Network Of Community Hospitals Research Articles

Identifying High-Cost, High-Need Patients in a Network of Community Hospitals.

We examined healthcare costs at HonorHealth, a community-based academic health center comprised of 5 hospitals and numerous ambulatory care facilities. Patient encounters that resulted in admission in 2019 were included in the study. Mean costs in 2019 for high costs and high needs (HCHN) patients were compared with all remaining patients using a framework developed by the National Academy of Medicine. HCHN patients were older (71 vs 52 years), with a lower percentage of females (41.7% vs 59.8%), more frequently White (90.1% vs 87.5%), less frequently married (52.4% vs 54.5%), with a longer length of stay (6.5 vs 3.0 days) and higher mean charges ($134 743 vs $16 414). The mean cost per patient in the HCHN group decreased by age group ($192, 963, $165 200, $144 584, $134 795, and $108 356) for 0 to 18, 19 to 44, 45 to 64, 65 to 84, and 85+ years, respectively. HCHN patients were more publicly insured (49% vs 38%). Targeted interventions to treat HCHN may lead to lower healthcare costs and improved health outcomes within this system.

The Covid-19 pandemic as a driver towards integrated health care-learning from the experiences of UK community hospitals

Introduction: Many changes occurred in the UK National Health Service (NHS) during the COVID-19 pandemic-some positive and some negative. We were interested in how the pandemic drove integration of health care in small community hospitals in the UK.
 Method: Appreciative inquiry was used to understand staff perspectives of how community hospitals responded. A total of 20 organisations participated, representing 168 (34%) of community hospitals in the UK. Qualitative interviews were conducted, with a total of 85 staff members, using an online video platform. Community representation was featured through the membership of our project board and advisory group which includes Hospital Leagues of Friends. 30 case studies were developed from these interviews.
 Results: From our case studies we examine 4 types of integrated care: Multi-Disciplinary Team Working, Community Hospital and Primary Care, Community Hospital and Acute Care, Community Hospital and Local Community. In the interviews staff gave accounts of improved collaborations and partnerships across the local health and care system, and the consequent impact on patients, families, staff and the community. Many staff said that in many cases teamworking and partnerships were already established, so the trust was there to build on even closer joint working.
 Case studies demonstrating enhanced integration of health care at the micro, meso and macro level are described. Examples of micro changes were small but significant local improvements which impacted positively on the patient experience. Examples of meso changes were those that were across a community hospital or hospitals, with partnerships and joint working supporting improved services. We focus particularly on the macro level, where system-wide changes were implemented to embed innovations and integrated working. 
 We pay particular reference to factors that are known to be associated with successful integration as shown in a recently published systematic review, namely: organisational culture, workforce management, inter-organisational collaboration, leadership ability of staff, economic factors and political factors.
 Discussion: We discuss the learning from the case studies that in order to make the most of our community hospitals we need to be: making decisions locally, benefiting from excellent leadership, recognising community hospitals as community assets and looking after our staff. In particular locally devolved decision-making appropriate to local context was viewed as a critical success factor in swiftly making changes and improvements for the benefit of patients and families, and also for staff. Where this was supported by strong leadership, staff reported successful quality improvements. We continue to work with staff in online discussion groups in our Community Hospital Q Community Special Interest Group to build on this learning and share widely across the community hospital network.
 Conclusion: This study shows how the pandemic accelerated integrated care between staff, services and systems, and the improved recognition of the vital role of community hospitals as community services in the local health and care system.
 
 

Increasing the use of anxiolysis and analgesia for paediatric procedures in a community emergency department network: a quality improvement initiative

Prior reports describe the care children receive in community EDs (CEDs) compared with paediatric EDs (PEDs) as uneven. The Emergency Medical Services for Children (EMSC) initiative works to close these...

Treatment patterns, resource utilization and clinical outcomes in patients with higher risk myelodysplastic syndromes (MDS) in United States community practices

Management of higher-risk myelodysplastic syndromes (HR-MDS) is challenging in the real world. We studied 200 patients with HR-MDS within a large US community hospital network. We describe the clinical presentation, patient-related factors, prognostic characteristics, treatment patterns, clinical outcomes and resource utilization. Patients with HR-MDS, treated in our community setting, were elderly (median age 76 years) with a high comorbidity burden. First-line therapy was hypomethylating agent (HMA) monotherapy (20%), lenalidomide (2%), and venetoclax (2%), while the rest were treated with supportive care. Sixty-one percent of the 200, were subsequently hospitalized within 6 months of initial diagnosis. Overall survival was 11.8 months. Curative transplantation was infrequent, HMA-based therapy was underutilized, responses were not durable, most patients became transfusion-dependent or transformed to AML, and resource utilization was substantial and was highly correlated with total in-hospital days. There is a clear unmet need for tolerable treatments that can produce durable remissions in this population.

Closing the Fluid Gap: Improving Isotonic Maintenance Intravenous Fluid Use in a Community Hospital Network.

The American Academy of Pediatrics recommends using isotonic intravenous fluids (IVF) for maintenance needs to decrease the risk of hyponatremia. We conducted a quality improvement project to increase the use of isotonic maintenance IVF in pediatric patients admitted to three sites in a community hospital network to >85% within 12 months. We used improvement methodology to identify causes of continued hypotonic fluid use, which involved provider behavior and systems factors. We implemented interventions to address these factors including: (1) education; (2) clinical decision support; and (3) stocking automated medication dispensing systems with isotonic IVF. We compared isotonic IVF use before and after interventions in all admitted patients aged 28 days to 18 years who received maintenance IVFs at the rate of at least 10 mL/hour. We excluded admissions of patients with active chronic medical conditions like diabetic ketoacidosis. Balancing measures were the occurrence of adverse events from hypo- or hypernatremia. Data were analyzed using Laney P' statistical process control charts. Isotonic IVF use among patients requiring maintenance fluids at all three sites surpassed the goal of >85% within 12 months. There were no reports of hypo- or hypernatremia or other adverse outcomes related to the use of isotonic IVF. A combination of interventions aimed at provider behavior and systems factors was critical to successfully adopting the American Academy of Pediatrics guideline regarding the use of maintenance isotonic IVF in hospitalized children.

A 7-year analysis of attributable costs of healthcare-associated infections in a network of community hospitals in the southeastern United States.

We calculated the attributable cost of several healthcare-associated infections in a community hospital network: central-line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), hospital-onset Clostridioides difficile infections (CDI-HOs) (43 hospitals); surgical site infections (SSIs) (40 hospitals). From 2016 to 2022, the total cost of CLABSIs, CAUTIs, CDI-HOs, and SSIs was $420,012,025.

A multivariate analysis of low-dose CT lung cancer screening in a Michigan community hospital network.

10576 Background: Lung cancer is the leading cause of cancer deaths in the United States. The USPSTF recommended screening for lung cancer with low-dose chest computer tomography (LDCT) in 2013. This was based on the National Lung Screening Trial (NLST) which showed a 20% relative reduction in mortality from LDCT compared with chest radiography in high-risk individuals. The major NLST eligibility criteria were age 55-74, a 30 + pack year smoking history and current smoking status or having quit in the last 15 years. The impact of other risk factors on screening results besides inclusion criteria is unknown. We sought to identify other factors for the risk of lung cancer detection in screened individuals. Methods: This was a retrospective cohort study employing a Michigan based McLaren Hospital Network Lung Cancer Screening Program (LCSP) database from 2015-2022. Participant eligibility in screening was the USPSTF criteria except for an age range of 50-80. Analyses were stratified by BMI, smoking pack-years, insurance status, smoking status, sex, other CT findings, pre- vs. during COVID pandemic (before and after January 2020). Multivariate logistic regression analysis was used for odds ratios (OR) with 95% confidence intervals (CI) as estimates of the relative risk of an elevated Lung-RADS category ≥3 (high risk of detecting lung cancer). Results: A total of 2638 subjects, 49.91% females, 50.09% males, mean BMI 29.50 ± 7.17 (SD), pack-years 44.52 ±18.29, Medicaid 6.66%, Medicare 32.01%, Private Insurance 57.62%, Self-pay /unknown 3.71%. Current smoker 65.49%, Former smoker 34.51%, other CT findings 51.99%, pre-COVID 46.08%, during COVID pandemic 53.92%. Lung-RADS category 0 (0.04%), 1 (35.33%), 2, (50.61%), 3 (6.56%), 4a (4.85%), 4b (1.55%), 4x (1.06%). A statistically significant association with a Lung-RADS category ≥3 was found with lower BMI, OR=0.980 (95% CI, 0.969-0.991), p=0.0005, and female gender, OR=1.232 (95% CI, 1.039-1.462), p=0.0166 (Table). Conclusions: In our study cohort a lower-than-average BMI and also female gender were statistically correlated with an elevated Lung-RADS category ≥3. These findings might be incorporated into a risk stratification model, however further larger studies are needed to validate our findings. [Table: see text]

Development, multi-institutional external validation, and algorithmic audit of an artificial intelligence-based Side-specific Extra-Prostatic Extension Risk Assessment tool (SEPERA) for patients undergoing radical prostatectomy: a retrospective cohort study

Accurate prediction of side-specific extraprostatic extension (ssEPE) is essential for performing nerve-sparing surgery to mitigate treatment-related side-effects such as impotence and incontinence in patients with localised prostate cancer. Artificial intelligence (AI) might provide robust and personalised ssEPE predictions to better inform nerve-sparing strategy during radical prostatectomy. We aimed to develop, externally validate, and perform an algorithmic audit of an AI-based Side-specific Extra-Prostatic Extension Risk Assessment tool (SEPERA). Each prostatic lobe was treated as an individual case such that each patient contributed two cases to the overall cohort. SEPERA was trained on 1022 cases from a community hospital network (Trillium Health Partners; Mississauga, ON, Canada) between 2010 and 2020. Subsequently, SEPERA was externally validated on 3914 cases across three academic centres: Princess Margaret Cancer Centre (Toronto, ON, Canada) from 2008 to 2020; L'Institut Mutualiste Montsouris (Paris, France) from 2010 to 2020; and Jules Bordet Institute (Brussels, Belgium) from 2015 to 2020. Model performance was characterised by area under the receiver operating characteristic curve (AUROC), area under the precision recall curve (AUPRC), calibration, and net benefit. SEPERA was compared against contemporary nomograms (ie, Sayyid nomogram, Soeterik nomogram [non-MRI and MRI]), as well as a separate logistic regression model using the same variables included in SEPERA. An algorithmic audit was performed to assess model bias and identify common patient characteristics among predictive errors. Overall, 2468 patients comprising 4936 cases (ie, prostatic lobes) were included in this study. SEPERA was well calibrated and had the best performance across all validation cohorts (pooled AUROC of 0·77 [95% CI 0·75-0·78] and pooled AUPRC of 0·61 [0·58-0·63]). In patients with pathological ssEPE despite benign ipsilateral biopsies, SEPERA correctly predicted ssEPE in 72 (68%) of 106 cases compared with the other models (47 [44%] in the logistic regression model, none in the Sayyid model, 13 [12%] in the Soeterik non-MRI model, and five [5%] in the Soeterik MRI model). SEPERA had higher net benefit than the other models to predict ssEPE, enabling more patients to safely undergo nerve-sparing. In the algorithmic audit, no evidence of model bias was observed, with no significant difference in AUROC when stratified by race, biopsy year, age, biopsy type (systematic only vs systematic and MRI-targeted biopsy), biopsy location (academic vs community), and D'Amico risk group. According to the audit, the most common errors were false positives, particularly for older patients with high-risk disease. No aggressive tumours (ie, grade >2 or high-risk disease) were found among false negatives. We demonstrated the accuracy, safety, and generalisability of using SEPERA to personalise nerve-sparing approaches during radical prostatectomy. None.

Continuation Rates of the Etonogestrel Implant and Factors Associated With Early Discontinuation.

The etonogestrel implant is generally consideredaneffective, three-year, long-acting reversible contraceptive device. Previous research, such as the landmark CHOICE study, has reported a one-year continuation rate of 72% to 84%, however, in a real-world setting these rates may be significantly lower. To study etonogestrel implant continuation rates and factors associated with early discontinuation in a specific clinical setting. Single-center, retrospective cohort study of patients who received the etonogestrel implant between January 1, 2015, and December 31, 2017, at several practices at an academic community hospital network. Records were reviewed up to three years after implant insertion to determine continuation rates (oneto threeyears), early discontinuation rates (≤12 months), and reasons for early discontinuation. A sample size calculation was performed to guide a subanalysis of side effects. A total of 774 patients underwent etonogestrel insertion during the study period.The one-year continuation rate was lower than that of the CHOICE study (62% vs. 83%, P <0.001). A subanalysis (n=216) revealed that a majority (82%, n=177) of patients reported side effects. Side effects were more common in patients with early discontinuation compared with patients who continued use longer than one year (93% vs. 71%, P <0.001). The most common side effect, abnormal uterine bleeding, was not significantly associated with early discontinuation. A significant association (P=0.02) was found between early discontinuation and neurologic/psychiatric complaints. The one-year continuation rate of the etonogestrel implant inourpopulation is significantly lower than the value reported by CHOICE. Implant side effects are common and significantly affect rates of discontinuation. Our data suggest there is an opportunity for education and counseling for individuals opting for this method of long-acting contraception.

Abstract WP41: Should They Stay Or Should They Go? The Impact Of AI-based Care Coordination On Stroke Patient Transfers Across A Hospital Network

Introduction: A key decision facing non-thrombectomy capable hospitals is whether to transfer a suspected large vessel occlusion (LVO) patient to a thrombectomy-capable stroke center (TSC). We report our experience with a commercially available AI-based care coordination platform (Viz.ai) designed to detect and alert LVOs on imaging (CTA) and improve communication among spoke and hub providers. Methods: All patients presenting across our community hospital network (consisting of two primary stroke centers, one stroke-ready hospital, and two freestanding emergency departments) with the diagnosis of acute stroke were included. We investigated the effect of the Viz.ai software platform on the number of stroke patients transferred out of our health system to the TSC and CTA utilization by comparing transfer patterns in a cohort of patients before (pre-Viz, 12/2018 - 10/2020) and after (post-Viz, 10/2020 - 08/2022) implementation. Results: A total of 1778 pre-Viz and 1779 post-Viz patients were compared. The post-Viz transfers significantly decreased by 33% (158 post-Viz vs 236 pre-Viz, p&lt;0.0001) and the post-Viz patients receiving a CTA within our system increased by 64% (1167 post-Viz vs 710 pre-Viz, p&lt;0.0001). The proportion of patients receiving a thrombolytic (tPA or TNK) who were cared for at the spokes was significantly higher post-Viz (74% vs 63%, p=0.02). The baseline clinical characteristics and study outcomes are summarized in the Table. Conclusions: In a consecutive cohort of stroke patients across a system of community hospitals that are not thrombectomy-capable, the implementation of the Viz.ai software platform was associated with reduced transfers to the thrombectomy center and an increased use of in-house CTA for LVO screening. There was an increase in the proportion of patients treated with intravenous thrombolysis who did not undergo transfer and received care locally suggesting improved identification of patients who benefit from transfer.

2042. Impact of the COVID-19 Pandemic on Healthcare-Associated Infections (HAI) by Race and Ethnicity in a Large Network of Community Hospitals: A Call to Action

Abstract Background Inequities in healthcare among racial and ethnic minorities are globally recognized. The focus has centered on access to healthcare, equitable treatment, and optimizing outcomes. However, there has been relatively little investigation into potential racial and ethnic disparities in HAI. Methods We performed a retrospective cohort analysis of select HAI prospectively-collected by a network of community hospitals in the southeastern US, including central line-associated bloodstream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), and laboratory-identified Clostridioides difficile infection (CDI). Outcomes were stratified by race/ethnicity as captured in the electronic medical record. We defined the pre-pandemic period from 1/1/2019 to 2/29/2020 and the pandemic period from 3/1/2020 to 6/30/2021. Outcomes were reported by race/ethnicity as a proportion of the total events. Relative rates were compared using Poisson regression. Results Overall, relatively few facilities consistently collect race/ethnicity information in surveillance databases within this hospital network (&amp;lt; 40%). Among 21 reporting hospitals, a greater proportion of CLABSI occurred in Black patients relative to White patients in both study periods (pre-pandemic, 49% vs 38%; during pandemic, 47% vs 31%; respectively, Figure 1a), while a higher proportion of CAUTI and CDI occurred in White patients (Figures 1b-c). Black patients had a 30% higher likelihood of CLABSI than White patients in the pre-COVID period (RR, 1.30; 95% CI, 0.83-2.05), which was not statistically significant (Table 1). However, this risk significantly increased to 51% after the start of the pandemic (RR, 1.51; 95% CI, 1.02-2.24). Similar trends were not observed in other HAI (Tables 2-3). Conclusion We found differences in HAI rates by race/ethnicity in a network of community hospitals. Black patients had higher likelihood of CLABSI, and this likelihood increased during the pandemic. Patient safety events, including HAI, may differ across racial and ethnic groups and negatively impact health outcomes. Disclosures Sonali D. Advani, MBBS, MPH, FIDSA, Locus Biosciences: Advisor/Consultant|Locus Biosciences: Honoraria|Sysmex America: Advisor/Consultant.

Colon surgical-site infections and the impact of "present at the time of surgery (PATOS)" in a large network of community hospitals.

To describe the epidemiology of complex colon surgical procedures (COLO), stratified by present at time of surgery (PATOS) surgical-site infections (SSIs) and non-PATOS SSIs and their impact on the epidemiology of colon-surgery SSIs. Retrospective cohort study. SSI data were prospectively collected from patients undergoing colon surgical procedures (COLOs) as defined by the National Healthcare Safety Network (NHSN) at 34 community hospitals in the southeastern United States from January 2015 to June 2019. Logistic regression models identified specific characteristics of complex COLO SSIs, complex non-PATOS COLO SSIs, and complex PATOS COLO SSIs. Over the 4.5-year study period, we identified 720 complex COLO SSIs following 28,188 COLO surgeries (prevalence rate, 2.55 per 100 procedures). Overall, 544 complex COLO SSIs (76%) were complex non-PATOS COLO SSIs (prevalence rate [PR], 1.93 per 100 procedures) and 176 (24%) complex PATOS COLO SSIs (PR, 0.62 per 100 procedures). Age >75 years and operation duration in the >75th percentile were independently associated with non-PATOS SSIs but not PATOS SSIs. Conversely, emergency surgery and hospital volume for COLO procedures were independently associated with PATOS SSIs but not non-PATOS SSIs. The proportion of polymicrobial SSIs was significantly higher for non-PATOS SSIs compared with PATOS SSIs. Complex PATOS COLO SSIs have distinct features from complex non-PATOS COLO SSIs. Removal of PATOS COLO SSIs from public reporting allows more accurate comparisons among hospitals that perform different case mixes of colon surgeries.

Cruel Apprenticeship: National Imaginaries in China’s Operating Rooms

Doctors learn to be doctors through clinical or therapeutic apprenticeships. By following, observing, and being mentored by more experienced physicians, trainees at various stages acquire embodied knowledge, affects, and ethics via both taught and hidden curricula. Previous research has demonstrated how biomedical training reproduces the social authority of scientific knowledge. This research article examines how for Chinese surgeons, apprenticeship not only immerses individuals within the scientific logics and hierarchical norms of biomedicine, but also embeds trainees within scientific imaginaries on a national scale. Drawing on ethnographic fieldwork in a Chinese academic hospital and a surrounding network of community hospitals, I examine how apprenticeship for Chinese surgical trainees extends beyond medical school and residency programmes, both in terms of temporality and geography. I examine how ‘technonational’ narratives, which permeate medical practice in China, impact the affects and ethics embodied by Chinese surgical trainees, and argue that changes in training expectations and the scope of training generates entanglements, dreams, and attachments which are cruel in their optimism. Thus, the therapeutic apprenticeship of Chinese surgical training reveals a ‘cruel apprenticeship’, a framing which encourages further exploration of the political and ethical stakes which permeate medical training and practice.

Impact of Rapid Susceptibility Testing System on the Management of Gram-Negative Bacteremia in a Network of Community Hospitals.

Rapid initiation of optimal antimicrobial therapy is crucial for the management of Gram-negative (GN) bacteremia. We aimed to evaluate the impact of Accelerate PhenoTM (AxDx) system on change in therapy and length of stay among patients with GN bacteremia. We conducted a retrospective cohort study of adult patients hospitalized who had at least 1 blood culture with presence of Enterobacterales. We compared clinical outcomes among patients who had their blood cultures processed through standard methods alone vs AxDx. We identified 255 bacteremia episodes among 243 unique patients. In the AxDx group, 31.1% of patients had deescalation of antibiotics within 48 h from blood culture collection compared to 20.0% of patients in the control group (P = 0.09). We found no impact of AxDx on the odds of deescalation at 48 h from blood culture collection [odds ratio (OR) 1.80 (95% CI 0.91-3.56), P = 0.09] or Gram stain report [OR 1.61 (95% CI 0.86-3.01), P = 0.14]. Escalation in therapy at 48 h from blood culture collection occurred in 16.8% and 16.9% of patients in the AxDx and control groups, respectively (P = 0.99). There was no impact on the odds of escalation at 48 h from blood culture collection [OR 0.99 (95% CI 0.47-2.11), P = 0.99] or Gram stain report [OR 1.26 (95% CI 0.57-2.80), P = 0.57]. No differences were seen in length of stay and mortality between the 2 groups. The impact of rapid identification and susceptibility technologies may differ according to the setting in which they are implemented.

811. Impact of the COVID-19 Pandemic on Surgical Volume and Surgical Site Infections (SSI) in a Large Network of Community Hospitals

BackgroundThe COVID-19 pandemic significantly impacted hospitalizations and healthcare utilization. Diversion of infection prevention resources toward COVID-19 mitigation limited routine infection prevention activities such as rounding, observations, and education in all areas, including the peri-operative space. There were also changes in surgical care delivery. The impact of the COVID-19 pandemic on SSI rates has not been well described, especially in community hospitals.MethodsWe performed a retrospective cohort study analyzing prospectively collected data on SSIs from 45 community hospitals in the southeastern United States from 1/2018 to 12/2020. We included the 14 most commonly performed operative procedure categories, as defined by the National Healthcare Safety Network. Coronary bypass grafting was included a priori due to its clinical significance. Only facilities enrolled in the network for the full three-year period were included. We defined the pre-pandemic time period from 1/1/18 to 2/29/20 and the pandemic period from 3/1/20 to 12/31/20. We compared monthly and quarterly median procedure totals and SSI prevalence rates (PR) between the pre-pandemic and pandemic periods using Poisson regression. ResultsPre-pandemic median monthly procedure volume was 384 (IQR 192-999) and the pre-pandemic SSI PR per 100 cases was 0.98 (IQR 0.90-1.04). There was a transient decline in surgical cases beginning in March 2020, reaching a nadir of 185 cases in April, followed by a return to pre-pandemic volume by June (figure 1). Overall and procedure-specific SSI PRs were not significantly different in the COVID-19 period relative to the pre-pandemic period (total PR per 100 cases 0.96 and 0.97, respectively, figure 2). However, when stratified by quarter and year, there was a trend toward increased SSI PR in the second quarter of 2020 with a PRR of 1.15 (95% CI 0.96-1.39, table 1). ConclusionThe decline in surgical procedures early in the pandemic was short-lived in our community hospital network. Although there was no overall change in the SSI PR during the study period, there was a trend toward increased SSIs in the early phase of the pandemic (figure 3). This trend could be related to deferred elective cases or to a shift in infection prevention efforts to outbreak management. Disclosures All Authors: No reported disclosures

Lung Cancer Screening: Development and Replication of a Decentralized Program to Increase Access.

Throughout its evolution, lung cancer screening has remained an evidence-based tool to detect earlier-stage disease and improve survival. Many lung cancer screening programs are planned and developed in one central location, which limits patient access. The purpose was to develop necessary and complex decentralized program components in affiliation with a large cancer care delivery system and a regional community hospital network in northeast Florida. A program was pilot tested among five geographically diverse primary care offices for three years. The role of oncology nursing was crucial to achieve quality and efficacy in program development, regulatory compliance, and screening outcomes. The program resulted in an increase in lung cancer screenings within the large healthcare network. The percentage of early-stage lung cancers identified increased, which led to improved patient outcomes and survival.

Effects of a Collaborative, Community Hospital Network for Antimicrobial Stewardship Program Implementation.

Individual hospitals may lack expertise, data resources, and educational tools to support antimicrobial stewardship programs (ASP). We established a collaborative, consultative network focused on hospital ASP implementation. Services included on-site expert consultation, shared database for routine feedback and benchmarking, and educational programs. We performed a retrospective, longitudinal analysis of antimicrobial use (AU) in 17 hospitals that participated for at least 36 months during 2013-2018. ASP practice was assessed using structured interviews. Segmented regression estimated change in facility-wide AU after a 1-year assessment, planning, and intervention initiation period. Year 1 AU trend (1-12 months) and AU trend following the first year (13-42 months) were compared using relative rates (RR). Monthly AU rates were measured in days of therapy (DOT) per 1000 patient days for overall AU, specific agents, and agent groups. Analyzed data included over 2.5 million DOT and almost 3 million patient-days. Participating hospitals increased ASP-focused activities over time. Network-wide overall AU trends were flat during the first 12 months after network entry but decreased thereafter (RR month 42 vs month 13, 0.95, 95% confidence interval [CI]: .91-.99). Large variation was seen in hospital-specific AU. Fluoroquinolone use was stable during year 1 and then dropped significantly. Other agent groups demonstrated a nonsignificant downward trajectory after year 1. Network hospitals increased ASP activities and demonstrated decline in AU over a 42-month period. A collaborative, consultative network is a unique model in which hospitals can access ASP implementation expertise to support long-term program growth.

905. Surgical Site Infections Following Colon Surgery in a Large Network of Community Hospitals

BackgroundColon surgeries are commonly performed, and surgical site infections (SSIs) following these procedures are routinely reported to the National Healthcare Safety Network (NHSN). However, the impact of infections present at the time of surgery (PATOS) and emergent surgeries on the epidemiology of colon surgery SSIs has not been well described.MethodsWe retrospectively analyzed prospectively collected data on complex (i.e., deep incisional or organ space) SSIs following colon surgery performed at 34 community hospitals in the southeastern United States from January 2015 to June 2019. We excluded SSIs categorized as PATOS. We then stratified colon surgery SSI rates according to age, sex, body mass index (BMI), operation duration, diabetes diagnosis, American Society of Anesthesiologists (ASA) physical status, wound class, emergent procedure, endoscopic procedure, and hospital colon surgery volume. Finally, we explored effect measure modification of emergent surgery and open surgery on hospital volume using log-binomial modeling and tests of homogeneity.ResultsA total of 722 complex SSIs occurred following 28,642 colon surgeries (prevalence rate [PR], 2.52 per 100 procedures). After PATOS SSIs were excluded, 545 complex SSIs remained (PR 1.90 per 100 procedures). Risk factor analysis revealed that age < 75 years and operation time > 75th percentile (188 minutes) during the 5-year study period) significantly increased risk of SSI (Table 1). The most common pathogens that caused SSIs in this study cohort were Escherichia coli, Enterococcus, and Klebsiella. (Table 2) 105 (19%) SSIs were culture-negative and 378 (69%) of the SSIs were polymicrobial. We defined hospital volume as high (>500 procedures in the 5-year period) based on the median hospital volume in the dataset. No significant effect measure modification occurred between hospital volume and either laparoscopic surgery or emergent surgery (Table 3).Table 1: Characteristics of patients who underwent colon surgery from January 2015 to June 2018 in 34 community hospitals. Table 2: Count and frequency of pathogens that caused complex surgical site infections after colon surgery Table 3: Colon surgery complex surgical site infection rates, stratified by emergent, elective, open, and laparoscopic procedures and hospital colon surgery volume ConclusionIn our cohort, we found that one-fourth of colon surgery SSIs were categorized as PATOS, which are no longer publicly reported to the Centers for Medicare & Medicaid Services. While most SSI literature describes higher volume hospitals having lower SSI rates, high colon surgery volume was associated with increased SSI rates in our community hospital cohort.Disclosures All Authors: No reported disclosures

Reflex Urine Culture Practices in a Regional Community Hospital Network

Background: Reflex urine cultures (RUCs) have the potential to reduce unnecessary urine cultures and antibiotic use. However, urinalysis parameters that best predict true infection are unknown. In this study, we surveyed different RUC practices in laboratories across a regional network of community hospitals. Methods: We conducted a voluntary electronic survey of infection preventionists to describe laboratory practices relating to RUCs across 51 community hospitals in the Duke Infection Control Outreach Network (DICON) between May 15, 2019, and July 3, 2019. Results: We received 51 responses (response rate, 100%). Most hospital laboratories were located in North Carolina (n = 25, 49%) and Georgia (n = 18, 35%); 28 laboratories (55%) incorporated RUCs. Surveyed laboratories accepted urine samples from any source and various collection methods (eg, indwelling catheter specimens, clean catch specimens). Moreover, 24 laboratories (86%) offered RUCs for all patients, whereas 4 laboratories (14%) restricted RUCs to specific populations (ie, outpatient, emergency room or children). We observed wide variability in the urinalysis criteria used for RUCs (Table 1); 26 unique approaches were used among 28 laboratories. Also, 24 laboratories (86%) used multiple criteria and 4 (14%) used 1 criterion. Of those that used multiple criteria, all 24 proceeded to RUC if at least 1 UA criterion was met. Furthermore, 22 laboratories (79%) incorporated the presence of nitrites as a urinalysis criterion; 21 laboratories (75%) incorporated white blood cell count (WBC) as a criterion. The most frequent WBC cutoffs were “≥5” (n = 11, 39%) and “≥10” (n = 7, 25%). In addition, 21 laboratories (75%) incorporated leukocyte esterase as a urinalysis criterion, with criteria including “positive” (n = 15, 54%), “trace” (n = 4, 14%), “moderate” (n = 1, 4%), and “large” (n = 1, 4%). Also, 17 (61%) laboratories incorporated magnitude of bacteriuria as a urinalysis criterion. The cutoff ranged from “few” (n = 8, 29%), “moderate” (n = 7, 25%), to “many” (n = 2, 7%). Another 3 (11%) laboratories incorporated other criteria: presence of blood (n = 2, 7%) and presence of fungal elements (n = 1, 4%). Only 3 (11%) laboratories utilized epithelial cells as an exclusion criterion where urinalysis would not proceed to culture if epithelial cells in urinalysis samples exceeded the designated limit, ranging from “&gt;5” to “&gt;15”. Conclusions: More than half of the hospitals in our community hospital network utilize RUCs, but criteria varied widely. Future epidemiological research should aim to identify ideal urinalysis parameters as well as specific patient populations that safely benefit from RUC strategies.Funding: NoneDisclosures: None

Awareness of Antimicrobial Stewardship Interventions Within a Community Hospital Network

Background: A system of 3 community hospitals in New Jersey has actively engaged in antimicrobial stewardship since November 2014. Consultations with infectious diseases specialists are mandatory for patients with sepsis, severe sepsis, septic shock, patients on 3 or more antibiotics, and for those diagnosed with Clostridioides difficile infection (CDI). A multidisciplinary team meets monthly and has begun to improve the appropriateness of antibiotics use and to reduce antibiotic days of therapy per 1,000 patient days. Recently, we participated in a targeted assessment program (TAP) for CDI, and we identified areas of opportunity for antimicrobial stewardship. Methods: The TAP survey was emailed to a wide distribution of employees in the hospital, primarily nurses, physicians, and others with a variable range of experience and for those working in the intensive care units and on the wards. Ultimately, the numbers of responses were 60 in hospital A, 88 in hospital B, and 124 in hospital C. Results: In hospital A, most respondents were nurses or nurse assistants or technicians (63%), and most of the total individuals surveyed worked outside the intensive care unit setting. In hospital B, nurses or nurse assistants or technicians comprised 69% of all responses. Hospital C had the highest percentage of physicians who responded (31%). One theme for all hospitals was that a little more than half of those surveyed felt that for patients with new or recent CDI infections, antibiotics prescribed for infections were reviewed by clinicians. Less than half of respondents believed that education was being given to patients and families about the risks of CDI from antibiotics. With regard to high-risk CDI antibiotics, there was a general lack of knowledge that these were being monitored. For example, survey respondents felt that this was always monitored on clindamycin by only 33% of respondents in hospital A, 40% in hospital B, and 42% in hospital C. With regard to strategies to reduce the unnecessary use of fluoroquinolones, the response of “always” ranged from 35% to 47% of the time. Conclusions: Even though hospitals may have robust antimicrobial stewardship programs, it is important to survey frontline staff. Although all of the antimicrobial stewardship interventions, such as monitoring high-risk-CDI antibiotics, reducing high-risk CDI antibiotics, among others, are performed, there may be lack of knowledge that these initiatives are even being implemented. In this TAP against CDI, we found opportunities to share data with respondents to increase awareness of antimicrobial stewardship to further combat hospital-acquired infections.Funding: NoneDisclosures: None