuria), excess duration (antibiotics prescribed for longer than necessary), or avoidable fluoroquinolones (safer alternative available) at hospital discharge.1–3 However, whether antibiotic overuse at discharge varies between hospitals or is associated with patient outcomes remains unknown. Methods: From July 2017 to December 2018, trained abstractors at 46 Michigan hospitals collected detailed data on a sample of adult, non–intensive care, hospitalized patients with bacteriuria (positive urine culture with or without symptoms) or treated for community-acquired pneumonia (CAP; includes those with the disease formerly known as healthcare-associated pneumonia [HCAP]). Antibiotic prescriptions at discharge were assessed for antibiotic overuse using a previously described, guideline-based hierarchical algorithm.3 Here, we report the proportion of patients discharged with antibiotic overuse by the hospital. We also assessed hospital-level correlation (using Pearson’s correlation coefficient) between antibiotic overuse at discharge for patients with bacteriuria and patients treated for CAP. Finally, we assessed the association of antibiotic overuse at discharge with patient outcomes (mortality, readmission, emergency department visit, and antibiotic-associated adverse events) at 30 days using logit generalized estimating equations adjusted for patient characteristics and probability of treatment. Results: Of 17,081 patients (7,207 with bacteriuria; 9,874 treated for pneumonia), nearly half (42.2%) had antibiotic overuse at discharge (36.3% bacteriuria and 51.1% pneumonia). The percentage of patients discharged with antibiotic overuse varied 5-fold among hospitals from 14.7% (95% CI, 8.0%–25.3%) to 74.3% (95% CI, 64.2%–83.8%). Hospital rates of antibiotic overuse at discharge were strongly correlated between bacteriuria and CAP (Pearson’s correlation coefficient, 0.76; P ≤ .001) (Fig. 1). In adjusted analyses, antibiotic overuse at discharge was not associated with death, readmission, emergency department visit, or Clostridioides difficile infection. However, each day of overuse was associated with a 5% increase in the odds of patient-reported antibiotic-associated adverse events after discharge (Fig. 2). Conclusions: Antibiotic overuse at discharge was common, varied widely between hospitals, and was associated with patient harm. Furthermore, antibiotic overuse at discharge was strongly correlated between 2 disparate diseases, suggesting that prescribing culture or discharge processes—rather than disease-specific factors—contribute to overprescribing at discharge. Thus, discharge stewardship may be needed to target multiple diseases.Funding: This study was supported by the Society for Healthcare Epidemiology of America and by Blue Cross Blue Shield of Michigan and Blue Care Network.Disclosures: Valerie M. Vaughn reports contracted research for Blue Cross and Blue Shield of Michigan, the Department of VA, the NIH, the SHEA, and the APIC. She also reports receipt of funds from the Gordon and Betty Moore Foundation Speaker’s Bureau, the CDC, the Pew Research Trust, Sepsis Alliance, and the Hospital and Health System Association of Pennsylvania.

BackgroundDespite focused initiatives to reduce device-associated infection among hospitalised patients, the practices US hospitals are currently using are unknown. We thus used a national survey to ascertain the use of several established and novel practices to prevent device-associated infections.MethodsWe mailed surveys to infection preventionists in a random sample of nearly 900 US acute care hospitals in 2017. Our survey asked about the use of practices to prevent three common device-associated infections: catheter-associated urinary tract infection (CAUTI), central line-associated bloodstream infection (CLABSI) and ventilator-associated pneumonia (VAP). Using sample weights, we estimated the percentage of hospitals reporting regular use of each practice. We also conducted multivariable regression to determine associations between selected hospital characteristics (eg, perceived support from leadership) and use of CAUTI, CLABSI and VAP prevention practices.ResultsThe response rate was 59%. Several practices are reportedly used in over 90% of US hospitals: aseptic technique during indwelling urethral catheter insertion and maintenance (to prevent CAUTI); maximum sterile barrier precautions during central catheter insertion and alcohol-containing chlorhexidine gluconate for insertion site antisepsis (to prevent CLABSI); and semirecumbent positioning of the patient (to prevent VAP). Antimicrobial devices are used in the minority of hospitals for these three device-associated infections.ConclusionsWe provide an updated snapshot of the practices US hospitals are currently using to prevent device-associated infections. Compared with previous studies using a similar design and questions, we found that the use of recommended practices increased in US hospitals, especially for CAUTI prevention.

ObjectivePeripherally inserted central catheters (PICC) are frequently used to deliver medical therapies, but our knowledge regarding PICC-related complications remains incomplete. The objective of this study was to systematically elicit and characterise PICC-related complications as experienced by patients during and after hospitalisation.DesignProspective cohort study.SettingInpatient medical units at four US hospitals in two states.ParticipantsConsecutive sample of patients who had a new PICC placed during a hospital stay between August 2015 and May 2017.Main outcome(s)Patient-reported signs and symptoms of a possible PICC-related complication or functional issues.ResultsOf the 438 patients in the analytic cohort (91.4% of those consented), two-thirds were male with a mean age of 56 years. The most common reason for PICC placement was long-term antibiotic therapy (43.4%). During the 70-day follow-up period, 61.4% of patients reported signs of at least one complication, including potentially serious complications, such as bloodstream infection (17.6%) and deep vein thrombosis (30.6%). Correspondence of these reported events with medical record documentation of the complication was generally low. More than one-quarter (27.9%) of patients reported minor complications, such as insertion site redness, discomfort or difficult removal. While the PICC was in place, 26.0% reported restrictions in activities of daily living, 14.4% social activity restrictions and 19.2% had difficulty with flushing or operating the PICC.ConclusionOver 60% of patients report signs or symptoms of a possible complication or adverse effect after PICC placement. Bothersome complications from the patient perspective are clearly more common than those that typically rise to the level of healthcare provider attention or concern. Understanding the patient experience is critical for providing safe and effective care.

A national survey conducted in 2012 revealed that the rates of regular use of many evidence-based practices to prevent device-associated infections were low in Japanese hospitals. We conducted a second survey 4 years later to evaluate changes in infection prevention practices.Between July 2016 and January 2017, the instrument used in a survey of Japanese hospitals in 2012 was sent to 1,456 Japanese hospitals. The survey assessed general hospital and infection prevention program characteristics and use of practices specific to preventing catheter-associated urinary tract infection (CAUTI), central line-associated bloodstream infection (CLABSI), and ventilator-associated pneumonia (VAP). Independent sample chi-square tests were used to compare prevention practice rates between the first and second surveys.A total of 685/971 (71%) and 940/1,456 (65%) hospitals responded to the first and second surveys, respectively. For CAUTI, only use of bladder ultrasound scanners (11.1%-18.1%; P.001) increased. For CLABSI, use of chlorhexidine gluconate for insertion site antisepsis (18.5%-41.1%; P.001), antimicrobial dressing with chlorhexidine (3.4%-7.1%; P = .001), and central line insertion bundle (22.9%-33.0%; P.001) increased. For VAP, use of semirecumbent positioning of patients (65.0%-72.3%; P = .002), sedation vacation (31.5%-41.6%; P.001), oscillating/kinetic beds (4.7%-8.6%; P = .002), and a collective VAP prevention bundle (24.8%-34.8%; P.001) increased. Fewer than 50% of Japanese hospitals reported conducting CAUTI and VAP surveillance.Collaborative approaches and stronger incentives promoting infection prevention efforts may be warranted to further increase use of most evidence-based practices to reduce common health care-associated infections in Japan.

Background Antibacterials may be initiated out of concern for bacterial coinfection in coronavirus disease 2019 (COVID-19). We determined prevalence and predictors of empiric antibacterial therapy and community-onset bacterial coinfections in hospitalized patients with COVID-19. Methods A randomly sampled cohort of 1705 patients hospitalized with COVID-19 in 38 Michigan hospitals between 3/13/2020 and 6/18/2020. Data were collected on early (within 2 days of hospitalization) empiric antibacterial therapy and community-onset bacterial coinfections (positive microbiologic test ≤3 days). Poisson generalized estimating equation models were used to assess predictors. Results Of 1705 patients with COVID-19, 56.6% were prescribed early empiric antibacterial therapy; 3.5% (59/1705) had a confirmed community-onset bacterial infection. Across hospitals, early empiric antibacterial use varied from 27% to 84%. Patients were more likely to receive early empiric antibacterial therapy if they were older (adjusted rate ratio [ARR]: 1.04 [1.00–1.08] per 10 years); had a lower body mass index (ARR: 0.99 [0.99–1.00] per kg/m2), more severe illness (eg, severe sepsis; ARR: 1.16 [1.07–1.27]), a lobar infiltrate (ARR: 1.21 [1.04–1.42]); or were admitted to a for-profit hospital (ARR: 1.30 [1.15–1.47]). Over time, COVID-19 test turnaround time (returned ≤1 day in March [54.2%, 461/850] vs April [85.2%, 628/737], P < .001) and empiric antibacterial use (ARR: 0.71 [0.63–0.81] April vs March) decreased. Conclusions The prevalence of confirmed community-onset bacterial coinfections was low. Despite this, half of patients received early empiric antibacterial therapy. Antibacterial use varied widely by hospital. Reducing COVID-19 test turnaround time and supporting stewardship could improve antibacterial use.

Background Peripherally inserted central catheter tip placement at the cavoatrial junction is associated with reduced catheter-related deep vein thrombosis. Electrocardiographic tip confirmation purportedly improves accuracy of tip placement, but whether this approach can reduce deep vein thrombosis is unknown. Methods Prospectively collected data from patients that received peripherally inserted central catheters at 52 Michigan hospitals were analyzed. The method used to confirm tip confirmation at insertion and deep vein thrombosis outcomes were extracted from medical records. Multivariate models (accounting for the clustered nature of the data) were fitted to assess the association between peripherally inserted central catheter-related deep vein thrombosis and method of tip confirmation (electrocardiographic vs radiographic imaging). Results A total of 42,687 peripherally inserted central catheters (21,098 radiology vs 21,589 electrocardiographic) were included. Patients receiving electrocardiographic-confirmed peripherally inserted central catheters had fewer comorbidities compared with those that underwent placement via radiology. Overall, deep vein thrombosis occurred in 594 (1.3%) of all peripherally inserted central catheters. Larger catheter size (odds radio [OR] 1.32; 95% confidence interval [CI], 0.93-1.90 per unit increase in gauge), history of deep vein thrombosis, and cancer were associated with increased risk of deep vein thrombosis (OR 2.00; 95% CI, 1.65-2.43 and OR 1.62; 95% CI, 1.16-2.26, respectively) using logistic regression. Following adjustment, electrocardiographic guidance was associated with a significant reduction in peripherally inserted central catheter-related deep vein thrombosis compared with radiographic imaging (OR 0.74; 95% CI, 0.58-0.93; P = .0098). Conclusion The use of electrocardiography to confirm peripherally inserted central catheter tip placement at the cavoatrial junction was associated with significantly fewer deep vein thrombosis events than radiographic imaging. Use of this approach for peripherally inserted central catheter insertion may help improve patient safety, particularly in high-risk patients.

Health care-associated infection (HAI) is associated with substantial harm. To reduce HAI, the largest integrated health care system in the United States-the Veterans Health Administration-was an early adopter of infection prevention policies and initiatives. Whether these efforts translated into increased use of practices to prevent HAI in Veterans Affairs (VA) hospitals is unknown.To evaluate changes over time in infection prevention practices and the perception of the importance of infection prevention to hospital leadership.For this survey study, every 4 years between 2005 and 2017, infection preventionists were surveyed at all VA hospitals on use of practices associated with common HAIs, including central line-associated bloodstream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), ventilator-associated pneumonia (VAP), and (beginning in 2013) Clostridioides difficile infection. Data analysis was performed from February 1, 2019, to July 1, 2019.Reported regular use of key infection prevention practices and perceived importance of infection prevention to hospital leadership.Between 2005 and 2017, 320 total surveys were completed with response rates ranging from 59% (73 of 124) in 2017 to 80% (95 of 119) in 2005. Use of 12 different infection prevention practices increased. Since 2013, 92% (69 of 75) to 100% of VA hospitals reported regular use of key infection prevention practices for C difficile infection and CLABSI. In contrast, adoption of many practices to prevent CAUTI, although increasing, have lagged. Despite reported increases in the use of some practices for VAP such as semirecumbent positioning (89% [79 of 89] in 2005 vs 97% [61 of 63] in 2017, P = .007 for trend) and subglottic secretion drainage (23% [19 of 84] in 2005 vs 65% [40 of 62] in 2017, P .001), use of other key practices such as daily interruptions of sedation (85% [55 of 65] in 2009 vs 87% [54 of 62] in 2017, P = .66) and early mobilization (81% [52 of 64] in 2013 vs 82% [51 of 62] in 2017, P = .88) has not increased. Antibiotic stewardship programs are now reported in nearly every VA hospital (97% [71 of 73]); however, some hospitals report practices for microbiologic testing for HAIs (eg, 22% [16 of 72] report routine urine culture testing in 2017) that could also contribute to antibiotic overuse.From 2005 to 2017, reported use of 12 different infection prevention practices increased in VA hospitals. Areas for continued improvement of infection prevention practices appear to include CAUTI, certain VAP practices, and diagnostic stewardship for HAI. The reported adoption of many infection prevention practices in VA hospitals was higher than in non-VA hospitals. As hospitals continue to merge and health systems become increasingly integrated, these successes could help inform patient safety broadly.

Objective To examine the extent to which acute care hospitals in the Netherlands have adopted recommended practices to prevent catheter-associated urinary tract infection (CAUTI), central line-associated bloodstream infection (CLABSI), ventilator-associated pneumonia (VAP), and Clostridioides difficile infection (CDI). Methods Between 18 July 2017 and 31 October 2017, we surveyed the infection prevention teams of all acute care hospitals in the Netherlands. The survey instrument was based on the ‘Translating Healthcare-Associated Infection Prevention Research into Practice’ (TRIP) questionnaire and adapted to the Dutch context. Descriptive statistics were used to examine the reported regular use of CAUTI, CLABSI, VAP, and CDI prevention practices as well as the hospital characteristics. Results Out of 72 eligible hospitals, 47 (65.3%) responded. Surveillance systems for monitoring CAUTI, CLABSI, VAP, and CDI were present in 17.8, 95.4, 26.2, and 77.3% of hospitals, respectively. Antimicrobial stewardship programs have been established in 91.5% of participating hospitals. For CAUTI, the majority of hospitals regularly used aseptic technique during catheter insertion (95%) and portable bladder ultrasound scanners (86.1%). Intermittent catheterization and catheter stop-orders were regularly used by 65.8 and 62.2% of hospitals. For CLABSI, all hospitals regularly used maximum sterile barrier precautions and chlorhexidine gluconate for insertion site antisepsis. Avoidance of the femoral site for central line insertions was regularly used by 65.9% of hospitals. Urinary catheters and central-lines impregnated with antibiotics or antiseptics were rarely used (≤ 5%). Selective decontamination strategies for preventing VAP were used in 84% of hospitals. With the exception of disposable thermometers (31.8%), all prevention practices to prevent CDI were regularly used by more than 80% of hospitals. Conclusions Most Dutch hospitals report regular use of recommended practices for preventing CLABSI and CDI. Several specific practices to prevent CAUTI and VAP were less frequently used, however, providing an opportunity for improvement.

Clostridioides difficile infection (CDI) can be prevented through infection prevention practices and antibiotic stewardship. Diagnostic stewardship (ie, strategies to improve use of microbiological testing) can also improve antibiotic use. However, little is known about the use of such practices in US hospitals, especially after multidisciplinary stewardship programs became a requirement for US hospital accreditation in 2017. Thus, we surveyed US hospitals to assess antibiotic stewardship program composition, practices related to CDI, and diagnostic stewardship.Surveys were mailed to infection preventionists at 900 randomly sampled US hospitals between May and October 2017. Hospitals were surveyed on antibiotic stewardship programs; CDI prevention, treatment, and testing practices; and diagnostic stewardship strategies. Responses were compared by hospital bed size using weighted logistic regression.Overall, 528 surveys were completed (59% response rate). Almost all (95%) responding hospitals had an antibiotic stewardship program. Smaller hospitals were less likely to have stewardship team members with infectious diseases (ID) training, and only 41% of hospitals met The Joint Commission accreditation standards for multidisciplinary teams. Guideline-recommended CDI prevention practices were common. Smaller hospitals were less likely to use high-tech disinfection devices, fecal microbiota transplantation, or diagnostic stewardship strategies.Following changes in accreditation standards, nearly all US hospitals now have an antibiotic stewardship program. However, many hospitals, especially smaller hospitals, appear to struggle with access to ID expertise and with deploying diagnostic stewardship strategies. CDI prevention could be enhanced through diagnostic stewardship and by emphasizing the role of non-ID-trained pharmacists and clinicians in antibiotic stewardship.

BackgroundArts exposure is associated with positive psychological constructs. To date, no randomized, controlled studies have integrated art into clinical medical education or measured its effects on positive psychological constructs or educational outcomes. In this study, we assessed the possibility and potential benefits of integrating visual arts education into a required internal medicine (IM) clinical clerkship.MethodsWe conducted a controlled trial in an academic healthcare system with an affiliated art museum. IM students were assigned to one of three interventions: museum-based arts (n = 11), hospital-based arts (n = 10), or hospital-based conventional education (n = 13). Arts groups explored empathy, resilience, and compassion in works of art during facilitator-guided discussions. We assessed pre- and post-intervention measures of empathy, mindfulness, tolerance of ambiguity, and grit and tracked National Board of Medical Examiners IM shelf exam performance to capture changes in educational outcomes. Focus group discussions with participants in the arts-based interventions were performed at the study’s conclusion.ResultsArts education was successfully integrated into a busy clinical clerkship in both hospital and art museum settings. Focus group participants reported increased implicit bias cognizance and time for reflection, but no significant differences in psychometric or educational outcomes were identified. While most students felt positively toward the experience; some experienced distress from missed clinical time.ConclusionsThis pilot study demonstrates the feasibility of integrating visual arts education into the clerkship. Although observable quantitative differences in measures of positive psychological constructs and educational outcomes were not found, qualitative assessment suggested benefits as well as the feasibility of bringing fine arts instruction into the clinical space. A larger, multi-center study is warranted.

Over 40% of patients with cirrhosis will develop hepatic encephalopathy (HE). HE is associated with decreased survival, falls, motor vehicle accidents, and frequent hospitalization. Accordingly, we aimed to develop a tool to risk-stratify patients for HE development. We studied a population-based cohort of all patients with cirrhosis without baseline HE (N=1,979) from the Veterans Administration from Michigan, Indiana, and Ohio (1/1/2005-12/31/10) using demographic, clinical, laboratory, and pharmacy data. The primary outcome was the development of HE. Risk-scores were constructed with both baseline and longitudinal data (annually updated parameters) and validated using bootstrapping. The cohort had mean age of 58.0±8.3 years, 36% had hepatitis C, 17% had ascites. Opiates, benzodiazepines, statins, and nonselective beta-blockers were taken at baseline by 24%, 13%, 17%, and 12%. Overall, 863(43.7%) developed HE within 5 years. In multivariable models, risk factors (HR, 95%CI) for HE included higher bilirubin (1.07, 1.05-1.09) and nonselective beta-blocker use (1.34, 1.09-1.64), while higher albumin (0.54, 0.48-0.59) and statin use (0.80, 0.65-0.98) were protective. Other clinical factors, including opiate and benzodiazepine use were not predictive. The AUROC for HE using the 4 significant variables in baseline and longitudinal models were 0.68 (0.66-0.70) and 0.73 (0.71-0.75), respectively. Model effects were validated and converted into a risk score. A score ≤0 in our longitudinal model assigns a 6% 1-year probability of HE while a score >20 assigns a 38% 1-year risk. Conclusion: Patients with cirrhosis can be stratified by a simple risk-score for HE that accounts for changing clinical data. Our data also highlight a role for statins in reducing cirrhosis complications including HE. This article is protected by copyright. All rights reserved.

OBJECTIVECollaborative programs have helped reduce catheter-associated urinary tract infection (CAUTI) rates in community-based nursing homes. We assessed whether collaborative participation produced similar benefits among Veterans Health Administration (VHA) nursing homes, which are part of an integrated system.SETTINGThis study included 63 VHA nursing homes enrolled in the “AHRQ Safety Program for Long-Term Care,” which focused on practices to reduce CAUTI.METHODSChanges in CAUTI rates, catheter utilization, and urine culture orders were assessed from June 2015 through May 2016. Multilevel mixed-effects negative binomial regression was used to derive incidence rate ratios (IRRs) representing changes over the 12-month program period.RESULTSThere was no significant change in CAUTI among VHA sites, with a CAUTI rate of 2.26 per 1,000 catheter days at month 1 and a rate of 3.19 at month 12 (incidence rate ratio [IRR], 0.99; 95% confidence interval [CI], 0.67–1.44). Results were similar for catheter utilization rates, which were 11.02% at month 1 and 11.30% at month 12 (IRR, 1.02; 95% CI, 0.95–1.09). The numbers of urine cultures per 1,000 residents were 5.27 in month 1 and 5.31 in month 12 (IRR, 0.93; 95% CI, 0.82–1.05).CONCLUSIONSNo changes in CAUTI rates, catheter use, or urine culture orders were found during the program period. One potential reason was the relatively low baseline CAUTI rate, as compared with a cohort of community-based nursing homes. This low baseline rate is likely related to the VHA’s prior CAUTI prevention efforts. While broad-scale collaborative approaches may be effective in some settings, targeting higher-prevalence safety issues may be warranted at sites already engaged in extensive infection prevention efforts.Infect Control Hosp Epidemiol 2018;820–825

BACKGROUNDUrinary catheters, many of which are placed in the emergency department (ED) setting, are often inappropriate, and they are associated with infectious and noninfectious complications. Although several studies evaluating the effect of interventions have focused on reducing catheter use in the ED setting, the organizational contexts within which these interventions were implemented have not been compared.METHODSA total of 18 hospitals in the Ascension health system (ie, system-based hospitals) and 16 hospitals in the state of Michigan (ie, state-based hospitals led by the Michigan Health and Hospital Association) implemented ED interventions focused on reducing urinary catheter use. Data on urinary catheter placement in the ED, indications for catheter use, and presence of physician order for catheter placement were collected for interventions in both hospital types. Multilevel negative binomial regression was used to compare the system-based versus state-based interventions.RESULTSA total of 13,215 patients (889 with catheters) from the system-based intervention were compared to 12,104 patients (718 with catheters) from the state-based intervention. Statistically significant and sustainable reductions in urinary catheter placement (incidence rate ratio, 0.79;P=.02) and improvements in appropriate use of urinary catheters (odds ratio [OR], 1.86;P=.004) in the ED were observed in the system-based intervention, compared to the state-based intervention. Differences by collaborative structure in changes in presence of physician order for urinary catheter placement (OR, 1.14;P=.60) were not observed.CONCLUSIONSAn ED intervention consisting of establishing institutional guidelines for appropriate catheter placement and identifying clinical champions to promote adherence was associated with reducing unnecessary urinary catheter use under a system-based collaborative structure.Infect Control Hosp Epidemiol2018;39:77–84

Background Antibiotic therapy has no known benefit against COVID-19, but is often initiated out of concern for concomitant bacterial infection. We sought to determine how common early empiric antibiotic therapy and community-onset bacterial co-infections are in hospitalized patients with COVID-19. Methods In this multi-center cohort study of hospitalized patients with COVID-19 discharged from 32 Michigan hospitals during the COVID-19 Michigan surge, we describe the use of early empiric antibiotic therapy (within the first two days) and prevalence of community-onset bacterial co-infection. Additionally, we assessed patient and hospital predictors of early empiric antibiotic using poison generalized estimating equation models. Results Between 3/10/2020 and 5/10/2020, data were collected on 951 COVID-19 PCR positive patients. Patient characteristics are described in Table 1. Nearly two thirds (62.4%, 593/951) of COVID-19 positive patients were prescribed early empiric antibiotic therapy, most of which (66.2%, 393/593) was directed at community-acquired pathogens. Across hospitals, the proportion of COVID-19 patients prescribed early empiric antibiotics varied from 40% to 90% (Figure 1). On multivariable analysis, patients were more likely to receive early empiric antibiotic therapy if they were older (adjusted rate ratio [ARR]: 1.01 [1.00–1.01] per year), required respiratory support (e.g., low flow oxygen, ARR: 1.16 [1.04–1.29]), had signs of a bacterial infection (e.g., lobar infiltrate, ARR: 1.17 [1.02–1.34]), or were admitted to a for-profit hospital (ARR: 1.27 [1.11–1.45]); patients admitted later were less likely to receive empiric antibiotics (April vs. March, ARR: 0.72 [0.62–0.84], Table 2). Community-onset bacterial co-infections were identified in 4.5% (43/951) of COVID-19 positive patients (2.4% [23/951] positive blood culture; 1.9% [18/951] positive respiratory culture). Conclusion Despite low prevalence of community-onset bacterial co-infections, patients hospitalized with COVID-19 often received early empiric antibiotic therapy. Given the potential harms from unnecessary antibiotic use, including additional personal protective equipment to administer antibiotics, judicious antibiotic use is key in hospitalized patients with COVID-19. Disclosures Tejal N. Gandhi, MD, Blue Cross Blue Shield of Michigan (Grant/Research Support) Scott A. Flanders, MD, Agency for Healthcare Research and Quality (Research Grant or Support)Blue Cross Blue Shield of Michigan (Research Grant or Support)

Background We evaluated the extent to which hospital characteristics, infection control practices, and compliance with prevention bundles impacted multidrug-resistant organism (MDRO) infections in Thai hospitals. Methods From 1 January 2014 to 30 November 2014, we surveyed all Thai hospitals with an intensive care unit and ≥250 beds. Infection control practices for methicillin-resistant Staphylococcus aureus (MRSA) and multidrug-resistant Acinetobacter baumannii (MDR-AB) were assessed. Linear regression was used to examine associations between hospital characteristics and prevention bundle compliance and changes in MDRO infection rates. Results A total of 212 of 245 (86.5%) eligible hospitals responded. Most hospitals regularly used several fundamental infection control practices for MRSA and MDR-AB (ie, contact precautions, private room/cohorting, hand hygiene, environmental cleaning, and antibiotic stewardship); advanced infection control practices (ie, active surveillance, chlorhexidine bathing, decolonization for MRSA, and hydrogen peroxide vaporizer for MDR-AB) were used less commonly. Facilities with ≥75% compliance with the MRSA prevention bundle experienced a 17.4% reduction in MRSA rates (P = .03). Although the presence of environmental cleaning services (41.3% reduction, P = .01) and a microbiology laboratory (82.8% reduction, P = .02) were among characteristics associated with decreases in MDR-AB rates, greater compliance with the MDR-AB prevention bundle did not lead to reductions in MDR-AB rates. Conclusions Although fundamental MRSA and MDR-AB control practices are used regularly in most Thai hospitals, compliance with more comprehensive bundled prevention approaches is suboptimal. Improving compliance with bundled infection prevention approaches and promoting the integration of certain hospital factors into infection control efforts may help reduce MDRO infections in Thai hospitals.

Background While the use of technologies such as ultrasound and electrocardiographic (ECG) guidance systems to place peripherally inserted central catheters (PICCs) has grown, little is known about the clinicians who use these tools or their work settings. Methods Using data from a national survey of vascular access specialists, we identified technology users as PICC inserters that: (a) use ultrasound to find a suitable vein for catheter placement; (b) measure catheter-to-vein ratio; and (c) use ECG for PICC placement. Individual and organizational-level characteristics between technology users versus non-users were assessed. Bivariable comparisons were made using Chi-squared or Fisher's exact tests; two-sided alpha with pResults Of the 2762 PICC inserters who accessed the survey, 1518 (55%) provided information regarding technology use. Technology users reported greater experience than non-technology users, with a higher percentage stating they had placed >1000 PICCs (55% vs. 45%, pConclusions Technology use by vascular access clinicians while placing PICCs is associated with clinician characteristics, work setting and practice factors. Understanding whether such differences influence clinical care or patient outcomes appears necessary.

Although the Awakening and Breathing Coordination, Delirium assessment, and Early exercise/mobility (ABCDE) bundle may be effective, individual components of ABCDE may not be implemented as intended. We examined the use of daily interruption of sedation (DIS) and early mobility, looking for an association between these bundle elements. Despite the growing use of DIS and early mobility, the two do not seem to be adopted together, with serious implications for the effectiveness of the ABCDE bundle.

Background: Clinicians often diagnose bacterial infections such as urinary tract infection (UTI) and pneumonia in patients who are asymptomatic or have nonbacterial causes of their symptoms. Misdiagnosis of infection leads to unnecessary antibiotic use and potentially delays correct diagnoses. Interventions to improve diagnosis often focus on infections separately. However, if misdiagnosis is linked, broader interventions to improve diagnosis may be more effective. Thus, we assessed whether misdiagnosis of UTI and community-acquired pneumonia (CAP) was correlated. Methods: From July 2017 to July 2019, abstractors at 46 Michigan hospitals collected data on a sample of adult, non–intensive care, hospitalized patients with bacteriuria (positive urine culture) or who were treated for presumed CAP (discharge diagnosis plus antibiotics). Patients with concomitant bacterial infections were excluded. Using a previously described method,1,2 patients were assessed for UTI or CAP based on symptoms, signs, and laboratory or radiology findings. Misdiagnosis of UTI was defined as patients with asymptomatic bacteriuria (ASB) treated with antibiotics number of patients with bacteriuria Misdiagnosis of CAP was defined as patients treated for presumed CAP who did not have CAP number of patients treated for presumed CAP. Hospital-level correlation was assessed using Pearson’s correlation coefficient between misdiagnosis of UTI and CAP. For patients with prescriber data (N = 3,293), we also assessed emergency department (ED)-level correlation. Results: Of 11,914 patients with bacteriuria, 31.9% (N = 3,796) had ASB. Of those, 2,973 of 3,796 (78.3%) received antibiotics. Of 14,085 patients treated for CAP, 1,602 (11.4%) did not have CAP. Incidence of misdiagnosis varied by hospital: those with high rates of misdiagnosis of UTI were more likely to have high rates of misdiagnosis of CAP (Pearson’s correlation coefficient, 0.58; P ≤ .001) (Fig. 1). Of 2,137 patients misdiagnosed with UTI, 1,159 (54.2%) had antibiotic treatment started in the ED; of those, 942 (81.3%) remained on antibiotics on day 3 of hospitalization. Of 1,156 patients misdiagnosed with CAP, 871 (75.3%) had antibiotic therapy started in the ED, and 789 of these 871 patients (90.6%) were still on antibiotics on day 3 of hospitalization. Hospitals with high rates of UTI misdiagnosis in the ED were more likely to have high rates of CAP misdiagnosis in the ED (Pearson’s correlation coefficient, 0.33; P ≤ .001). Conclusions: Misdiagnosis of 2 unrelated infections was moderately correlated by hospital and weakly correlated by hospital ED. Potential causes include differences in organizational culture (eg, low tolerance for diagnostic uncertainty, emergency department culture), organizational initiatives (eg, sepsis, stewardship), or coordination between emergency and hospital medicine. Additionally, antibiotics initiated in the ED were typically continued following admission, potentially reflecting diagnosis momentum.Funding: This work was supported by Blue Cross Blue Shield of Michigan and Blue Care Network.Disclosures: Valerie M. Vaughn reports contract research for Blue Cross and Blue Shield of Michigan, the Department of Veterans’ Affairs, the NIH, the SHEA, and the APIC. She also reports fees from the Gordon and Betty Moore Foundation Speaker’s Bureau, the CDC, the Pew Research Trust, Sepsis Alliance, and The Hospital and Health System Association of Pennsylvania.

Background Central line-associated bloodstream infection (CLABSI) remains prevalent in hospitals in the United States. Objective To evaluate the impact of a multimodal intervention in hospitals with elevated rates of health care-associated infection. Design Pre-post observational evaluation of a prospective, national, clustered, nonrandomized initiative of 3 cohorts of hospitals. Setting Acute care, long-term acute care, and critical access hospitals, including intensive care units and medical/surgical wards. Participants Target hospitals had a cumulative attributable difference above the first tertile of performance for Clostridioides difficile infection and another health care-associated infection (such as CLABSI). Some hospitals that did not meet these criteria also participated. Intervention A multimodal intervention consisting of recommendations and tools for prioritizing and implementing evidence-based infection prevention strategies, on-demand educational videos, webinars led by content experts, and access to content experts. Measurements Rates of CLABSI and device utilization ratio pre- and postintervention. Results Between November 2016 and May 2018, 387 hospitals in 23 states and the District of Columbia participated. Monthly preimplementation CLABSI rates ranged from 0 to 71.4 CLABSIs per 1000 catheter-days. Over the study period, the unadjusted CLABSI rate was low and decreased from 0.88 to 0.80 CLABSI per 1000 catheter-days. Between the pre- and postintervention periods, device utilization decreased from 24.05 to 22.07 central line-days per 100 patient-days. However, a decreasing trend in device utilization was also observed during the preintervention period. Limitations The intervention period was brief. Participation in and adherence to recommended interventions were not fully assessed. Rates of CLABSI were low. Patient characteristics could not be assessed. Conclusion In hospitals with a disproportionate burden of health care-associated infection, a multimodal intervention did not reduce rates of CLABSI. Primary funding source Centers for Disease Control and Prevention.

Background Many hospitals struggle to prevent catheter-associated urinary tract infection (CAUTI). Objective To evaluate the effect of a multimodal initiative on CAUTI in hospitals with high burden of health care-associated infection (HAI). Design Prospective, national, nonrandomized, clustered, externally facilitated, pre-post observational quality improvement initiative, for 3 cohorts active between November 2016 and May 2018. Setting Acute care, long-term acute care, and critical access hospitals, including intensive care and non-intensive care wards. Participants Target hospitals had a high burden of Clostridioides difficile infection plus central line-associated bloodstream infection, CAUTI, or hospital-onset methicillin-resistant Staphylococcus aureus bloodstream infection, defined as cumulative attributable differences above the first tertile in the Targeted Assessment for Prevention (TAP) strategy. Some additional nonrecruited hospitals also joined. Intervention Multimodal intervention, including Practice Change Assessment tool to identify infection prevention and control (IPC) and HAI prevention gaps; Web-based, on-demand modules involving onboarding, foundational IPC practices, HAI-specific 2-tiered approach to prioritize and implement interventions, and TAP resources; monthly webinars; state partner-led in-person meetings; and feedback. State partners made site visits to at least 50% of their enrolled hospitals, to support self-assessments and coach. Measurements Rates of CAUTI and urinary catheter device utilization ratio. Results Of 387 participating hospitals from 23 states and the District of Columbia, 361 provided CAUTI data. Over the study period, the unadjusted CAUTI rate was low and relatively stable, decreasing slightly from 1.12 to 1.04 CAUTIs per 1000 catheter-days. Catheter utilization decreased from 21.46 to 19.83 catheter-days per 100 patient-days from the pre- to the postintervention period. Limitations The intervention period was brief, with no assessment of fidelity. Baseline CAUTI rates were low. Patient characteristics were not assessed. Conclusion This multimodal intervention yielded no substantial improvements in CAUTI or urinary catheter utilization. Primary funding source Centers for Disease Control and Prevention.

Our goal was to evaluate the 5-year sustainability of a multimodal intervention that included a prize to the hospital with the highest overall hand hygiene adherence rates among health care workers.We conducted an observational study in 3 Japanese tertiary care hospitals using unobtrusive direct observation of physician and nurse hand hygiene adherence. Observations were performed by a trained observer on inpatient medical, surgical, intensive care, and emergency units. The primary outcome was hand hygiene adherence rates before patient contact. Secondary outcomes were health care worker survey responses to a World Health Organization (WHO) questionnaire on hand hygiene practices.Hand hygiene adherence rates had improved significantly after the introduction of a multimodal intervention (based on principles recommend by the WHO) in 2012 and 2013 (from 18.0% pre-intervention to 32.7% 6 months post-intervention; P.001). No significant changes were found in hand hygiene adherence in these hospitals 5 years after the original intervention (31.9% 5 years after intervention; P = .53); however, substantial variability in hand hygiene adherence by unit and health care worker type was noted.A multimodal hand hygiene initiative achieved sustained improvement in hand hygiene adherence in 3 Japanese hospitals 5 years after the original intervention.

To assess complications of condom catheters compared with indwelling urethral catheters, we conducted a prospective cohort study in two Veterans Affairs hospitals. Male patients who used a condom catheter or indwelling urethral catheter during their hospital stay were followed for one month by interview and medical record review. Participants included 36 men who used condom catheters and 44 who used indwelling urethral catheters. At least one catheter-related complication was reported by 80.6% of condom catheter users and 88.6% of indwelling catheter users (P = .32), and noninfectious complications (eg, leaking urine, pain, or discomfort) were more common than infectious complications in both groups. Condom catheter patients were significantly less likely than indwelling catheter patients to report complications during catheter placement (13.9% vs 43.2%; P < .001). Patients reported approximately three times more noninfectious complications than the number recorded in the medical record.

BackgroundPreventing central line-associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI) remains challenging in intensive care units (ICUs).ObjectiveThe Agency for Healthcare Research and Quality Safety Program for ICUs aimed to reduce CLABSI and CAUTI in units with elevated rates.MethodsInvited hospitals had at least one adult ICU with elevated CLABSI or CAUTI rates, defined by a positive cumulative attributable difference metric (CAD >0) in the Centers for Disease Control and Prevention’s Targeted Assessment for Prevention strategy. This externally facilitated programme implemented by a national project team and state hospital associations included on-demand video modules and live webinars reviewing a two-tiered approach for implementing key technical and socioadaptive factors to prevent catheter infections, using principles and tools based on the Comprehensive Unit-based Safety Program. CLABSI, CAUTI and catheter use data were collected (preintervention 13 months, intervention 12 months). Multilevel negative binomial models assessed changes in catheter-associated infection rates and catheter use.ResultsOf 366 recruited ICUs from 220 hospitals in 16 states and Puerto Rico for two cohorts, 280 ICUs completed the programme including infection outcome reporting; 274 ICUs had complete outcome data for analyses. Statistically significant reductions in adjusted infection rates were not observed (CLABSI incidence rate ratio (IRR)=0.75, 95% CI 0.52 to 1.08, p=0.13; CAUTI IRR=0.79, 95% CI 0.59 to 1.06, p=0.12). Adjusted central line utilisation (IRR=0.97, 95% CI 0.93 to 1.00, p=0.09) and adjusted urinary catheter utilisation were unchanged (IRR=0.98, 95% CI 0.95 to 1.01, p=0.14).ConclusionThis multistate programme targeted ICUs with elevated catheter infection rates, but yielded no statistically significant reduction in CLABSI, CAUTI or catheter utilisation in the first two of six planned cohorts. Improvements in the interventions based on lessons learnt from these initial cohorts are being applied to subsequent cohorts.

BACKGROUND: Catheter-associated urinary tract infection (UTI) is a common device-associated infection in hospitals. Both technical factors — appropriate catheter use, aseptic insertion, and proper maintenance — and socioadaptive factors, such as cultural and behavioral changes in hospital units, are important in preventing catheter-associated UTI. METHODS: The national Comprehensive Unit-based Safety Program, funded by the Agency for Healthcare Research and Quality, aimed to reduce catheter-associated UTI in intensive care units (ICUs) and non-ICUs. The main program features were dissemination of information to sponsor organizations and hospitals, data collection, and guidance on key technical and socioadaptive factors in the prevention of catheter-associated UTI. Data on catheter use and catheter-associated UTI rates were collected during three phases: baseline (3 months), implementation (2 months), and sustainability (12 months). Multilevel negative binomial models were used to assess changes in catheter use and catheter-associated UTI rates. RESULTS: Data were obtained from 926 units (59.7% were non-ICUs, and 40.3% were ICUs) in 603 hospitals in 32 states, the District of Columbia, and Puerto Rico. The unadjusted catheter-associated UTI rate decreased overall from 2.82 to 2.19 infections per 1000 catheter-days. In an adjusted analysis, catheter-associated UTI rates decreased from 2.40 to 2.05 infections per 1000 catheter-days (incidence rate ratio, 0.86; 95% confidence interval [CI], 0.76 to 0.96; P = 0.009). Among non-ICUs, catheter use decreased from 20.1% to 18.8% (incidence rate ratio, 0.93; 95% CI, 0.90 to 0.96; P

BACKGROUNDThe number of peripherally inserted central catheter (PICC) lumens is associated with thrombotic and infectious complications. Because multilumen PICCs are not necessary in all patients, policies that limit their use may improve safety and cost.OBJECTIVETo design a simulation-based analysis to estimate outcomes and cost associated with a policy that encourages single-lumen PICC use.METHODSModel inputs, including risk of complications and costs associated with single- and multilumen PICCs, were obtained from available literature and a multihospital collaborative quality improvement project. Cost savings and reduction in central line–associated bloodstream infection and deep vein thrombosis events from institution of a single-lumen PICC default policy were reported.RESULTSAccording to our model, a hospital that places 1,000 PICCs per year (25% of which are single-lumen and 75% multilumen) experiences annual PICC-related maintenance and complication costs of $1,228,598 (95% CI, $1,053,175–$1,430,958). In such facilities, every 5% increase in single-lumen PICC use would prevent 0.5 PICC-related central line-associated bloodstream infections and 0.5 PICC-related deep vein thrombosis events, while saving $23,500. Moving from 25% to 50% single-lumen PICC utilization would result in total savings of $119,283 (95% CI, $74,030–$184,170) per year. Regardless of baseline prevalence, a single-lumen default PICC policy would be associated with approximately 10% cost savings. Findings remained robust in multiway sensitivity analyses.CONCLUSIONHospital policies that limit the number of PICC lumens may enhance patient safety and reduce healthcare costs. Studies measuring intended and unintended consequences of this approach, followed by rapid adoption, appear necessary.Infect Control Hosp Epidemiol 2016;37:811–817

AIMS To examine the characteristics of patients with diabetes who regularly receive help from a supporter in preparing for and attending medical visits, and the association between this help and clinical risk factors for diabetes complications. METHODS We linked survey data about family involvement for patients in the Veterans Health Administration system with poorly controlled Type 2 diabetes (n = 588; mean 67 years; 97% male) with health record data on blood pressure, glycaemic control and prescription-fill gaps. We used multivariable regression to assess whether supporter presence and, among patients with supporters, supporter role (visit preparation, accompaniment to medical visit or no involvement) were associated with concurrent trends in clinical risk factors over 2 years, adjusting for sociodemographic and health characteristics. RESULTS Most patients (78%) had a main health supporter; of these, more had regular support for preparing for appointments (69%) than were regularly accompanied to them (45%). Patients with preparation help only were younger and more educated than accompanied patients. Support presence and type was not significantly associated with clinical risk factors. CONCLUSIONS Family help preparing for appointments was common among these patients with high-risk diabetes. In its current form, family support for medical visits may not affect clinical factors in the short term. Supporters helping patients engage in medical visits may need training and assistance to have an impact on the clinical trajectory of patients with diabetes.

BACKGROUND Peripherally inserted central catheters (PICCs) are increasingly used in hospitalized patients. Yet, little is known about the vascular access nurses who often place them. METHODS We conducted a Web-based survey to assess vascular access nursing experience, practice, knowledge, and beliefs related to PICC insertion and care in 47 Michigan hospitals. RESULTS The response rate was 81% (172 received invitations, 140 completed the survey). More than half of all respondents (58%) reported placing PICCs for ≥5 years, and 23% had obtained dedicated vascular access certification. The most common reported indications for PICC insertion included intravenous antibiotics, difficult venous access, and chemotherapy. Many respondents (46%) reported placing a PICC in a patient receiving dialysis; however, 91% of these respondents reported receiving approval from nephrology prior to insertion. Almost all respondents (91%) used ultrasound to find a suitable vein for PICC insertion, and 76% used electrocardiography guidance to place PICCs. PICC occlusion was reported as the most frequently encountered complication, followed by device migration and deep vein thrombosis. Although 94% of respondents noted that their hospitals tracked the number of PICCs placed, only 40% reported tracking duration of PICC use. Relatedly, 30% of nurses reported that their hospitals had a written policy to evaluate PICC necessity or appropriateness. CONCLUSION This survey of vascular nursing experiences highlights opportunities to improve practices such as avoiding PICC use in dialysis, better tracking of PICC dwell times, and necessity. Hospitalists may use these data to inform clinical practice, appropriateness, and safety of PICCs in hospitalized patients. Journal of Hospital Medicine 2016;11:269–275. 2015 Society of Hospital Medicine