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

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

In a cross-sectional survey of US acute care hospitals, antimicrobial stewardship programs were present in most Veterans Affairs and nonfederal hospitals but varied in team composition, scope, and impact. Diagnostic stewardship was common across hospitals. Veterans Affairs hospitals had increased reach in outpatient settings. Telestewardship remains an opportunity in all hospital systems. [ABSTRACT FROM AUTHOR]

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

Abstract: Background: Growing use of peripherally inserted central catheters (PICCs) has led to recognition of the risk of PICC-associated bloodstream infection. We sought to identify rates, patterns, and patient, provider, and device characteristics associated with this adverse outcome. Methods: A retrospective cohort of consecutive adults who underwent PICC placement from June 2009 to July 2012 was assembled. Using multivariable logistic and Cox-proportional hazards regression models, covariates specified a priori were analyzed for their association with PICC-associated bloodstream infection. Odds ratios (OR) and hazard ratios (HR) with corresponding 95% confidence intervals (CI) were used to express the association between each predictor and the outcome of interest. Results: During the study period, 966 PICCs were inserted in 747 unique patients for a total of 26,887 catheter days. Indications for PICC insertion included: long-term antibiotic administration (52%, n = 503), venous access (21%, n = 201), total parenteral nutrition (16%, n = 155), and chemotherapy (11%, n = 107). On bivariate analysis, intensive care unit (ICU) status (OR 3.23; 95% CI, 1.84-5.65), mechanical ventilation (OR 4.39; 95% CI, 2.46-7.82), length of stay (hospital, OR 1.04; 95% CI, 1.02-1.06 and ICU, OR 1.03; 95% CI, 1.02-1.04), PowerPICCs (C. R. Bard, Inc., Murray Hill, NJ; OR 2.58; 95% CI, 1.41-4.73), and devices placed by interventional radiology (OR 2.57; 95% CI, 1.41-4.68) were associated with PICC-bloodstream infection. Catheter lumens were strongly associated with this event (double lumen, OR 5.21; 95% CI, 2.46-11.04, and triple lumen, OR 10.84; 95% CI, 4.38-26.82). On multivariable analysis, only hospital length of stay, ICU status, and number of PICC lumens remained significantly associated with PICC bloodstream infection. Notably, the HR for PICC lumens increased substantially, suggesting earlier time to infection among patients with multi-lumen PICCs (HR 4.08; 95% CI, 1.51-11.02 and HR 8.52; 95% CI, 2.55-28.49 for double- and triple-lumen devices, respectively). Conclusions: PICC-associated bloodstream infection is most associated with hospital length of stay, ICU status, and number of device lumens. Policy and procedural oversights targeting these factors may be necessary to reduce the risk of this adverse outcome. [Copyright &y& Elsevier]

Background Inappropriate diagnosis of infections results in antibiotic overuse and may delay diagnosis of underlying conditions. Here we describe the development and characteristics of 2 safety measures of inappropriate diagnosis of urinary tract infection (UTI) and community-acquired pneumonia (CAP), the most common inpatient infections on general medicine services. Methods Measures were developed from guidelines and literature and adapted based on data from patients hospitalized with UTI and CAP in 49 Michigan hospitals and feedback from end-users, a technical expert panel (TEP), and a patient focus group. Each measure was assessed for reliability, validity, feasibility, and usability. Results Two measures, now endorsed by the National Quality Forum (NQF), were developed. Measure reliability (derived from 24 483 patients) was excellent (0.90 for UTI; 0.91 for CAP). Both measures had strong validity demonstrated through (a) face validity by hospital users, the TEPs, and patient focus group, (b) implicit case review (ĸ 0.72 for UTI; ĸ 0.72 for CAP), and (c) rare case misclassification (4% for UTI; 0% for CAP) due to data errors (<2% for UTI; 6.3% for CAP). Measure implementation through hospital peer comparison in Michigan hospitals (2017 to 2020) demonstrated significant decreases in inappropriate diagnosis of UTI and CAP (37% and 32%, respectively, P <.001), supporting usability. Conclusions We developed highly reliable, valid, and usable measures of inappropriate diagnosis of UTI and CAP for hospitalized patients. Hospitals seeking to improve diagnostic safety, antibiotic use, and patient care should consider using these measures to reduce inappropriate diagnosis of CAP and UTI. [ABSTRACT FROM AUTHOR]

Conditions with the Worst Physical Functioning Conditions that had the greatest impact on physical functioning were predominantly progressive neurologic (ALS, Parkinson disease, paralysis) and musculoskeletal (hemiplegia/paraplegia, limb amputation, hip fracture) conditions, select cancers (lung), and end-stage organ conditions (congestive heart failure, COPD, dementia) (eTable 2; eFigure 2). Even an unweighted MICD (disease count of negative coefficients) outperformed a "complete" simple disease count (negative and positive coefficients) for future physical functioning and mortality risk, demonstrating that indiscriminate disease counts are suboptimal. We also compared an unweighted MICD (count of negative coefficient conditions) with "complete" simple disease count encompassing negative and positive coefficient conditions (eTable 7). Graph: Figure 1 Distribution of multimorbidity-weighted index ICD-coded conditions (MICD), simple disease count, and Elixhauser comorbidity score. [Extracted from the article]

Quality improvement and patient safety (QIPS) curricula are critical in graduate medical education, yet barriers limit the educational experience and project outcomes. To explore the impact of QIPS curricular enhancements and integration of continuous improvement specialists (CIS) by examining the A3 document, the primary project product and surrogate for project quality. Since 2009, University of Michigan internal medicine and medicine-pediatric residents participate in a QIPS curriculum, which includes a 4-week group project. In 2016, residency leaders collaborated with CIS staff, non-clinical experts in QIPS with backgrounds in engineering and business, to improve the curriculum. Informed by a needs assessment, the intervention was implemented in 2017 and consisted of a set of enhancements including integration of CIS staff into groups as co-facilitators. In this retrospective cohort study, a blinded reviewer evaluated all available A3 documents before and after the intervention using a quantitative analysis tool. All residents participated in the curriculum during the pre-intervention (July 2009 to June 2016, n=351) and post-intervention (July 2017 to June 2020, n=148) periods. A total of 23 of 84 (27%) pre-intervention and 31 of 34 (91%) post-intervention A3 documents were available for review. Scores improved significantly for 17 of 23 (74%) A3 items and for 7 of 8 (88%) sections. Mean A3 total scores increased from 29.0 to 47.0 (95% CI 12.6-23.4; P<.001) out of a possible 69.0. Embedding CIS experts into residency QIPS curricula is associated with improved A3 document quality. [ABSTRACT FROM AUTHOR]

Background: As the COVID-19 pandemic evolves, it is critical to understand characteristics that have allowed US healthcare systems, including the Veterans Affairs (VA) and non-federal hospitals, to mount an effective response in the setting of limited resources and unpredictable clinical demands generated by this system shock. Objective: To compare the impact of and response to resource shortages to both VA and non-federal healthcare systems during the COVID-19 pandemic. Design: Cross-sectional national survey administered April 2021 through May 2022. Participants: Lead infection preventionists from VA and non-federal hospitals across the US. Main Measures: Surveys collected hospital demographic factors along with 11 questions aimed at assessing the effectiveness of the hospital's COVID response. Key Results: The response rate was 56% (71/127) from VA and 47% (415/881) from non-federal hospitals. Compared to VA hospitals, non-federal hospitals had a larger average number of acute care (214 vs. 103 beds, p<.001) and intensive care unit (24 vs. 16, p<.001) beds. VA hospitals were more likely to report no shortages of personal protective equipment or medical supplies during the pandemic (17% vs. 9%, p=.03) and more frequently opened new units to care specifically for COVID patients (71% vs. 49%, p<.001) compared with non-federal hospitals. Non-federal hospitals more frequently experienced increased loss of staff due to resignations (76% vs. 53%, p=.001) and financial hardships stemming from the pandemic (58% vs. 7%, p<0.001). Conclusions: In our survey-based national study, lead infection preventionists noted several distinct advantages in VA versus non-federal hospitals in their ability to expand bed capacity, retain staff, mitigate supply shortages, and avoid financial hardship. While these benefits appear to be inherent to the VA's structure, non-federal hospitals can adapt their infrastructure to better weather future system shocks. [ABSTRACT FROM AUTHOR]

Background The presence and proliferation of vascular access nursing in hospital settings has been identified as a potential contributor to growing demand, and possible overuse, of peripherally inserted central catheters (PICCs). Objective We examined vascular access nurses’ perceived role related to use of PICCs and the association with appropriateness of PICC use in hospitals. Design A web-based survey was administered to members of two vascular access professional organizations. Participants Of 2762 potentially eligible respondents who accessed the link, 1698 (61%) completed the survey. This sample was further restricted to vascular access nurses who worked in a U.S. hospital (n = 1147). Methods Respondents were categorized based on perceived role: 1) an operator who inserts PICCs; 2) a consultant whose views are not valued by the care team (unvalued consultant); 3) a consultant whose views are valued by the care team (valued consultant). Facility and respondent characteristics, reported practices, leadership support and relationships with other providers were compared across groups using chi-squared tests and analysis of variance. Multivariable logistic regression was used to assess the association between perceived role and reported percentage of PICCs placed for inappropriate reasons. Results Among the 1147 respondents, 210 (18%) viewed themselves as operators, 683 (59%) as valued consultants, 236 (21%) as unvalued consultants, and 18 (2%) could not be categorized. A significantly higher percentage (93%) of valued consultants reported that vascular access nurses placed the majority of PICCs at their facility, compared to operators (83%) or unvalued consultants (76%) (p < 0.001). After adjustment, compared with operators, valued consultants were significantly more likely to report that <10% of PICCs at their facility were inserted for inappropriate reasons (OR 1.7, p = 0.002); the finding was reversed for unvalued consultants (OR 0.69, p = 0.06). Conclusions Vascular access nurses and their perceived role as part of the healthcare team are associated with PICC use in hospitals. Strong inter-professional collaboration and respect may help ensure more appropriate use of PICCs. [ABSTRACT FROM AUTHOR]

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

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

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

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

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

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

Background Reducing antibiotic use in patients with asymptomatic bacteriuria (ASB) has been inpatient focused. However, testing and treatment is often started in the emergency department (ED). Thus, for hospitalized patients with ASB, we sought to identify patterns of testing and treatment initiated by emergency medicine (EM) clinicians and the association of treatment with outcomes. Methods We conducted a 43-hospital, cohort study of adults admitted through the ED with ASB (February 2018–February 2020). Using generalized estimating equation models, we assessed for (1) factors associated with antibiotic treatment by EM clinicians and, after inverse probability of treatment weighting, (2) the effect of treatment on outcomes. Results Of 2461 patients with ASB, 74.4% (N = 1830) received antibiotics. The EM clinicians ordered urine cultures in 80.0% (N = 1970) of patients and initiated treatment in 68.5% (1253 of 1830). Predictors of EM clinician treatment of ASB versus no treatment included dementia, spinal cord injury, incontinence, urinary catheter, altered mental status, leukocytosis, and abnormal urinalysis. Once initiated by EM clinicians, 79% (993 of 1253) of patients remained on antibiotics for at least 3 days. Antibiotic treatment was associated with a longer length of hospitalization (mean 5.1 vs 4.2 days; relative risk = 1.16; 95% confidence interval, 1.08–1.23) and Clostridioides difficile infection (CDI) (0.9% [N = 11] vs 0% [N = 0]; P  = .02). Conclusions Among hospitalized patients ultimately diagnosed with ASB, EM clinicians commonly initiated testing and treatment; most antibiotics were continued by inpatient clinicians. Antibiotic treatment was not associated with improved outcomes, whereas it was associated with prolonged hospitalization and CDI. For best impact, stewardship interventions must expand to the ED. [ABSTRACT FROM AUTHOR]

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

Background: Methicillin-resistant Staphylococcus aureus (MRSA) remains one of the most common causes of health care-associated infection (HAI).Objective: To evaluate the effect of education and a tiered, evidence-based infection prevention strategy on rates of hospital-onset MRSA bloodstream infection (BSI).Design: Prospective, national, nonrandomized, interventional, 12-month, multiple cohort, pre-post observational quality improvement project.Setting: Acute care, long-term acute care, and critical access hospitals with a disproportionate burden of HAI.Patients: All patients admitted to participating facilities during the project period.Intervention: A multimodal infection prevention intervention consisting of recommendations and tools for prioritizing and implementing evidence-based infection prevention strategies, on-demand educational videos, Internet-based live educational presentations, and access to content experts.Measurements: Rates of hospital-onset MRSA BSI, overall and stratified by hospital type, during 12-month baseline and postintervention periods. Variation in outcomes across hospital types was examined.Results: Between November 2016 and May 2018, 387 hospitals in 23 states and the District of Columbia participated, 353 (91%) submitted MRSA data, and 172 (49%) indicated that MRSA prevention was a priority. Unadjusted overall rates of hospital-onset MRSA BSI were 0.075 (95% CI, 0.065 to 0.085) and 0.071 (CI, 0.063 to 0.080) per 1000 patient-days in the baseline and postintervention periods, respectively.Limitations: The intervention period was short. Participation and adherence to recommended interventions were not fully assessed. Baseline rates of hospital-onset MRSA BSI were relatively low. Prevention of MRSA was a priority in a minority of participating hospitals. Patient characteristics and other MRSA risk factors were not assessed.Conclusion: In hospitals with a disproportionate burden of HAIs, access to tools to assist with implementation of evidence-based prevention strategies and education resources alone may not be sufficient to prevent MRSA BSI.Primary Funding Source: Centers for Disease Control and Prevention. [ABSTRACT FROM AUTHOR]

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

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

Background: Although certification by an accredited agency is often a practice prerequisite in health care, it is not required of vascular access specialists who insert peripherally inserted central catheters (PICCs). Whether certification is associated with differences in practice among inserters is unknown. Purpose: The purpose of this study was to gather information regarding whether certified and noncertified PICC inserters differ with respect to their practices and views about PICC use. Methods: We conducted a national survey of vascular access specialists, identifying certified PICC inserters as those who had received board certification from the Association for Vascular Access, the Infusion Nurses Society, or both. The 76-item survey asked about PICC policies and procedures at respondents' facilities, use of insertion technologies, device management, management of complications, perceptions about PICC use, and relationships with other health care providers. Additional data about respondents, including years in practice and primary practice settings, were also gathered. Bivariable comparisons were made using χ2 tests; two-sided α with P ≤ 0.05 was considered statistically significant. Results: Of the 1,450 respondents in the final sample, 1,007 (69%) said they were certified inserters and 443 (31%) said they were not. Significantly higher percentages of certified than noncertified inserters reported having practiced for five or more years (78% versus 54%) and having placed 1,000 or more PICCs (58% versus 32%). Significantly more certified than noncertified inserters also reported being the vascular access lead for their facility (56% versus 44%). Reported practice patterns for insertion, care, and management of PICCs varied based on certification status. Some evidence-based practices (such as the use of ultrasound to measure catheter-to-vein ratios) were more often reported by certified inserters, while others (such as the use of maximal sterile barriers during PICC insertion) were not. Asked about their perceptions of PICC use at their institution, certified inserters reported higher percentages of inappropriate insertion and removal than noncertified inserters. Conclusion: Certified PICC inserters appear to be a distinct group of vascular access specialists. A better understanding of how and why practices differ between certified and noncertified inserters is necessary to ensuring safer, high-quality patient care. [ABSTRACT FROM AUTHOR]

Background. Numerous evidence-based practices for preventing device-associated infections are available, yet the extent to which these practices are regularly used in acute care hospitals across different countries has not been compared, to our knowledge. Methods. Data from hospital surveys conducted in Japan, the United States, and Thailand in 2012, 2013, and 2014, respectively, were evaluated to determine the use of recommended practices to prevent central line-associated bloodstream infection (CLABSI), ventilator-associated pneumonia (VAP), and catheter-associated urinary tract infection (CAUTI). The outcomes were the percentage of hospitals reporting regular use (a score of 4 or 5 on a scale from 1 [never use] to 5 [always use]) of each practice across countries and identified hospital characteristics associated with the use of selected practices in each country. Results. Survey response rates were 71% in Japan and the United States and 87% in Thailand. A majority of hospitals in Japan (76.6%), Thailand (63.2%), and the United States (97.8%) used maximum barrier precautions for preventing CLABSI and semirecumbent positioning to prevent VAP (66.2% for Japan, 86.7% for Thailand, and 98.7% for the United States). Nearly all hospitals (>90%) in Thailand and the United States reported monitoring CLABSI, VAP, and CAUTI rates, whereas in Japan only CLABSI rates were monitored by a majority of hospitals. Regular use of CAUTI prevention practices was variable across the 3 countries, with only a few practices adopted by >50% of hospitals. Conclusions. A majority of hospitals in Japan, Thailand, and the United States have adopted certain practices to prevent CLABSI and VAP. Opportunities for targeting prevention activities and reducing device-associated infection risk in hospitals exist across all 3 countries. [ABSTRACT FROM AUTHOR]

Background: Catheter-associated urinary tract infection (UTI) is a common device-associated infection in hospitals. Both technical factors--appropriate catheter use, aseptic insertion, and proper maintenance--and socioadaptive factors, such as cultural and behavioral changes in hospital units, are important in preventing catheter-associated UTI.Methods: The national Comprehensive Unit-based Safety Program, funded by the Agency for Healthcare Research and Quality, aimed to reduce catheter-associated UTI in intensive care units (ICUs) and non-ICUs. The main program features were dissemination of information to sponsor organizations and hospitals, data collection, and guidance on key technical and socioadaptive factors in the prevention of catheter-associated UTI. Data on catheter use and catheter-associated UTI rates were collected during three phases: baseline (3 months), implementation (2 months), and sustainability (12 months). Multilevel negative binomial models were used to assess changes in catheter use and catheter-associated UTI rates.Results: Data were obtained from 926 units (59.7% were non-ICUs, and 40.3% were ICUs) in 603 hospitals in 32 states, the District of Columbia, and Puerto Rico. The unadjusted catheter-associated UTI rate decreased overall from 2.82 to 2.19 infections per 1000 catheter-days. In an adjusted analysis, catheter-associated UTI rates decreased from 2.40 to 2.05 infections per 1000 catheter-days (incidence rate ratio, 0.86; 95% confidence interval [CI], 0.76 to 0.96; P=0.009). Among non-ICUs, catheter use decreased from 20.1% to 18.8% (incidence rate ratio, 0.93; 95% CI, 0.90 to 0.96; P<0.001) and catheter-associated UTI rates decreased from 2.28 to 1.54 infections per 1000 catheter-days (incidence rate ratio, 0.68; 95% CI, 0.56 to 0.82; P<0.001). Catheter use and catheter-associated UTI rates were largely unchanged in ICUs. Tests for heterogeneity (ICU vs. non-ICU) were significant for catheter use (P=0.004) and catheter-associated UTI rates (P=0.001).Conclusions: A national prevention program appears to reduce catheter use and catheter-associated UTI rates in non-ICUs. (Funded by the Agency for Healthcare Research and Quality.). [ABSTRACT FROM AUTHOR]

Background: Complications associated with central venous catheters (CVCs) increase over time. Although early removal of unnecessary CVCs is important to prevent complications, the extent to which clinicians are aware that their patients have a CVC is unknown.Objective: To assess how often clinicians were unaware of the presence of triple-lumen catheters or peripherally inserted central catheters (PICCs) in hospitalized patients.Design: Multicenter, cross-sectional study.Setting: 3 academic medical centers in the United States.Patients: Hospitalized medical patients in intensive care unit (ICU) and non-ICU settings.Measurements: To ascertain awareness of CVCs, whether a PICC or triple-lumen catheter was present was determined; clinicians were then queried about device presence. Differences in device awareness among clinicians were assessed by chi-square tests.Results: 990 patients were evaluated, and 1881 clinician assessments were done. The overall prevalence of CVCs was 21.1% (n=209), of which 60.3% (126 of 209) were PICCs. A total of 21.2% (90 of 425) of clinicians interviewed were unaware of the presence of a CVC. Unawareness was greatest among patients with PICCs, where 25.1% (60 of 239) of clinicians were unaware of PICC presence. Teaching attendings and hospitalists were more frequently unaware of the presence of CVCs than interns and residents (25.8% and 30.5%, respectively, vs. 16.4%). Critical care physicians were more likely to be aware of CVC presence than general medicine physicians (12.6% vs. 26.2%; P=0.003).Limitations: Awareness was determined at 1 point in time and was not linked to outcomes. Patient length of stay and indication for CVC were not recorded.Conclusion: Clinicians are frequently unaware of the presence of PICCs and triple-lumen catheters in hospitalized patients. Further study of mechanisms that ensure that clinicians are aware of these devices so that they may assess their necessity seems warranted.Primary Funding Source: None. [ABSTRACT FROM AUTHOR]

Background: Complications associated with central venous catheters (CVCs) increase over time. Although early removal of unnecessary CVCs is important to prevent complications, the extent to which clinicians are aware that their patients have a CVC is unknown. Objective: To assess how often clinicians were unaware of the presence of triple-lumen catheters or peripherally inserted central catheters (PICCs) in hospitalized patients. Design: Multicenter, cross-sectional study. Setting: 3 academic medical centers in the United States. Patients: Hospitalized medical patients in intensive care unit (ICU) and non-ICU settings. Measurements: To ascertain awareness of CVCs, whether a PICC or triple-lumen catheter was present was determined; clinicians were then queried about device presence. Differences in device awareness among clinicians were assessed by chi-square tests. Results: 990 patients were evaluated, and 1881 clinician assessments were done. The overall prevalence of CVCs was 21.1% (n = 209), of which 60.3% (126 of 209) were PICCs. A total of 21.2% (90 of 425) of clinicians interviewed were unaware of the presence of a CVC. Unawareness was greatest among patients with PICCs, where 25.1% (60 of 239) of clinicians were unaware of PICC presence. Teaching attendings and hospitalists were more frequently unaware o f the presence of CVCs than interns and residents (25.8% and 30.5%, respectively, vs. 16.4%). Critical care physicians were more likely to be aware of CVC presence than general medicine physicians (12.6% vs. 26.2%; P = 0.003). Limitations: Awareness was determined at 1 point in time and was not linked to outcomes. Patient length of stay and indication for CVC were not recorded. Conclusion: Clinicians are frequently unaware of the presence of PICCs and triple-lumen catheters in hospitalized patients. Further study of mechanisms that ensure that clinicians are aware of these devices so that they may assess their necessity seems warranted. [ABSTRACT FROM AUTHOR]

Abstract: Background: Examination of ≥12 lymph nodes (LNs) ensures accurate staging in colon cancer. The aim of this study was to compare nodal positivity between sentinel LN mapping (SLNM) and conventional surgery in patients with <12 and ≥12 LNs harvested. Methods: From 1993 to 2008, 407 and 380 patients with colon cancer underwent SLNM and conventional surgery, respectively. Total LNs harvested and nodal positivity were analyzed. Patients were grouped according to number of LNs harvested: 2 to 11, 12 to 25, or >25. Results: The average numbers of LNs harvested in the groups with 2 to 11, 12 to 25, and >25 LNs harvested for SLNM and conventional surgery, respectively, were 8.3 and 7.1 (P < .0001), 17.2 and 16.5 (P = .09), and 34.2 and 32.1 (P = .40). Nodal positivity for SLNM and conventional surgery in the groups with <12 and ≥12 LNs harvested was 42% and 29% (P = .01) and 50% and 36% (P = .003), respectively. Overall nodal positivity was 47% for SLNM and 32% for conventional surgery (P < .0001). When SLNM with 2 to 11 LNs was compared with conventional surgery with 12 to 25 LNs, nodal positivity was 42% versus 36% (P = .35). Conclusions: SLNM possessed higher nodal positivity compared with conventional surgery. SLNM is a valuable adjunct to accurate nodal staging in colon cancer. [Copyright &y& Elsevier]

Background Fluoroquinolones increase the risk of Clostridioides difficile infection and antibiotic resistance, but are frequently used for hospitalized patients with bacteriuria. We assessed patterns and predictors of inappropriate fluoroquinolone (FQ) use among hospitalized patients with asymptomatic bacteriuria (ASB) and cystitis. Methods This is a retrospective cohort study of non-ICU medicine patients with ASB or cystitis (complicated or uncomplicated) from January 2018 to March 2019 at 43 Michigan hospitals. Patients with concomitant infections, bacteremia, or pyelonephritis were excluded. Each day of FQ (ciprofloxacin, levofloxacin) use (inpatient and post discharge) was assessed for appropriateness. FQ use was inappropriate if: (A) ASB, (B) urine culture with an FQ-resistant bacteria, (C) a safer alternative empiric or definitive antibiotic (treatment ≥2 days after urine culture collection) based on disease severity, cultures, allergies, and renal function, or (D) excess duration (>7 days complicated cystitis; >3 days uncomplicated cystitis). Hospitals were also surveyed on existing stewardship (ASP) practices targeting FQ use. ASP practices associated with inappropriate FQ use were evaluated using logistic generalized estimated equation models adjusting for patient factors and hospital clustering. Results Of 4849 included patients with ASB (39.7%) or cystitis (60.3%), 21.9% (n = 1,061) received an FQ and 92.7% (n = 984) received a, FQ inappropriately (Figure 1). Of 5,465 FQ days of therapy (DOT), 90.7% (n = 4,959) were inappropriate. Definitive treatment of complicated cystitis led to the greatest proportion of inappropriate FQ DOTs (50.6%), followed by ASB (36.4%) (Table 1). Hospitals varied (Figure 2), but those with cascade reporting of antibiotic susceptibilities, urinary tract infection (UTI) treatment guideline or an ASP performing prospective audit and feedback on FQ use had lower inappropriate FQ treatment rates (Table 2). Conclusion Hospitalized patients with ASB and cystitis often receive an FQ. Most FQ use is inappropriate due to ASB treatment or FQ use for complicated cystitis despite the option of an alternative antibiotic. Prospective audit and feedback, UTI guidelines, and cascade reporting of antibiotic susceptibilities can be used by ASP to reduce inappropriate FQ use. Disclosures All authors: No reported disclosures. [ABSTRACT FROM AUTHOR]

Background Antimicrobial stewardship interventions to decrease testing and treatment of asymptomatic bacteriuria (ASB) have primarily focused on inpatient clinicians, however emergency medicine (EM) clinicians also test and treat ASB. We identified testing attributable to EM clinicians and patient-level factors associated with EM treatment of ASB. Methods Between November 2017 and March 2019, data were abstracted from medical records of adult non-ICU medical patients at 43 Michigan hospitals admitted through the Emergency Department (ED) with a positive urine culture (Ucx) collected on day 1 or 2 of hospitalization. Exclusions included pregnancy, urologic surgery or abnormality, immune-compromise, severe sepsis, or concomitant infection. ASB was defined as a positive Ucx without signs or symptoms of a urinary tract infection (UTI). The treatment group included patients receiving ≥1 antibiotic dose ordered by an EM clinician. Patient factors associated with ASB treatment by EM clinicians vs. no treatment were evaluated using logistic generalized estimating equation models. Results Of 1,778 patients with ASB, 74.7% (N = 1328) had a Ucx ordered by an EM clinician (Figure 1), and 74.4% (N = 1323) were treated with antibiotics (Figure 2). Of those treated for ASB, 64.3% (851/1328) had the first dose ordered by an EM clinician (Figure 2). Patient variables associated with EM treatment included nonambulatory status, incontinence, presence of a urinary catheter, acutely altered mental status (AMS), leukocytosis, and positive urinalysis (Table 1). When EM initiated treatment, most patients (80%) remained on antibiotics for ≥3 days (Figure 3), with a median treatment duration of 6 days [IQR 4–9]. Conclusion Among patients with ASB admitted through the ED with a Ucx collected on day 1 or 2 of hospitalization, most were treated with antibiotics. The majority of testing and initial treatment for ASB was by EM clinicians. The strongest predictors of EM treatment of ASB were positive urinalysis and AMS. Once started by EM, patients often received a full course for UTI. Given the burden of ASB testing and treatment, expanding stewardship into the ED is critical and should start with addressing interpretation of urinalyses in patients without specific urinary symptoms. Disclosures All authors: No reported disclosures. [ABSTRACT FROM AUTHOR]

Background To strengthen state collaborative efforts and reduce common healthcare-associated infections (HAIs) in short-stay and long-term acute care hospitals, the Centers for Disease Control and Prevention (CDC) launched "States Targeting Reduction in Infections via Engagement" (STRIVE) - a national quality improvement program. Methods STRIVE consisted of a multimodal intervention implemented from November 2016 to May 2018 (Figure 1). Hospitals with excess Clostridioides difficile infection (CDI) and a high burden of at least one of the following HAIs - central line-associated bloodstream infection (CLABSI), catheter-associated urinary tract infection (CAUTI) or methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infection were targeted. Monthly aggregate HAI and device utilization ratios - according to CDC National Healthcare Safety Network definitions - were measured during the pre vs. post-intervention periods. Thematic analysis of qualitative interviews with state partners was conducted to understand the influence of the intervention. Results Overall, 387 hospitals from 23 states and the District of Columbia participated. Changes in HAI rates and catheter utilization are illustrated in Figure 2. From pre- to post-intervention, substantial changes in HAI rates above temporal trends were not observed (CDI, 7.0 to 5.7 per 10000 patient-days; CLABSI, 0.88 to 0.80 per 1000 catheter days; CAUTI, 1.12 to 1.04 per 1000 catheter days; MRSA bloodstream infection, 0.075 to 0.071 per 1,000 patient-days) Similarly, catheter utilization did not differ substantially between the pre- and post-intervention periods (24.05 to 22.07 central line days per 100 patient-days; 21.46 to 19.83 urinary catheter days per 100 patient-days). Qualitative analysis of 17 interviews with state partners showed that relationships among state partners and hospitals were strengthened, potentially facilitating collaboration on future infection prevention efforts. Conclusion Though HAI reductions were observed during STRIVE, these reductions were consistent with temporal trends. Hospitals struggling with high HAI rates may require additional novel approaches. Disclosures All authors: No reported disclosures. [ABSTRACT FROM AUTHOR]

Background To evaluate the 5-year sustainability of a multimodal intervention which included a prize to the hospital with the highest overall hand hygiene adherence rates among healthcare workers. Methods Design: An observational study using direct observation of hand hygiene adherence performed by a trained observer coupled with a survey of healthcare workers about their knowledge of hand hygiene practices. Setting: Three Japanese tertiary care hospitals. Study Population: Physicians and nurses working on an inpatient medical or surgical ward, an intensive care unit (ICU), or the emergency department. Outcome Measures: Hand hygiene adherence rates before patient contact using unobtrusive direct observation. Secondary outcomes were survey responses on a World Health Organization (WHO) questionnaire on hand hygiene. Results Data for the current study were collected between September and December 2017 at the 3 participating hospitals. An additional 2,485 observations were conducted during this 5-year post-intervention assessment. These observations were compared with 2,679 observations from the pre-intervention period, and 2,982 observations from the 6-month post-intervention period. Hand hygiene adherence rates had previously improved significantly after the introduction of a multimodal intervention – based on principles recommend by the WHO – in 2012 and 2013 in 3 Japanese hospitals (18.0% pre-intervention to 32.7% 6-months post-intervention; P < 0.001). No significant changes were found in hand hygiene adherence in these hospitals 5 years after the original intervention (31.9% 5-years post-intervention; P = 0.53); however, substantial variability in hand hygiene adherence by unit and healthcare worker type was noted. Conclusion A multimodal hand hygiene initiative achieved sustained improvement in hand hygiene adherence in 3 Japanese hospitals 5 years after the original intervention. Disclosures All authors: No reported disclosures. [ABSTRACT FROM AUTHOR]