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BACKGROUND:Universal skin and nasal decolonisation reduces multidrug-resistant pathogens and bloodstream infections in intensive care units. The effect of universal decolonisation on pathogens and infections in non-critical-care units is unknown. The aim of the ABATE Infection trial was to evaluate the use of chlorhexidine bathing in non-critical-care units, with an intervention similar to one that was found to reduce multidrug-resistant organisms and bacteraemia in intensive care units. METHODS:The ABATE Infection (active bathing to eliminate infection) trial was a cluster-randomised trial of 53 hospitals comparing routine bathing to decolonisation with universal chlorhexidine and targeted nasal mupirocin in non-critical-care units. The trial was done in hospitals affiliated with HCA Healthcare and consisted of a 12-month baseline period from March 1, 2013, to Feb 28, 2014, a 2-month phase-in period from April 1, 2014, to May 31, 2014, and a 21-month intervention period from June 1, 2014, to Feb 29, 2016. Hospitals were randomised and their participating non-critical-care units assigned to either routine care or daily chlorhexidine bathing for all patients plus mupirocin for known methicillin-resistant Staphylococcus aureus (MRSA) carriers. The primary outcome was MRSA or vancomycin-resistant enterococcus clinical cultures attributed to participating units, measured in the unadjusted, intention-to-treat population as the HR for the intervention period versus the baseline period in the decolonisation group versus the HR in the routine care group. Proportional hazards models assessed differences in outcome reductions across groups, accounting for clustering within hospitals. This trial is registered with ClinicalTrials.gov, number NCT02063867. FINDINGS:There were 189 081 patients in the baseline period and 339 902 patients (156 889 patients in the routine care group and 183 013 patients in the decolonisation group) in the intervention period across 194 non-critical-care units in 53 hospitals. For the primary outcome of unit-attributable MRSA-positive or VRE-positive clinical cultures (figure 2), the HR for the intervention period versus the baseline period was 0·79 (0·73-0·87) in the decolonisation group versus 0·87 (95% CI 0·79-0·95) in the routine care group. No difference was seen in the relative HRs (p=0·17). There were 25 (

Background: Universal skin and nasal decolonization reduces multidrug-resistant pathogens and bloodstream infections in intensive care units. The effect of universal decolonization on pathogens and infections in non-critical care units is unknown. Methods: A two-arm cluster-randomized trial was conducted in 53 hospitals in the Hospital Corporation of America Healthcare system. Hospitals were randomized and their participating non-critical care units assigned to either routine care or daily chlorhexidine bathing for all patients plus mupirocin for known methicillin-resistant Staphylococcus aureus (MRSA) carriers. The trial involved a 12-month baseline (Mar 2013-Feb 2014) and 21-month intervention (Jun 2014-Feb 2016). Primary outcome was MRSA or vancomycin-resistant enterococcus (VRE) clinical cultures attributed to participating units, and secondary outcome was all-pathogen bloodstream infection. Proportional hazards models assessed differences in outcome reductions across arms, accounting for clustering by hospital. Post-hoc subgroup analyses were performed. Findings: There were 189,081 patients in the baseline period and 339,902 patients in the intervention period across 194 non-critical care units in 53 hospitals. Hazard ratios for MRSA/VRE clinical isolates during intervention vs. baseline periods were 0·87 (CI:0·79, 0·95) for routine care, and 0·79 (CI:0·73, 0·87) for decolonization (p=0·17), and 0·96 (CI:0·85, 1·08) and 0·90 (0·81, 1·01) for all-pathogen bloodstream infection, respectively (p=0·44). Among patients with central venous catheters, midline catheters, or lumbar drains, the hazard ratio for MRSA/VRE clinical cultures was 1·17 (CI:1·00, 1·37) for routine care and 0·80 (CI:0·69, 0·92) for decolonization, (p=0·0004), and the hazard ratio for all-pathogen bloodstream infections was 1·13 (CI:0·96, 1·33) for routine care and 0·82 (CI:0·71, 0·94) for decolonization, p=0·004. Interpretation: Decolonization with universal chlorhexidine bathing and targeted mupirocin for MRSA carriers did not reduce multidrug-resistant organisms or all-pathogen bloodstream infection in all non-critical care patients, but patients with invasive devices experienced 37% reduction in MRSA/VRE and 31% reduction in bloodstream infections. Clinical Trial Registration Number: clinicaltrials.gov Identifier: NCT0206386 Funding Statement: This project was funded by the National Institutes of Health Common Fund and administered by the National Institute of Allergy and Infectious Diseases (UH2/UH3 AT007769‐01 (Huang)). Declaration of Interest: Sage Products and Molnlycke contributed antiseptic chlorhexidine product to this trial. Investigators are also conducting other studies in which contributed antiseptic product is provided to participating hospitals and nursing homes from Stryker (Sage Products) (KK, LH, MHC, MKH, RAW, SSH), 3M (LH, SSH), Clorox (CS, ES, JH, JM, JP, KH, KK, LH, LS, MHC, MKH, RAW, RP, SSH, TRA), Xttrium (LH, SSH), and Medline (CS, ES, JH, JM, JP, KH, KK, LH, LS, MHC, MKH, RAW, RP, SSH, TRA). Investigator-initiated grant funds were received from Clorox (MKH, MHC, LS, KH, RP). Companies contributing product or providing grant funds have no role in the design, conduct, analysis, or publication of the ABATE Infection Trial or other studies conducted by these investigators. All other authors have no disclosures. Ethics Approval Statement: Central IRB approval was obtained from Harvard Pilgrim Health Care with a waiver of informed consent. All participating hospitals formally ceded IRB oversight to the HPHC IRB, except for the designated medical center IRB (Chippenham & Johnston Willis Hospitals) that provided prisoner oversight for the trial.

Background Hospital-specific surgical site infection (SSI) performance following colon surgery and abdominal hysterectomies can impact hospitals' relative rankings around quality metrics used to determine financial penalties. Current SSI surveillance largely focuses on SSI detected at the operative hospital. Methods We performed a retrospective cohort study to assess the impact on hospitals' relative SSI performance rankings when SSI detected at nonoperative hospitals are included. We used data from a California statewide hospital registry to assess for evidence of SSI following colon surgery or abdominal hysterectomies performed 1 March 2011 through 30 November 2013 using previously validated claims-based SSI surveillance methods. Risk-adjusted hospital-specific rankings based on SSI detected at operative hospitals versus any California hospital were generated. Results Among 60059 colon surgeries at 285 hospitals and 64918 abdominal hysterectomies at 270 hospitals, 5921 (9.9%) colon surgeries and 1481 (2.3%) abdominal hysterectomies received a diagnosis code for SSI within the 30 days following surgery. Operative hospital surveillance alone would have missed 7.2% of colon surgery and 13.4% of abdominal hysterectomy SSIs. The proportion of an individual hospital's SSIs detected during hospitalizations at other hospitals varied widely. Including nonoperative hospital SSIs resulted in improved relative ranking of 11 (3.9%) colon surgery and 13 (4.8%) hysterectomy hospitals so that they were no longer in the worst performing quartile, mainly among hospitals with relatively high surgical volumes. Conclusions Standard SSI surveillance that mainly focuses on infections detected at the operative hospital causes varying degrees of SSI underestimation, leading to inaccurate assignment or avoidance of financial penalties for approximately 1 in 11-16 hospitals.

Objective.To estimate and compare the impact on healthcare costs of 3 alternative strategies for reducing bloodstream infections in the intensive care unit (ICU): methicillin-resistant Staphylococcus aureus (MRSA) nares screening and isolation, targeted decolonization (ie, screening, isolation, and decolonization of MRSA carriers or infections), and universal decolonization (ie, no screening and decolonization of all ICU patients).Design.Cost analysis using decision modeling.Methods.We developed a decision-analysis model to estimate the health care costs of targeted decolonization and universal decolonization strategies compared with a strategy of MRSA nares screening and isolation. Effectiveness estimates were derived from a recent randomized trial of the 3 strategies, and cost estimates were derived from the literature.Results.In the base case, universal decolonization was the dominant strategy and was estimated to have both lower intervention costs and lower total ICU costs than either screening and isolation or targeted decolonization. Compared with screening and isolation, universal decolonization was estimated to save $171,000 and prevent 9 additional bloodstream infections for every 1,000 ICU admissions. The dominance of universal decolonization persisted under a wide range of cost and effectiveness assumptions.Conclusions.A strategy of universal decolonization for patients admitted to the ICU would both reduce bloodstream infections and likely reduce healthcare costs compared with strategies of MRSA nares screening and isolation or screening and isolation coupled with targeted decolonization.

Author(s): Yokoe, Deborah S; Avery, Taliser R; Platt, Richard; Huang, Susan S | Abstract: BackgroundPublic reporting of surgical site infections (SSIs) by hospitals is largely limited to infections detected during surgical hospitalizations or readmissions to the same facility. SSI rates may be underestimated if patients with SSIs are readmitted to other hospitals. We assessed the impact of readmissions to other facilities on hospitals' SSI rates following primary total hip arthroplasty (THA) or total knee arthroplasty (TKA).MethodsThis was a retrospective cohort study of all patients who underwent primary THA or TKA at California hospitals between 1 January 2006 and 31 December 2009. SSIs were identified using ICD-9-CM diagnosis codes predictive of SSI assigned at any California hospital within 365 days of surgery using a statewide repository of hospital data that allowed tracking of patients between facilities. We used statewide data to estimate the fraction of each hospital's THA and TKA SSIs identified at the operative hospital versus other hospitals.ResultsA total of 91 121 THA and 121 640 TKA procedures were identified. Based on diagnosis codes, SSIs developed following 2214 (2.3%) THAs and 2465 (2.0%) TKAs. Seventeen percent of SSIs would have been missed by operative hospital surveillance alone. The proportion of hospitals' SSIs detected at nonoperative hospitals ranged from 0% to 100%. Including SSIs detected at nonoperative hospitals resulted in better relative ranking for 61% of THA hospitals and 61% of TKA hospitals.ConclusionsLimiting SSI surveillance to the operative hospital caused varying degrees of SSI underestimation and substantially impacted hospitals' relative rankings, suggesting that alternative methods for comprehensive postdischarge surveillance are needed for accurate benchmarking.

Background Because patients can remain colonized with vancomycin-resistant enterococci (VRE) for long periods of time, VRE may spread from one health care facility to another. Methods Using the Regional Healthcare Ecosystem Analyst, an agent-based model of patient flow among all Orange County, California, hospitals and communities, we quantified the degree and speed at which changes in VRE colonization prevalence in a hospital may affect prevalence in other Orange County hospitals. Results A sustained 10% increase in VRE colonization prevalence in any 1 hospital caused a 2.8% (none to 62%) average relative increase in VRE prevalence in all other hospitals. Effects took from 1.5 to >10 years to fully manifest. Larger hospitals tended to have greater affect on other hospitals. Conclusions When monitoring and controlling VRE, decision makers may want to account for regional effects. Knowing a hospital's connections with other health care facilities via patient sharing can help determine which hospitals to include in a surveillance or control program.

Both targeted decolonization and universal decolonization of patients in intensive care units (ICUs) are candidate strategies to prevent health care-associated infections, particularly those caused by methicillin-resistant Staphylococcus aureus (MRSA).We conducted a pragmatic, cluster-randomized trial. Hospitals were randomly assigned to one of three strategies, with all adult ICUs in a given hospital assigned to the same strategy. Group 1 implemented MRSA screening and isolation; group 2, targeted decolonization (i.e., screening, isolation, and decolonization of MRSA carriers); and group 3, universal decolonization (i.e., no screening, and decolonization of all patients). Proportional-hazards models were used to assess differences in infection reductions across the study groups, with clustering according to hospital.A total of 43 hospitals (including 74 ICUs and 74,256 patients during the intervention period) underwent randomization. In the intervention period versus the baseline period, modeled hazard ratios for MRSA clinical isolates were 0.92 for screening and isolation (crude rate, 3.2 vs. 3.4 isolates per 1000 days), 0.75 for targeted decolonization (3.2 vs. 4.3 isolates per 1000 days), and 0.63 for universal decolonization (2.1 vs. 3.4 isolates per 1000 days) (P=0.01 for test of all groups being equal). In the intervention versus baseline periods, hazard ratios for bloodstream infection with any pathogen in the three groups were 0.99 (crude rate, 4.1 vs. 4.2 infections per 1000 days), 0.78 (3.7 vs. 4.8 infections per 1000 days), and 0.56 (3.6 vs. 6.1 infections per 1000 days), respectively (P0.001 for test of all groups being equal). Universal decolonization resulted in a significantly greater reduction in the rate of all bloodstream infections than either targeted decolonization or screening and isolation. One bloodstream infection was prevented per 54 patients who underwent decolonization. The reductions in rates of MRSA bloodstream infection were similar to those of all bloodstream infections, but the difference was not significant. Adverse events, which occurred in 7 patients, were mild and related to chlorhexidine.In routine ICU practice, universal decolonization was more effective than targeted decolonization or screening and isolation in reducing rates of MRSA clinical isolates and bloodstream infection from any pathogen. (Funded by the Agency for Healthcare Research and the Centers for Disease Control and Prevention; REDUCE MRSA ClinicalTrials.gov number, NCT00980980).

Purpose In post-marketing drug safety surveillance, data mining can potentially detect rare but serious adverse events. Assessing an entire collection of drug–event pairs is traditionally performed on a predefined level of granularity. It is unknown a priori whether a drug causes a very specific or a set of related adverse events, such as mitral valve disorders, all valve disorders, or different types of heart disease. This methodological paper evaluates the tree-based scan statistic data mining method to enhance drug safety surveillance. Methods We use a three-million-member electronic health records database from the HMO Research Network. Using the tree-based scan statistic, we assess the safety of selected antifungal and diabetes drugs, simultaneously evaluating overlapping diagnosis groups at different granularity levels, adjusting for multiple testing. Expected and observed adverse event counts were adjusted for age, sex, and health plan, producing a log likelihood ratio test statistic. Results Out of 732 evaluated disease groupings, 24 were statistically significant, divided among 10 non-overlapping disease categories. Five of the 10 signals are known adverse effects, four are likely due to confounding by indication, while one may warrant further investigation. Conclusion The tree-based scan statistic can be successfully applied as a data mining tool in drug safety surveillance using observational data. The total number of statistical signals was modest and does not imply a causal relationship. Rather, data mining results should be used to generate candidate drug–event pairs for rigorous epidemiological studies to evaluate the individual and comparative safety profiles of drugs. Copyright © 2013 John Wiley & Sons, Ltd. key words—pharmacovigilance; drug safety surveillance; adverse events; data mining; scan statistics; clusters; pharmacoepidemiology

Background: Drug adverse event (AE) signal detection using the Gamma Poisson Shrinker (GPS) is commonly applied in spontaneous reporting. AE signal detection using large observational health plan databases can expand medication safety surveillance. Methods: Using data from nine health plans, we conducted a pilot study to evaluate the implementation and findings of the GPS approach for two antifungal drugs, terbinafine and itraconazole, and two diabetes drugs, pioglitazone and rosiglitazone. We evaluated 1676 diagnosis codes grouped into 183 different clinical concepts and four levels of granularity. Several signaling thresholds were assessed. GPS results were compared to findings from a companion study using the identical analytic dataset but an alternative statistical method—the tree-based scan statistic (TreeScan). Results: We identified 71 statistical signals across two signaling thresholds and two methods, including closely-related signals of overlapping diagnosis definitions. Initial review found that most signals represented known adverse drug reactions or confounding. About 31% of signals met the highest signaling threshold. Conclusions: The GPS method was successfully applied to observational health plan data in a distributed data environment as a drug safety data mining method. There was substantial concordance between the GPS and TreeScan approaches. Key method implementation decisions relate to defining exposures and outcomes and informed choice of signaling thresholds.

Purpose This study describes practical considerations for implementation of near real-time medical product safety surveillance in a distributed health data network. Methods We conducted pilot active safety surveillance comparing generic divalproex sodium to historical branded product at four health plans from April to October 2009. Outcomes reported are all-cause emergency room visits and fractures. One retrospective data extract was completed (January 2002–June 2008), followed by seven prospective monthly extracts (January 2008–November 2009). To evaluate delays in claims processing, we used three analytic approaches: near real-time sequential analysis, sequential analysis with 1.5 month delay, and nonsequential (using final retrospective data). Sequential analyses used the maximized sequential probability ratio test. Procedural and logistical barriers to active surveillance were documented. Results We identified 6586 new users of generic divalproex sodium and 43 960 new users of the branded product. Quality control methods identified 16 extract errors, which were corrected. Near real-time extracts captured 87.5% of emergency room visits and 50.0% of fractures, which improved to 98.3% and 68.7% respectively with 1.5 month delay. We did not identify signals for either outcome regardless of extract timeframe, and slight differences in the test statistic and relative risk estimates were found. Conclusions Near real-time sequential safety surveillance is feasible, but several barriers warrant attention. Data quality review of each data extract was necessary. Although signal detection was not affected by delay in analysis, when using a historical control group differential accrual between exposure and outcomes may theoretically bias near real-time risk estimates towards the null, causing failure to detect a signal. Copyright © 2013 John Wiley & Sons, Ltd.

Background: A range of strategies and approaches have been developed for preventing health care-associated infections. Understanding the variation in practices among facilities is necessary to improve compliance with existing programs and aid the implementation of new interventions. Methods: In 2009, HCA Inc administered an electronic survey to measure compliance with evidence-based infection prevention practices as well as identify variation in products or methods, such as use of special approach technology for central vascular catheters and ventilator care. Responding adult intensive care units (ICUs) were those considering participation in a clinical trial to reduce health care-associated infections. Results: Responses from 99 ICUs in 55 hospitals indicated that many evidenced-based practices were used consistently, including methicillin-resistant Staphylococcus aureus (MRSA) screening and use of contact precautions for MRSA-positive patients. Other practices exhibited wide variability including discontinuation of precautions and use of antimicrobial technology or chlorhexidine patches for central vascular catheters. MRSA decolonization was not a predominant practice in ICUs. Conclusion: In this large, community-based health care system, there was substantial variation in the products and methods to reduce health care-associated infections. Despite system-wide emphasis on basic practices as a precursor to adding special approach technologies, this survey showed that these technologies were commonplace, including in facilities where improvement in basic practices was needed. Copyright © 2013 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.

Background.Since hospitals in a region often share patients, an outbreak of methicillin-resistant Staphylococcus aureus (MRSA) infection in one hospital could affect other hospitals.Methods.Using extensive data collected from Orange County (OC), California, we developed a detailed agent-based model to represent patient movement among all OC hospitals. Experiments simulated MRSA outbreaks in various wards, institutions, and regions. Sensitivity analysis varied lengths of stay, intraward transmission coefficients (β), MRSA loss rate, probability of patient transfer or readmission, and time to readmission.Results.Each simulated outbreak eventually affected all of the hospitals in the network, with effects depending on the outbreak size and location. Increasing MRSA prevalence at a single hospital (from 5% to 15%) resulted in a 2.9% average increase in relative prevalence at all other hospitals (ranging from no effect to 46.4%). Single-hospital intensive care unit outbreaks (modeled increase from 5% to 15%) caused a 1.4% average relative increase in all other OC hospitals (ranging from no effect to 12.7%).Conclusion.MRSA outbreaks may rarely be confined to a single hospital but instead may affect all of the hospitals in a region. This suggests that prevention and control strategies and policies should account for the interconnectedness of health care facilities.

Summary Background Urinary tract infections (UTIs) are common health-care-associated infections. Bacteriuria commonly precedes UTI and is often treated with antibiotics, particularly in hospital intensive care units (ICUs). In 2013, a cluster-randomised trial (REDUCE MRSA Trial [Randomized Evaluation of Decolonization vs Universal Clearance to Eradicate MRSA]) showed that body surface decolonisation reduced all-pathogen bloodstream infections. We aim to further assess the effect of decolonisation on bacteriuria and candiduria in patients admitted to ICUs. Methods We did a secondary analysis of a three-group, cluster-randomised trial of 43 hospitals (clusters) with patients in 74 adult ICUs. The three groups included were either meticillin-resistant Staphylococcus aureus (MRSA) screening and isolation, targeted decolonisation (screening, isolation, and decolonisation of MRSA carriers) with chlorhexidine and mupirocin, and universal decolonisation (no screening, all patients decolonised) with chlorhexidine and mupirocin. Protocol included chlorhexidine cleansing of the perineum and proximal 6 inches (15·24 cm) of urinary catheters. ICUs within the same hospital were assigned the same strategy. Outcomes included high-level bacteriuria (≥50 000 colony forming units [CFU]/mL) with any uropathogen, high-level candiduria (≥50 000 CFU/mL), and any bacteriuria with uropathogens. Sex-specific analyses were specified a priori. Proportional hazards models assessed differences in outcome reductions across groups, comparing an 18-month intervention period to a 12-month baseline period. Findings 122 646 patients (48 390 baseline, 74 256 intervention) were enrolled. Intervention versus baseline hazard ratios (HRs) for high-level bacteriuria were 1·02 (95% CI 0·88–1·18) for screening or isolation, 0·88 (0·76–1·02) for targeted decolonisation, and 0·87 (0·77–1·00) for universal decolonisation (no difference between groups, p=0·26), with no sex-specific reductions (HRs for men: 1·09 [95% CI 0·85–1·40] for screening or isolation, 1·01 [0·79–1·29] for targeted decolonisation, and 0·78 [0·63–0·98] for universal decolonisation, p=0·12; HRs for women: 0·97 [0·80–1·17] for screening and isolation, 0·83 [0·70–1·00] for targeted decolonisation, and 0·93 [0·79–1·09] for universal decolonisation, p=0·49). HRs for high-level candiduria were 1·14 (0·95–1·37) for screening and isolation, 0·99 (0·83–1·18) for targeted decolonisation, and 0·83 (0·70–0·99) for universal decolonisation (p=0·05). Differences between sexes were due to reductions in men in the universal decolonisation group (HRs: 1·21 [95% CI 0·88–1·68] for screening or isolation, 1·01 [0·73–1·39] for targeted decolonisation, and 0·63 [0·45–0·89] for universal decolonisation, p=0·02). Bacteriuria with any CFU/mL was also reduced in men in the universal decolonisation group (HRs 1·01 [0·81–1·25] for screening or isolation, 1·04 [0·83–1·30] for targeted decolonisation, and 0·74 [0·61–0·90] for universal decolonisation, p=0·04). Interpretation Universal decolonisation of patients in the ICU with once a day chlorhexidine baths and short-course nasal mupirocin could be a potential preventive strategy in male patients because it significantly decreases candiduria and any bacteriuria, but not for women. Funding HAI Program from AHRQ, US Department of Health and Human Services as part of the Developing Evidence to Inform Decisions about Effectiveness (DEcIDE) program, CDC Prevention Epicenters Program.

Closing the Translation Gap: Toolkit-based Implementation of Universal Decolonization in Adult Intensive Care Units Reduces Central Line–associated Bloodstream Infections in 95 Community Hospitals Edward Septimus,1,2 Jason Hickok,1 Julia Moody,1 Ken Kleinman,3 Taliser R. Avery,3 Susan S. Huang,4 Richard Platt,3 and Jonathan Perlin1 1Hospital Corporation of America, Nashville, Tennessee; 2Texas AM 3Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts; and 4University of California, Irvine Health School of Medicine Background. Challenges exist in implementing evidence-based strategies, reaching high compliance, and achieving desired out- comes. The rapid adoption of a publicly available toolkit featuring routine universal decolonization of intensive care unit (ICU) patients may affect catheter-related bloodstream infections. Methods. Implementation of universal decolonization—treatment of all ICU patients with chlorhexidine bathing and nasal mupirocin—used a prerelease version of a publicly available toolkit. Implementation in 136 adult ICUs in 95 acute care hospitals across the United States was supported by planning and deployment tactics coordinated by a central infection prevention team using toolkit resources, along with coaching calls and engagement of key stakeholders. Operational and process measures derived from a common electronic health record system provided real-time feedback about performance. Healthcare-associated central line–associated bloodstream infections (CLABSIs), using National Healthcare Safety Network surveillance definitions and comparing the preimplementation period of January 2011 through December 2012 to the postimplementation period of July 2013 through February 2014, were assessed via a Poisson generalized linear mixed model regression for CLABSI events. Results. Implementation of universal decolonization was completed within 6 months. The estimated rate of CLABSI decreased by 23.5% (95% confidence interval, 9.8%–35.1%; P = .001). There was no evidence of a trend over time in either the pre- or postimplementation period. Adjusting for seasonality and number of beds did not materially affect these results. Conclusions. Dissemination of universal decolonization of ICU patients was accomplished quickly in a large community health system and was associated with declines in CLABSI consistent with published clinical trial findings. Keywords. universal decolonization; decolonization; healthcare-associated central line–associated bloodstream infections (CLABSI); quality improvement; learning health system. There has been increasing interest in improving the dissemination of best practices into routine clinical care. Despite frequent acknowledgment of the need for faster translation of evidence- based interventions into practice, it can be challenging to accomplish this. This is often the case even when the desired interventions are the product of pragmatic trials that are intended to test interventions under conditions of routine practice [1, 2]. Growing evidence suggests that universal decolonization of intensive care unit (ICU) patients reduces the risk of healthcare- associated bloodstream infections (BSIs). These include central line–associated bloodstream infections (CLABSIs), which comprise the majority of these

We surveyed infection prevention programs in 16 hospitals for hospital-associated methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci, extended-spectrum β-lactamase, and multidrug-resistant Acinetobacter acquisition, as well as hospital-associated MRSA bacteremia and Clostridium difficile infection based on defining events as occurring >2 days versus >3 days after admission. The former resulted in significantly higher median rates, ranging from 6.76% to 45.07% higherInfect Control Hosp Epidemiol 2014;35(11):1417–1420

Norovirus outbreak may spread among hospitals via patient sharing. Within 30 days, it spread 4.1-17.5% of the time (R0 3.74). Highlights need to cooperatively track and control outbreaks, Background Because hospitals in a region are connected via patient sharing, a norovirus outbreak in one hospital may spread to others. Methods. We utilized our Regional Healthcare Ecosystem Analyst software to generate an agent-based model of all the acute care facilities in Orange County (OC), California and simulated various norovirus outbreaks in different locations, both with and without contact precautions. Results. At the lower end of norovirus reproductive rate (R0) estimates (1.64), an outbreak tended to remain confined to the originating hospital (≤6.1% probability of spread). However, at the higher end of R0 (3.74), an outbreak spread 4.1%–17.5% of the time to almost all other OC hospitals within 30 days, regardless of the originating hospital. Implementing contact precautions for all symptomatic cases reduced the probability of spread to other hospitals within 30 days and the total number of cases countywide, but not the number of other hospitals seeing norovirus cases. Conclusions. A single norovirus outbreak can continue to percolate throughout a system of different hospitals for several months and appear as a series of unrelated outbreaks, highlighting the need for hospitals within a region to more aggressively and cooperatively track and control an initial outbreak.

Objective As healthcare systems continue to expand and interconnect with each other through patient sharing, administrators, policy makers, infection control specialists, and other decision makers may have to take account of the entire healthcare ‘ecosystem’ in infection control. Materials and methods We developed a software tool, the Regional Healthcare Ecosystem Analyst (RHEA), that can accept user-inputted data to rapidly create a detailed agent-based simulation model (ABM) of the healthcare ecosystem (ie, all healthcare facilities, their adjoining community, and patient flow among the facilities) of any region to better understand the spread and control of infectious diseases. Results To demonstrate RHEA's capabilities, we fed extensive data from Orange County, California, USA, into RHEA to create an ABM of a healthcare ecosystem and simulate the spread and control of methicillin-resistant Staphylococcus aureus . Various experiments explored the effects of changing different parameters (eg, degree of transmission, length of stay, and bed capacity). Discussion Our model emphasizes how individual healthcare facilities are components of integrated and dynamic networks connected via patient movement and how occurrences in one healthcare facility may affect many other healthcare facilities. Conclusions A decision maker can utilize RHEA to generate a detailed ABM of any healthcare system of interest, which in turn can serve as a virtual laboratory to test different policies and interventions.

Hospital infection control strategies and programs may not consider control of methicillin-resistant Staphylococcus aureus (MRSA) in nursing homes in a county.Using our Regional Healthcare Ecosystem Analyst, we augmented our existing agent-based model of all hospitals in Orange County (OC), California, by adding all nursing homes and then simulated MRSA outbreaks in various health care facilities.The addition of nursing homes substantially changed MRSA transmission dynamics throughout the county. The presence of nursing homes substantially potentiated the effects of hospital outbreaks on other hospitals, leading to an average 46.2% (range, 3.3%-156.1%) relative increase above and beyond the impact when only hospitals are included for an outbreak in OC's largest hospital. An outbreak in the largest hospital affected all other hospitals (average 2.1% relative prevalence increase) and the majority (~90%) of nursing homes (average 3.2% relative increase) after 6 months. An outbreak in the largest nursing home had effects on multiple OC hospitals, increasing MRSA prevalence in directly connected hospitals by an average 0.3% and in hospitals not directly connected through patient transfers by an average 0.1% after 6 months. A nursing home outbreak also had some effect on MRSA prevalence in other nursing homes.Nursing homes, even those not connected by direct patient transfers, may be a vital component of a hospital's infection control strategy. To achieve effective control, a hospital may want to better understand how regional nursing homes and hospitals are connected through both direct and indirect (with intervening stays at home) patient sharing.

We calculated hospital-onset methicillin-resistant Staphylococcus aureus (HO-MRSA) rates for Orange County, California, hospitals using survey and state data. Numerators were variably defined as HO-MRSA occurring more than 48 hours (37%), more than 2 days (30%), and more than 3 days (33%) postadmission. Survey-reported denominators differed from state-reported patient-days. Numerator and denominator choices substantially impacted HO-MRSA rates.

This study describes practical considerations for implementation of near real-time medical product safety surveillance in a distributed health data network.We conducted pilot active safety surveillance comparing generic divalproex sodium to historical branded product at four health plans from April to October 2009. Outcomes reported are all-cause emergency room visits and fractures. One retrospective data extract was completed (January 2002-June 2008), followed by seven prospective monthly extracts (January 2008-November 2009). To evaluate delays in claims processing, we used three analytic approaches: near real-time sequential analysis, sequential analysis with 1.5 month delay, and nonsequential (using final retrospective data). Sequential analyses used the maximized sequential probability ratio test. Procedural and logistical barriers to active surveillance were documented.We identified 6586 new users of generic divalproex sodium and 43,960 new users of the branded product. Quality control methods identified 16 extract errors, which were corrected. Near real-time extracts captured 87.5% of emergency room visits and 50.0% of fractures, which improved to 98.3% and 68.7% respectively with 1.5 month delay. We did not identify signals for either outcome regardless of extract timeframe, and slight differences in the test statistic and relative risk estimates were found.Near real-time sequential safety surveillance is feasible, but several barriers warrant attention. Data quality review of each data extract was necessary. Although signal detection was not affected by delay in analysis, when using a historical control group differential accrual between exposure and outcomes may theoretically bias near real-time risk estimates towards the null, causing failure to detect a signal.

In post-marketing drug safety surveillance, data mining can potentially detect rare but serious adverse events. Assessing an entire collection of drug-event pairs is traditionally performed on a predefined level of granularity. It is unknown a priori whether a drug causes a very specific or a set of related adverse events, such as mitral valve disorders, all valve disorders, or different types of heart disease. This methodological paper evaluates the tree-based scan statistic data mining method to enhance drug safety surveillance.We use a three-million-member electronic health records database from the HMO Research Network. Using the tree-based scan statistic, we assess the safety of selected antifungal and diabetes drugs, simultaneously evaluating overlapping diagnosis groups at different granularity levels, adjusting for multiple testing. Expected and observed adverse event counts were adjusted for age, sex, and health plan, producing a log likelihood ratio test statistic.Out of 732 evaluated disease groupings, 24 were statistically significant, divided among 10 non-overlapping disease categories. Five of the 10 signals are known adverse effects, four are likely due to confounding by indication, while one may warrant further investigation.The tree-based scan statistic can be successfully applied as a data mining tool in drug safety surveillance using observational data. The total number of statistical signals was modest and does not imply a causal relationship. Rather, data mining results should be used to generate candidate drug-event pairs for rigorous epidemiological studies to evaluate the individual and comparative safety profiles of drugs.

Background.Hospitalized patients are at increased risk for acquisition of methicillin-resistant Staphylococcus aureus (MRSA). As hospital length of stay shortens, hospital-acquired MRSA events may be more likely to be detected after discharge.Objective.We assessed the impact of attributing MRSA cases discovered within 30 days after discharge to the most recent hospitalization and identified patient characteristics associated with MRSA detection after discharge.Design.Retrospective cohort study.Setting.Twenty-seven acute care hospitals in Orange County, California.Participants.Adult acute care admissions (2002–2007).Methods.Using a countywide hospital data set containing diagnostic codes with present-on-admission (POA) indicators, we identified the first admission with a MRSA code for each patient. This incident MRSA admission was defined as predischarge-detected (pre-DD) hospital-onset MRSA (HO-MRSA) when MRSA was not POA. If MRSA was POA and a prior admission occurred within 30 days, this prior admission was assigned postdischarge-detected (post-DD) HO-MRSA. We evaluated the impact of including post-DD HO-MRSA in the calculation of hospital HO-MRSA incidence using signed-rank tests and reviewed changes in hospital rankings. We conducted multivariate comparisons of patient characteristics of pre-DD versus post-DD HO-MRSA patients.Results.Among 1,217,253 at-risk hospitalizations, the inclusion of post-DD HO-MRSA tripled the median hospital HO-MRSA incidence, from 12.2 to 35.7 cases per 10,000 at-risk admissions (PConclusions.On the basis of administrative claims data, the inclusion of post-DD HO-MRSA significantly increased the estimated HO-MRSA incidence and altered hospital rankings. This finding underscores the limitations of single-facility data when deriving HO-MRSA incidence and rank.Infect Control Hosp Epidemiol 2012;33(2):114-121

Objective.Clostridium difficile infection (CDI) is associated with hospitalization and may cause readmission following admission for any reason. We aimed to measure the incidence of readmissions due to CDI.Design.Retrospective cohort study.Patients.Adult inpatients in Orange County, California, who presented with new-onset CDI within 12 weeks of discharge.Methods.We assessed mandatory 2000–2007 hospital discharge data for trends in hospital-associated CDI (HA-CDI) incidence, with and without inclusion of postdischarge CDI (PD-CDI) events resulting in rehospitalization within 12 weeks of discharge. We measured the effect of including PD-CDI events on hospital-specific CDI incidence, a mandatory reporting measure in California, and on relative hospital ranks by CDI incidence.Results.From 2000 to 2007, countywide hospital-onset CDI (HO-CDI) incidence increased from 15 per 10,000 to 22 per 10,000 admissions. When including PD-CDI events, HA-CDI incidence doubled (29 per 10,000 in 2000 and 52 per 10,000 in 2007). Overall, including PD-CDI events resulted in significantly higher hospital-specific CDI incidence, although hospitals had disproportionate amounts of HA-CDI occurring postdischarge. This resulted in substantial shifts in some hospitals' rankings by CDI incidence. In multivariate models, both HO and PD-CDI were associated with increasing age, higher length of stay, and select comorbidities. Race and Hispanic ethnicity were predictive of PD-CDI but not HO-CDI.Conclusions.PD-CDI events associated with rehospitalization are increasingly common. The majority of HA-CDI cases may be occurring postdischarge, raising important questions about both accurate reporting and effective prevention strategies. Some risk factors for PD-CDI may be different than those for HO-CDI, allowing additional identification of high-risk groups before discharge.Infect Control Hosp Epidemiol 2012;33(1):20-28

Background/Aims When new medications are introduced, safety data are often sparse. Health plan data may be useful for active surveillance for adverse events. We conducted a 12-month pilot study to demonstrate the feasibility of prospective active surveillance using data from several large health insurers. This presentation will summarize logistical challenges and lessons learned.