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We performed antimicrobial drug susceptibility testing and molecular typing on invasive methicillin-resistant Staphylococcus aureus (MRSA) isolates (n = 1,666) submitted to the University of Iowa Hygienic Laboratory during 1999-2006 as part of a statewide surveillance system. All USA300 and USA400 isolates were resistant to

BACKGROUND: To transfuse blood products safely, health care workers must accurately identify patients, blood samples, and the blood components. A comprehensive bar code-based computerized tracking system was developed and implemented to identify and prevent transfusion errors. STUDY DESIGN AND METHODS: A data network, wireless devices, and bar-coded labels were pilot tested before the system was introduced hospitalwide. The system provided a complete audit trail for all transactions. Data from before and after implementation were analyzed. RESULTS: Incident reports decreased from a mean of 41.5 reports per month in the 6 months before the system was implemented to a mean of 7.2 reports per month after implementation. The blood sample rejection rate decreased from 1.82 percent to a mean of 0.17 percent after implementation. Errors detected by the new system were sorted into misscans, skipped steps, wrong steps, and prevented identification errors (PIEs). Misscans and skipped steps were the most common errors in the first 10 months after implementation. During the final transfusion step, PIEs occurred at the rate of about one per month and scans were omitted approximately 1 percent of the time. Therefore, it is estimated that mistransfusions could occur about once every 100 months on average with the new system. CONCLUSIONS: The bar code-based computerized tracking system detected and prevented identification and matching errors, thereby reducing the proportion of blood samples rejected and increasing patient safety. [ABSTRACT FROM AUTHOR]

BACKGROUND: Routine culturing of patients in intensive care units (ICUs) for methicillin-resistant Staphylococcus aureus (MRSA) identifies unrecognized carriers and facilitates timely isolation. However, the benefit of surveillance in detecting prevalent and incident carriers likely varies among ICUs. In addition, many assessments underestimate the incidence of acquisition by including prevalent carriers in the at-risk population. METHODS: We performed a retrospective cohort study using accurate at-risk populations to evaluate the range of benefit of admission and weekly surveillance cultures in detecting otherwise unrecognized MRSA in 12 ICUs in 5 states. RESULTS: We assessed 142 ICU-months. Among the 12 ICUs, the admission prevalence of imported MRSA was 5%-21%, with admission surveillance providing 30%-135% increases in rates of detection. The monthly hospital-associated incidence was 2%-6%, with weekly surveillance providing 7%-157% increases in detection. The common practice of reporting incidence using the total number of patients or total patient-days underestimated incidence by one-third. Surgical ICUs had lower MRSA importation but higher MRSA incidence. Overall, routine surveillance prevented the misclassification of 17% (unit range, 11%-29%) of 'incident' carriers, compared with clinical cultures, and increased precaution days by 18% (unit range, 11%-91%). CONCLUSIONS: Routine surveillance significantly increases the detection of MRSA, but this benefit is not uniform across ICUs, even with high compliance and the use of correct denominators. Copyright © 2007 Infectious Diseases Society of America [ABSTRACT FROM AUTHOR]

BACKGROUND: As infection with vancomycin-resistant enterococci (VRE) increases in hospitals, knowledge about VRE reservoirs and improved accuracy of epidemiologic measures are needed. Many assessments underestimate incidence by including prevalent carriers in at-risk populations. Routine surveillance cultures can substantially improve prevalence and incidence estimates, and assessing the range of improvement across diverse units is important. METHODS: We performed a retrospective cohort study using accurate at-risk populations to evaluate the range of benefit of admission and weekly surveillance cultures in detecting unrecognized VRE in 14 patient-care units. RESULTS: We assessed 165 unit-months. The admission prevalence of VRE was 2.2%-27.2%, with admission surveillance providing 2.2-17-fold increased detection. Medical units were significantly more likely to admit VRE carriers than were surgical units. Monthly incidence was 0.8%-9.7%, with weekly surveillance providing 3.3-15.4-fold increased detection. The common practice of reporting incidence using the total number of patients, rather than patients at risk, underestimated incidence by one-third. Overall, routine surveillance prevented the misclassification of 43.0% (unit range, 0%-85.7%) of 'incident' carriers on the basis of clinical cultures alone and increased VRE precaution days by 2.4-fold (unit range, 2.0-2.6-fold). CONCLUSIONS: Routine surveillance markedly increases the detection of VRE, despite variability across patient-care units. Correct denominators prevent the substantial underestimation of incidence. Copyright © 2007 Infectious Diseases Society of America [ABSTRACT FROM AUTHOR]

Objectives: This study aimed to identify the prevalence of and factors associated with diagnostic uncertainty when critically ill children are admitted to the PICU. Understanding diagnostic uncertainty is necessary to develop effective strategies to reduce diagnostic errors in the PICU., Design: Multicenter retrospective cohort study with structured medical record review by trained clinicians using a standardized instrument to identify diagnostic uncertainty in narrative clinical notes. Diagnoses and diagnostic uncertainty were compared across time from PICU admission to hospital discharge. Generalized linear mixed models were used to determine patient, clinician, and encounter characteristics associated with diagnostic uncertainty at PICU admission., Setting: Four academic tertiary-referral PICUs., Patients: Eight hundred eighty-two randomly selected patients 0-18 years old who were nonelectively admitted to participating PICUs., Interventions: None., Measurements and Main Results: PICU admission notes for 228 of 882 patients (25.9%) indicated diagnostic uncertainty. Patients with uncertainty decreased over time but 58 (6.6%) had remaining diagnostic uncertainty at hospital discharge. Multivariable analysis showed that diagnostic uncertainty was significantly associated with off hours admission (odds ratio [OR], 1.52; p = 0.037), greater severity of illness (OR, 1.04; p = 0.025), an atypical presentation (OR, 2.14; p = 0.046), diagnostic discordance at admission between attending intensivists and resident physicians/advanced practice providers (OR, 3.62; p < 0.001), and having a neurologic primary diagnosis (OR, 1.87; p = 0.03). Older patients (OR, 0.96; p = 0.014) and those with a respiratory (OR, 0.58; p = 0.009) or trauma primary diagnosis (OR, 0.08; p < 0.001) were less likely to have diagnostic uncertainty. There were no significant associations between diagnostic uncertainty and attending intensivists' characteristics., Conclusions: Diagnostic uncertainty at PICU admission was common and was associated with off hours admission, severe illness, atypical presentation, diagnostic discordance between clinicians, and a neurologic primary diagnosis. Further study on the recognition and management of diagnostic uncertainty is needed to inform interventions to improve diagnosis among critically ill children., Competing Interests: Dr. Landrigan has consulted with and holds equity in the I-PASS (Handoff elements mnemonic: I-illness severity, P-patient summary, A-action items, S-situation awareness, S-synthesis) Institute, which seeks to train institutions in best handoff practices and aid in their implementation. In addition, Dr. Landrigan has received monetary awards, honoraria, and travel reimbursement from multiple academic and professional organizations for teaching and consulting on sleep deprivation, physician performance, handoffs, and safety; he has served as an expert witness in cases regarding patient safety and sleep deprivation; and he received funding from the Agency for Healthcare Research and Quality (AHRQ). Drs. Cifra’s, K. A. Smith’s, Bloxham’s, Hoppe’s, Miller’s, Riffe’s, Robb’s, Simone’s, Tumulty’s, Dawson’s, and Herwaldt’s institutions received funding from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the AHRQ, and the National Center for Advancing Translational Sciences. Drs. Cifra, Bloxham, Miller, and Tumulty received funding from the AHRQ, MedStar Research Institute, and De Gruyter. Drs. Cifra, C. M. Smith, K. A. Smith, Bagdure, Bloxham, Goldhar, Hoppe, Miller, Pizzo, Riffe, Robb, Tumulty, Wolfe, Wendt, Eyck, Dawson, Reisingerr, Singh, and Herwaldt received support for article research from the National Institutes of Health. Dr. Gorga disclosed institutional grant funding. Dr. Ten Eyck disclosed work for hire. Dr. Dawson received funding from Neurosurgery, the University of Nebraska Medical Center, and IotaSoft. Dr. Singh is supported in part by the AHRQ (R01HS028595 and R18HS029347), the Houston Veterans Administration (VA) Health Services Research and Development Center for Innovations in Quality, Effectiveness and Safety (CIN 13–413), and the VA National Center for Patient Safety; he disclosed government work. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of the VA or the U.S. government. Dr. Herwaldt’s institution received funding from the Centers for Disease Control and Prevention. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2024 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.)

Objectives: For patients requiring transfer to a higher level of care, excellent interfacility communication is essential. Our objective was to characterize verbal handoffs for urgent interfacility transfers of children to the PICU and compare these characteristics with known elements of high-quality intrahospital shift-to-shift handoffs., Design: Mixed methods retrospective study of audio-recorded referral calls between referring clinicians and receiving PICU physicians for urgent interfacility PICU transfers., Setting: Academic tertiary referral PICU., Patients: Children 0-18 years old admitted to a single PICU following interfacility transfer over a 4-month period (October 2019 to January 2020)., Interventions: None., Measurements and Main Results: We reviewed interfacility referral phone calls for 49 patients. Referral calls between clinicians lasted a median of 9.7 minutes (interquartile range, 6.8-14.5 min). Most referring clinicians provided information on history (96%), physical examination (94%), test results (94%), and interventions (98%). Fewer clinicians provided assessments of illness severity (87%) or code status (19%). Seventy-seven percent of referring clinicians and 6% of receiving PICU physicians stated the working diagnosis. Only 9% of PICU physicians summarized information received. Interfacility handoffs usually involved: 1) indirect references to illness severity and diagnosis rather than explicit discussions, 2) justifications for PICU admission, 3) statements communicating and addressing uncertainty, and 4) statements indicating the referring hospital's reliance on PICU resources. Interfacility referral communication was similar to intrahospital shift-to-shift handoffs with some key differences: 1) use of contextual information for appropriate PICU triage, 2) difference in expertise between communicating clinicians, and 3) reliance of referring clinicians and PICU physicians on each other for accurate information and medical/transport guidance., Conclusions: Interfacility PICU referral communication shared characteristics with intrahospital shift-to-shift handoffs; however, communication did not adhere to known elements of high-quality handovers. Structured tools specific to PICU interfacility referral communication must be developed and investigated for effectiveness in improving communication and patient outcomes., Competing Interests: Dr. Landrigan has consulted with and holds equity in the Illness severity, Patient summary, Action list, Situation awareness, Synthesis by receiver (I-PASS) Institute, which seeks to train institutions in best handoff practices and aid in their implementation. He has consulted with the Missouri Hospital Association/Executive Speaker’s Bureau regarding I-PASS. In addition, Dr. Landrigan has received monetary awards, honoraria, and travel reimbursement from multiple academic and professional organizations for teaching and consulting on sleep deprivation, physician performance, handoffs, and safety, and he has served as an expert witness in cases regarding patient safety and sleep deprivation. Dr. Singh is funded in part by the Houston Veterans Administration (VA) Health Services Research and Development (HSR&D) Center for Innovations in Quality, Effectiveness, and Safety (CIN13–413), the VA National Center for Patient Safety, and the Agency for Healthcare Research and Quality (R01HS028595 and R18 HS029347) . Drs. Thirnbeck’s, Espinoza’s, Herwaldt’s, Landrigan’s, and Cifra’s and Ms. Beaman’s institutions received funding from the Agency for Healthcare Research & Quality and the National Institutes of Health (NIH). Drs. Thirnbeck, Espinoza, Dukes, Herwaldt, Landrigan, and Cifra and Ms. Beaman received support for article research from the NIH. Drs. Beaman and Cifra received funding from De Gruyter and MedStar Health Research Institute. Dr. Dukes’ institution received funding from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (No. HD027748-28). Dr. Herwaldt received funding from the I-PASS Institute and Malpractice Law Firms. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2024 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.)

Background: A substantial proportion of patients undergoing hemodialysis carry Staphylococcus aureus in their noses, and carriers are at increased risk of S. aureus bloodstream infections. Our pragmatic clinical trial implemented nasal povidone-iodine (PVI) decolonization for the prevention of bloodstream infections in the novel setting of hemodialysis units., Objective: We aimed to identify pragmatic strategies for implementing PVI decolonization among patients in outpatient hemodialysis units., Design: Qualitative descriptive study., Setting: Outpatient hemodialysis units affiliated with five US academic medical centers. Units varied in size, patient demographics, and geographic location., Interviewees: Sixty-six interviewees including nurses, hemodialysis technicians, research coordinators, and other personnel., Methods: We conducted interviews with personnel affiliated with all five academic medical centers and conducted thematic analysis of transcripts., Results: Hemodialysis units had varied success with patient recruitment, but interviewees reported that patients and healthcare personnel (HCP) found PVI decolonization acceptable and feasible. Leadership support, HCP engagement, and tailored patient-focused tools or strategies facilitated patient engagement and PVI implementation. Interviewees reported both patients and HCP sometimes underestimated patients' infection risks and experienced infection-prevention fatigue. Other HCP barriers included limited staffing and poor staff engagement. Patient barriers included high health burdens, language barriers, memory issues, and lack of social support., Conclusion: Our qualitative study suggests that PVI decolonization would be acceptable to patients and clinical personnel, and implementation is feasible for outpatient hemodialysis units. Hemodialysis units could facilitate implementation by engaging unit leaders, patients and personnel, and developing education for patients about their infection risk.

Objective: The gold standard for hand hygiene (HH) while wearing gloves requires removing gloves, performing HH, and donning new gloves between WHO moments. The novel strategy of applying alcohol-based hand rub (ABHR) directly to gloved hands might be effective and efficient., Design: A mixed-method, multicenter, 3-arm, randomized trial., Setting: Adult and pediatric medical-surgical, intermediate, and intensive care units at 4 hospitals., Participants: Healthcare personnel (HCP)., Interventions: HCP were randomized to 3 groups: ABHR applied directly to gloved hands, the current standard, or usual care., Methods: Gloved hands were sampled via direct imprint. Gold-standard and usual-care arms were compared with the ABHR intervention., Results: Bacteria were identified on gloved hands after 432 (67.4%) of 641 observations in the gold-standard arm versus 548 (82.8%) of 662 observations in the intervention arm ( P < .01). HH required a mean of 14 seconds in the intervention and a mean of 28.7 seconds in the gold-standard arm ( P < .01). Bacteria were identified on gloved hands after 133 (98.5%) of 135 observations in the usual-care arm versus 173 (76.6%) of 226 observations in the intervention arm ( P < .01). Of 331 gloves tested 6 (1.8%) were found to have microperforations; all were identified in the intervention arm [6 (2.9%) of 205]., Conclusions: Compared with usual care, contamination of gloved hands was significantly reduced by applying ABHR directly to gloved hands but statistically higher than the gold standard. Given time savings and microbiological benefit over usual care and lack of feasibility of adhering to the gold standard, the Centers for Disease Control and Prevention and the World Health Organization should consider advising HCP to decontaminate gloved hands with ABHR when HH moments arise during single-patient encounters. Trial Registration: NCT03445676.

Background: Surgical-site infections (SSIs) can be catastrophic. Bundles of evidence-based practices can reduce SSIs but can be difficult to implement and sustain., Objective: We sought to understand the implementation of SSI prevention bundles in 6 US hospitals., Design: Qualitative study., Methods: We conducted in-depth semistructured interviews with personnel involved in bundle implementation and conducted a thematic analysis of the transcripts., Setting: The study was conducted in 6 US hospitals: 2 academic tertiary-care hospitals, 3 academic-affiliated community hospitals, 1 unaffiliated community hospital., Participants: In total, 30 hospital personnel participated. Participants included surgeons, laboratory directors, clinical personnel, and infection preventionists., Results: Bundle complexity impeded implementation. Other barriers varied across services, even within the same hospital. Multiple strategies were needed, and successful strategies in one service did not always apply in other areas. However, early and sustained interprofessional collaboration facilitated implementation., Conclusions: The evidence-based SSI bundle is complicated and can be difficult to implement. One implementation process probably will not work for all settings. Multiple strategies were needed to overcome contextual and implementation barriers that varied by setting and implementation climate. Appropriate adaptations for specific settings and populations may improve bundle adoption, fidelity, acceptability, and sustainability.

Objectives: Effective interventions to prevent diagnostic error among critically ill children should be informed by diagnostic error prevalence and etiologies. We aimed to determine the prevalence and characteristics of diagnostic errors and identify factors associated with error in patients admitted to the PICU., Design: Multicenter retrospective cohort study using structured medical record review by trained clinicians using the Revised Safer Dx instrument to identify diagnostic error (defined as missed opportunities in diagnosis). Cases with potential errors were further reviewed by four pediatric intensivists who made final consensus determinations of diagnostic error occurrence. Demographic, clinical, clinician, and encounter data were also collected., Setting: Four academic tertiary-referral PICUs., Patients: Eight hundred eighty-two randomly selected patients 0-18 years old who were nonelectively admitted to participating PICUs., Interventions: None., Measurements and Main Results: Of 882 patient admissions, 13 (1.5%) had a diagnostic error up to 7 days after PICU admission. Infections (46%) and respiratory conditions (23%) were the most common missed diagnoses. One diagnostic error caused harm with a prolonged hospital stay. Common missed diagnostic opportunities included failure to consider the diagnosis despite a suggestive history (69%) and failure to broaden diagnostic testing (69%). Unadjusted analysis identified more diagnostic errors in patients with atypical presentations (23.1% vs 3.6%, p = 0.011), neurologic chief complaints (46.2% vs 18.8%, p = 0.024), admitting intensivists greater than or equal to 45 years old (92.3% vs 65.1%, p = 0.042), admitting intensivists with more service weeks/year (mean 12.8 vs 10.9 wk, p = 0.031), and diagnostic uncertainty on admission (77% vs 25.1%, p < 0.001). Generalized linear mixed models determined that atypical presentation (odds ratio [OR] 4.58; 95% CI, 0.94-17.1) and diagnostic uncertainty on admission (OR 9.67; 95% CI, 2.86-44.0) were significantly associated with diagnostic error., Conclusions: Among critically ill children, 1.5% had a diagnostic error up to 7 days after PICU admission. Diagnostic errors were associated with atypical presentations and diagnostic uncertainty on admission, suggesting possible targets for intervention., Competing Interests: Drs. Cifra, Smith, Riffe, Landrigan, and Dawson’s institutions received funding from the Eunice Kennedy Shriver National Institute of Child Health and Human Development through a K12 grant to the University of Iowa Stead Family Department of Pediatrics (no. HD027748-28) and the National Center for Advancing Translational Sciences. Drs. Cifra, KA Smith, Riffe, Landrigan, Dawson, and Herwaldt’s institutions received funding from the Agency for Healthcare Research and Quality (AHRQ) through a K08 grant (no. HS026965). This work was further supported by the National Center for Advancing Translational Sciences of the National Institutes of Health (no. UL1TR002537) through the University of Iowa’s Institute for Clinical and Translational Science. Dr. Cifra received funding from the AHRQ, MedStar Research Institute, and De Gruyter. Drs. Cifra, CM Smith, KA Smith, Riffe, Ten Eyck, Landrigan, and Dawson received support for article research from the National Institutes of Health. Drs. Custer and Tumulty’s institution received funding from University of Iowa. Dr. Miller’s institution received funding from the University of Iowa Department of Pediatrics. Dr. Landrigan received funding from I-PASS Institute and Missouri Hospital Association Executive Speakers Bureau. Dr. Singh is funded in part by the Houston Veterans Administration (VA) Health Services Research and Development (HSR&D) Center for Innovations in Quality, Effectiveness, and Safety (CIN13–413), the VA HSR&D Service (IIR17–127 and the Presidential Early Career Award for Scientists and Engineers USA 14–274), the VA National Center for Patient Safety, the Agency for Healthcare Research and Quality (R01HS27363), and the Gordon and Betty Moore Foundation. He disclosed government work. Dr. Herwaldt’s institution received funding from the Centers for Disease Control and Prevention; she disclosed that Professional Disposables International, Inc. (PDI) is providing a product for a clinical trial. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2023 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.)

Importance: Current guidelines require hand hygiene before donning nonsterile gloves, but evidence to support this requirement is lacking., Objective: To evaluate the effectiveness of a direct-gloving policy on adherence to infection prevention practices in a hospital setting., Design, Setting, and Participants: This mixed-method, multicenter, cluster randomized clinical trial was conducted at 4 academic centers in Baltimore, Maryland, or Iowa City, Iowa, from January 1, 2016, to November 30, 2017. Data analysis was completed April 25, 2019. Participants were 3790 health care personnel (HCP) across 13 hospital units., Intervention: Hospital units were randomly assigned to direct gloving, with hand hygiene not required before donning gloves (intervention), or to usual care (hand hygiene before donning nonsterile gloves)., Main Outcomes and Measures: The primary outcome was adherence to the expected practice at room entry and exit. A random sample of HCPs' gloved hands were imprinted on agar plates at entry to contact precautions rooms. The intention-to-treat approach was followed, and all analyses were conducted at the level of the participating unit. Primary and secondary outcomes between treatment groups were assessed using generalized estimating equations with an unstructured working correlation matrix to adjust for clustering; multivariate analysis using generalized estimating equations was conducted to adjust for covariates, including baseline adherence., Results: In total, 13 hospital units participated in the trial, and 3790 HCP were observed. Adherence to expected practice was greater in the 6 units with the direct-gloving intervention than in the 7 usual care units (1297 of 1491 [87%] vs 954 of 2299 [41%]; P < .001) even when controlling for baseline hand hygiene rates, unit type, and universal gloving policies (risk ratio [RR], 1.76; 95% CI, 1.58-1.97). Glove use on entry to contact precautions rooms was also higher in the direct-gloving units (1297 of 1491 [87%] vs 1530 of 2299 [67%]; P = .008. The intervention had no effect on hand hygiene adherence measured at entry to non-contact precautions rooms (951 of 1315 [72%] for usual care vs 1111 of 1688 [66%] for direct gloving; RR, 1.00 [95% CI, 0.91-1.10]) or at room exit (1587 of 1897 [84%] for usual care vs 1525 of 1785 [85%] for direct gloving; RR, 0.98 [95% CI, 0.91-1.07]). The intervention was associated with increased total bacteria colony counts (adjusted incidence RR, 7.13; 95% CI, 3.95-12.85) and greater detection of pathogenic bacteria (adjusted incidence RR, 10.18; 95% CI, 2.13-44.94) on gloves in the emergency department and reduced colony counts in pediatrics units (adjusted incidence RR, 0.34; 95% CI, 0.19-0.63), with no change in either total colony count (RR, 0.87 [95% CI, 0.60 to 1.25] for adult intensive care unit; RR, 0.59 [95% CI, 0.31-1.10] for hemodialysis unit) or presence of pathogenic bacteria (RR, 0.93 [95% CI, 0.40-2.14] for adult intensive care unit; RR, 0.55 [95% CI, 0.15-2.04] for hemodialysis unit) in the other units., Conclusions and Relevance: Current guidelines require hand hygiene before donning nonsterile gloves, but evidence to support this requirement is lacking. The findings from this cluster randomized clinical trial indicate that a direct-gloving strategy without prior hand hygiene should be considered by health care facilities., Trial Registration: ClinicalTrials.gov Identifier: NCT03119389.

Competing Interests: Potential conflicts of interest. L. A. H. reports grants or contracts from the Centers for Disease Control and Prevention (CDC) and the Agency for Healthcare Research and Quality (AHRQ), and receipt of povidone iodine for a clinical trial from Professional Disposables International (PDI) and 3M, unrelated to this work. All other authors report no potential conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.

We evaluated povidone-iodine (PVI) decolonization among 51 fracture-fixation surgery patients. PVI was applied twice on the day of surgery. Patients were tested for S. aureus nasal colonization and surveyed. Mean S. aureus concentrations decreased from 3.13 to 1.15 CFU/mL ( P = .03). Also, 86% of patients stated that they felt neutral or positive about their PVI experience.

Background: To improve adherence with pre-surgical screening for Staphylococcus aureus nasal carriage and decolonization, we need more information about patients' experiences with these protocols., Methods: We surveyed patients undergoing orthopedic, neurosurgical, or cardiac operations at Johns Hopkins Hospitals (JHH), the University of Iowa Hospitals and Clinics (UIHC) at MercyOne Northeast Iowa Neurosurgery (MONIN) to assess patients' experiences with decolonization protocols., Results: Five hundred thirty-four patients responded. Respondents at JHH were significantly more likely than those at the UIHC to report using mupirocin and were significantly more likely than those at the UIHC and MONIN to feel they received adequate information about surgical site infection (SSI) prevention and decolonization. Respondents at JHH were the least likely to not worry about SSI and they were more willing to do anything they could to prevent SSI. Few patients reported barriers to adherence and side effects of mupirocin or chlorhexidine., Conclusion: Respondents did not report either major side effects or barriers to adherence. Patients varied in their level of concern about SSI, their willingness to invest effort in preventing SSI, and their assessments of preoperative information. To improve patients' adherence, clinicians and hospitals should assess their patients' needs and desires and tailor their preoperative processes, education, and prophylaxis accordingly., (Copyright © 2022 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.)

Objectives: Intensivists and subspecialists often collaborate in diagnosing patients in the pediatric intensive care unit (PICU). Our objectives were to characterize critically ill children for whom subspecialty consultations were requested, describe consultation characteristics, and determine consultations' impact on PICU diagnosis., Methods: We performed a retrospective study using chart review in a single tertiary referral PICU including children admitted for acute illness. We collected data on patients with and without subspecialty consultations within the first three days of PICU admission and determined changes in PICU clinicians' diagnostic evaluation or treatment after consultations., Results: PICU clinicians requested 152 subspecialty consultations for 87 of 101 (86%) patients. Consultations were requested equally for assistance in diagnosis (65%) and treatment (66%). Eighteen of 87 (21%) patients with consultations had a change in diagnosis from PICU admission to discharge, 11 (61%) attributed to subspecialty input. Thirty-nine (45%) patients with consultations had additional imaging and/or laboratory testing and 48 (55%) had medication changes and/or a procedure performed immediately after consultation., Conclusions: Subspecialty consultations were requested during a majority of PICU admissions. Consultations can influence the diagnosis and treatment of critically ill children. Future research should investigate PICU interdisciplinary collaborations, which are essential for teamwork in diagnosis., (© 2022 Walter de Gruyter GmbH, Berlin/Boston.)

Objectives: Multidisciplinary PICU teams must effectively share information while caring for critically ill children. Clinical documentation helps clinicians develop a shared understanding of the patient's diagnosis, which informs decision-making. However, diagnosis-related documentation in the PICU is understudied, thus limiting insights into how pediatric intensivists convey their diagnostic reasoning. Our objective was to describe how pediatric critical care clinicians document patients' diagnoses at PICU admission., Design: Retrospective mixed methods study describing diagnosis documentation in electronic health records., Setting: Academic tertiary referral PICU., Patients: Children 0-17 years old admitted nonelectively to a single PICU over 1 year., Interventions: None., Measurements and Main Results: One hundred PICU admission notes for 96 unique patients were reviewed. In 87% of notes, both attending physicians and residents or advanced practice providers documented a primary diagnosis; in 13%, primary diagnoses were documented by residents or advanced practice providers alone. Most diagnoses (72%) were written as narrative free text, 11% were documented as problem lists/billing codes, and 17% used both formats. At least one rationale was documented to justify the primary diagnosis in 91% of notes. Diagnostic uncertainty was present in 52% of notes, most commonly suggested by clinicians' use of words indicating uncertainty (65%) and documentation of differential diagnoses (60%). Clinicians' integration and interpretation of information varied in terms of: 1) organization of diagnosis narratives, 2) use of contextual details to clarify the diagnosis, and 3) expression of diagnostic uncertainty., Conclusions: In this descriptive study, most PICU admission notes documented a rationale for the primary diagnosis and expressed diagnostic uncertainty. Clinicians varied widely in how they organized diagnostic information, used contextual details to clarify the diagnosis, and expressed uncertainty. Future work is needed to determine how diagnosis narratives affect clinical decision-making, patient care, and outcomes., Competing Interests: Drs. Vivtcharenko’s, Dukes’, Herwaldt's, Reisinger's, and Cifra’s institutions received funding from the Agency for Healthcare Research and Quality (AHRQ), the National Institute of Child Health and Human Development, and the National Center for Advancing Translational Sciences. Dr. Cifra is supported by the AHRQ through a K08 grant (HS026965) and an internal start-up grant from the University of Iowa Carver College of Medicine Department of Pediatrics. Dr. Singh disclosed government work. He is supported by the Veterans Affairs Health Services Research and Development Service (Presidential Early Career Award for Scientists and Engineers USA 14-274), the Agency for Health Care Research and Quality (R01HS022087), the Gordon and Betty Moore Foundation, and the Houston VA Health Services Research and Development Center for Innovations in Quality, Effectiveness, and Safety (Center for Innovations 13–413). Dr. Herwaldt’s institution received funding from the Centers for Disease Control and Prevention, the AHRQ, and PDI. Dr. Reisinger is supported by an NIH Clinical and Translational Science Award (UL1TR002537) through the University of Iowa’s Institute for Clinical and Translational Science. Dr. Cifra received funding from AHRQ. Dr. Ramesh has disclosed that she does not have any potential conflicts of interest., (Copyright © 2021 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.)

Introduction: Approximately 38% of haemodialysis patients carry Staphylococcus aureus in their noses, and carriers have a nearly four-fold increased risk of S. aureus access-related bloodstream infections (BSIs) compared with non-carriers. Our objective is to determine the clinical efficacy and effectiveness of a novel intervention using nasal povidone-iodine (PVI) to prevent BSIs among patients in haemodialysis units. We will survey patients and conduct qualitative interviews with healthcare workers to identify barriers and facilitators to implementing the intervention., Methods and Analysis: We will perform an open-label, stepped-wedge cluster randomised trial to assess the effectiveness of nasal PVI compared with standard care. Sixteen outpatient haemodialysis units will participate in the study. The 3-year trial period will be divided into a 4-month baseline period and eight additional 4-month time blocks. The primary outcome of the study will be S. aureus BSI, defined as a S. aureus positive blood culture collected in the outpatient setting or within one calendar day after a hospital admission. The study team will evaluate characteristics of individual patients and the clusters by exposure status (control or intervention) to assess the balance between groups, and calculate descriptive statistics such as average responses separately for control and intervention survey questions., Ethics and Dissemination: This study has received IRB approval from all study sites. A Data Safety and Monitoring Board will monitor this multicentre clinical trial. We will present our results at international meetings. The study team will publish findings in peer-reviewed journals and make each accepted peer-reviewed manuscript publicly available., Trial Registration Number: NCT04210505., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: The effect of communication between referring and accepting clinicians during patient transitions to the pediatric intensive care unit (PICU) on diagnostic quality is largely unknown. This pilot study aims to determine the feasibility of using focused ethnography to understand the relationship between referral communication and the diagnostic process for critically ill children., Materials and Methods: We conducted focused ethnography in an academic tertiary referral PICU by directly observing the referral and admission of 3 non-electively admitted children 0-17 years old. We also conducted 21 semi-structured interviews of their parents and admitting PICU staff (intensivists, fellows/residents, medical students, nurses, and respiratory therapists) and reviewed their medical records post-discharge., Results: Performing focused ethnography in a busy PICU is feasible. We identified three areas for additional exploration: (1) how information transfer affects the PICU diagnostic process; (2) how uncertainty in patient assessment affects the decision to transfer to the PICU; and (3) how the PICU team's expectations are influenced by referral communication., Conclusions: Focused ethnography in the PICU is feasible to investigate relationships between clinician referral communication and the diagnostic process for critically ill children., Competing Interests: Declaration of Competing Interest Dr. Cifra is supported by the Agency for Healthcare Research and Quality (AHRQ) through a K08 grant (HS026965) and an internal start-up grant from the University of Iowa Carver College of Medicine Department of Pediatrics. Dr. Singh is funded in part by the Houston VA Health Services Research and Development (HSR&D) Center for Innovations in Quality, Effectiveness, and Safety (CIN13-413), the VA HSR&D Service (CRE17-127) and the Presidential Early Career Award for Scientists and Engineers (USA 14–274), the VA National Center for Patient Safety, AHRQ (R01HS27363), and the Gordon and Betty Moore Foundation. The content is solely the responsibility of the authors and does not necessarily represent the official views of the AHRQ. Dr. Reisinger is supported by an NIH Clinical and Translational Science Award (UL1TR002537) through the University of Iowa's Institute for Clinical and Translational Science. The remaining authors have no declarations of interest., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background Front-line clinicians are expected to make accurate and timely diagnostic decisions before transferring patients to the pediatric intensive care unit (PICU) but may not always learn their patients' outcomes. We evaluated the characteristics of post-transfer updates received by referring clinicians regarding PICU patients and determined preferences regarding content, delivery, and timing of such updates. Methods We administered an electronic cross-sectional survey to Iowa clinicians who billed for ≥5 pediatric patients or referred ≥1 patient to the University of Iowa (UI) PICU in the year before survey administration. Results One hundred and one clinicians (51 non-UI, 50 UI-affiliated) responded. Clinicians estimated that, on average, 8% of pediatric patients they saw over 1 year required PICU admission; clinicians received updates on 40% of patients. Seventy percent of UI clinicians obtained updates via self-initiated electronic record review, while 37% of non-UI clinicians relied on PICU communication (p = 0.013). Clinicians indicated that updates regarding diagnoses/outcomes will be most relevant to their practice. Among clinicians who received updates, 13% received unexpected information; 40% changed their practice as a result. Conclusions Clinicians received updates on less than half of the patients they referred to a PICU, although such updates could potentially influence clinical practice. Study findings will inform the development of a formal feedback system from the PICU to referring clinicians.

Objectives: Diagnostic errors can harm critically ill children. However, we know little about their prevalence in PICUs and factors associated with error. The objective of this pilot study was to determine feasibility of record review to identify patient, provider, and work system factors associated with diagnostic errors during the first 12 hours after PICU admission., Design: Pilot retrospective cohort study with structured record review using a structured tool (Safer Dx instrument) to identify diagnostic error., Setting: Academic tertiary referral PICU., Patients: Patients 0-17 years old admitted nonelectively to the PICU., Interventions: None., Measurements and Main Results: Four of 50 patients (8%) had diagnostic errors in the first 12 hours after admission. The Safer Dx instrument helped identify delayed diagnoses of chronic ear infection, increased intracranial pressure (two cases), and Bartonella encephalitis. We calculated that 610 PICU admissions are needed to achieve 80% power (α = 0.05) to detect significant associations with error., Conclusions: Our pilot study found four patients with diagnostic error out of 50 children admitted nonelectively to a PICU. Retrospective record review using a structured tool to identify diagnostic errors is feasible in this population. Pilot data are being used to inform a larger and more definitive multicenter study.

Importance: An understanding of the incidence and outcomes of Clostridium difficile infection (CDI) in the United States can inform investments in prevention and treatment interventions., Objective: To quantify the incidence of CDI and its associated hospital length of stay (LOS) in the United States using a systematic literature review and meta-analysis., Data Sources: MEDLINE via Ovid, Cochrane Library Databases via Wiley, Cumulative Index of Nursing and Allied Health Complete via EBSCO Information Services, Scopus, and Web of Science were searched for studies published in the United States between 2000 and 2019 that evaluated CDI and its associated LOS., Study Selection: Incidence data were collected only from multicenter studies that had at least 5 sites. The LOS studies were included only if they assessed postinfection LOS or used methods accounting for time to infection using a multistate model or compared propensity score-matched patients with CDI with control patients without CDI. Long-term-care facility studies were excluded. Of the 119 full-text articles, 86 studies (72.3%) met the selection criteria., Data Extraction and Synthesis: Two independent reviewers performed the data abstraction and quality assessment. Incidence data were pooled only when the denominators used the same units (eg, patient-days). These data were pooled by summing the number of hospital-onset CDI incident cases and the denominators across studies. Random-effects models were used to obtain pooled mean differences. Heterogeneity was assessed using the I2 value. Data analysis was performed in February 2019., Main Outcomes and Measures: Incidence of CDI and CDI-associated hospital LOS in the United States., Results: When the 13 studies that evaluated incidence data in patient-days due to hospital-onset CDI were pooled, the CDI incidence rate was 8.3 cases per 10 000 patient-days. Among propensity score-matched studies (16 of 20 studies), the CDI-associated mean difference in LOS (in days) between patients with and without CDI varied from 3.0 days (95% CI, 1.44-4.63 days) to 21.6 days (95% CI, 19.29-23.90 days)., Conclusions and Relevance: Pooled estimates from currently available literature suggest that CDI is associated with a large burden on the health care system. However, these estimates should be interpreted with caution because higher-quality studies should be completed to guide future evaluations of CDI prevention and treatment interventions.

Hand hygiene compliance is subject to the Hawthorne effect, which may be attenuated by covert observers and brief observation periods. This study demonstrated that hand hygiene compliance rates were between 8% and 29% greater when reported by infection prevention programs than when reported by covert observers over brief observation periods., (Copyright © 2018 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.)

The study objective was to determine the prevalence of Staphylococcus aureus colonisation in the nares and oropharynx of healthy persons and identify any risk factors associated with such S. aureus colonisation. In total 263 participants (177 adults and 86 minors) comprising 95 families were enrolled in a year-long prospective cohort study from one urban and one rural county in eastern Iowa, USA, through local newspaper advertisements and email lists and through the Keokuk Rural Health Study. Potential risk factors including demographic factors, medical history, farming and healthcare exposure were assessed. Among the participants, 25.4% of adults and 36.1% minors carried S. aureus in their nares and 37.9% of adults carried it in their oropharynx. The overall prevalence was 44.1% among adults and 36.1% for minors. Having at least one positive environmental site for S. aureus in the family home was associated with colonisation (prevalence ratio: 1.34, 95% CI: 1.07-1.66). The sensitivity of the oropharyngeal cultures was greater than that of the nares cultures (86.1% compared with 58.2%, respectively). In conclusion, the nares and oropharynx are both important colonisation sites for healthy community members and the presence of S. aureus in the home environment is associated with an increased probability of colonisation.

Purpose of Review: The present review summarizes new knowledge about Legionella epidemiology, clinical characteristics, community-associated and hospital-based outbreaks, molecular typing and molecular epidemiology, prevention, and detection in environmental and clinical specimens., Recent Findings: The incidence of Legionnaire's disease is rising and the mortality rate remains high, particularly for immunocompromised patients. Extracorporeal membrane oxygenation may help support patients with severe respiratory failure. Fluoroquinolones and macrolides appear to be equally efficacious for treating Legionnaires' disease. Whole genome sequencing is an important tool for determining the source for Legionella infections and for understanding routes of transmission and mechanisms by which new pathogenic clones emerge. Real-time quantitative polymerase chain reaction testing of respiratory specimens may improve our ability to diagnose Legionnaire's disease. The frequency of viable but nonculturable organisms is quite high in some water systems but their role in causing clinical disease has not been defined., Summary: Legionellosis remains an important public health threat. To prevent these infections, staff of municipalities and large buildings must implement effective water system management programs that reduce Legionella growth and transmission and all Medicare-certified healthcare facilities must have water management policies. In addition, we need better methods for detecting Legionella in water systems and in clinical specimens to improve prevention strategies and clinical diagnosis.

Purpose of Review: Human factors engineering (HFE) approaches are increasingly being used in healthcare, but have been applied in relatively limited ways to infection prevention and control (IPC). Previous studies have focused on using selected HFE tools, but newer literature supports a system-based HFE approach to IPC., Recent Findings: Cross-contamination and the existence of workarounds suggest that healthcare workers need better support to reduce and simplify steps in delivering care. Simplifying workflow can lead to better understanding of why a process fails and allow for improvements to reduce errors and increase efficiency. Hand hygiene can be improved using visual cues and nudges based on room layout. Using personal protective equipment appropriately appears simple, but exists in a complex interaction with workload, behavior, emotion, and environmental variables including product placement. HFE can help prevent the pathogen transmission through improving environmental cleaning and appropriate use of medical devices., Summary: Emerging evidence suggests that HFE can be applied in IPC to reduce healthcare-associated infections. HFE and IPC collaboration can help improve many of the basic best practices including use of hand hygiene and personal protective equipment by healthcare workers during patient care.

OBJECTIVE Craniectomy is often performed to decrease intracranial pressure following trauma and vascular injuries. The subsequent cranioplasty procedures may be complicated by surgical site infections (SSIs) due to prior trauma, foreign implants, and multiple surgeries through a common incision. Several studies have found that intrawound vancomycin powder (VP) is associated with decreased risk of SSIs after spine operations. However, no previously published study has evaluated the effectiveness of VP in cranioplasty procedures. The purpose of this study was to determine whether intrawound VP is associated with decreased risk of SSIs, to evaluate VP's safety, and to identify risk factors for SSIs after cranioplasty among patients undergoing first-time cranioplasty. METHODS The authors conducted a retrospective cohort study of adult patients undergoing first-time cranioplasty for indications other than infections from January 1, 2008, to July 31, 2014, at an academic health center. Data on demographics, possible risk factors for SSIs, and treatment with VP were collected from the patients' electronic health records. RESULTS During the study period, 258 patients underwent first-time cranioplasties, and 15 (5.8%) of these patients acquired SSIs. Ninety-two patients (35.7%) received intrawound VP (VP group) and 166 (64.3%) did not (no-VP group). Patients in the VP group and the no-VP group were similar with respect to age, sex, smoking history, body mass index, and SSI rates (VP group 6.5%, no-VP group 5.4%, p = 0.72). Patients in the VP group were less likely than those in the no-VP group to have undergone craniectomy for tumors and were more likely to have an American Society of Anesthesiologists physical status score > 2. Intrawound VP was not associated with other postoperative complications. Risk factors for SSI from the bivariable analyses were diabetes (odds ratio [OR] 3.65, 95% CI 1.07-12.44), multiple craniotomy procedures before the cranioplasty (OR 4.39, 95% CI 1.47-13.18), prior same-side craniotomy (OR 4.73, 95% CI 1.57-14.24), and prosthetic implants (OR 4.51, 95% CI 1.40-14.59). The multivariable analysis identified prior same-side craniotomy (OR 3.37, 95% CI 1.06-10.79) and prosthetic implants (OR 3.93, 95% CI 1.15-13.40) as significant risk factors for SSIs. After adjusting for potential confounders, patients with SSIs were more likely than those without SSIs to be readmitted (OR 7.28, 95% CI 2.07-25.60). CONCLUSIONS In this study, intrawound VP was not associated with a decreased risk of SSIs or with an increased risk of complications. Prior same-side craniotomy and prosthetic implants were risk factors for SSI after first-time cranioplasty.

Objective: Deep brain stimulation is an effective surgical treatment for managing some neurological and psychiatric disorders. Infection related to the deep brain stimulator (DBS) hardware causes significant morbidity: hardware explantation may be required; initial disease symptoms such as tremor, rigidity, and bradykinesia may recur; and the medication requirements for adequate disease management may increase. These morbidities are of particular concern given that published DBS-related infection rates have been as high as 23%. To date, however, the key risk factors for and the potential preventive measures against these infections remain largely uncharacterized. In this study, the authors endeavored to identify possible risk factors for DBS-related infection and analyze the efficacy of prophylactic intrawound vancomycin powder (VP)., Methods: The authors performed a retrospective cohort study of patients who had undergone primary DBS implantation at a single institution in the period from December 2005 through September 2015 to identify possible risk factors for surgical site infection (SSI) and to assess the impact of perioperative (before, during, and after surgery) prophylactic antibiotics on the SSI rate. They also evaluated the effect of a change in the National Healthcare Safety Network's definition of SSI on the number of infections detected. Statistical analyses were performed using the 2-sample t-test, the Wilcoxon rank-sum test, the chi-square test, Fisher's exact test, or logistic regression, as appropriate for the variables examined., Results: Four hundred sixty-four electrodes were placed in 242 adults during 245 primary procedures over approximately 10.5 years; most patients underwent bilateral electrode implantation. Among the 245 procedures, 9 SSIs (3.7%) occurred within 90 days and 16 (6.5%) occurred within 1 year of DBS placement. Gram-positive bacteria were the most common etiological agents. Most patient- and procedure-related characteristics did not differ between those who had acquired an SSI and those who had not. The rate of SSIs among patients who had received intrawound VP was only 3.3% compared with 9.7% among those who had not received topical VP (OR 0.32, 95% CI 0.10-1.02, p = 0.04). After controlling for patient sex, the association between VP and decreased SSI risk did not reach the predetermined level of significance (adjusted OR 0.32, 95% CI 0.10-1.03, p = 0.06). The SSI rates were similar after staged and unstaged implantations., Conclusions: While most patient-related and procedure-related factors assessed in this study were not associated with the risk for an SSI, the data did suggest that intrawound VP may help to reduce the SSI risk after DBS implantation. Furthermore, given the implications of SSI after DBS surgery and the frequency of infections occurring more than 90 days after implantation, continued follow-up for at least 1 year after such a procedure is prudent to establish the true burden of these infections and to properly treat them when they do occur.

Rationale: Existing real-time surveillance of influenza morbidity, based primarily on time-trended U.S. hospitalization and death data, is inadequate. These surveillance methods do not accurately predict hospital resource requirements or sufficiently capture the public health impact of the current influenza season., Objectives: To determine the feasibility and potential usefulness of tracking surrogate markers of influenza morbidity among patients hospitalized with influenza., Methods: We performed a pilot study at three tertiary care referral hospitals and retrospectively collected and analyzed data on patients admitted with influenza during the 2013-2014 influenza season. We analyzed traditional influenza surveillance metrics, including weekly statistics on admissions and deaths, as well as weekly rates and trends of intensive care unit (ICU), mechanical ventilation, and extracorporeal membrane oxygenation (ECMO) utilization., Results: In our three-hospital cohort, 431 patients were hospitalized with influenza and spent a total of 1,520 days in ICUs. Eighty-six (20%) of these patients required 1,080 days of mechanical ventilation, and 17 patients (4%) received 229 days of ECMO. Trends of ICU and mechanical ventilation use were similar but differed notably from trends of ECMO use, hospitalization, and death. In particular, at two hospitals, increases in utilization of ICU and mechanical ventilation among patients with influenza occurred several weeks after increases in hospitalization rates. Furthermore, ICU, mechanical ventilation, and ECMO utilization rates at the three-hospital network remained elevated for several weeks after the influenza-associated hospitalization rate declined., Conclusions: Surrogate markers of influenza severity were feasible to collect and revealed trends of ICU resource utilization that differed notably from trends of hospitalization and death given by traditional influenza surveillance metrics. A national network of sentinel hospitals that prospectively collects, time-trends, and reports additional influenza morbidity data would be useful to hospital administrators, hospital epidemiologists, infection preventionists, and public health officials.

Background: Certified Nursing Assistants (CNAs) frequently wear gloves when they care for patients in standard precautions. If CNAs use gloves inappropriately, they may spread pathogens to patients and the environment, potentially leading to health care-associated infections (HAIs)., Methods: Using a descriptive structured observational design, we examined the degree of inappropriate health care personnel glove use in a random sample of 74 CNAs performing toileting and perineal care at 1 long-term care facility., Results: During the 74 patient care events, CNAs wore gloves for 80.2% (1,774/2,213) of the touch points, failing to change gloves at 66.4% (225/339) of glove change points. CNAs changed gloves a median of 2.0 times per patient care event. A median of 1.0 change occurred at a change point. CNAs failed to change their gloves at a glove change point a median of 2.5 times per patient care event. Most (61/74; 82.4%) patient care events had >1 contaminated touch point. Over 44% (782/1,774) of the gloved touch points were defined as contaminated for a median of 8.0 contaminated glove touch points per patient care event. All contaminated touches were with gloved hands (P <.001)., Conclusions: Inappropriate glove use was frequently observed in this study. Contaminated gloves may be a significant cause of cross-contamination of pathogens in health care environments. Future research studies should evaluate strategies to improve glove use to reduce HAIs., (Copyright © 2017. Published by Elsevier Inc.)

OBJECTIVE A diverse group of hospitals in Iowa implemented a program to objectively evaluate and improve the thoroughness of disinfection cleaning of near-patient surfaces. Administrative benefits of, challenges of, and impediments to the program were also evaluated. METHODS We conducted a prospective, quasi-experimental pre-/postintervention trial to improve the thoroughness of terminal room disinfection cleaning. Infection preventionists utilized an objective cleaning performance monitoring system (DAZO) to evaluate the thoroughness of disinfection cleaning (TDC) expressed as a proportion of objects confirmed to have been cleaned (numerator) to objects to be cleaned per hospital policy (denominator)×100. Data analysis, educational interventions, and objective performance feedback were modeled on previously published studies using the same monitoring tool. Programmatic analysis utilized unstructured and structured information from participants irrespective of whether they participated in the process improvement aspects to the program. RESULTS Initially, the overall TDC was 61% in 56 hospitals. Hospitals completing 1 or 2 feedback cycles improved their TDC percentages significantly (P90% for at least 38 months. A survey of infection preventionists found that lack of time and staff turnover were the most common reasons for terminating the study early. CONCLUSION The study confirmed that hospitals using this program can improve their TDC percentages significantly. Hospitals must invest resources to improve cleaning and to sustain their gains. Infect Control Hosp Epidemiol 2017;38:960-965.

OBJECTIVE To identify predictors of treatment for urinary tract infections (UTI) among patients undergoing total hip (THA) or knee (TKA) arthroplasties and to assess an intervention based on these predictors. DESIGN We conducted a retrospective cohort study of 200 consecutive patients undergoing THA/TKA between February 21, 2011, and June 30, 2011, to identify predictors of treatment for UTI and a prospective cohort study of 50 patients undergoing these procedures between May 21, 2012, and July 17, 2012, to assess the association of signs or symptoms and UTI treatment. We then conducted a before-and-after study to assess whether implementing an intervention affected the frequency of treatment for UTI before or after THA/TKA. SETTING The orthopedics department of a university health center. PATIENTS Patients undergoing THA or TKA. INTERVENTION Surgeons revised their UTI screening and treatment practices. RESULTS Positive leukocyte esterase (P5 (P=.01; P=.01) were associated with preoperative or postoperative UTI treatment. In the prospective study, 12 patients (24%) had signs and symptoms consistent with UTI. The number of patients treated for presumed UTI decreased 80.2% after the surgeons changed their practices, and surgical site infection (SSI) rates, including prosthetic joint infections (PJIs), did not increase. CONCLUSIONS Urine leukocyte esterase and white blood cell count were the strongest predictors of treatment for UTI before or after THA/TKA. The intervention was associated with a significant decrease in treatment for UTI, and SSI/PJI rates did not increase. Infect Control Hosp Epidemiol 2017;38:281-286.

BACKGROUND Information about the health and economic impact of infections caused by vancomycin-resistant enterococci (VRE) can inform investments in infection prevention and development of novel therapeutics. OBJECTIVE To systematically review the incidence of VRE infection in the United States and the clinical and economic outcomes. METHODS We searched various databases for US studies published from January 1, 2000, through June 8, 2015, that evaluated incidence, mortality, length of stay, discharge to a long-term care facility, readmission, recurrence, or costs attributable to VRE infections. We included multicenter studies that evaluated incidence and single-center and multicenter studies that evaluated outcomes. We kept studies that did not have a denominator or uninfected controls only if they assessed postinfection length of stay, costs, or recurrence. We performed meta-analysis to pool the mortality data. RESULTS Five studies provided incidence data and 13 studies evaluated outcomes or costs. The incidence of VRE infections increased in Atlanta and Detroit but did not increase in national samples. Compared with uninfected controls, VRE infection was associated with increased mortality (pooled odds ratio, 2.55), longer length of stay (3-4.6 days longer or 1.4 times longer), increased risk of discharge to a long-term care facility (2.8- to 6.5-fold) or readmission (2.9-fold), and higher costs ($9,949 higher or 1.6-fold more). CONCLUSIONS VRE infection is associated with large attributable burdens, including excess mortality, prolonged in-hospital stay, and increased treatment costs. Multicenter studies that use suitable controls and adjust for time at risk or confounders are needed to estimate the burden of VRE infections. Infect Control Hosp Epidemiol. 2017;38:203-215.

Using an algorithm including both enzyme immunoassay (EIA) and nucleic acid amplification (NAAT) for Clostridium difficile infection (CDI) diagnosis, we found that the use of NAAT versus EIA almost doubled our hospital-onset CDI laboratory-identified (LabID) event standardized infection ratio (SIR). We recommend that the current risk adjustment approach be modified. Infect Control Hosp Epidemiol 2016:1-3.

Human factors engineering (HFE), with its focus on studying how humans interact with systems, including their physical and organizational environment, the tools and technologies they use, and the tasks they perform, provides principles, tools, and techniques for systematically identifying important factors, for analyzing and evaluating how these factors interact to increase or decrease the risk of Healthcare-associated infections (HAI), and for identifying and implementing effective preventive measures. We reviewed the literature on HFE and infection prevention and control and identified major themes to document how researchers and infection prevention staff have used HFE methods to prevent HAIs and to identify gaps in our knowledge about the role of HFE in HAI prevention and control. Our literature review found that most studies in the healthcare domain explicitly applying (HFE) principles and methods addressed patient safety issues not infection prevention and control issues. In addition, most investigators who applied human factors principles and methods to infection prevention issues assessed only one human factors element such as training, technology evaluations, or physical environment design. The most significant gap pertains to the limited use and application of formal HFE tools and methods. Every infection prevention study need not assess all components in a system, but investigators must assess the interaction of critical system components if they want to address latent and deep-rooted human factors problems., Competing Interests: Conflict of InterestDr. Priyadarshini R. Pennathur and Dr. Loreen A. Herwaldt were supported by a grant from The Centers for Disease Control and Prevention CK000448-02 to conduct this work. Dr. Pennathur was also supported by a grant from the National Library of Medicine, NIH (5R00 LM0111384-03)., (© Springer Science+Business Media New York 2017.)

OBJECTIVE To identify risk factors for surgical site infections (SSIs) after spine operations. DESIGN Case-control study of SSIs among patients undergoing spine operations. SETTING An academic health center. PATIENTS We studied patients undergoing spinal fusions or laminectomies at the University of Iowa Hospitals and Clinics from January 1, 2007, through June 30, 2009. We included patients who acquired SSIs meeting the National Healthcare Safety Network definition. We randomly selected controls among patients who had spine operations during the study period and did not meet the SSI definition. RESULTS In total, 54 patients acquired SSIs after 2,309 spine operations (2.3 per 100 procedures). SSIs were identified a median of 20 days after spinal fusions and 17 days after laminectomies; 90.7% were identified after discharge and 72.2% were deep incisional or organ-space infections. Staphylococcus aureus caused 53.7% of SSIs. Of patients with SSIs, 64.9% (fusion) and 70.6% (laminectomy) were readmitted and 59.5% (fusion) and 64.7% (laminectomy) underwent reoperation. By multivariable analysis, increased body mass index, Surgical Department A, fusion of 4-8 vertebrae, and operation at a thoracic or lumbar/sacral level were significant risk factors for SSIs after spinal fusions. Lack of private insurance and hypertension were significant risk factors for SSIs after laminectomies. Surgeons from Department A were more likely to use nafcillin or vancomycin for perioperative prophylaxis and to do more multilevel fusions than surgeons from Department B. CONCLUSIONS SSIs after spine operations significantly increase utilization of healthcare resources. Possible remediable risk factors include obesity, hypertension, and perioperative antimicrobial prophylaxis. Infect Control Hosp Epidemiol 2016;1458-1467.

Background: Methicillin-resistant S. aureus (MRSA) pneumonia is associated with poor clinical outcomes. This study examined the association between microbial characteristics and poor outcomes among patients with methicillin-resistant Staphylococcus aureus pneumonia., Findings: This retrospective cohort study included 75 patients with MRSA pneumonia who were admitted to two large tertiary care medical centers during 2003-2010. Multivariable models were created using Cox proportional hazards regression and ordinal logistic regression to identify predictors of mortality or increased length of stay (LOS). None of the microbial characteristics (PFGE type, agr dysfunction, SCCmec type, and detection of PVL, ACME, and TSST-1) were significantly associated with 30-day mortality or post-infection hospital length of stay, after adjusting for gender, age, previous hospital admission within 12 months, previous MRSA infection or colonization, positive influenza test, Charlson Comorbidity Index score, and treatment (linezolid or vancomycin)., Conclusion: Large prospective studies are needed to examine the impact of microbial characteristics on the risk of death and other adverse outcomes among patients with MRSA pneumonia.

Background: Previous studies indicate that vancomycin is inferior to beta-lactams for treatment of methicillin-susceptible Staphylococcus aureus (MSSA) bloodstream infections. However, it is unclear if this association is true for empiric and definitive therapy. Here, we compared beta-lactams with vancomycin for empiric and definitive therapy of MSSA bloodstream infections among patients admitted to 122 hospitals., Methods: This retrospective cohort study included all patients admitted to Veterans Affairs hospitals from 2003 to 2010 who had positive blood cultures for MSSA. Hazard ratios (HR) and 95% confidence intervals (CIs) were calculated using Cox proportional hazards regression. Empiric therapy was defined as starting treatment 2 days before and up to 4 days after the first MSSA blood culture was collected. Definitive therapy was defined as starting treatment between 4 and 14 days after the first positive blood culture was collected., Results: Patients who received empiric therapy with a beta-lactam had similar mortality compared with those who received vancomycin (HR, 1.03; 95% CI, .89-1.20) after adjusting for other factors. However, patients who received definitive therapy with a beta-lactam had 35% lower mortality compared with patients who received vancomycin (HR, 0.65; 95% CI, .52-.80) after controlling for other factors. The hazard of mortality decreased further for patients who received cefazolin or antistaphylococcal penicillins compared with vancomycin (HR, 0.57; 95% CI, .46-.71)., Conclusions: For patients with MSSA bloodstream infections, beta-lactams are superior to vancomycin for definitive therapy but not for empiric treatment. Patients should receive beta-lactams for definitive therapy, specifically antistaphylococcal penicillins or cefazolin., (Published by Oxford University Press on behalf of the Infectious Diseases Society of America 2015. This work is written by (a) US Government employee(s) and is in the public domain in the US.)