Acute Care Facilities Research Articles

The impact of statewide educational webinars on infection prevention and control knowledge and policy updates in acute and long-term care facilities during the COVID-19 pandemic: the Nebraska experience.

A Nebraska statewide webinar series was initiated during the coronavirus disease 2019 (COVID-19) pandemic for long-term care (LTC) and acute care/outpatient (AC) facilities. An impact survey was completed by 48 of 96 AC and 109 of 429 LTC facilities. The majority reported increased regulatory awareness (AC: 65%, LTC: 54%) and updated COVID-19 (AC: 61%, LTC: 69%) and general infection prevention (AC: 61%, LTC: 60%) policies.

Assessing for race, ethnicity, and socioeconomic disparities in central line-associated bloodstream infection risk in a large academic health system.

To examine the relationship between race and ethnicity and central line-associated bloodstream infections (CLABSI) while accounting for inherent differences in CLABSI risk related to central venous catheter (CVC) type. Retrospective cohort analysis. Acute care facilities within an academic healthcare system. Adult inpatients from January 2012 through December 2017 with CVC present for ≥2 contiguous days. We describe variability in demographics, comorbidities, CVC type/configuration, and CLABSI rate by patient's race and ethnicity. We estimated the unadjusted risk of CLABSI for each demographic and clinical characteristic and then modelled the effect of race on time to CLABSI, adjusting for total parenteral nutrition use and CVC type. We also performed exploratory analysis replacing race and ethnicity with social vulnerability index (SVI) metrics. 32,925 patients with 57,642 CVC episodes met inclusion criteria, most of which (51,348, 89%) were among non-Hispanic White or non-Hispanic Black patients. CVC types differed between race/ethnicity groups. However, after adjusting for CVC type, configuration, and indication in an adjusted cox regression, the risk of CLABSI among non-Hispanic Black patients did not significantly differ from non-Hispanic White patients (adjusted hazard ratio [aHR] 1.19; 95% confidence interval [CI]: 0.94, 1.51). The odds of having a CLABSI among the most vulnerable SVI subset compared to the less vulnerable was no different (odds ratio [OR] 0.95; 95% CI: 0.75-1.2). We did not find a difference in CLABSI risk between non-Hispanic White and non-Hispanic Black patients when adjusting for CLABSI risk inherent in type and configuration of CVC.

Surviving septic patients endotyped with a functional assay demonstrate active immune responses.

Sepsis is a complex clinical syndrome characterized by a heterogenous host immune response. Historically, static protein and transcriptomic metrics have been employed to describe the underlying biology. Here, we tested the hypothesis that ex vivo functional TNF expression as well as an immunologic endotype based on both IFNγ and TNF expression could be used to model clinical outcomes in sepsis patients. This prospective, observational study of patient samples collected from the SPIES consortium included patients at five health systems enrolled over 17 months, with 46 healthy control patients, 68 ICU patients without sepsis, and 107 ICU patients with sepsis. Whole blood was collected on day 1, 4, and 7 of ICU admission. Outcomes included in-hospital and 180-day mortality and non-favorable discharge disposition defined by skilled nursing facility, long-term acute care facility, or hospice. Whole blood ELISpot assays were conducted to quantify TNF expression [stimulated by lipopolysaccharide (LPS)] and IFNγ expression (stimulated by anti-CD3/CD28 mAb), which were then used for assignment to one of four subgroups including an 'immunocompetent', 'immunosuppressed endotype', and two 'mixed' endotypes. Whole blood TNF spot-forming units were significantly increased in septic and CINS patients on days 4 and 7 compared to healthy subjects. In contrast, TNF expression per cell on days 1, 4, and 7 was significantly lower in both septic and critically ill non-septic (CINS) patients compared to healthy subjects. Early increases in total TNF expression were associated with favorable discharge disposition and lower in-hospital mortality. 'Immunocompetent' endotype patients on day 1 had a higher proportion of favorable to non-favorable discharges compared to the 'immunosuppressed' endotype. Similarly, 'immunocompetent' endotype patients on day 4 had a higher in-hospital survival compared to the 'immunosuppressed' endotype patients. Finally, among septic patients, decreased total TNF and IFNγ expression were associated with 180-day mortality. Increased ex vivo whole blood TNF expression is associated with improved clinical outcomes. Further, the early 'immunocompetent' endotype is associated with favorable discharge and improved in-hospital and 180-day survival. The ability to functionally stratify septic patients based on blood cell function ex vivo may allow for identification of future immune modulating therapies.

Reducing Readmissions Using Collaborative Care.

After noting an elevated chronic obstructive pulmonary disease readmission rate for 2022, the inpatient Nurse Navigator at a rural nonprofit, 116-bed acute care facility in the State of Virginia met with interdisciplinary team (IDT) members to identify improvement efforts to decrease 30-day readmission rates. A 116-bed health care facility in Southside Virginia. Quality improvement initiative aimed to decrease 30-day penalty readmission rates using a collaborative IDT approach, focusing on patients 65years or older who are discharged home or to an assisted living facility with a diagnosis of acute myocardial infarction, heart failure, chronic obstructive pulmonary disease, and pneumonia. Compared to the readmission rates obtained in 2022, the 2023 readmission rates among the four diagnoses groups met or were under the disease-specific targets for 2023, supporting the efforts of the collaborative interdisciplinary approach to decrease 30-day readmission rates. Addressing community barriers and social determinants of health at the index admission. Collaborating with IDT members for a safe transition of care. Using the community paramedic program to provide additional resources to a rural community.

They Will Come, You Must Build It: A Modified Delphi Process Applied to Preparing Acute Care Facilities Infrastructure for High-Consequence Infectious Diseases.

Patients with suspected or confirmed high-consequence infectious diseases (HCIDs) may present for care at any acute care facility. However, there are limited data to inform recommendations for the design, maintenance, and operation of isolation spaces for patients with suspected or confirmed HCIDs. To address this gap, we developed consensus statements by convening a group of 29 subject matter experts to participate in a modified Delphi process facilitated by a validated tool (the RAND-developed ExpertLens system). The subject matter experts participated in 3 consensus rounds, providing feedback and rating the appropriateness of 36 draft consensus statements. These draft statements were then revised based on their feedback. As a result, we developed 36 consensus statements addressing 5 domains: (1) patient room physical space, (2) doors and windows, (3) air handling, (4) electrical and plumbing, and (5) soiled utility rooms and waste management. These statements could inform the approaches of frontline acute care facilities when building new spaces or modifying existing spaces to enable appropriate HCID patient isolation and care.

Minimum National Prevalence of Diagnosed Atrial Fibrillation Inferred From California Acute Care Facilities

BackgroundPrevalence estimates of atrial fibrillation (AF) from large populations have not been updated for >2 decades. Using data from 1996 to 1997, a previous study projected that there would be 3.3 million adults with AF in the United States in 2020. ObjectivesThe purpose of this study was to determine the contemporary age-, sex-, and race-standardized prevalence and the number of adults with diagnosed AF in the United States. MethodsWe merged California’s state-wide health care databases to assemble a cohort of adults aged ≥20 years who received hospital-based care in California from 2005 to 2019. International Classification of Diseases codes were used to identify AF and other comorbidities. After accounting for deaths, we utilized the U.S. Census to calculate the national age-, sex-, and race-standardized estimates of diagnosed AF. ResultsOf 29,250,310 patients (mean age 50.6 ± 19.8 years, 53.8% women, 50.1% White), 2,003,867 (6.8%) had an AF diagnosis. The proportion of patients with diagnosed AF increased from 4.49% in 2005 to 2009 to 6.82% in 2015 to 2019. Over time, AF patients became relatively younger, were less likely to be female or White, and were more likely to have hypertension and diabetes. Standardizing based on age-, sex-, race-, and ethnicity-based proportions to the U.S. population, we estimate that the current national prevalence of diagnosed AF is at least 10.55 million (95% CI: 10.48-10.62 million), comprising 4.48% (95% CI: 4.47%-4.49%) of the adult population. ConclusionsThe prevalence of diagnosed AF in the United States is higher than previously estimated. More efficient prevention and treatment strategies are needed to curb the burden of AF in the United States.

Standardized order set for the management of infective endocarditis.

Infective endocarditis (IE) is a potentially life-threatening infection that affects the inner lining of the heart, particularly the heart valves. Patients with preexisting heart conditions, damaged heart valves, or a history of intravenous drug use are at a higher risk of acquiring IE. A rural acute care facility reported that 68.75% of patients who had a methicillin-resistant Staphylococcus aureus infection were diagnosed with IE. Review of medical records showed that 65% of patients with IE did not have antibiotic start/stop dates and 51% were discharged before the 6-week completion date. The quality-improvement project used a pretest and posttest design. An order set was created based on evidence-based guidelines to assist with the management of patients with IE. The order set included administering intravenous (IV) antibiotics for a minimum of 6 weeks for patients with IE and included a set of recommended weekly follow-up laboratory tests. An order set with the standard of care and reminders in the electronic health records (EHRs) were implemented for the management of IE, including antibiotic start and stop dates and weekly follow-up labs. After implementation, there was an improvement in the completion of IV antibiotics, documentation of start/stop dates for IV antibiotics, and completion of recommended laboratory tests. An order set with the standard of care and reminders in the EHR reduced variations in care and improved patient outcomes by ensuring that all providers were following the same evidence-based guidelines for the management of IE.

Complexities of a Provincial CIS Implementation: Thinking Beyond Scale.

CIS implementations are complex processes involving numerous teams, planning changes to both business and technical processes, and extensive change management. The complexity of implementation increases exponentially when dealing with implementation across an entire province rather than just a single site implementation. This paper addresses the One Person One Record Program in Nova Scotia, Canada where a single CIS will be implemented across the entire province involving 47 acute care facilities and 1400 individual ambulatory clinics. Developing and delivering localized role-specific training to end users is directly affected by the extensive arrange of unique user roles and is part of the complexity in this transformation program. Challenges arising from the additional complexity will be shared as well as lessons learned to support the implementations of future leaders with plans to lead such transformations in their own regions.

Patient Harm Events and Associated Cost Outcomes Reported to a Patient Safety Organization.

The aims of the study were to describe inpatient harm events detected via an automatic electronic trigger system (ETS) and to consider their financial consequences. Over a 27-month period, inpatient harm events were identified and documented in 1 healthcare system with 37 acute care facilities. Patients who experienced harm (all harm or preventable harm only) were compared with similar patients who did not. Clinical, financial, and demographic data were used to identify labor-adjusted direct variable costs (DVC) and potential differences in length of stay (LOS) associated with all-harm, preventable-harm, and nonharmed cohorts. Age-adjusted Charlson Comorbidity Index, case mix index, diagnosis-related groups, major diagnostic category, sex, age, location, diagnosis, adverse event category and subcategory, preventability, and harm severity were used to compare cohorts. Total harm events reported via the ETS and the health system's voluntary event reporting system were compared. Nearly 93,000 encounters for all-harm (n = 25,665) and nonharmed cohorts (n = 67,217) were compared by random sampling of diagnosis-related group-matched all-harm and nonharmed groups to ensure similar clinical conditions, as measured by Charlson Comorbidity Index and case mix index. Sampling (2 groups, n = 100 and n = 200) showed that increased LOS was associated with harm; yet other clinical comparators were similar across groups. the preventable-harm subcohort had longer LOS (10.7 versus 5.9 days) and higher DVC ($13,442 versus $8024) than the nonharmed cohort. Identification of harm events was nearly 6-fold higher with the ETS than with the voluntary event reporting system. Patients with preventable harm had increased LOS that was associated with higher DVC per preventable-harm encounter in a large US healthcare system.

Patient-Centered Outcomes of a Lymphedema Pump in Patients with Symptomatic Lower Extremity Edema

Phlebolymphedema is a challenging condition to manage, with limited options for effective treatment. For patients, this may be debilitating and lead to infection, loss of independence and affect quality of life. This study aims to evaluate patient-reported outcomes of an advanced pneumatic compression device (APCD) in the treatment of lower extremity phlebolymphedema. Patients with diagnosis of lower extremity phlebolymphedema at an acute care facility within the New York City Health and Hospitals Cooperation treated with the Flexitouch (FLX) (Tactile Systems Technology, Inc, Minneapolis, Minnesota) APCD from December 2021 to March 2023 were evaluated. Patient-perceived subjective outcomes were assessed via a short questionnaire, with subsequent analysis using chi-squared test. Primary end points were subjective improvements in 1) swelling, 2) pain, and 3) ease of use of device as surrogates for patient satisfaction. Secondary end point was subjective patient-reported compliance, obtained by investigating 1) if patients were trained to use device, and 2) if patients were using the device. A total of 52 participants were included in this study, consisting of 30.8% male and 69.2% female patients with a mean age of 71.7years. While selection criteria did not exclude unilateral disease or alternative etiologies, we note that the entire study population had been diagnosed with bilateral lower extremity lymphedema in the setting of chronic venous insufficiency. Other patient characteristics including race, comorbidities and smoking status were documented in Table1. Table2 demonstrates the results of chi-squared analysis. This study noted significant patient-perceived improvement in swelling and pain (91.4% with P<0.00001; 85.7% with P=0.00002 respectively) and patient-reported ease of use of the FLX device (85.7% with P=0.00002). Additional secondary findings included a majority of patients reporting being trained on how to use FLX and also maintaining compliance with the device (69.2% with P=0.005; 67.3% with P=0.012 respectively). FLX APCD use has been found to demonstrate desirable patient-reported outcomes as a general trend. The participants in this study noted statistically significant subjective improvement in swelling and pain, ease of use of device and adherence to training and compliance with device. FLX appears to be positively received by patients, and the authors recommend its consideration for management of bilateral lower extremity phlebolymphedema.

Clinical and Genomic Characteristics of Candida auris in Central Ohio: An Insight into Epidemiological Surveillance

Background: Candida auris is an emerging threat to hospitalized patients and invasive disease is associated with high mortality. This study describes clinical and microbiological characteristics of nine patients identified with C. auris at Ohio State Wexner Medical Center discovered through active surveillance or clinical investigation and uses whole genome sequencing (WGS) to compare isolates. Methods: In November 2022, an active C. auris surveillance program was implemented to screen patients admitted to high-risk units (intensive care units and progressive care units). Bilateral axilla and groin swabs were obtained upon unit admission and, if positive, were submitted for C. auris polymerase chain reaction (PCR) with culture and sensitivity testing. Patients with a positive screening or clinical isolate from November 2022 to November 2023 underwent chart review for clinical characteristics, microbiologic data, and index admission information. For each isolate, DNA was extracted and WGS was performed. Core single nucleotide polymorphism (SNP) variation identified from the sequence data was used to infer genetic relationships among the isolates. Results: Nine patients were identified between November 2022 and November 2023. The clinical and microbiologic characteristics are summarized in Table 1. All patients were hospitalized at various acute care facilities across the state at least once in the preceding 12 months. C. auris was determined to be present on admission for 6 patients. For 5 of these patients, it was their first interaction with our healthcare system. Three patients were not in contact isolation for &gt;3 days before C. auris was identified. Unit wide point-prevalence screening was completed in these cases and no evidence of transmission was found. WGS showed eight of the nine isolates were related with 28 or less core SNP differences between isolates (Figure 1). One isolate (8) was genetically distinct with &gt;45000 core SNP differences. Five isolates were highly related with a range of 4-15 SNP differences. No temporal or spatial overlap at our institution was identified among these five patients. Conclusions: The active surveillance program identified several patients colonized with C. auris in addition to those found through clinical testing. Multiple risk factors for C. auris were identified with high patient mortality (67%). Majority of the isolates were closely related without association with a known outbreak or epidemiologic link, suggesting a possible diffuse common reservoir. Next steps with surveillance in acute care and long-term care facilities will be critical for early detection to halt transmission of this organism.

Impact of Point Prevalence Surveillance on Transmission of Candida auris Within an Acute Care Health System

Background: Patients infected or colonized with Candida auris can serve as a transmission source for other patients. Screening patients for Candida auris colonization allows facilities to implement infection prevention and control measures and minimize the risk of transmission. The Centers for Disease Control and Prevention (CDC) recommends healthcare facilities perform three types of screening; admission screening in patients with specific risks, close contact screening of patients who overlap a confirmed positive case for 3 or more days or point prevalence surveillance if there is evidence of ongoing transmission within the facility. The CDC further recommends that patients being screened for Candida auris be maintained in transmission-based precautions while awaiting Results: In 2022-2023 there was ongoing transmission of Candida auris occurring in a community served by a large multi-state healthcare system. Close contact and point prevalence surveillance screening for both acute and non-acute healthcare facilities were implemented by the local health jurisdiction. Methods: A composite swab of the bilateral axilla and groin was used to screen close contacts of patients confirmed to be infected or colonized with Candida auris. Close contact was defined as having been on the same unit as the positive patient for 3 or more days while the patient was not in transmission-based precautions. Point prevalence surveillance was performed on all patients currently housed on units where close contact screen-positive patients resided. Potentially exposed patients who had been discharged were not screened. Patients were placed in contact transmission-based precautions until results were received. In 1657 patients in six acute care facilities were identified for Candida auris screening. 161 patients refused or were unable to be screened. Of the 1496 patients screened, 40 screened positive, demonstrating a 2.67% secondary attack rate. Of the 40 screen-positive patients, 5 were identified through point prevalence and 35 through close contact screening. Conclusion: Performing point prevalence surveillance in acute care facilities is operationally challenging and costly with little benefit in the prevention of Candida auris transmission. More robust collection and reporting of screening data is needed to inform surveillance protocols and prevention strategies specific to different healthcare settings. Limitations of this study include the lack of screening completion in discharged patients identified as close contact or point prevalence surveillance eligible. Additionally, some patients had a history of contact with healthcare facilities outside of this healthcare system, with unknown exposure risks or prevention strategies.

Assessment of 19 Operation Room and Sterile Processing Units in Puerto Rico, 2023: Preliminary Findings using a new ICAR Tool

Background: Infection prevention and control assessments in healthcare settings serve as a primary resource for obtaining data and providing recommendations based on safety, compliance, and quality assurance guidelines. In Puerto Rico (PR), surgical site infections are underreported in the Epi Info platform used by the Puerto Rico Department of Health (PRDOH), mainly due to the complexity of their identification. By focusing on evaluating Operating Rooms/Sterile Processing and Distribution (OR/SPD) units in acute care facilities (ACFs), our goal is to generate new data within the Healthcare-Associated Infection/Antibiotic Resistance (HAI/AR) Program, specifically related to patient management throughout preoperative, intraoperative, and postoperative phases, as well as reprocessing practices. Methods: Nineteen evaluations of ACFs' OR/SPDs were conducted from May through December 2023. Direct observations, file reviews, and personnel assessments were performed using an infection control assessment and response (ICAR) tool developed collaboratively by a team from an acute facility in PR and the HAI/AR Program staff. This ICAR Tool was customized based on guidelines from the certified Board for Sterile Processing and Distribution (CBSPD), the Association of periOperative Registered Nurses (AORN), and the Association for the Advancement of Medical Instrumentation (AAMI), among other regulatory agencies. The Division of Health Quality Promotion (DHQP) reviewed and approved the tool for use in these evaluations. Results: Key findings indicate that 32% of Sterile Processing Department (SPD) units restrict access to dedicated personnel with available manufacturer’s instructions, yet only 36% of SPD personnel are certified in CBSPD and packaging practices. Only 10% of facilities had a water treatment system for sterilization and Immediate Use Steam Sterilization (IUSS) policies. Notably, 84% of endoscopy areas require additional equipment for cultivating endoscopes, and no facility possessed a borescope for visually inspecting endoscope lumens. Tray inspection occurred in 21%, and only 31% of staff knew the Spaulding Classification and Class V Indicators. Conclusion: These data underscore the necessity of evaluating OR/SPD units in ACFs to provide updated recommendations and mitigate the incidence of surgical site infections (SSI). They offer insight into the structural and functional status of OR/SPD units in Puerto Rico, aligning reporting with OR/SPD practices to enhance patient care and minimize infection risks.

Impact of Vascular Access Teams on Central Line Associated Bloodstream Infections

Background: During the COVID-19 pandemic, rates of central line bloodstream infections (CLABSI) increased nationally. Studies pre-pandemic showed improved CLABSI rates with implementation of a standardized vascular access team (VAT).[PL1] [PL2] [mi3] Varying VAT resources and coverage existed in our 10 acute care facilities (ACF) prior to and during the pandemic. VAT scope also varied in 1) process for line selection during initial placement, 2) ability to place a peripherally inserted central catheter (PICC), midline or ultrasound-guided peripheral IV in patients with difficult vascular access, 3) ownership of daily assessment of central line (CL) necessity, and 4) routine CL dressing changes. We aimed to define and implement the ideal VAT structure and evaluate the impact on CLABSI standardized infection ratios (SIR) and rates prior to and during the pandemic. Methods: A multidisciplinary workgroup including representatives from nursing, infection prevention, and vascular access was formed to understand the current state of VAT responsibilities across all ACFs. The group identified key responsibilities a VAT should conduct to aid in CLABSI prevention. Complete VAT coverage[mi4] was defined as the ability to conduct the identified responsibilities daily. We compared the SIR and CLABSI rates between hospitals who had complete VAT (CVAT) coverage to hospitals with incomplete VAT (IVAT) coverage. Given this work occurred during the pandemic, we further stratified our analysis based on a time frame prior to the pandemic (1/2015 – 12/2019) and intra-pandemic (1/2020 - 12/2022). Results: The multidisciplinary team identified 6 key components of complete VAT coverage: Assessment for appropriate line selection prior to insertion, ability to insert PICC and midlines, daily CL and midline care and maintenance assessments, daily assessment of necessity for CL, and weekly dressing changes for CL and midlines[NA5] . A cross walk of VAT scope (Figure 1) was performed in October 2022 which revealed two facilities (A and E) which met CVAT criteria. Pre-pandemic, while IVAT CLABSI rates and SIR were higher than in CVAT units, the difference was not statistically significant. During the pandemic, however, CLABSI rates and SIR were 40-50% higher in IVAT compared to CVAT facilities (Incident Rate Ratio 1.5, 95% CI 1.1-2.0 and SIR Relative Ratio 1.4, 95% CI1.1-1.9 respectively) (Table 1). Conclusions: CLABSI rates were lower in facilities with complete VAT coverage prior to and during the COVID-19 pandemic suggesting a highly functioning VAT can aid in preventing CLABSIs, especially when a healthcare system is stressed and resources are limited.

Immediate Use Steam Sterilization and the Effect on Surgical Site Infections in an Acute Care Facility

Background: Immediate use steam sterilization (IUSS) shortens the time from sterilization to the aseptic transfer onto the surgical sterile field. Published data incompletely defines the extent to which IUSS increases risk of surgical site infection (SSI), compared to standard sterile reprocessing methods. We aimed to measure the association between IUSS use for surgical instrument reprocessing and SSI risk in a facility where IUSS use increased due to staffing constraints and case volumes. Methods: In this retrospective observational study at a tertiary care hospital with a diverse mix of surgery types, we used sterile reprocessing logs and SSI outcomes defined using National Health and Safety Network definitions to compare SSI rates among surgeries using surgical devices sterilized using IUSS compared to standard terminal sterilization methods. We calculated a risk ratio (RR) and 95% confidence interval (95%CI), including stratification by eleven high-volume service lines. Results: Among 23,919 surgical procedures, 416 (1.74%) developed SSIs. IUSS was used to sterilize instruments prior to 1,524 (6.37%) surgical procedures, and of these procedures 39 (2.56%) developed an SSI, compared to 1.68% of non-IUSS procedures (377 SSI in 22,395 procedures; risk ratio [RR] 1.52, 95% confidence interval [95%CI] 1.10-2.11). Two surgical services had statistically significant RRs for SSI development after IUSS: transplant surgery (RR 2.47, 95%CI 1.32-4.60] and plastic surgery (RR 3.64, 95%CI 1.13-11.74; Figure). Conclusion: IUSS is associated with a significant increase in SSIs, including among varied surgery types. IUSS utilization should be minimized.

Relationship between Hand Hygiene and MDRO Acquisition after Implementation of an Electronic Hand Hygiene Monitoring System

Background: Hand hygiene (HH) is fundamental to preventing the transmission of pathogens between patients. Unfortunately, adherence to HH is suboptimal and monitoring adherence is challenging. Electronic HH monitoring systems (EHHMS) are emerging potential solutions to increase the number of HH observations and eliminate the potential for observation bias. This aim of this study is to assess the impact of improved HH adherence after the introduction of an EHHMS on the rates of healthcare facility-onset multidrug-resistant organisms and Clostridioides difficile (HO-MDRO). Methods: We performed a retrospective, quasi-experimental study to evaluate the impact of HH on HO-MDROs across 4 acute care facilities (59 hospital units, 14 of which were ICUs) from January 2021 - September 2022 after implementing an EHHMS in a large academic healthcare system. Clinical cultures from all sources were included; routine surveillance cultures were not collected during this period. HO determination was made using National Healthcare Safety Network (NHSN) definitions. The association between monthly unit-level HH adherence (%) and HO-MDRO rate per 1000 patient-days was assessed using mixed-effects Poisson regression using rate ratios (RR), which accounts for unobserved heterogeneity between units while controlling for number of tests ordered per month per hospital unit. HH adherence was stratified in quartiles (Q1: 24-43%, Q2: 43-51%, Q3: 52-61%, Q4: 61-84%). Results: During the study period, there were 23 million HH opportunities and 1875 MDROs in 772,930 patient-days. HH adherence increased from 41% January 2021 to 57% September 2022. ESBL, MSSA, and CDIFF accounted for most MDROs (Figure 1). The mean monthly HH adherence rate was 52% per unit, with a median of 1.66 (IQR: 0-3.5) MDROs/1000 patient-days. Mixed-effects Poisson regression suggested no significant overall relationship between HH adherence and MDRO rate (Figure 2). A close to null association was observed when comparing quartile two to quartile one (RR: 0.97, 95% CI: 0.82, 1.15), quartile three to quartile one (RR: 0.96, 95% CI: 0.79, 1.17), and quartile four to quartile one (RR: 1.05, 95% CI: 0.86, 1.28). Results were similar across hospitals (Figure 3). Conclusions: Although implementing an EHHMS led to an improvement in HH adherence, we were not able to demonstrate a resultant decrease in HO-MDROs. Potential explanations include the relatively rare outcomes of interest, unrecognized confounders, and the complex interaction between HH and HO-MDROs, since poor HH adherence on a unit may lead to increased attention from infection prevention and therefore increased focus on other MDRO prevention measures.

Candida auris Response in a Tennessee Dialysis Facility, 2023

Background: Candida auris, a multi-drug resistant fungal pathogen, was introduced to Tennessee in 2021. There are limited studies on the spread of C. auris in highly specialized care settings including outpatient dialysis facilities. Facilities are concerned that C. auris transmission is difficult to prevent in this setting due to patient vulnerability, treatment frequency and length, and isolation challenges. As a result, these facilities may reject patients based on their positive colonization status. In 2023, the Tennessee Department of Health (TDH) conducted two containment-driven colonization screenings in response to a colonized patient receiving dialysis treatment for one month without their status being known to the facility. Methods: An initial point prevalence survey (PPS) was conducted to assess for ongoing transmission among dialysis patients. Patient screening was prioritized for the cohort of patients who received dialysis at the same time as the index patient (Cohort A). The screening was broadened to include patients dialyzed directly before Cohort A (Cohort B) by request of the Cohort B patients. A second PPS was conducted 7 weeks later, targeting the same cohorts. Specimens were collected through supervised patient self-collection of a skin swab from the axilla and groin. Flocked Eswabs were used for collection and transferred in Amies transport media to the Tennessee State Public Health Lab. The presence of C. auris was detected via Polymerase Chain Reaction (PCR). Results: Twenty-three patients (12 from Cohort A; 11 from Cohort B) were screened in the first PPS. One patient from Cohort A tested positive. This colonized patient was determined to be a known C. auris case first detected four months prior, but the patient’s status was never communicated to the dialysis facility from the discharging acute care facility. Eleven patients, excluding the previously identified positives, participated (9 from Cohort A; 2 from Cohort B) in the second PPS; no positives were identified. Discussion: The index patient and an additional patient identified by the PPS both received dialysis at this facility for up to 4 months without facility knowledge. These results suggest that the standard infection control practices at this dialysis facility were adequate to prevent the transmission of C. auris among dialysis patients on multiple shifts. Additionally, patient self-collection identified a known C. auris patient. Future TDH work includes further evaluating the risk of C. auris transmission and developing targeted infection prevention and control practices for the outpatient dialysis setting.

Survey of VA Laboratory Practices for Carbapenem-resistant Acinetobacter baumannii and Pseudomonas aeruginosa

Background: Carbapenem-resistant Acinetobacter baumannii (CRAB) and Pseudomonas aeruginosa (CRPA) are drug-resistant pathogens causing high mortality rates with limited treatment options. Understanding the incidence of these organisms and laboratory knowledge of testing protocols is important for controlling their spread in healthcare settings. This project assessed how often Veterans Affairs (VA) healthcare facilities identify CRAB and CRPA and testing practices used. Method: An electronic survey was distributed to 126 VA acute care facilities September-October 2023. The survey focused on CRAB and CRPA incidence, testing and identification, and availability of testing resources. Responses were analyzed by complexity of patients treated at VA facilities (High, Medium, Low) using Fisher’s exact tests. Result: 77 (61.1%) facilities responded, most in urban settings (85.4%). Most respondents were lead or supervisory laboratory technologists (84.2%) from high complexity facilities (69.0%). Few facilities detected CRAB ≥ once/month (4.4%), with most reporting that they have not seen CRAB at their facility (55.0%). CRPA was detected more frequently: 19% of facilities with isolates ≥ once/month, 29.2% a few times per year, and 26.9% reporting had not seen the organism. No differences in CRAB or CRPA incidence was found by facility complexity. Nearly all facilities, regardless of complexity, utilize the recommended methods of MIC or disk diffusion to identify CRAB or CRPA (91.9%) with remaining facilities reporting that testing is done off-site (7.8%). More high complexity facilities perform on-site testing compared to low complexity facilities (32.0% vs 2.7%, p=0.04). 83% of laboratories test for Carbapenemase production, with one-fourth using off-site reference labs. One-fourth of facilities perform additional antibiotic susceptibility testing for CRAB and CRPA isolates, most of which test for susceptibility to combination antibiotics; no differences between complexities were found. Agreement that sufficient laboratory and equipment resources were available was higher in high complexity than in medium complexity facilities (70.7% vs 33.3%, p=0.01), but not low complexity facilities (43.8%). Conclusion: Having timely and accurate testing protocols for CRAB and CRPA are important to quickly control spread and reduce associated mortality. This study shows that most VA protocols follow recommended testing and identification guidelines. Interestingly, there was no difference in CRAB or CRPA incidence for facilities providing higher vs lower complexity of care. While high and low complexity facilities generally reported sufficient resources for CRAB and CRPA evaluation, some medium-complexity labs, who may feel more compelled than low-complexity labs to bring testing in house, reported that additional resources would be required.

The Impact of COVID-19 on Healthcare-Associated Infections: A Survey of Acute Care Hospitals

Background: The COVID-19 pandemic has placed an enormous strain on the healthcare system, including infection prevention and control. The response to the COVID-19 pandemic required extraordinary resources, which were often diverted from routine infection prevention and control activities and may have contributed to increased rates of HAI in the acute care setting. However, the impact of the COVID-19 pandemic on infection prevention and control departments, including staffing and resources, and on routine infection prevention and control activities is not well-described. The objective of this study was to describe the impact of the COVID-19 pandemic on IPC departments and department response to the pandemic. Methods: Between August and December of 2023, we conducted an electronic survey of all acute care facilities participating in the National Healthcare Safety Network. Survey data were analyzed using descriptive statistics. Results: Over 594 infection control departments participated in the survey, representing 1,400 NHSN facilities (20% response rate based on number of eligible NHSN facilities). Half of the respondents reported that their hospital experienced increases in the following HAI rates during the first two years of the pandemic: central-line associated bloodstream infections (54%), catheter-associated urinary tract infections (46%) and ventilator associated pneumonia (45%). When asked to identify the top three contributors to increased HAI rates in their facility, respondents cited the following factors: staffing shortages (70%), patient acuity (69%), use of travel nurses (48%), increased device utilization (37%), and reduced bedside acuity (31%). Respondents reported that their department utilized the following actions to decrease these HAI rates: increased rounding and monitoring of IPC procedures (81%), reeducation of frontline staff on IPC policies and procedures (77%), environmental care rounds (69%), monitoring of isolation compliance (66%), HAI Task Force/Committee (57%), nurse-driven catheter removal protocols (53%), and insertion prevention protocols (53%). When asked if the department experienced applied pressure or attempts to influence HAI reporting due to the increase in HAI rates in the facility experienced in the wake of the pandemic, 19% of respondents reported increased pressure from management/C-suite and 7% reported increased pressure from providers. Conclusion: The COVID-19 pandemic had a substantial impact on IPC departments in acute care hospitals and had a profound effect on IPC staffing, resources and routine IPC activities. Future work needs to identify best practices and lessons learned from the pandemic to inform future pandemic preparedness.

Carbapenem-resistant Acinetobacter baumannii and Carbapenem-resistant Enterobacterales in US Dialysis Populations, 2016-2021

Background: Infections lead to high mortality among patients on chronic dialysis; knowledge of multi-drug resistant infections is limited. The Centers for Disease Control and Prevention’s Emerging Infections Program (EIP) conducts laboratory- and population-based surveillance for carbapenem-resistant Enterobacterales (CRE) in 10 U.S. sites and carbapenem-resistant Acinetobacter baumannii (CRAB) in 9 U.S. sites. We investigated clinical characteristics, healthcare exposures, and outcomes of CRE and CRAB cases in persons on chronic dialysis from 2016-2021. Methods: Among EIP catchment-area residents on chronic dialysis, we defined a CRE case as the first isolation of Escherichia coli, Enterobacter cloacae complex, Klebsiella aerogenes (formerly Enterobacter aerogenes), Klebsiella oxytoca, Klebsiella pneumoniae, or Klebsiella variicola resistant to any carbapenem, from a normally sterile site or urine in a 30-day period. A CRAB case was defined as the first isolation of Acinetobacter baumannii complex resistant to any carbapenem (excluding ertapenem), from a normally sterile site or urine (or lower respiratory tract or wound since 2021) in a 30-day period. Medical records were reviewed. A case was considered colonized if the case culture had no associated infection type or colonization was documented in the medical record. Descriptive analyses, including analyses stratified by pathogen, were conducted. Results: Among 426 cases, 314 were CRE, and 112 were CRAB; most cases were male (235, 55.2%), Black (229, 53.8%), and 51-80 years old (320, 75.1%) (Table). An infection was associated with 363 (85.2%) case cultures; bloodstream infections (148; 40.8%), urinary tract infections (134; 36.9%), and pneumonia (17; 4.7%) were the most frequent. Overall, most cases had documented healthcare exposures (excluding outpatient dialysis) in the year before incident specimen collection, including: 366 (85.9%) hospitalizations, 235 (55.2%) surgeries, 209 (49.1%) long-term care facility stays, 54 (12.7%) long-term acute care facility stays. Additionally, 125 (29.3%) had an intensive care unit admission within the 7 days before incident specimen collection. Compared to CRE cases, a higher proportion of CRAB cases (a) had a long-term care facility stay (82/112 [73.2%] versus 127/314 [40.5%], P&lt;.0001) or hospitalization (103/112 [92%] versus 263/314 [83.8%], P = .03) within the preceding year and (b) died within 30 days of incident specimen collection (40/112 [35.7%] versus 64/314 [20.4%], P = .001). Discussion: Among CRE and CRAB cases in persons on chronic dialysis, healthcare exposures were common, and mortality was high. Additional efforts to better describe the burden of these organisms and associated risk factors in the dialysis population are needed for tailoring infection prevention strategies to this vulnerable.