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Immunoassays designed to detect SARS-CoV-2 protein antigens (Ag) are commonly used to diagnose COVID-19. The most widely used tests are lateral flow assays that generate results in approximately 15 minutes for diagnosis at the point-of-care. Higher throughput, laboratory-based SARS-CoV-2 Ag assays have also been developed. The number of commercially available SARS-CoV-2 Ag detection tests has increased rapidly, as has the COVID-19 diagnostic literature. The Infectious Diseases Society of America (IDSA) convened an expert panel to perform a systematic review of the literature and develop best-practice guidance related to SARS-CoV-2 Ag testing. This guideline is an update to the third in a series of frequently updated COVID-19 diagnostic guidelines developed by the IDSA. IDSA's goal was to develop evidence-based recommendations or suggestions that assist clinicians, clinical laboratories, patients, public health authorities, administrators, and policymakers in decisions related to the optimal use of SARS-CoV-2 Ag tests in both medical and nonmedical settings. A multidisciplinary panel of infectious diseases clinicians, clinical microbiologists, and experts in systematic literature review identified and prioritized clinical questions related to the use of SARS-CoV-2 Ag tests. A review of relevant, peer-reviewed published literature was conducted through 1 April 2022. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology was used to assess the certainty of evidence and make testing recommendations. The panel made 10 diagnostic recommendations that address Ag testing in symptomatic and asymptomatic individuals and assess single versus repeat testing strategies. US Food and Drug Administration (FDA) SARS-CoV-2 Ag tests with Emergency Use Authorization (EUA) have high specificity and low to moderate sensitivity compared with nucleic acid amplification testing (NAAT). Ag test sensitivity is dependent on the presence or absence of symptoms and, in symptomatic patients, on timing of testing after symptom onset. In most cases, positive Ag results can be acted upon without confirmation. Results of point-of-care testing are comparable to those of laboratory-based testing, and observed or unobserved self-collection of specimens for testing yields similar results. Modeling suggests that repeat Ag testing increases sensitivity compared with testing once, but no empirical data were available to inform this question. Based on these observations, rapid RT-PCR or laboratory-based NAAT remain the testing methods of choice for diagnosing SARS-CoV-2 infection. However, when timely molecular testing is not readily available or is logistically infeasible, Ag testing helps identify individuals with SARS-CoV-2 infection. Data were insufficient to make a recommendation about the utility of Ag testing to guide release of patients with COVID-19 from isolation. The overall quality of available evidence supporting use of Ag testing was graded as very low to moderate. [ABSTRACT FROM AUTHOR]

Accurate molecular diagnostic tests are necessary for confirming a diagnosis of coronavirus disease 2019 (COVID-19) and for identifying asymptomatic carriage of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The number of available SARS-CoV-2 nucleic acid detection tests continues to increase as does the COVID-19 diagnostic literature. Thus, the Infectious Diseases Society of America (IDSA) developed an evidence-based diagnostic guideline to assist clinicians, clinical laboratorians, patients, and policymakers in decisions related to the optimal use of SARS-CoV-2 nucleic acid amplification tests. In addition, we provide a conceptual framework for understanding molecular diagnostic test performance, discuss nuances of test result interpretation in a variety of practice settings, and highlight important unmet research needs related to COVID-19 diagnostic testing. IDSA convened a multidisciplinary panel of infectious diseases clinicians, clinical microbiologists, and experts in systematic literature review to identify and prioritize clinical questions and outcomes related to the use of SARS-CoV-2 molecular diagnostics. Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was used to assess the certainty of evidence and make testing recommendations. The panel agreed on 12 diagnostic recommendations. Access to accurate SARS-CoV-2 nucleic acid testing is critical for patient care, hospital infection prevention, and the public health response to COVID-19 infection. Information on the clinical performance of available tests continues to grow, but the quality of evidence of the current literature to support this updated molecular diagnostic guideline remains moderate to very low. Recognizing these limitations, the IDSA panel weighed available diagnostic evidence and recommends nucleic acid testing for all symptomatic individuals suspected of having COVID-19. In addition, testing is suggested for asymptomatic individuals with known or suspected contact with a COVID-19 case when the results will impact isolation/quarantine/personal protective equipment (PPE) usage decisions. Evidence in support of rapid testing and testing of upper respiratory specimens other than nasopharyngeal swabs, which offer logistical advantages, is sufficient to warrant conditional recommendations in favor of these approaches. [ABSTRACT FROM AUTHOR]

Background Clostridioides difficile is the most common cause of healthcare-associated infections in the United States. It is unknown whether universal gown and glove use in intensive care units (ICUs) decreases acquisition of C. difficile. Methods This was a secondary analysis of a cluster-randomized trial in 20 medical and surgical ICUs in 20 US hospitals from 4 January 2012 to 4 October 2012. After a baseline period, ICUs were randomized to standard practice for glove and gown use versus the intervention of all healthcare workers being required to wear gloves and gowns for all patient contact and when entering any patient room (contact precautions). The primary outcome was acquisition of toxigenic C. difficile determined by surveillance cultures collected on admission and discharge from the ICU. Results A total of 21 845 patients had both admission and discharge perianal swabs cultured for toxigenic C. difficile. On admission, 9.43% (2060/21 845) of patients were colonized with toxigenic C. difficile. No significant difference was observed in the rate of toxigenic C. difficile acquisition with universal gown and glove use. Differences in acquisition rates in the study period compared with the baseline period in control ICUs were 1.49 per 100 patient-days versus 1.68 per 100 patient-days in universal gown and glove ICUs (rate difference, −0.28; generalized linear mixed model, P =.091). Conclusions Glove and gown use for all patient contact in medical and surgical ICUs did not result in a reduction in the acquisition of C. difficile compared with usual care. Clinical Trials Registration NCT01318213. [ABSTRACT FROM AUTHOR]

Background Inappropriate Clostridioides difficile testing has adverse consequences for patients, hospitals, and public health. Computerized clinical decision support (CCDS) systems in the electronic health record (EHR) may reduce C. difficile test ordering; however, effectiveness of different approaches, ease of use, and best fit into healthcare providers' (HCP) workflow are not well understood. Methods Nine academic and 6 community hospitals in the United States participated in this 2-year cohort study. CCDS (hard stop or soft stop) triggered when a duplicate C. difficile test order was attempted or if laxatives were recently received. The primary outcome was the difference in testing rates pre– and post–CCDS interventions, using incidence rate ratios (IRRs) and mixed-effect Poisson regression models. We performed qualitative evaluation (contextual inquiry, interviews, focus groups) based on a human factors model. We identified themes using a codebook with primary nodes and subnodes. Results In 9 hospitals implementing hard-stop CCDS and 4 hospitals implementing soft-stop CCDS, C. difficile testing incidence rate (IR) reduction was 33% (95% confidence interval [CI]: 30%–36%) and 23% (95% CI: 21%–25%), respectively. Two hospitals implemented a non-EHR-based human intervention with IR reduction of 21% (95% CI: 15%–28%). HCPs reported generally favorable experiences and highlighted time efficiencies such as inclusion of the patient's most recent laxative administration on the CCDS. Organizational factors, including hierarchical cultures and communication between HCPs caring for the same patient, impact CCDS acceptance and integration. Conclusions CCDS systems reduced unnecessary C. difficile testing and were perceived positively by HCPs when integrated into their workflow and when displaying relevant patient-specific information needed for decision making. [ABSTRACT FROM AUTHOR]

Background Methicillin-resistant Staphylococcus aureus (MRSA) is a common cause of health care–associated infections in long-term care facilities (LTCFs). The Centers for Disease Control and Prevention recommends contact precautions for the prevention of MRSA within acute care facilities, which are being used within the United States Department of Veterans Affairs (VA) for LTCFs in a modified fashion. The impact of contact precautions in long-term care is unknown. Methods To evaluate whether contact precautions decreased MRSA acquisition in LTCFs, compared to standard precautions, we performed a retrospective effectiveness study (pre-post, with concurrent controls) using data from the VA health-care system from 1 January 2011 until 31 December 2015, 2 years before and after a 2013 policy recommending a more aggressive form of contact precautions. Results Across 75 414 patient admissions from 74 long-term care facilities in the United States, the overall unadjusted rate of MRSA acquisition was 2.6/1000 patient days. Patients were no more likely to acquire MRSA if they were cared for using standard precautions versus contact precautions in a multivariable, discrete time survival analysis, controlling for patient demographics, risk factors, and year of admission (odds ratio, 0.97; 95% confidence interval,.85–1.12; P =.71). Conclusions MRSA acquisition and infections were not impacted by the use of active surveillance and contact precautions in LTCFs in the VA. [ABSTRACT FROM AUTHOR]

Background Influenza, which peaks seasonally, is an important driver for antibiotic prescribing. Although influenza vaccination has been shown to reduce severe illness, evidence of the population-level effects of vaccination coverage on rates of antibiotic prescribing in the United States is lacking. Methods We conducted a retrospective analysis of influenza vaccination coverage and antibiotic prescribing rates from 2010 to 2017 across states in the United States, controlling for differences in health infrastructure and yearly vaccine effectiveness. Using data from IQVIA's Xponent database and the US Centers for Disease Control and Prevention's FluVaxView, we employed fixed-effects regression analysis to analyze the relationship between influenza vaccine coverage rates and the number of antibiotic prescriptions per 1000 residents from January to March of each year. Results We observed that, controlling for socioeconomic differences, access to health care, childcare centers, climate, vaccine effectiveness, and state-level differences, a 10–percentage point increase in the influenza vaccination rate was associated with a 6.5% decrease in antibiotic use, equivalent to 14.2 (95% CI, 6.0–22.4; P =.001) fewer antibiotic prescriptions per 1000 individuals. Increased vaccination coverage reduced prescribing rates the most in the pediatric population (0–18 years), by 15.2 (95% CI, 9.0–21.3; P <.001) or 6.0%, and the elderly (aged 65+), by 12.8 (95% CI, 6.5–19.2; P <.001) or 5.2%. Conclusions Increased influenza vaccination uptake at the population level is associated with state-level reductions in antibiotic use. Expanding influenza vaccination could be an important intervention to reduce unnecessary antibiotic prescribing. [ABSTRACT FROM AUTHOR]

Data from the National Inpatient Sample show that the decrease in hospitalizations related to methicillin-resistant Staphylococcus aureus (MRSA) infections between 2010 and 2014 primarily reflected declines in skin and soft tissue infections. Hospitalizations related to invasive MRSA remained largely unchanged. [ABSTRACT FROM AUTHOR]

Examines the influence of intercultural communication on the interaction between disabled and nondisabled persons in the U.S. Major problem for millions of disabled Americans ages 16–24; Usage of a three-tier model of intercultural communication developed by P. E. Rohrlich in 1983 in analyzing their communication from an intercultural perspective; Normative forces effecting the communication between them in a helping situation; Identification of the problems of disconfirmation for disabled persons and a heightened sense of the relational power exerted by nondisabled persons.

The article discusses a medical diagnostic stewardship concept in relation to efforts to improve antimicrobial use as of 2017, and it mentions medical laboratories and the problems that are associated with the inappropriate ordering and implementation of medical diagnostics tests by physicians and clinicians in America. The pretest likelihood of disease is addressed, along with overdiagnoses and false-positive medical test results. Preanalytic tests and postanalytic reporting are assessed.

The article discusses various developments involving hospital and medical personnel contact precautions for endemic diseases such as methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) as of 2017, and it mentions the authors' claim that legal mandates and metrics for active MRSA and VRE surveillance cultures should be eliminated. The use of medical gloves and gowns when treating patients infected with MRSA and VRE is examined.

A personal narrative is presented which explores the author's experience of working with Charles L. Cantrell, former law faculty at the Oklahoma City University (OCU) School of Law.

An obituary for American law professor J. William Conger, who passed away on January 1, 2013, is presented.

Objectives: Adverse events (AEs) are unintended physical injuries resulting from or contributed to by medical or surgical care. We determined the frequency and type of AEs before, during, and after hospital admission.Methods: We conducted a cohort study of 296 adult hospital patients. We used the standardized Institute for Healthcare Improvement Global Trigger Tool for Measuring Adverse Events to review the medical records of the hospital patients for occurrence, timing relative to hospital admission, severity, and preventability of AEs. We also identified the primary physiologic system affected by the AE.Results: Among 296 patients, we identified 338 AEs. AEs occurred with similar frequency before (n = 148; 43.8%) and during hospital admission (n = 162; 47.9%). Fewer AEs occurred after discharge (n = 28; 8.3%). Half of all AEs (n = 169; 50.0%) were severe, whereas 47.9% (n = 162) were preventable.Conclusions: AEs occur with similar frequency before and during hospitalization and may contribute more to hospital admissions than previously recognized. These findings suggest that efforts to improve patient safety should include outpatient settings in addition to the more commonly targeted acute care settings. [ABSTRACT FROM AUTHOR]

Importance: Knowing the expected effect of treatment on an individual patient is essential for patient care., Objective: To explore clinicians' conceptualizations of the chance that treatments will decrease the risk of disease outcomes., Design, Setting, and Participants: This survey study of attending and resident physicians, nurse practitioners, and physician assistants was conducted in outpatient clinical settings in 8 US states from June 2018 to November 2019. The survey was an in-person, paper, 26-item survey in which clinicians were asked to estimate the probability of adverse disease outcomes and expected effects of therapies for diseases common in primary care., Main Outcomes and Measures: Estimated chance that treatments would benefit an individual patient., Results: Of 723 clinicians, 585 (81%) responded, and 542 completed all the questions necessary for analysis, with a median (interquartile range [IQR]) age of 32 (29-44) years, 287 (53%) women, and 294 (54%) White participants. Clinicians consistently overestimated the chance that treatments would benefit an individual patient. The median (IQR) estimated chance that warfarin would prevent a stroke in the next year was 50% (5%-80%) compared with scientific evidence, which indicates an absolute risk reduction (ARR) of 0.2% to 1.0% based on a relative risk reduction (RRR) of 39% to 50%. The median (IQR) estimated chance that antihypertensive therapy would prevent a cardiovascular event within 5 years was 30% (10%-70%) vs evidence of an ARR of 0% to 3% based on an RRR of 0% to 28%. The median (IQR) estimated chance that bisphosphonate therapy would prevent a hip fracture in the next 5 years was 40% (10%-60%) vs evidence of ARR of 0.1% to 0.4% based on an RRR of 20% to 40%. The median (IQR) estimated chance that moderate-intensity statin therapy would prevent a cardiovascular event in the next 5 years was 20% (IQR 5%-50%) vs evidence of an ARR of 0.3% to 2% based on an RRR of 19% to 33%. Estimates of the chance that a treatment would prevent an adverse outcome exceeded estimates of the absolute chance of that outcome for 60% to 70% of clinicians. Clinicians whose overestimations were greater were more likely to report using that treatment for patients in their practice (eg, use of warfarin: correlation coefficient, 0.46; 95% CI, 0.40-0.53; P < .001)., Conclusions and Relevance: In this survey study, clinicians significantly overestimated the benefits of treatment to individual patients. Clinicians with greater overestimates were more likely to report using treatments in actual patients.

Study Objective . Suicide is a serious health problem that is shaped by a variety of social and mental health factors. A growing body of research connects the arts to positive health outcomes; however, no previous systematic reviews have examined the use of the arts in suicide prevention and survivorship. This review examined how the arts have been used to address suicide prevention and survivorship in nonclinical settings in Australia, Canada, the United Kingdom, and the United States of America. Design and Setting . Ten bibliographic databases, five research repositories, and reference sections of articles were searched to identify published studies. Articles presenting outcomes of interventions conducted between 2014 and 2019 and written in English, were included. Primary Results . Nine studies met inclusion criteria, including qualitative, quantitative randomized controlled trials, quantitative nonrandomized, quantitative descriptive, and mixed-methods studies. The programs studied used film and television (n = 3), mixed-arts (n = 3), theatre (n = 2), and quilting (n = 1). All nine interventions used the arts to elicit emotional involvement, while seven also used the arts to encourage engagement with themes of health. Study outcomes included increased self-efficacy, awareness of mental health issues, and likelihood for taking action to prevent suicide, as well as decreases in suicidal risk and self-harming behaviors. Conclusions . Factors that influence suicide risk and survivorship may be effectively addressed through arts-based interventions. While the current evidence is promising with regard to the potential for arts programs to positively affect suicide prevention and survivorship, this evidence needs to be supplemented to inform recommendations for evidence-based arts interventions.

Background: The Centers for Medicare and Medicaid Services (CMS) implemented a core measure sepsis (SEP-1) bundle in 2015. One element was initiation of broad-spectrum antibiotics within 3 hours of diagnosis. The policy has the potential to increase antibiotic use and Clostridioides difficile infection (CDI). We evaluated the impact of SEP-1 implementation on broad-spectrum antibiotic use and CDI occurrence rates., Methods: Monthly adult antibiotic data for 4 antibiotic categories (surgical prophylaxis, broad-spectrum for community-acquired infections, broad-spectrum for hospital-onset/multidrug-resistant [MDR] organisms, and anti-methicillin-resistant Staphylococcus aureus [MRSA]) from 111 hospitals participating in the Clinical Data Base Resource Manager were evaluated in periods before (October 2014-September 2015) and after (October 2015-June 2017) policy implementation. Interrupted time series analyses, using negative binomial regression, evaluated changes in antibiotic category use and CDI rates., Results: At the hospital level, there was an immediate increase in the level of broad-spectrum agents for hospital-onset/MDR organisms (+2.3%, P = .0375) as well as a long-term increase in trend (+0.4% per month, P = .0273). There was also an immediate increase in level of overall antibiotic use (+1.4%, P = .0293). CDI rates unexpectedly decreased at the time of SEP-1 implementation. When analyses were limited to patients with sepsis, there was a significant level increase in use of all antibiotic categories at the time of SEP-1 implementation., Conclusions: SEP-1 implementation was associated with immediate and long-term increases in broad-spectrum hospital-onset/MDR organism antibiotics. Antimicrobial stewardship programs should evaluate sepsis treatment for opportunities to de-escalate broad therapy as indicated., (© The Author(s) 2020. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.)

Objective: In the absence of pyuria, positive urine cultures are unlikely to represent infection. Conditional urine reflex culture policies have the potential to limit unnecessary urine culturing. We evaluated the impact of this diagnostic stewardship intervention., Design: We conducted a retrospective, quasi-experimental (nonrandomized) study, with interrupted time series, from August 2013 to January 2018 to examine rates of urine cultures before versus after the policy intervention. We compared 3 intervention sites to 3 control sites in an aggregated series using segmented negative binomial regression., Setting: The study included 6 acute-care hospitals within the Veterans' Health Administration across the United States., Participants: Adult patients with at least 1 urinalysis ordered during acute-care admission, excluding pregnant patients or those undergoing urological procedures, were included., Methods: At the intervention sites, urine cultures were performed if a preceding urinalysis met prespecified criteria. No such restrictions occurred at the control sites. The primary outcome was the rate of urine cultures performed per 1,000 patient days. The safety outcome was the rate of gram-negative bloodstream infection per 1,000 patient days., Results: The study included 224,573 urine cultures from 50,901 admissions in 24,759 unique patients. Among the intervention sites, the overall average number of urine cultures performed did not significantly decrease relative to the preintervention period (5.9% decrease; P = 0.8) but did decrease by 21% relative to control sites (P < .01). We detected no significant difference in the rates of gram-negative bloodstream infection among intervention or control sites (P = .49)., Conclusions: Conditional urine reflex culture policies were associated with a decrease in urine culturing without a change in the incidence of gram-negative bloodstream infection.

The Medical Library Association (MLA) appointed a Diversity and Inclusion Task Force (DITF) in 2017. Sandra G. Franklin, AHIP, FMLA, chaired the task force and guided initiatives. From 2017 to 2020, the task force completed a review of MLA defining documents-including the mission, vision, values, and code of ethics-resulting in language updates to these documents. As MLA transitioned through the communities process, the DITF contributed to the transition. Other recommended essential changes to MLA profiles to promote awareness included updating pronouns to promote gender inclusivity and suggestions for the Annual Meeting Innovation Task Force. DITF members actively brought diversity and inclusion programming and engagement to MLA members at annual meetings. The task force held a fish bowl conversation, an open forum, and a Diversity Dialogues roundtable discussion; provided interactive discussion boards; and designed an MLA diversity button. Beyond MLA annual meetings, the task force hosted two critical librarianship meetings and a Twitter chat to engage MLA members with diversity and inclusion topics. Task force members promoted diversity and inclusion beyond their task force appointments with presentations at chapter meetings and other non-DITF MLA annual meeting programming. A notable task force accomplishment included completing a survey of MLA members to gather baseline demographic characteristics, including never before collected data about disability, socioeconomics, and caregiver status. This report provides an overview of DITF activities from 2017 to 2020., (Copyright © 2021 Jane Morgan-Daniel, Xan Y. Goodman, Sandra G. Franklin, Kelsa Bartley, Matthew Nicholas Noe, JJ Pionke.)

Objectives: Guided by the hypothesis that the arts can play a role in changing attitudes, beliefs, and health behaviors, the objectives of the study were to (1) overview artistic practices, interventions, and research being conducted at the intersection of the arts and health communication and (2) identify desired and observed outcomes and variables measured in these studies., Data Source: The search strategy was developed iteratively with 2 health science librarians and conducted using 8 databases (Applied Social Sciences Index and Abstracts, Art and Architecture Source, CINAHL, Communication and Mass Media Complete, ERIC, PsycINFO, PubMed, and Web of Science) and hand searching. Articles included were published between 2014 and 2018., Study Inclusion and Exclusion Criteria: Inclusion criteria include US nonclinical setting and use of the arts (broadly defined) to change health knowledge, beliefs, behaviors, or awareness. Any articles not meeting inclusion criteria were excluded., Data Extraction: Covidence's data extraction tool exported to MS Excel., Data Synthesis: This final set of results was analyzed and synthesized by research design, population, sample size, health issue, purpose, variables measured, and findings., Results: In all, 78 articles met inclusion criteria. Number of participants ranged from 4 to 2140 (mean = 179); 61 (78.2%) outcome studies, including 8 experimental studies; 17 (21.79%) formative research or reports. Many different health topics were addressed and different art forms used., Conclusion: The arts can help build knowledge and awareness of health issues. The authors highlight the need to build an evidence base for arts and public health.

Background: Long-term care facility residents are at higher risk of methicillin-resistant Staphylococcus aureus infection and colonization than the general population. In 2009, the Department of Veterans Affairs (VA) implemented the "methicillin-resistant S. aureus prevention initiative" in long-term care facilities (ie, Community Living Centers or "CLCs")., Methods: Over 4 months, 40 semistructured interviews were conducted with staff in medicine, nursing, and environmental services at 5 geographically dispersed CLCs. Interviews addressed knowledge, attitudes, and beliefs concerning infection prevention and resident-centered care. A modified constant comparative approach was used for data analysis., Results: In CLCs, staff work to prevent and control infections in spaces where residents live. Nurses and Environmental Service Workers daily balance infection prevention conventions with the CLC setting. Infection control team members, who are accustomed to working in acute care settings, struggle to reconcile the CLC context with infection prevention., Discussion: The focus on the resident's room as the locus of care, and thus the main target of infection control, misses opportunities for addressing infection prevention in the spaces beyond the residents' rooms., Conclusions: Environmental Service Workers' daily work inside the rooms and within the wider facility produces a unique perspective that might help in the design of workable infection control policies in CLCs., (Published by Elsevier Inc.)

Objective: We examined Clostridioides difficile infection (CDI) prevention practices and their relationship with hospital-onset healthcare facility-associated CDI rates (CDI rates) in Veterans Affairs (VA) acute-care facilities., Design: Cross-sectional study., Methods: From January 2017 to February 2017, we conducted an electronic survey of CDI prevention practices and hospital characteristics in the VA. We linked survey data with CDI rate data for the period January 2015 to December 2016. We stratified facilities according to whether their overall CDI rate per 10,000 bed days of care was above or below the national VA mean CDI rate. We examined whether specific CDI prevention practices were associated with an increased risk of a CDI rate above the national VA mean CDI rate., Results: All 126 facilities responded (100% response rate). Since implementing CDI prevention practices in July 2012, 60 of 123 facilities (49%) reported a decrease in CDI rates; 22 of 123 facilities (18%) reported an increase, and 41 of 123 (33%) reported no change. Facilities reporting an increase in the CDI rate (vs those reporting a decrease) after implementing prevention practices were 2.54 times more likely to have CDI rates that were above the national mean CDI rate. Whether a facility's CDI rates were above or below the national mean CDI rate was not associated with self-reported cleaning practices, duration of contact precautions, availability of private rooms, or certification of infection preventionists in infection prevention., Conclusions: We found considerable variation in CDI rates. We were unable to identify which particular CDI prevention practices (i.e., bundle components) were associated with lower CDI rates.

Importance: Although hand hygiene (HH) is considered the most effective strategy for preventing hospital-acquired infections, HH adherence rates remain poor., Objective: To examine whether the frequency of changing reminder signs affects HH adherence among health care workers., Design, Setting, and Participants: This cluster randomized clinical trial in 9 US Department of Veterans Affairs acute care hospitals randomly assigned 58 inpatient units to 1 of 3 schedules for changing signs designed to promote HH adherence among health care workers: (1) no change; (2) weekly; and (3) monthly. Hand hygiene rates among health care workers were documented at entry and exit to patient rooms during the baseline period from October 1, 2014, to March 31, 2015, of normal signage and throughout the intervention period of June 8, 2015, to December 28, 2015. Data analyses were conducted in April 2018., Interventions: Hospital units were randomly assigned into 3 groups: (1) no sign changes throughout the intervention period, (2) signs changed weekly, and (3) signs changed monthly., Main Outcomes and Measures: Hand hygiene adherence as measured by covert observation. Interrupted time series analysis was used to examine changes in HH adherence from baseline through the intervention period by group., Results: Among 58 inpatient units, 19 units were assigned to the no change group, 19 units were assigned to the weekly change group, and 20 units were assigned to the monthly change group. During the baseline period, 9755 HH opportunities were observed at room entry and 10 095 HH opportunities were observed at room exit. During the intervention period, a total of 15 855 HH opportunities were observed at room entry, and 16 360 HH opportunities were observed at room exit. Overall HH adherence did not change from baseline compared with the intervention period at either room entry (4770 HH events [48.9%] vs 3057 HH events [50.1%]; P = .14) or exit (6439 HH events [63.8%] vs 4087 HH events [65.2%]; P = .06). In units that changed signs weekly, HH adherence declined from baseline at room entry (-1.9% [95% CI, -2.7% to -0.8%] per week; P < .001) and exit (-0.8% [95% CI, -1.5% to 0.1%] per week; P = .02). No significant changes in HH adherence were observed in other groups., Conclusions and Relevance: The frequency of changing reminder signs had no effect on HH rates overall. Units assigned to change signs most frequently demonstrated worsening adherence. Considering the abundance of signs in the acute care environment, the frequency of changing signs did not appear to provide a strong enough cue by itself to promote behavioral change., Trial Registration: ClinicalTrials.gov Identifier: NCT02223455.

We used a survey to characterize contemporary infection prevention and antibiotic stewardship program practices across 64 healthcare facilities, and we compared these findings to those of a similar 2013 survey. Notable findings include decreased frequency of active surveillance for methicillin-resistant Staphylococcus aureus, frequent active surveillance for carbapenem-resistant Enterobacteriaceae, and increased support for antibiotic stewardship programs.

Importance: Hospital readmissions are associated with patient harm and expense. Ways to prevent hospital readmissions have focused on identifying patients at greatest risk using prediction scores., Objective: To identify the type of score that best predicts hospital readmissions., Design, Setting, and Participants: This prognostic study included 14 062 consecutive adult hospital patients with 16 649 discharges from a tertiary care center, suburban community hospital, and urban critical access hospital in Maryland from September 1, 2016, through December 31, 2016. Patients not included as eligible discharges by the Centers for Medicare & Medicaid Services or the Chesapeake Regional Information System for Our Patients were excluded. A machine learning rank score, the Baltimore score (B score) developed using a machine learning technique, for each individual hospital using data from the 2 years before September 1, 2016, was compared with standard readmission risk assessment scores to predict 30-day unplanned readmissions., Main Outcomes and Measures: The 30-day readmission rate evaluated using various readmission scores: B score, HOSPITAL score, modified LACE score, and Maxim/RightCare score., Results: Of the 10 732 patients (5605 [52.2%] male; mean [SD] age, 54.56 [22.42] years) deemed to be eligible for the study, 1422 were readmitted. The area under the receiver operating characteristic curve (AUROC) for individual rules was 0.63 (95% CI, 0.61-0.65) for the HOSPITAL score, which was significantly lower than the 0.66 for modified LACE score (95% CI, 0.64-0.68; P < .001). The B score machine learning score was significantly better than all other scores; 48 hours after admission, the AUROC of the B score was 0.72 (95% CI, 0.70-0.73), which increased to 0.78 (95% CI, 0.77-0.79) at discharge (all P < .001). At the hospital using Maxim/RightCare score, the AUROC was 0.63 (95% CI, 0.59-0.69) for HOSPITAL, 0.64 (95% CI, 0.61-0.68) for Maxim/RightCare, and 0.66 (95% CI, 0.62-0.69) for modified LACE score. The B score was 0.72 (95% CI, 0.69-0.75) 48 hours after admission and 0.81 (95% CI, 0.79-0.84) at discharge. In directly comparing the B score with the sensitivity at cutoff values for modified LACE, HOSPITAL, and Maxim/RightCare scores, the B score was able to identify the same number of readmitted patients while flagging 25.5% to 54.9% fewer patients., Conclusions and Relevance: Among 3 hospitals in different settings, an automated machine learning score better predicted readmissions than commonly used readmission scores. More efficiently targeting patients at higher risk of readmission may be the first step toward potentially preventing readmissions.

This survey investigated interventions used by acute-care hospitals to reduce the detection of asymptomatic bacteriuria. Half of the respondents reported using reflex urine cultures but with varied urinalysis criteria and perceived outcomes. Other diagnostic stewardship interventions for urine culture ordering and specimen quality were less common.

OBJECTIVETo directly observe healthcare workers in a nursing home setting to measure frequency and duration of resident contact and infection prevention behavior as a factor of isolation practiceDESIGNObservational studySETTING AND PARTICIPANTSHealthcare workers in 8 VA nursing homes in Florida, Maryland, Massachusetts, Michigan, Washington, and TexasMETHODSOver a 15-month period, trained research staff without clinical responsibilities on the units observed nursing home resident room activity for 15-30-minute intervals. Observers recorded time of entry and exit, isolation status, visitor type (staff, visitor, etc), hand hygiene, use of gloves and gowns, and activities performed in the room when visible.RESULTSA total of 999 hours of observation were conducted across 8 VA nursing homes during which 4,325 visits were observed. Residents in isolation received an average of 4.73 visits per hour of observation compared with 4.21 for nonisolation residents (P<.01), a 12.4% increase in visits for residents in isolation. Residents in isolation received an average of 3.53 resident care activities per hour of observation, compared with 2.46 for residents not in isolation (P<.01). For residents in isolation, compliance was 34% for gowns and 58% for gloves. Healthcare worker hand hygiene compliance was 45% versus 44% (P=.79) on entry and 66% versus 55% (P<.01) on exit for isolation and nonisolation rooms, respectively.CONCLUSIONSHealthcare workers visited residents in isolation more frequently, likely because they required greater assistance. Compliance with gowns and gloves for isolation was limited in the nursing home setting. Adherence to hand hygiene also was less than optimal, regardless of isolation status of residents.Infect Control Hosp Epidemiol 2018;39:683-687.

OBJECTIVE To determine whether patients using the Centers for Medicare and Medicaid Services (CMS) Hospital Compare website (http://medicare.gov/hospitalcompare) can use nationally reported healthcare-associated infection (HAI) data to differentiate hospitals. DESIGN Secondary analysis of publicly available HAI data for calendar year 2013. METHODS We assessed the availability of HAI data for geographically proximate hospitals (ie, hospitals within the same referral region) and then analyzed these data to determine whether they are useful to differentiate hospitals. We assessed data for the 6 HAIs reported by hospitals to the Centers for Disease Control and Prevention (CDC). RESULTS Data were analyzed for 4,561 hospitals representing 88% of registered community and federal government hospitals in the United States. Healthcare-associated infection data are only useful for comparing hospitals if they are available for multiple hospitals within a geographic region. We found that data availability differed by HAI. Clostridium difficile infections (CDI) data were most available, with 82% of geographic regions (ie, hospital referral regions) having >50% of hospitals reporting them. In contrast, 4% of geographic regions had >50% of member hospitals reporting surgical site infections (SSI) for hysterectomies, which had the lowest availability. The ability of HAI data to differentiate hospitals differed by HAI: 72% of hospital referral regions had at least 1 pair of hospitals with statistically different risk-adjusted CDI rates (SIRs), compared to 9% for SSI (hysterectomy). CONCLUSIONS HAI data generally are reported by enough hospitals to meet minimal criteria for useful comparisons in many geographic locations, though this varies by type of HAI. CDI and catheter-associated urinary tract infection (CAUTI) are more likely to differentiate hospitals than the other publicly reported HAIs. Infect Control Hosp Epidemiol 2017;38:1167-1171.

OBJECTIVE Hospital-acquired infection (HAI) data are reported to the public on the Centers for Medicare and Medicaid Services (CMS) Hospital Compare website. We previously found that public understanding of these data is poor. Our objective was to develop an improved method for presenting HAI data that could be used on the CMS website. DESIGN Randomized controlled trial comparing understanding of data presented using the current CMS presentation strategy versus a new strategy. SETTING A 760-bed tertiary referral hospital. PARTICIPANTS A total of 61 patients were randomly selected within 24 hours of admission. INTERVENTION Participants were shown HAI data as presented on the CMS Hospital Compare website (control arm) or data formatted using a new method (experimental arm). RESULTS No statistically significant demographic differences were identified between study arms. Although 47% percent of participants said a website for comparing hospitals would have been helpful, only 10% had ever used such a website. Participants viewing data using the new presentation strategy compared hospitals correctly 56% of the time, compared with 32% in the control arm (P=.0002). CONCLUSIONS Understanding of HAI data increased significantly with the new data presentation method compared to the method currently used on the CMS Hospital Compare website. Many participants expressed interest in a website for comparing hospitals. Improved methods for presenting CMS HAI data, such as the one assessed here, should be adopted to increase public understanding. Infect Control Hosp Epidemiol 2016;1-6.

We compared the ability to observe hand hygiene opportunities using the World Health Organization My 5 Moments method to the Entry/Exit method. Under covert direct observation, Entry/Exit method opportunities were observed at all times. My 5 Moments were observable in 32.3% of episodes, with a lower rate in wards versus intensive care units (28.0% vs 39.4%; P < .01). In US hospitals, the Entry/Exit method appears to be more feasible for directly observed hand hygiene compliance monitoring due to line-of-sight issues and other barriers., (Published by Elsevier Inc.)

Background: Public reporting of hospital quality data is a key element of US healthcare reform. Data for hospital-acquired infections (HAIs) are especially complex., Objective: To assess interpretability of HAI data as presented on the Centers for Medicare and Medicaid Services Hospital Compare website among patients who might benefit from access to these data., Methods: We randomly selected inpatients at a large tertiary referral hospital from June to September 2014. Participants performed 4 distinct tasks comparing hypothetical HAI data for 2 hospitals, and the accuracy of their comparisons was assessed. Data were presented using the same tabular formats used by Centers for Medicare and Medicaid Services. Demographic characteristics and healthcare experience data were also collected., Results: Participants (N=110) correctly identified the better of 2 hospitals when given written descriptions of the HAI measure in 72% of the responses (95% CI, 66%-79%). Adding the underlying numerical data (number of infections, patient-time, and standardized infection ratio) to the written descriptions reduced correct responses to 60% (55%-66%). When the written HAI measure description was not informative (identical for both hospitals), 50% answered correctly (42%-58%). When no written HAI measure description was provided and hospitals differed by denominator for infection rate, 38% answered correctly (31%-45%)., Conclusions: Current public HAI data presentation methods may be inadequate. When presented with numeric HAI data, study participants incorrectly compared hospitals on the basis of HAI data in more than 40% of the responses. Research is needed to identify better ways to convey these data to the public.

Background: Whether contact precautions (CP) are required to control the endemic transmission of methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus (VRE) in acute care hospitals is controversial in light of improvements in hand hygiene, MRSA decolonization, environmental cleaning and disinfection, fomite elimination, and chlorhexidine bathing., Objective: To provide a framework for decision making around use of CP for endemic MRSA and VRE based on a summary of evidence related to use of CP, including impact on patients and patient care processes, and current practices in use of CP for MRSA and VRE in US hospitals., Design: A literature review, a survey of Society for Healthcare Epidemiology of America Research Network members on use of CP, and a detailed examination of the experience of a convenience sample of hospitals not using CP for MRSA or VRE., Participants: Hospital epidemiologists and infection prevention experts., Results: No high quality data support or reject use of CP for endemic MRSA or VRE. Our survey found more than 90% of responding hospitals currently use CP for MRSA and VRE, but approximately 60% are interested in using CP in a different manner. More than 30 US hospitals do not use CP for control of endemic MRSA or VRE., Conclusions: Higher quality research on the benefits and harms of CP in the control of endemic MRSA and VRE is needed. Until more definitive data are available, the use of CP for endemic MRSA or VRE in acute care hospitals should be guided by local needs and resources.

Background: Hospital Ebola preparation is underway in the United States and other countries; however, the best approach and resources involved are unknown., Objective: To examine costs and challenges associated with hospital Ebola preparation by means of a survey of Society for Healthcare Epidemiology of America (SHEA) members., Design: Electronic survey of infection prevention experts., Results: A total of 257 members completed the survey (221 US, 36 international) representing institutions in 41 US states, the District of Columbia, and 18 countries. The 221 US respondents represented 158 (43.1%) of 367 major medical centers that have SHEA members and included 21 (60%) of 35 institutions recently defined by the US Centers for Disease Control and Prevention as Ebola virus disease treatment centers. From October 13 through October 19, 2014, Ebola consumed 80% of hospital epidemiology time and only 30% of routine infection prevention activities were completed. Routine care was delayed in 27% of hospitals evaluating patients for Ebola., Limitations: Convenience sample of SHEA members with a moderate response rate., Conclusions: Hospital Ebola preparations required extraordinary resources, which were diverted from routine infection prevention activities. Patients being evaluated for Ebola faced delays and potential limitations in management of other diseases that are more common in travelers returning from West Africa.

Background: Modification of empirical antimicrobials when warranted by culture results or clinical signs is recommended to control antimicrobial overuse and resistance. We aimed to assess the frequency with which patients were started on empirical antimicrobials, characteristics of the empirical regimen and the clinical characteristics of patients at the time of starting antimicrobials, patterns of changes to empirical therapy at different timepoints, and modifiable factors associated with changes to the initial empirical regimen in the first 5 days of therapy., Methods: We did a chart review of adult inpatients receiving one or more antimicrobials in six US hospitals on 4 days during 2009 and 2010. Our primary outcome was the modification of antimicrobial regimen on or before the 5th day of empirical therapy, analysed as a three-category variable. Bivariate analyses were used to establish demographic and clinical variables associated with the outcome. Variables with p values below 0·1 were included in a multivariable generalised linear latent and mixed model with multinomial logit link to adjust for clustering within hospitals and accommodate a non-binary outcome variable., Findings: Across the six study sites, 4119 (60%) of 6812 inpatients received antimicrobials. Of 1200 randomly selected patients with active antimicrobials, 730 (61%) met inclusion criteria. At the start of therapy, 220 (30%) patients were afebrile and had normal white blood cell counts. Appropriate cultures were collected from 432 (59%) patients, and 250 (58%) were negative. By the 5th day of therapy, 12·5% of empirical antimicrobials were escalated, 21·5% were narrowed or discontinued, and 66·4% were unchanged. Narrowing or discontinuation was more likely when cultures were collected at the start of therapy (adjusted OR 1·68, 95% CI 1·05-2·70) and no infection was noted on an initial radiological study (1·76, 1·11-2·79). Escalation was associated with multiple infection sites (2·54, 1·34-4·83) and a positive culture (1·99, 1·20-3·29)., Interpretation: Broad-spectrum empirical therapy is common, even when clinical signs of infection are absent. Fewer than one in three inpatients have their regimens narrowed within 5 days of starting empirical antimicrobials. Improved diagnostic methods and continued education are needed to guide discontinuation of antimicrobials., Funding: US Centers for Disease Control and Prevention, Division of Healthcare Quality Promotion; Robert Wood Johnson Foundation; US Department of Veterans Administration; US Department of Homeland Security., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

We surveyed hospital epidemiologists and infection preventionists on their usage of and satisfaction with infection prevention-specific software supplementing their institution's electronic medical record. Respondents with supplemental software were more satisfied with their software's infection prevention and antimicrobial stewardship capabilities than those without. Infection preventionists were more satisfied than hospital epidemiologists.

Objective: Multidrug-resistant Enterobacteriaceae pose a serious infection control challenge and have emerged as a public health threat. We examined national trends in the proportion of Klebsiella pneumoniae isolates resistant to carbapenems (CRKP) and third-generation cephalosporins (G3CRKP)., Design and Setting: Retrospective analysis of approximately 500,000 K. pneumoniae isolates cultured between January 1999 and July 2010 at 287 clinical laboratories throughout the United States., Methods: Isolates were defined as CRKP if they were nonsusceptible to 1 or more carbapenems and were defined as G3CRKP if they were nonsusceptible to ceftazidime, ceftriaxone, or related antibiotics. A multivariable analysis examined trends in the proportion of resistant isolates, adjusting for age, sex, isolate source, patient location, and geographic region., Results: The crude proportion of CRKP increased from less than 0.1% to 4.5% between 2002 and 2010; the frequency of G3CRKP increased from 5.3% to 11.5% between 1999 and 2010. G3CRKP and CRKP were more common among elderly patients (those greater than 65 years of age); the adjusted odds ratio (aOR) relative to pediatric patients (those less than 18 years of age) was 1.2 for G3CRKP (95% confidence interval [CI], 1.2-1.3) and 3.3 for CRKP (95% CI, 2.6-4.2). G3CRKP and CRKP were also more common among patients from the northeastern United States (aOR, 2.9 [95% CI, 2.8-3.0] and 9.0 [95% CI, 7.9-10.4]) than among those from the western United States. The prevalence of outpatient CRKP isolates increased after 2006, reaching 1.9% of isolates in our sample in 2010 (95% CI, 1.6%-2.1%)., Conclusions: The frequency of G3CRKP and CRKP is increasing in all regions of the United States, and resistance is emerging among isolates recovered in the outpatient setting. This underscores the need for enhanced laboratory capacity and coordinated surveillance strategies to contain the further spread of these emerging pathogens.

Background and Objective: Contact precautions are a cornerstone of infection prevention but have also been associated with less healthcare worker (HCW) contact and adverse events. We studied how contact precautions modified HCW behavior in 4 acute care facilities., Design: Prospective cohort study., Participants and Setting: Four acute care facilities in the United States performing active surveillance for methicillin-resistant Staphylococcus aureus., Methods: Trained observers performed "secret shopper" monitoring of HCW activities during routine care, using a standardized collection tool and fixed 1-hour observation periods., Results: A total of 7,743 HCW visits were observed over 1,989 hours. Patients on contact precautions had 36.4% fewer hourly HCW visits than patients not on contact precautions (2.78 vs 4.37 visits per hour; [Formula: see text]) as well as 17.7% less direct patient contact time with HCWs (13.98 vs 16.98 minutes per hour; [Formula: see text]). Patients on contact precautions tended to have fewer visitors (23.6% fewer; [Formula: see text]). HCWs were more likely to perform hand hygiene on exiting the room of a patient on contact precautions (63.2% vs 47.4% in rooms of patients not on contact precautions; [Formula: see text])., Conclusion: Contact precautions were found to be associated with activities likely to reduce transmission of resistant pathogens, such as fewer visits and better hand hygiene at exit, while exposing patients on contact precautions to less HCW contact, less visitor contact, and potentially other unintended outcomes.

Background: On 1 October 2008, in an effort to stimulate efforts to prevent catheter-associated urinary tract infection (CAUTI), the Centers for Medicare & Medicaid Services (CMS) implemented a policy of not reimbursing hospitals for hospital-acquired CAUTI. Since any urinary tract infection present on admission would not fall under this initiative, concerns have been raised that the policy may encourage more testing for and treatment of asymptomatic bacteriuria., Methods: We conducted a retrospective multicenter cohort study with time series analysis of all adults admitted to the hospital 16 months before and 16 months after policy implementation among participating Society for Healthcare Epidemiology of America Research Network hospitals. Our outcomes were frequency of urine culture on admission and antimicrobial use., Results: A total of 39 hospitals from 22 states submitted data on 2 362 742 admissions. In 35 hospitals affected by the CMS policy, the median frequency of urine culture performance did not change after CMS policy implementation (19.2% during the prepolicy period vs 19.3% during the postpolicy period). The rate of change in urine culture performance increased minimally during the prepolicy period (0.5% per month) and decreased slightly during the postpolicy period (-0.25% per month; P < .001). In the subset of 10 hospitals providing antimicrobial use data, the median frequency of fluoroquinolone antimicrobial use did not change substantially (14.6% during the prepolicy period vs 14.0% during the postpolicy period). The rate of change in fluoroquinolone use increased during the prepolicy period (1.26% per month) and decreased during the postpolicy period (-0.60% per month; P < .001)., Conclusions: We found no evidence that CMS nonpayment policy resulted in overtesting to screen for and document a diagnosis of urinary tract infection as present on admission.

Background: Contact Isolation is a common hospital infection prevention method that may improve infectious outcomes but may also hinder healthcare delivery., Methods: To evaluate the impact of Contact Isolation on compliance with individual and composite process of care quality measures, we formed four retrospective diagnosis-based cohorts from a 662-bed tertiary-care medical center. Each cohort contained patients evaluated for one of four Centers for Medicare and Medicaid Services (CMS) Hospital Compare process measures including Acute Myocardial Infarction (AMI), Congestive Heart Failure (CHF), Pneumonia (PNA) and Surgical Care Improvement Project (SCIP) from January 1, 2007 through May 30, 2009., Results: The 6716-admission cohort included 1259 with AMI, 834 with CHF, 1377 with PNA and 3246 in SCIP. Contact Isolation was associated with not meeting 4 of 23 individual hospital measures (4 of 10 measures were not met for care provided while patients are typically isolated). Contact Isolation was independently associated with lower compliance with the composite pneumonia process-of-care measure (OR 0.3, 95% CI 0.1-0.7). AMI, CHF and SCIP composite measures were not impacted by Contact Isolation., Conclusions: Contact Isolation was associated with lower adherence to some pneumonia quality of care process measures of care on inpatient wards but did not impact CHF, AMI or SCIP measures.