Multihospital System Research Articles

High Burden of Resistant Gram Negative Pathogens Causing Device-associated Healthcare Infections in a Tertiary Care Setting in Saudi Arabia, 2008-2016

ObjectivesThere is local and regional deficiency in the data examining the contribution of resistant pathogens to device-associated healthcare-associated infections (DA-HAIs). The objective was to examine such data in a multi-hospital system in Saudi Arabia in comparison with the US National Health Surveillance Network (NHSN). MethodsSurveillance of DA-HAIs was prospectively conducted between 2008 and 2016 in four hospitals of Ministry of National Guard Health Affairs. Consecutive NHSN reports were used for comparisons. Definitions and methodology of DA-HAIs and bacterial resistance were based on NHSN. ResultsA total 1260 pathogens causing 1141 DA-HAI events were included. Gram negative pathogens (GNPs) were responsible for 62.5% of DA-HAIs, with a significantly higher Klebsiella, Pseudomonas, Acinetobacter, and Enterobacter than NHSN hospitals. Approximately 28.3% of GNPs and 23.5% of gram positive pathogens (GPPs) had some type of resistance. Nearly 34.3% of Klebsiella were resistant to third/fourth generation cephalosporins, 4.8% of Enterobacteriaceae were carbapenem-resistant (CRE), 24.4% of Staphylococcus aureus were methicillin-resistant (MRSA), and 21.9% of Enterococci were vancomycin-resistant (VRE). Multidrug resistance (MDR) was 65.0% in Acinetobacter, 26.4% in Escherichia coli, 23.0% in Klebsiella, and 14.9% in Pseudomonas. Resistant GNPs including cephalosporin-resistant Klebsiella, MDR Klebsiella, and MDR Escherichia coli were significantly more frequent while resistant GPPs including MRSA and VRE were significantly less frequent than NHSN hospitals. ConclusionThe current findings showed heavier and more resistant contribution of GNPs to DA-HAIs in Saudi hospitals compared with American hospitals. The higher resistance rates in Klebsiella and Escherichia coli are alarming and call for effective antimicrobial stewardship programs.

Pre-existing traits associated with Covid-19 illness severity.

Certain individuals, when infected by SARS-CoV-2, tend to develop the more severe forms of Covid-19 illness for reasons that remain unclear. To determine the demographic and clinical characteristics associated with increased severity of Covid-19 infection. Retrospective observational study. We curated data from the electronic health record, and used multivariable logistic regression to examine the association of pre-existing traits with a Covid-19 illness severity defined by level of required care: need for hospital admission, need for intensive care, and need for intubation. A large, multihospital healthcare system in Southern California. All patients with confirmed Covid-19 infection (N = 442). Of all patients studied, 48% required hospitalization, 17% required intensive care, and 12% required intubation. In multivariable-adjusted analyses, patients requiring a higher levels of care were more likely to be older (OR 1.5 per 10 years, P<0.001), male (OR 2.0, P = 0.001), African American (OR 2.1, P = 0.011), obese (OR 2.0, P = 0.021), with diabetes mellitus (OR 1.8, P = 0.037), and with a higher comorbidity index (OR 1.8 per SD, P<0.001). Several clinical associations were more pronounced in younger compared to older patients (Pinteraction<0.05). Of all hospitalized patients, males required higher levels of care (OR 2.5, P = 0.003) irrespective of age, race, or morbidity profile. In our healthcare system, greater Covid-19 illness severity is seen in patients who are older, male, African American, obese, with diabetes, and with greater overall comorbidity burden. Certain comorbidities paradoxically augment risk to a greater extent in younger patients. In hospitalized patients, male sex is the main determinant of needing more intensive care. Further investigation is needed to understand the mechanisms underlying these findings.

Rapid development of visualization dashboards to enhance situation awareness of COVID-19 telehealth initiatives at a multihospital healthcare system.

The COVID-19 pandemic has led to the rapid expansion of telehealth services as healthcare organizations aim to mitigate community transmission while providing safe patient care. As technology adoption rapidly increases, operational telehealth teams must maintain awareness of critical information, such as patient volumes and wait times, patient and provider experience, and telehealth platform performance. Using a model of situation awareness as a conceptual foundation and a user-centered design approach we describe our process for rapidly developing and disseminating dashboard visualizations to support telehealth operations. We used a 5-step process to gain domain knowledge, identify user needs, identify data sources, design and develop visualizations, and iteratively refine these visualizations. Through this process we identified 3 distinct stakeholder groups and designed and developed visualization dashboards to meet their needs. Feedback from users demonstrated the dashboard’s support situation awareness and informed important operational decisions. Lessons learned are shared to provide other organizations with insights from our process.

Effect of Preoperative Imaging and Provocative Procedures on Long-term Outcomes in 146 Patients Undergoing Surgical Intervention for Median Arcuate Ligament Syndrome

Compression of the celiac artery by the median arcuate ligament can be seen in approximately 5% of the population. With increasing use of cross-sectional imaging, more patients are being referred for consideration of operative intervention. As there is an absence of a clear preoperative protocol to determine appropriate surgical candidates, we sought to identify factors on imaging and provocative testing associated with positive long-term outcomes. This study describes the experience of a multihospital system in regards to preoperative evaluation and outcomes after median arcuate ligament release.

Determinants of hospital efficiency: A literature review

Background: Inefficiency is a pervasive problem in health systems. The World Health Organization estimates that on average, 20%-40% of the global total health expenditure is wasted. The proportion of total health expenditure attributed to hospitals is high, which implies that improving the efficiency of hospitals will lead to more efficient health systems. This study aims to synthetize the major determinants of hospital inefficiency and to develop a framework to identify causes of inefficiency and develop multi-factor interventions to address inefficiencies.Methods: The study is based on survey of the literature on the determinants of hospital efficiency. The studies include those that employ ratio methods of efficiency analysis, data envelopment analysis and stochastic frontier models and econometric models such as the Tobit regression to assess determinants of technical efficiency. Data was extracted in a table format categorized as those that are within the hospital, outside the hospital but within the health system and those that are outside the hospital and health system in the broader macroeconomic system and analyzed.Results: Hospital efficiency is influenced by factors that may be internal to the hospital or external and thus could be wholly or partially out of the control of the hospital. Hospital-level characteristics that influence efficiency include ownership, size, specialization/scope economies, teaching status, membership of multihospital system and other factors such as case-mix and ratio of outpatients to inpatients. However, the effects of these variables are not definitive and consistent; all depends on the context. Factors out of the direct control of the hospital include geographic location, competition and reimbursement systems. The findings further elucidate that no single factor is effective in addressing hospital inefficiencies in isolation from others.Conclusion: There is no one single magic formula or intervention that can be adopted by different hospitals to improve hospital efficiencies. Multiple factors influence the efficiency of hospitals. To address hospital inefficiency multi-intervention packages focusing on the hospital and its environment should be developed.

An audit of inpatient stool ova and parasite (O&P) testing in a multi-hospital health system

ABSTRACT Background & Objectives Stool ova and parasite (O&P) examinations are routinely ordered initial tests in patients admitted to the hospital with acute diarrhea, despite low test positivity rates. We examined the diagnostic yield of inpatient stool O&P exams and identified risk factors associated with positive tests. Methods A retrospective, case-control analysis of inpatients admitted with diarrhea, who underwent O&P examination, was conducted. Clinical and demographic variables of cases were compared with age-and gender-matched controls via uni- and multivariate conditional logistic regression analyses. Results The yield of inpatient O&P exams was 2.15% (37/1723). Blastocystisspp. represented the most common parasites. All patients with positive tests, excluding Blastocystisspp., had at least one of the following risk factors: smoking, prior parasitic disease, HIV-positive status, travel to an endemic area, and institutionalization. Conclusions Superfluous inpatient stool O&P exams confer a financial and labor burden to hospital systems. Stool O&P exams should be restricted to individuals admitted to the hospital for <3 days, having diarrhea >7 days and possessing at least one of the following risk factors: smoking, prior parasitic disease, HIV-positive status, travel to an endemic area, and institutionalization. Such selective testing can confer a 51% reduction in testing, costs, and labor.

High contribution and impact of resistant gram negative pathogens causing surgical site infections at a multi-hospital healthcare system in Saudi Arabia, 2007\u20132016

BackgroundDespite being largely preventable, surgical site infections (SSIs) are still one of the most frequent healthcare-associated infections. The presence of resistant pathogens can further augment their clinical and economic impacts. The objective was to estimate the distribution and resistance in SSI pathogens in Saudi Arabia and to compare them to the US National Healthcare Safety Network (NHSN) hospitals.MethodsTargeted SSI surveillance was prospectively conducted on several surgical procedures done between 2007 and 2016 in four hospitals of Ministry of National Guard Health Affairs. Definitions and methodology of SSI and bacterial resistance were based on NHSN.ResultsA total 492 pathogens causing 403 SSI events were included. The most frequent pathogens were Staphylococcus aureus (22.8%), Pseudomonas aeruginosa (20.1%), Klebsiella spp. (12.2%), and Escherichia coli (12.2%), with marked variability between surgeries. Approximately 30.3% of Staphylococcus aureus was methicillin-resistant (MRSA), 13.0% of Enterococcus spp. was vancomycin-resistant (VRE), and 5.5% of Enterobacteriaceae were carbapenem resistant (CRE). The highest multidrug-resistant (MDR) GNPs were Acinetobacter spp. (58.3%), Klebsiella spp. (20.4%) and Escherichia coli (16.3%). MRSA was significantly less frequent while cephalosporin-resistant Klebsiella spp., MDR Klebsiella spp., and MDR Escherichia coli were significantly more frequent in our hospitals compared with NHSN hospitals.ConclusionGNPs in a tertiary care setting in Saudi Arabia are responsible for more than 60% of SSI with more resistant patterns than Western countries. This information may be critical to secure resources and ensure support for caregivers and healthcare leaders in implementing antimicrobial stewardship programs and evidence-based SSI preventive practices.

PD01-10 SURGICAL SITE INFLUENCES COST EFFECTIVENESS OF URETEROSCOPY IN A LARGE HEALTHCARE SYSTEM

You have accessJournal of UrologyStone Disease: Surgical Therapy I (PD01)1 Apr 2020PD01-10 SURGICAL SITE INFLUENCES COST EFFECTIVENESS OF URETEROSCOPY IN A LARGE HEALTHCARE SYSTEM Sari Khaleel*, Andrew Portis, James Anderson, and Michael Borofsky Sari Khaleel*Sari Khaleel* More articles by this author , Andrew PortisAndrew Portis More articles by this author , James AndersonJames Anderson More articles by this author , and Michael BorofskyMichael Borofsky More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000821.010AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Ureteroscopy(URS) has become the most common surgical management for urolithiasis. Disposable instruments (DI’s) used during URS may vary, which in turn affects overall procedure cost. To date, the influence of surgeon and hospital site on the total DI cost (DIC) of URS has not been formally studied. We sought to assess whether surgeon and site were independently associated with DIC in a large multi-hospital system. METHODS: Our institutional electronic medical record (Epic Systems, Madison, WI) was retrospectively searched for procedures billed for CPT codes 52356/52353 (URS with/without stent placement), performed from 8/2018 – 08/2019. We developed a computer program in Perl programming language to analyze raw EMR data. Our outcomes of interest were mean case length, number of DI’s, and hospital-incurred total DIC. DI’s were classified as laser fiber, wires, ureteral stent, stone basket, ureteral access sheath, ureteral dilator, dual lumen catheter, or other “miscellaneous” items with DIC ≥$50. We selected for surgeons who performed at least 20 procedures at more than one site. Sites were deemed high- or low-volume (HV, LV) sites if their annual volume was above or below median site volume in the system.Multivariate regression was used identify predictive factors, and analysis of variance (ANOVA) was used to assess variation across different sites and surgeons. RESULTS: We identified 368 cases performed by 8 surgeons across 6 sites (3 HV sites, 3 LV sites). Median site volume was 100 cases. Most cases (304, 75.2%) were performed at HV sites. Mean case DIC, case length, and number DI’s used varied significantly across sites (ANOVA p = 0.000 for all three variables). Overall mean DIC was $975 ($388.8 – $1863), mean number of DI’s used was 5.48 (3-9), and mean total case length was 78.7 minutes (28 – 187.8). On multivariate regression, only surgical site was a significant predictor of DIC (p = 0.000), when adjusting for surgeon and high/low volume status (Figure 1). Site and surgeon were both significant predictors of number of DI’s used (p=0.000), and case length (p = <0.01). CONCLUSIONS: Procedural costs related to URS may vary between hospitals even when performed by the same surgeon. Further investigation into hospital practices with low DIC’s is warranted in an effort to potentially identify opportunities for cost savings. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e63-e64 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Sari Khaleel* More articles by this author Andrew Portis More articles by this author James Anderson More articles by this author Michael Borofsky More articles by this author Expand All Advertisement PDF downloadLoading ...

Creating a Palliative Care Inpatient Response Plan for COVID-19—The UW Medicine Experience

ContextThe coronavirus disease 2019 (COVID-19) pandemic is stressing health care systems throughout the world. Significant numbers of patients are being admitted to the hospital with severe illness, often in the setting of advanced age and underlying comorbidities. Therefore, palliative care is an important part of the response to this pandemic. The Seattle area and UW Medicine have been on the forefront of the pandemic in the U.S. MethodsUW Medicine developed a strategy to implement a palliative care response for a multihospital health care system that incorporates conventional capacity, contingency capacity, and crisis capacity. The strategy was developed by our palliative care programs with input from the health care system leadership. ResultsIn this publication, we share our multifaceted strategy to implement high-quality palliative care in the context of the COVID-19 pandemic that incorporates conventional, contingency, and crisis capacity and focuses on the areas of the hospital caring for the most patients: the emergency department, intensive care units, and acute care services. The strategy focuses on key content areas, including identifying and addressing goals of care, addressing moderate and severe symptoms, and supporting family members. ConclusionStrategy planning for delivery of high-quality palliative care in the context of the COVID-19 pandemic represents an important area of need for our health care systems. We share our experiences of developing such a strategy to help other institutions conduct and adapt such strategies more quickly.

Implementation of a Renal Precision Medicine Program: Clinician Attitudes and Acceptance.

A precision health initiative was implemented across a multi-hospital health system, wherein a panel of genetic variants was tested and utilized in the clinical care of chronic kidney disease (CKD) patients. Pharmacogenomic predictors of antihypertensive response and genomic predictors of CKD were provided to clinicians caring for nephrology patients. To assess clinician knowledge, attitudes, and willingness to act on genetic testing results, a Likert-scale survey was sent to and self-administered by these nephrology providers (N = 76). Most respondents agreed that utilizing pharmacogenomic-guided antihypertensive prescribing is valuable (4.0 ± 0.7 on a scale of 1 to 5, where 5 indicates strong agreement). However, the respondents also expressed reluctance to use genetic testing for CKD risk stratification due to a perceived lack of supporting evidence (3.2 ± 0.9). Exploratory sub-group analyses associated this reluctance with negative responses to both knowledge and attitude discipline questions, thus suggesting reduced exposure to and comfort with genetic information. Given the evolving nature of genomic implementation in clinical care, further education is warranted to help overcome these perception barriers.

Baseline Factors Associated with Mortality in Patients Who Engaged in Buprenorphine Treatment for Opioid Use Disorder: a Cohort Study.

Opioid agonist therapy (OAT) has been shown to reduce mortality in patients with opioid use disorder (OUD), yet mortality in individuals receiving OAT remains higher than in an age- and gender-matched population. To identify baseline risk factors in patients who engaged in buprenorphine treatment that are associated with this elevated risk of death. We performed a retrospective cohort study from January 1, 2007, to December 31, 2018, using a centralized clinical data registry within a multi-hospital health system in Boston, MA, USA. All adult patients who had ≥ 2 consecutive encounters with sublingual buprenorphine on the active medication list from January 1, 2007, to December 31, 2018. We abstracted several sociodemographic, clinical, and healthcare use characteristics from the clinical data registry. The primary outcome was all-cause mortality and the secondary outcome was opioid overdose-related mortality. We performed multivariable cox regression to identify baseline characteristics independently associated with these outcomes. Of 5948 patients in the cohort, the majority were white (80.7%) and male (59.7%), with a mean age of 38.2years. The all-cause mortality rate was 24.0 deaths per 1000 person-years. Baseline characteristics independently associated with an increased hazard of all-cause mortality included homelessness (adjusted hazard ratio [aHR] = 1.39; 95% confidence interval [CI] = 1.09, 1.78), an opioid on the active medication list (aHR = 1.28; 95% CI = 1.08, 1.52), and entry into the cohort during an inpatient hospitalization (aHR = 1.43; 95% CI = 1.18, 1.73). Homelessness was also associated with an increased hazard of opioid overdose-related mortality (aHR = 1.77; 95% CI = 1.25, 2.50). We identified several novel and potentially modifiable predictors of mortality among patients engaging in buprenorphine treatment who remain at an increased risk of death compared with the general population. Understanding these risk factors can assist healthcare providers in risk stratification and inform the design of targeted interventions to improve outcomes in a high-risk patient population.

Retrospective analysis of cases of intraoperative awareness in a large multi-hospital health system reported in the early postoperative period

BackgroundAwareness with recall under general anesthesia remains a rare but important issue that warrants further study.MethodsWe present a series of seven cases of awareness that were identified from provider-reported adverse event data from the electronic anesthesia records of 647,000 general anesthetics.ResultsThe low number of identified cases suggests an under-reporting bias. Themes that emerge from this small series can serve as important reminders to anesthesia providers to ensure delivery of an adequate anesthetic for each patient. Commonalities between a majority of our identified anesthetic awareness cases include: obesity, use of total intravenous anesthesia, use of neuromuscular blockade, and either a lack of processed electroencephalogram (EEG) monitoring or documented high depth of consciousness index values. An interesting phenomenon was observed in one case, where adequately-dosed anesthesia was delivered without technical issue, processed EEG monitoring was employed, and the index value suggested an adequate depth of consciousness throughout the case.ConclusionsProvider-reported adverse event data in the immediate post-operative period are likely insensitive for detecting cases of intraoperative awareness. Though causation cannot firmly be established from our data, themes identified in this series of cases of awareness with recall under general anesthesia provide important reminders for anesthesia providers to maintain vigilance in monitoring depth and dose of anesthesia, particularly with total intravenous anesthesia.

Predictors for Adverse Outcomes in Diabetic Ketoacidosis in a Multihospital Health System

Objective: To determine predictors of prolonged length of stay (LOS), 30-day readmission, and 30-day mortality in a multihospital health system. Methods: We performed a retrospective review of 531 adults admitted with diabetic ketoacidosis (DKA) to a multihospital health system between November 2015 and December 2016. Demographic and clinical data were collected. Linear regression was used to calculate odds ratios (ORs) for predictors and their association with prolonged LOS (3.2 days), 30-day readmission, and 30-day mortality. Results: Significant predictors for prolonged LOS included: intensive care unit (ICU) admission (OR, 2.12; 95% confidence interval [CI], 1.38 to 3.27), disease duration (nonlinear) (OR, 1.28; 95% CI, 1.10 to 1.49), non-white race (OR, 1.73; 95% CI, 1.15 to 2.60), age at admission (OR, 1.03; 95% CI, 1.01 to 1.04), and Elixhauser index (EI) (OR, 1.21; 95% CI, 1.13 to 1.29). Shorter time to consult after admission (median [Q1, Q3] of 11.3 [3.9, 20.7] vs. 14.8 [7.4, 37.3] hours, P<.001) was associated with a shorter LOS. Significant 30-day readmission predictors included: Medicare insurance (OR, 2.35; 95% CI, 1.13 to 4.86) and EI (OR, 1.31; 95% CI, 1.21 to 1.41). Endocrine consultation was associated with reduced 30-day readmission (OR, 0.51; 95% CI, 0.28 to 0.92). A predictive model for mortality was not generated because of low event rates. Conclusion: EI, non-white race, disease duration, age, Medicare, and ICU admission were associated with adverse outcomes. Endocrinology consultation was associated with lower 30-day readmission, and earlier consultation resulted in a shorter LOS. Abbreviations: CI = confidence interval; DKA = diabetic ketoacidosis; EI = Elixhauser index; HbA1c = hemoglobin A1c; ICD = International Classification of Diseases; ICU = intensive care unit; LOS = length of stay; OR = odds ratio; Q = quartile.

Electronic Health Record and Parenteral Nutrition Functionality: A Gap Analysis.

Parenteral nutrition (PN) is a complex, high-alert medication that contains up to 40 different ingredients. Surveys have shown that current electronic health record (EHR) systems may lack functionality for safe and optimal delivery of PN. A gap analysis was performed by a multihospital system to identify opportunities to enhance the current PN process using the EHR utilized by the organization.

Ten-year resistance trends in pathogens causing healthcare-associated infections; reflection of infection control interventions at a multi-hospital healthcare system in Saudi Arabia, 2007\u20132016

BackgroundStudying temporal changes in resistant pathogens causing healthcare-associated infections (HAIs) is crucial in improving local antimicrobial and infection control practices. The objective was to describe ten-year trends of resistance in pathogens causing HAIs in a tertiary care setting in Saudi Arabia and to compare such trends with those of US National Health Surveillance Network (NHSN).MethodsPooled analysis of surveillance data that were prospectively collected between 2007 and 2016 in four hospitals of Ministry of National Guard Health Affairs. Definitions and methodology of HAIs and antimicrobial resistance were based on NHSN. Consecutive NHSN reports were used for comparisons.ResultsA total 1544 pathogens causing 1531 HAI events were included. Gram negative pathogens (GNP) were responsible for 63% of HAIs, with a significant increasing trend in Klebsiella spp. and a decreasing trend in Acinetobacter. Methicillin-resistant Staphylococcus aureus (27.0%) was consistently less frequent than NHSN. Vancomycin-resistant Enterococci (VRE, 20.3%) were more than doubled during the study, closing the gap with NHSN. Carbapenem resistance was highest with Acinetobacter (68.3%) and Pseudomonas (36.8%). Increasing trends of carbapenem resistance were highest in Pseudomonas and Enterobacteriaceae, closing initial gaps with NHSN. With the exception of Klebsiella and Enterobacter, multidrug-resistant (MDR) GNPs were generally decreasing, mainly due to the decreasing resistance towards cephalosporins, fluoroquinolones, and aminoglycosides.ConclusionThe findings showed increasing trends of carbapenem resistance and VRE, which may reflect heavy use of carbapenems and vancomycin. These findings may highlight the need for effective antimicrobial stewardship programs, including monitoring and feedback on antimicrobial use and resistance.

The impact of race and socioeconomic status on the presentation, management and outcomes for gastric cancer patients: Analysis from a metropolitan area in the southeast United States.

Socioeconomic disparities in gastric cancer have been associated with differences in care and inferior outcomes. We evaluated the presentation, treatment, and survival for patients with gastric cancer (GC) in a metropolitan setting with a large African American population. Retrospective cohort analysis of patients with GC (2003-2018) across a multi-hospital system was performed. Associations between socioeconomic and clinicopathologic data with the presentation, treatment, and survival were examined. Of 359 patients, 255 (71%) were African American and 104 (29%) Caucasian. African Americans were more likely to present at a younger age (64.0 vs 72.5, P < .001), have state-sponsored or no insurance (19.7% vs 6.9%, P = .02), reside within the lowest 2 quintiles for median income (67.4% vs 32.7%, P < .001), and have higher rates of Helicobacter pylori (14.9% vs 4.8%, P = .02). Receipt of multi-modality therapy was not impacted by race or insurance status. On multivariable analysis, only AJCC T class (HR 1.68) and node positivity (HR 2.43) remained significant predictors of disease-specific survival. Despite socioeconomic disparities, African Americans, and Caucasians with GC had similar treatment and outcomes. African Americans presented at a younger age with higher rates of H. pylori positivity, warranting further investigation into differences in risk factors and tumor biology.

A comparison of the incidence of midline catheter–associated bloodstream infections to that of central line–associated bloodstream infections in 5 acute care hospitals

In a retrospective study conducted over 12 months in a multi-hospital system, the incidence of bloodstream infections associated with midline catheters was not significantly lower than that associated with central venous catheters (0.88 vs 1.10 infections per 1,000 catheter-days). Additional research is needed to further characterize the infectious risks of midline catheters and to determine optimal strategies to minimize these risks.

PROcess for the Design of User-Centered Environments (PRODUCE): Guiding Change in the Health Care Environment.

Changes in the physical environments of health care settings have become increasingly common to meet the evolving needs of the health care marketplace, new technologies, and infrastructure demands. Physical environment change takes many forms including new build construction, renovation of existing space, and relocation of units with little to no construction customization. The interrelated nature of the complex socio-technical health care system suggests that even small environmental modifications can result in system-level changes. Environmental modifications can lead to unintended consequences and introduce the potential for latent safety threats. Engaging users throughout the change lifecycle allows for iterative design and testing of system modifications. This chapter introduces a flexible process model, PROcess for the Design of User-Centered Environments (PRODUCE), designed to guide system change. The model was developed and refined across a series of real-world renovations and relocations in a large multihospital health care system. Utilizing the principles of user-centered design, human factors, and in-situ simulation, the model engages users in the planning, testing, and implementation of physical environment change. Case studies presented here offer exemplars of how to modify the model to support individual project objectives and outcomes to assess at each stage of the project.

1986. Impact of Two-Step Testing on the Diagnosis and Management of Clostridium difficile in a Multi-Hospital Healthcare System

BackgroundDistinguishing active C. difficile infection (CDI) from asymptomatic colonization remains a significant challenge. A multi-step testing algorithm can improve the diagnostic accuracy of CDI and associated antibacterial prescribing. This study evaluated the impact of two-step testing on CDI rates and management in a multi-hospital community health system.MethodsTwo-step C. difficile testing (PCR for initial screening followed by EIA for toxin detection) was implemented in 6 acute care community hospitals in April 2018. EIA testing was automatically performed on all stool samples with a positive C. difficile PCR result. Prior to implementation, PCR alone was used to identify CDI. Messaging attached to the PCR laboratory report alerted prescribers of discrepant results (PCR +/EIA -). Anti-C. difficile therapy was at the discretion of the prescriber. We performed a retrospective cohort analysis over a 2-year period to evaluate the effect of two-step testing on system-wide hospital-onset CDI (HO-CDI) per 10,000 patient-days (PD) and anti-CDI antimicrobial use (AU) in days of therapy (DOT) per 1,000 PD. Segmented negative binomial regression with hospital clustering was used to estimate predicted HO-CDI rate for the baseline period between April 1, 2017 through March 31, 2018 and the post-intervention between May 1, 2018 through March 31, 2019. The implementation date at all sites in April 2018 was unknown; therefore, this month was removed from the analysis. Anti-CDI agents included fidaxomicin, metronidazole, and oral vancomycin, but may have included non-CDI indications for metronidazole.ResultsA total of 115 HO-CDI cases were identified; 91 (79%) before and 24 (21%) after. Prior to implementation of two-step testing, CDI rates declined at 4% per month (P = NS). The rate immediately dropped by 36% (P = 0.004) after two-step testing was implemented, but the trend did not significantly change (P = 0.52, Figure 1). Community-onset CDI rates also decreased during this time period. Combined facility-wide anti-CDI agent use was 824.87 before and 838.21 DOT/1,000 PD after and did not significantly change.ConclusionUse of a two-step approach for CDI testing reduced HO-CDI rates, but did not have a significant impact on anti-CDI antibiotic use in a multi-hospital community health system. Disclosures All authors: No reported disclosures.

2344. Evaluation of a Best Practice Alert (BPA) to Reduce Inappropriate Testing for Clostridium difficile Infection (CDI) Within a Multi-Hospital System

BackgroundHospital-acquired CDI contribute to significant morbidity, mortality, and cost burden in hospitalized patients. Clinical practice guidelines recommend strict testing criteria when employing nucleic acid amplification testing alone as to not test asymptomatic carriers. A BPA within the electronic medical record (EMR) may assist with this screening.MethodsAt our 9-hospital system, we created a BPA to help identify patients who may not meet criteria for CDI testing. Initial BPA (January 2018) asked if patient had 3 or more stools (yes/no) and if laxatives were administered in the last 48 hours (yes/no). An expanded BPA was updated to pull medication administration records for use of laxatives in the prior 48 hours (August 2018) and notified providers of recent C. difficile testing in the past 7 days (January 2019). C. difficile orders from March 2017 (historical), March 2018 (intervention 1), and March 2019 (intervention 2) were evaluated to assess impact of these interventions.Results C. difficile testing during 30,621 (historical), 31,299 (intervention 1), and 31,960 (intervention 2) patient-days were evaluated. Rates of C. difficile orders and infections are reported in the table. Ratio of positive C. difficile specimens to tested specimens were similar between the historical arm (51 of 402; 12.7%) and both intervention 1 (42 of 271; 15.5%) and intervention 2 (45 of 316; 14.2%) arms (P = 0.3 and P = 0.5, respectively). Intervention 1 and intervention 2 arms were similar in all metrics. Statistical analysis was performed using Stata, v.14.2.ConclusionImplementation of a decision support tool to assist with C. difficile testing significantly decreased order rates in both the initial and expanded BPA intervention arms. Compared with historical rates, incidence of CDI decreased in both intervention arms though these were not statistically significant. Similarly, ratio of positive specimens to specimens tested increased in both intervention arms, though not significant, indicating a trend toward improved patient selection. To improve appropriate CDI testing, further oversight and/or education is needed to accompany implementation of an EMR decision support tool, such as BPAs. Disclosures All authors: No reported disclosures.