Pre-intervention Period Research Articles

The effect of aerobic training and hydroalcoholic extract of dill on skeletal muscle inflammation in a high-fat diet-induced obesity rat model

Abstract Aerobic training (AT) and herbal medicine interventions are effective in reducing chronic inflammation and achieving weight loss. The present study aimed to investigate the effect of 10 weeks of AT and hydroalcoholic extract of dill (HED) on tumour necrosis factor-alpha (TNF-α), interleukin-4 (IL-4), and peroxisome proliferator-activated receptor gamma (PPARγ) concentrations in gastrocnemius muscle and Lee index of obese male rats. Thirty-two obese male Wistar rats were randomly divided into AT (70-80% of maximal oxygen uptake, 5 times/week), HED (300 mg/kg body weight, 3 times/week), AT+HED, and obese control (Ctr), and eight non-obese rats were included in the non-obese control group (NCtr). Lee index was measured before and after 10 weeks of interventions. Also, rats were sacrificed 48 hs after the last intervention session and gastrocnemius muscle was removed to measure protein concentrations of TNF-α, IL-4, and PPARγ. When compared with the pre-intervention period, the Lee index decreased in the AT and AT+HED groups and increased in the NCtr group at the post-intervention period. Also, there was no significant difference between non-obese and obese rats in the concentrations of TNF-α and IL-4, but the AT+HED group showed a higher concentration of TNF-α than the AT group. Furthermore, the expression of PPARγ protein in the HED group was higher than in the Ctr and AT groups. Although we observed the beneficial effects of AT and its combination with HED in reducing the Lee index, we found that the administration of HED compared with AT can provide better protection against some metabolic complications in the skeletal muscles of obese rats caused by a high-fat diet. Lastly, it seems that the AT combined with HED interferes with possible anti-inflammatory effects of AT or HED intervention alone.

Transfusion Audit and Targeted Education as Tools to Improve Clinical Practice of Fresh Frozen Plasma Transfusions: An Interventional Study

Background and Objectives: The transfusion of fresh frozen plasma (FFP) is an essential modality of treatment but carries a residual risk of transfusion-transmitted infections and other adverse events. Continuous education and promotion of evidence-based practice are essential among clinicians to follow good clinical practices with respect to transfusion. This study aims to assess the impact of transfusion audit and educational interventions on the appropriateness of FFP transfusions with respect to indications, by comparing the proportion of appropriate FFP requests before and after the intervention. The study was an interventional study done on all medical professionals who requested FFP for various reasons from the department of transfusion medicine, for 1 year from April 01, 2011, to March 31, 2012. Methods: The study was done in three phases, preintervention audit; intervention including continuous education, one-to-one interactions, and hospital transfusion committee-mediated regulations; and postintervention audit. Statistical analysis was done by SPSS version 16. A paired t-test was used to compare quantitative variables which were continuous. Chi-square test was used for associations in categorical data. Results: A total of 3281 units of FFP were transfused in the preintervention period, and 2480 units in the postintervention period. Out of a total of 823 appropriate indications 75.6% indications were definitely indicated in the preintervention period. This increased to 81.8% of total 1290 requests after the intervention. The increase in definite indications was found to be statistically significant. Conclusion: Transfusion audits and educational interventions can create an impact on the appropriateness of FFP Transfusions especially if targeted to particular specialties and continued to follow-up.

Impact of SARS-CoV-2 Preventive Measures against Healthcare-Associated Infections from Antibiotic-Resistant ESKAPEE Pathogens: A Two-Center, Natural Quasi-Experimental Study in Greece.

The COVID-19 pandemic led to unprecedented stress on healthcare systems worldwide, forming settings of concern for increasing antimicrobial resistance. We investigated the impact of SARS-CoV-2 preventive measures against healthcare-associated infections (HAIs) from antibiotic-resistant bacteria in two tertiary-care hospitals. We compared infection rates between March 2019 and February 2020 (pre-intervention period) and March 2020 and February 2021 (COVID-19 intervention period) from drug-resistant ESKAPEE bacteria (methicillin-resistant Staphylococcus aureus; vancomycin-resistant Enterococci; carbapenem-resistant Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, Enterobacter species and Escherichia coli). Over 24 months, 586 drug-resistant ESKAPEE HAIs occurred in 439 patients (0.3% of 179,629 inpatients) with a mean age of 63 years, with 43% being treated in intensive care units (ICUs), and having a 45% inpatient mortality rate. Interrupted time series analysis revealed increasing infection rates before the intervention that were sharply interrupted by abrupt drops for most pathogens and henceforth remained stable in the ICUs but progressively increased in ordinary wards. In the ICUs, the pooled infection rate was 44% lower over the intervention period compared to the pre-intervention period (incidence rate ratio (IRR) 0.56, 95%CI 0.41-0.75, p < 0.001). Pooled infection rates in the wards were slightly higher over the COVID-19 period (IRR 1.12, 95%CI 0.87-1.45, p = 0.368). The findings confirmed the ancillary beneficial impact of the enhanced bundle of transmission-based precautions adopted against SARS-CoV-2 in rapidly constraining antimicrobial-resistant HAIs in two Greek hospitals.

Impact of Technology on Neonatal Intensive Care Unit Admissions and Length of Stay: A Retrospective Study.

Background Neonatal intensive care units (NICU) provide essential medical care to neonates; however, they are associated with hospital-acquired infections, less maternal-newborn bonding, and high costs.Implementing strategies to lower NICU admission rates and shorten NICU length of stay (LOS) is essential.This study uses causal-inference methods to evaluate the impact of care managers using new technology to identify and risk stratify pregnancies on NICU admissions and NICU LOS. The NICU LOS willdecreaseas a result of the use of new technology by care managers. Study design This retrospective study utilized delivery claims data of pregnant women from the CareFirst BlueCross BlueShield Community Health Plan District of Columbia from 2013 to 2022, which includes the pre-intervention period before the use of new technology by care managers and the post-intervention period with the use of new technology by care managers.Our sample had 4,917 deliveries whose maternal comorbidities were matched with their neonate's outcomes. Methods To evaluate the impact of the technological intervention, both Generalized Linear Models (GLMs) and Bayesian Structural Time-Series (BSTS) models were used. Results Our findings from the GLM models suggest an overall average reduction in the odds of NICU admissions of 29.2% and an average decrease in NICU LOS from 7.5%-58.5%.Using BSTS models, we estimate counterfactuals for NICU admissions and NICU LOS, which suggest an average reduction in 48 NICU admissions and 528 NICU days per year. Conclusion Equipping care managers with better technological tools can lead to significant improvements in neonatal health outcomes as indicated by a reduction in NICU admissions and NICU LOS.

Effect of Clinical Decision Support System and Clinical Pharmacists’ Practice in Preventing Drug-drug Interactions among Inpatients in Bac Ninh General Hospital

Drug-drug interaction is one of the drug-related problems that can reduce therapeutic efficacy or increase the risk of undesirable effects. Subjects and methods: interventional study design with before-after comparison. In the pre-intervention period, we retrospectively carried out all electronic prescriptions and medical records of inpatients treated from 01/11/2021 to 31/01/2022. In the post-intervention period, we prospectively performed monitoring reports on the drug-drug interaction warning system and medical records of inpatients from 01/02/2022 to 31/03/2022. Results: The proportion of patients exposed to drug-drug interactions (DDIs) decreased significantly from 4.27% in the pre-intervention period to 3.56% in the post-intervention period (p&lt;0.05). There were no medical records with contraindicated DDIs in the post-intervention period. The percentage of patients for contraindication DDIs with conditions determined to patients with the condition was 39.33% and 27.59%, respectively, in the pre-and post-intervention phases. Medical records rate with major DDIs decreased significantly in the post-intervention period (2.95% vs 3.68%; p&lt;0.05). Conclusion: Clinical decision support systems with drug-drug interaction warnings and clinical pharmacy activities help to reduce the frequency of DDIs. The results show that the combination of these two measures initially brings about effective DDIs management in hospitals.

The impact of autocancellation of uncollected Clostridioides difficile specimens after 24 hours on reported healthcare-associated infections: A quality improvement intervention.

To assess the impact of a 24-hour autocancellation of uncollected Clostridioides difficile samples in reducing reported healthcare-associated infections (HAIs). Quality-improvement, before-and-after implementation study. The study was conducted in 17 hospitals in Pennsylvania. Clostridioides difficile tests that are not collected within 24 hours are automatically canceled ("autocancel") through the electronic health record. The intervention took place at 2 facilities (intervention period November 2021-July 2022) and subsequently at 15 additional facilities (April 2022-July 2022). Quality measures included percentage of orders canceled, C. difficile HAI rate, percent positivity of completed tests, and potential adverse outcomes of canceled or delayed testing. Of 6,101 orders, 1,090 (17.9%) were automatically canceled after not being collected for 24 hours during the intervention periods. The reported C. difficile HAI rates per 10,000 patient days did not significantly change. These rates were 8.07 in the 6-month preintervention period and 8.77 in the intervention period for facilities A and B combined (incidence rate ratio [IRR], 1.09; 95% CI, 0.88-1.34; P = .43), and were 5.23 HAIs per 10,000 patient days in the 6-month preintervention period and 5.33 in the intervention period for facilities C-Q combined (IRR, 1.02; 95% CI, 0.79-1.32; P = .87). From the preintervention to the intervention periods, the percent positivity rates of completed C. difficile tests increased by 1.1% for facilities A and B and by 1.4% for facilities C-Q. No adverse outcomes were observed. The 24-hour autocancellation of uncollected C. difficile orders reduced testing but did not result in reported HAI reduction.

Medicaid expansion and risk of eclampsia

Eclampsia is an indicator of severe maternal morbidity and can be prevented through increased prenatal care access and early prenatal care utilization. The 2014 Medicaid expansion under the Patient Protection and Affordable Care Act allowed states to expand Medicaid coverage to nonelderly adults with incomes up to 138% of the federal poverty level. Its implementation has led to a significant increase in prenatal care access and utilization. This study aimed to assess the association of Medicaid expansion under the Affordable Care Act with eclampsia incidence. This natural experiment study was based on US birth certificate data from January 2010 to December 2018 in 16 states that expanded Medicaid in January 2014 and in 13 states that did not expand Medicaid during the study period. The outcome was eclampsia incidence, the intervention was the implementation of the Medicaid expansion, and the exposure was state expansion status. Using the interrupted time series method, we compared temporal trends in the incidence of eclampsia before and after the intervention in expansion vs non-expansion states with adjustments for patient and hospital county characteristics. Of the 21,570,021 birth certificates analyzed, 11,433,862 (53.0%) were in expansion states and 12,035,159 (55.8%) were in the postintervention period. The diagnosis of eclampsia was recorded in 42,677 birth certificates or 19.8 per 10,000 (95% confidence interval, 19.6-20.0). The incidence of eclampsia was higher for Black people (29.1 per 10,000) than for White (20.7 per 10,000), Hispanic (15.3 per 10,000), and birthing people of other race and ethnicity (15.4 per 10,000). In the expansion states, the incidence of eclampsia increased during the preintervention period and decreased during the postintervention period; in the nonexpansion states, a reverse pattern was observed. A statistically significant difference was observed between expansion and nonexpansion states in temporal trends between the pre- and postintervention periods, with an overall 1.6% decrease (95% confidence interval, 1.3-1.9) in the incidence of eclampsia in expansion states compared with nonexpansion states. The results were consistent in subgroup analyses according to maternal race and ethnicity, education level (less than high school or high school and higher), parity (nulliparous or parous), delivery mode (vaginal or cesarean delivery), and poverty in the residence county (high or low). Implementation of the Affordable Care Act Medicaid expansion was associated with a small statistically significant reduction in the incidence of eclampsia. Its clinical significance and cost-effectiveness remain to be determined.

Changes in sodium levels in Australian packaged foods between 2014 and 2019: an interrupted time series analysis of the impact of the Victorian Salt Reduction Partnership’s media advocacy strategy

BackgroundThe Victorian Salt Reduction Partnership (VSRP) implemented a media advocacy strategy (intervention) to stimulate food manufacturers to reduce sodium levels across targeted Australian packaged foods between 2017 and 2019. This study assessed changes in sodium levels of targeted and non-targeted packaged foods during the intervention (2017 to 2019) compared to before the intervention (2014 to 2016) in Australia.MethodsAnnually collected branded-food composition data from 2014 to 2019 were used. Interrupted time series analyses was conducted to compare the trend in sodium levels in packaged foods during the intervention (2017–2019) to the trend in the pre-intervention period (2014–2016). The difference between these trends was derived to estimate the effect of the intervention.ResultsA total of 90,807 products were included in the analysis, of which 14,743 were targeted by the intervention. The difference in before and during intervention trends between targeted and non-targeted food categories was 2.59 mg/100 g (95% CI: -13.88 to 19.06). There was a difference in the pre-intervention slope (2014, 2015, 2016) and intervention slope (2017, 2018, 2019) for four of 17 targeted food categories. There was a decrease in sodium levels (mg/100 g) in one food category: frozen ready meals (-13.47; 95% CI: -25.40 to -1.53), and an increase in three categories: flat bread (20.46; 95% CI: 9.11 to 31.81), plain dry biscuits (24.53; 95% CI: 5.87 to 43.19), and bacon (44.54; 95% CI: 6.36 to 82.72). For the other 13 targeted categories, the difference in slopes crossed the line of null effect.ConclusionsThe VSRP’s media advocacy strategy did not result in a meaningful reduction in sodium levels of targeted packaged food products during the intervention years compared to trends in sodium levels before the intervention. Our study suggests media advocacy activities highlighting the differences in sodium levels in packaged food products and industry meetings alone are not sufficient to lower average sodium levels in packaged foods in the absence of government leadership and measurable sodium targets.

Impact of an Automated Closed-Loop Communication and Tracking Tool on the Rate of Recommendations for Additional Imaging in Thoracic Radiology Reports

ObjectiveAssess the effects of feedback reports and implementing a closed-loop communication system on rates of recommendations for additional imaging (RAIs) in thoracic radiology reports. MethodsIn this retrospective, institutional review board–approved study at an academic quaternary care hospital, we analyzed 176,498 thoracic radiology reports during a pre-intervention (baseline) period from April 1, 2018, to November 30, 2018; a feedback report only period from December 1, 2018, to September 30, 2019; and a closed-loop communication system plus feedback report (IT intervention) period from October 1, 2019, to December 31, 2020, promoting explicit documentation of rationale, time frame, and imaging modality for RAI, defined as complete RAI. A previously validated natural language processing tool was used to classify reports with an RAI. Primary outcome of rate of RAI was compared using a control chart. Multivariable logistic regression determined factors associated with likelihood of RAI. We also estimated the completeness of RAI in reports comparing IT intervention to baseline using χ2 statistic. ResultsThe natural language processing tool classified 3.2% (5,682 of 176,498) reports as having an RAI; 3.5% (1,783 of 51,323) during the pre-intervention period, 3.8% (2,147 of 56,722) during the feedback report only period (odds ratio: 1.1, P = .03), and 2.6% (1,752 of 68,453) during the IT intervention period (odds ratio: 0.60, P < .001). In subanalysis, the proportion of incomplete RAI decreased from 84.0% (79 of 94) during the pre-intervention period to 48.5% (47 of 97) during the IT intervention period (P < .001). DiscussionFeedback reports alone increased RAI rates, and an IT intervention promoting documentation of complete RAI in addition to feedback reports led to significant reductions in RAI rate, incomplete RAI, and improved overall completeness of the radiology recommendations.

A comprehensive strategy to address shortage of Erwinia asparaginase in pediatric acute lymphoblastic leukemia

ABSTRACT Background Pegylated form of E. coli derived asparaginase (PEG) is a crucial component of pediatric ALL therapy. Patients who develop a hypersensitivity (HSR) reaction with PEG receive an alternative form – Erwinia asparaginase (EA). However, an international shortage in 2017 had made it challenging to treat these patients. We have developed a comprehensive strategy to address this need. Patients and methods This is a single center, retrospective analysis. All patients receiving PEG were premedicated to reduce infusion reactions. Patients who developed HSR underwent PEG desensitization. Patients were compared to historic controls. Results Fifty-six patients were treated within the study period. There was no difference in the frequency of reactions before and after the adoption of universal premedication (p = 0.78). Eight patients (14.2%) developed either ≥ Grade 2 HSR or silent inactivation and 5 patients (62.5%) successfully underwent desensitization. The remaining three patients received EA asparaginase. This intervention led to a decrease in PEG substitution, with 3 patients (5.3%) requiring EA compared to 8 patients (15.09%) in the pre-intervention period. (p = 0.11) PEG desensitization was more cost effective than EA administration. Conclusion PEG desensitization is a safe, cost effective, and practical alternative in children with ALL and a Grade 2 or higher HSR.

Racial, Ethnic, and Sex Differences in Methadone-Involved Overdose Deaths Before and After the US Federal Policy Change Expanding Take-home Methadone Doses

In March 2020, the Substance Abuse and Mental Health Services Administration (SAMHSA) permitted states to relax restrictions on take-home methadone doses for treatment-adherent patients to minimize COVID-19 exposures. To assess whether the methadone take-home policy change was associated with drug overdose deaths among different racial, ethnic, and sex groups. Interrupted time series analysis from January 1, 2018, to June 30, 2022. Data analysis was conducted from February 18, 2023, to February 28, 2023. In this population-based cohort study of drug overdose mortality including 14 529 methadone-involved deaths, monthly counts of methadone-involved drug overdose deaths were obtained for 6 demographic groups: Hispanic men and women, non-Hispanic Black men and women, and non-Hispanic White men and women. On March 16, 2020, in response to the first wave of the COVID-19 pandemic, SAMHSA issued an exemption to the states that permitted up to 28 days of take-home methadone for stable patients and 14 days for less stable patients. Monthly methadone-involved overdose deaths. From January 1, 2018, to June 30, 2022 (54 months), there were 14 529 methadone-involved deaths in the United States; 14 112 (97.1%) occurred in the study's 6 demographic groups (Black men, 1234; Black women, 754; Hispanic men, 1061; Hispanic women, 520; White men, 5991; and White women, 4552). Among Black men, there was a decrease in monthly methadone deaths associated with the March 2020 policy change (change of slope from the preintervention period, -0.55 [95% CI, -0.95 to -0.15]). Hispanic men also experienced a decrease in monthly methadone deaths associated with the policy change (-0.42 [95% CI, -0.68 to -0.17]). Among Black women, Hispanic women, White men, and White women, the policy change was not associated with a change in monthly methadone deaths (Black women, -0.27 [95% CI, -1.13 to 0.59]; Hispanic women, 0.29 [95% CI, -0.46 to 1.04]; White men, -0.08 [95% CI, -1.05 to 0.88]; and White women, -0.43 [95% CI, -1.26 to 0.40]). In this interrupted time series study of monthly methadone-involved overdose deaths, the take-home policy may have helped reduce deaths for Black and Hispanic men but had no association with deaths of Black or Hispanic women or White men or women.

Intervention to reduce the incidence of non–ventilator-associated hospital-acquired pneumonia: A pilot study

Our aim was to evaluate the effectiveness of an intervention to reduce the incidence of non-ventilator-associated hospital-acquired pneumonia (NV-HAP) and determine compliance with preventive measures. This was a quasi-experimental before-after study involving patients in the 53-bed Internal Medicine ward in a university hospital in Spain. The preventive measures included hand hygiene, dysphagia detection, head-of-bed elevation, withdrawal of sedatives in the event of confusion, oral care, and sterile or bottled water use. A prospective post-intervention study of the incidence of NV-HAP was carried out from February 2017 to January 2018 and compared with baseline incidence (May 2014 to April 2015). Compliance with preventive measures was analyzed with 3-point-prevalence studies (December 2015, October 2016, and June 2017). The rate of NV-HAP decreased from 0.45 cases (95% confidence interval 0.24-0.77) in the pre-intervention period to 0.18 cases per 1,000patient-days (95% confidence interval 0.07-0.39) in the post-intervention period (P =.07). Compliance with most preventive measures improved after intervention and remained stable over time. The strategy improved the adherence to most of the preventive measures, with a decrease in the incidence of NV-HAP. Efforts to enhance adherence to such fundamental preventive measures are critical to lowering the incidence of NV-HAP.

Evaluation of Assisted Reproductive Technology Health Insurance Coverage for Multiple Pregnancies and Births in Korea

While various policies to support couples experiencing infertility have been introduced due to the fertility rate rapidly dropping in developed countries, few large-scale nationwide cohort studies have evaluated the outcomes of assisted reproductive technology (ART) health insurance coverage policies. To evaluate ART health insurance coverage for multiple pregnancies and births in Korea. This population-based cohort study used delivery cohort data from the Korean National Health Insurance Service database between July 1, 2015, and December 31, 2019. A total of 1 474 484 women were included after exclusion of those who gave birth at nonmedical institutions and those with missing data. Two 27-month periods were examined before and after the Korean National Health Insurance Service had begun covering ART treatment (preintervention period, July 1, 2015, to September 30, 2017; postintervention period, October 1, 2017, to December 31, 2019). Multiple pregnancies and multiple births were identified by International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnosis codes. Total births were defined as the total number of babies born to each pregnant woman during the follow-up period. An interrupted time series with segmented regression was conducted to analyze the time trend and its change in outcomes. Data analysis was conducted between December 2, 2022, and February 15, 2023. Of the 1 474 484 women eligible for the analysis (mean [SD] age, 33.2 [4.6] years), approximately 1.60% had multiple pregnancies and 1.10% had multiple births. After covering ART treatment, the likelihood of multiple pregnancies and multiple births was estimated to increase by 0.7% (estimate, 1.007; 95% CI, 1.004-1.011; P < .001) and 1.2% (estimate, 1.012; 95% CI, 1.007-1.016; P < .001) compared with before coverage. The probability of an increase in the number of total births per pregnant woman after the intervention was estimated to be 0.5% (estimate, 1.005; 95% CI, 1.005-1.005; P < .001). The relatively high-income class above the median income showed a decreasing trend in multiple births and total births before the intervention, but after the intervention, a significant increase was observed. This population-based cohort study found that the possibility of multiple pregnancies and births in Korea significantly increased after the implementation of an ART health insurance coverage policy. These findings suggest that the development and coverage of policies to support couples experiencing infertility may help address low fertility rates.

An external facilitation intervention to increase uptake of an adverse drug event reporting intervention.

Adverse drug events (ADEs) are a leading cause of emergency department visits and hospital admissions in Canada. ActionADE prevents repeat ADEs by enabling clinicians to document and communicate standardized ADE information across care settings. We used an external facilitation intervention to promote the uptake of ActionADE in four hospitals in British Columbia, Canada. This study examined whether, how and in what context external facilitation influenced the uptake of ActionADE. In this convergent-parallel mixed-methods study, an external facilitator used a four-step iterative process to support site champions using context-specific implementation strategies to increase the ADE reporting rate at their sites. We extracted archival data to assess implementation determinants before and after the implementation of the external facilitation and implementation strategies. We also retrieved data on the mean monthly counts of reported ADEs for each user from the ActionADE server. Zero-inflated Poisson models were used to examine changes in mean monthly counts of reported ADEs per user between pre-intervention (June 2021 to October 2021) and intervention (November 2021 to March 2022) periods. The external facilitator and site champions co-created three functions: (1) educate pharmacists about what and how to report in ActionADE, (2) educate pharmacists about the impact of ActionADE on patient outcomes, and (3) provide social support for pharmacists to integrate ADE reporting into clinical workflows. Site champions used eight forms to address the three functions. Peer support and reporting competition were the two common strategies used by all sites. Sites' responses to external facilitation varied. The rate of mean monthly counts of reported ADEs per user significantly increased during the intervention period compared to the pre-intervention period at LGH (RR: 3.74, 95% CI 2.78 to 5.01) and RH (RR: 1.43, 95% CI 1.23 to 1.94), but did not change at SPH (RR: 0.68, 95% CI: 0.43 to 1.09) and VGH (RR: 1.17, 95% CI 0.92 to 1.49). Leave of absence of the clinical pharmacist champion and failure to address all identified functions were implementation determinants that influenced the effectiveness of external facilitation. External facilitation effectively supported researchers and stakeholders to co-create context-specific implementation strategies. It increased ADE reporting at sites where clinical pharmacist champions were available, and where all functions were addressed.

The impact of a blood-culture diagnostic stewardship intervention on utilization rates and antimicrobial stewardship

Background: Blood cultures are often ordered when an infection is suspected; however, they have a low yield in most cases. The overuse of blood culture is associated with high contamination rates, resulting in excess diagnostics, unnecessary antibiotics, longer hospital stays, and higher hospital costs. We evaluated the safety of a multifaceted intervention, which encompassed education and blood-culture restriction, and its impact on blood-culture utilization and antibiotic use in adult intensive care unit (ICU) patients. Methods: The study was performed between October 2020 and October 2021 in the 12 general medicine and specialty ICUs of a quaternary academic care center. The intervention, implemented in April 2021, included providing education to ICU and infectious disease physicians based on an algorithm adapted from the Johns Hopkins DISTRIBUTE study in addition to restricting blood-culture ordering on these units to these providers. The month of April 2021 was excluded as a washout period. Study outcomes comprised blood-culture utilization, blood-culture positivity, days of therapy (DOT), and length of therapy (LOT), which were compared across the study periods using IRR or the Pearson χ2 test, as appropriate. In addition, 30-day mortality and 30-day ICU readmission were evaluated utilizing multiple COX regression models. Results: In total, 6,303 patients (2,087 MICU, 3,636 SICU, and 580 both) were included in the study, with a median age of 65 years (IQR, 21). Most participants were male (57.5%), with a median length of stay of 175 hours (IQR, 186). After the intervention, blood-culture utilization rates decreased from 15.4% to 12.4% (IRR 0.80, 95% CI, 0.76–0.85) (Fig. 1). There was no difference in blood-culture positivity between the preintervention period (11.05%) and the postintervention period (11.64%; P = .459). Days of therapy decreased from 1,180 to 1,130 per 1,000 patient days (IRR, 0.96; 95% CI, 0.95–0.98), and the length of therapy decreased from 602 to 579 per 1,000 patient days (IRR, 0.96; 95% CI, 0.94–0.99) (Fig. 2). There was no difference in 30-day mortality (P = .241) nor 30-day ICU readmission (P = .888) across the study periods after adjusting for potential confounders (Table 1). Conclusions: Our multifaceted intervention decreased blood-culture and antimicrobial utilization in the ICUs without significantly affecting the positivity rate, mortality, or readmission. This study suggests that educating providers on appropriate blood-culture use along with restriction could safely improve healthcare outcomes. Further studies are warranted to validate our results across various institutions and to evaluate the impact of blood-culture optimization in non-ICU patients.Disclosures: None

Implementation of diagnostic stewardship in two surgical ICUs: Time for a blood-culture change

Background: Blood cultures are commonly ordered for patients with low risk of bacteremia. Liberal blood-culture ordering increases the risk of false-positive results, which can lead to increased length of stay, excess antibiotics, and unnecessary diagnostic procedures. We implemented a blood-culture indication algorithm with data feedback and assessed the impact on ordering volume and percent positivity. Methods: We performed a prospective cohort study from February 2022 to November 2022 using historical controls from February 2020 to January 2022. We introduced the blood-culture algorithm (Fig. 1) in 2 adult surgical intensive care units (ICUs). Clinicians reviewed charts of eligible patients with blood cultures weekly to determine whether the blood-culture algorithm was followed. They provided feedback to the unit medical directors weekly. We defined a blood-culture event as ≥1 blood culture within 24 hours. We excluded patients aged &lt;18 years, absolute neutrophil count &lt;500, and heart and lung transplant recipients at the time of blood-culture review. Results: In total, 7,315 blood-culture events in the preintervention group and 2,506 blood-culture events in the postintervention group met eligibility criteria. The average monthly blood-culture rate decreased from 190 blood cultures per 1,000 patient days to 142 blood cultures per 1,000 patient days (P &lt; .01) after the algorithm was implemented. (Fig. 2) The average monthly blood-culture positivity increased from 11.7% to 14.2% (P = .13). Average monthly days of antibiotic therapy (DOT) was lower in the postintervention period than in the preintervention period (2,200 vs 1,940; P &lt; .01). (Fig. 3) The ICU length of stay did not change before the intervention compared to after the intervention: 10 days (IQR, 5–18) versus 10 days (IQR, 5–17; P = .63). The in-hospital mortality rate was lower during the postintervention period, but the difference was not statistically significant: 9.24% versus 8.34% (P = .17). The all-cause 30-day mortality was significantly lower during the intervention period: 11.9% versus 9.7% (P &lt; .01). The unplanned 30-day readmission percentage was significantly lower during the intervention period (10.6% vs 7.6%; P &lt; .01). Over the 9-month intervention, we reviewed 916 blood-culture events in 452 unique patients. Overall, 74.6% of blood cultures followed the algorithm. The most common reasons overall for ordering blood cultures were severe sepsis or septic shock (37%), isolated fever and/or leukocytosis (19%), and documenting clearance of bacteremia (15%) (Table 1). The most common indications for inappropriate blood cultures were isolated fever and/or leukocytosis (53%). Conclusions: We introduced a blood-culture algorithm with data feedback in 2 surgical ICUs and observed decreases in blood-culture volume without a negative impact on ICU LOS or mortality rate.Disclosure: None

Feasibility of a low-intensity intervention to improve antimicrobial use in outpatient settings

Background: Overall, ~12% of outpatient visits result in an antibiotic prescription, and 30% of those prescriptions are inappropriate. Behavioral nudges help influence practitioner behavior. We hypothesized that peer comparison combined with a behavioral nudge (a patient alert letter) would influence prescribers to reduce antibiotic prescriptions and improve antimicrobial stewardship in the outpatient setting. We pilot-tested this intervention in outpatient primary care clinics associated with a large Veterans Affairs (VA) medical center. Methods: We conducted a clustered randomized controlled trial of 12 community-based outpatient clinics. All practitioners in the intervention arm received quarterly comparative feedback reports and, when indicated, quarterly patient alert letters. Comparative feedback reports gave personalized feedback about antibiotic prescriptions for upper respiratory tract infections, comparing the recipient’s antibiotic prescriptions to the average for all practitioners at the primary care clinics included in our study. Patient alert letters notified practitioners to patients in their panel with recently detected Clostridioides difficile or resistant organism and their antibiotic exposures. We assessed outpatient visits during the preintervention period (April–September 2020), the intervention period (October 2020–September 2021), and the postintervention period (October 2021–September 2022). A mixed-effects logistic regression model predicting antibiotic prescriptions compared the arms across these periods. Results: The outpatient populations observed in the intervention and control arms were similar during each phase of the study. Prior to the intervention, the average proportion of visits with an antibiotic prescription was lower among clinics in the intervention arm (1.4% vs 1.8% in control arm; P = .45). This difference broadened slightly during the intervention period (1.4% vs 2.1%, respectively; P = .03) and the postintervention period (1.3% vs 2.1%, respectively; P = .01) (Fig. 1). Throughout the study, clinics in the intervention arm typically used more doxycycline and azithromycin and less amoxicillin-clavulanate and sulfamethoxazole-trimethoprim compared to clinics in the control arm. (Fig. 2). In the 6-month preintervention period, which coincided with the early phase of the COVID-19 pandemic, antibiotic prescriptions in the intervention compared to control clinics were similar. During the intervention and postintervention periods, the proportion of visits with an antibiotic prescription remained steady for clinics in the intervention arm and increased for those in the control arm. These results suggest that this pilot study using a low-intensity intervention consisting of comparative feedback reports and patient alert letters was successful in influencing the antibiotic prescribing behavior of primary care clinicians practicing in community-based outpatient clinics affiliated with a VA medical center.Financial support: This study was funded by Merck.Disclosures: None

Enhancing Resident Education by Embedding Improvement Specialists Into a Quality and Safety Curriculum.

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

Reducing the rate of guideline-discordant therapy for inpatients with community-acquired pneumonia

Background: Despite guidelines recommending shorter durations of therapy and empiric coverage of Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus (MRSA) only for patients with certain risk factors, optimizing therapy for community-acquired pneumonia (CAP) remains a challenge for antimicrobial stewardship (AMS) teams. We investigated the impact of a multimodal AMS initiative on the rate of guideline-discordant empiric antibiotic selection and total duration of therapy for CAP. Methods: A quality improvement initiative was implemented at 9 community hospitals in 2022 to optimize CAP therapy. Education was provided to pharmacists and providers. Alerts were implemented within the electronic medical record to prompt the AMS team to review fluoroquinolones, antipseudomonal β-lactams, and anti-MRSA agents ordered for CAP. Clinical pharmacists reviewed antibiotic orders for CAP at hospital discharge and encouraged providers to prescribe a total antibiotic duration of 5–7 days. For the preintervention period (July– September 2021) and the postintervention period (July to September 2022), a random sample of 320 patients with an antibiotic order for CAP were evaluated retrospectively via chart review. Patients treated for an indication other than CAP were excluded. The primary outcome was the proportion of patients with a total duration of therapy &gt;7 days. Secondary outcomes included average duration of therapy, rate of guideline-discordant empiric therapy, and type of guideline discordance. Results: In total, 317 patients were included. The proportion of patients with a total duration of therapy &gt;7 days decreased from 29% to 14% (P &lt; .01). Average duration of therapy and guideline-discordant empiric therapy also decreased significantly (Table 1). Conclusions: This multifaceted AMS initiative was associated with decreased guideline-discordant empiric therapy and decreased total duration of therapy for CAP.Disclosures: None

Paradoxical consequences of wastewater interventions targeting carbapenemase-producing Enterobacterales

Background:Serratia marcescens is a leading cause of hospital-acquired infections. There has been increasing recognition of hospital wastewater as a reservoir for carbapenemase-producing Enterobacterales (CPE), including S. marcescens. Because CPE can proliferate in biofilms in sink drains and traps, controlling nosocomial spread is challenging. The ideal approach to eliminate transmission from wastewater to patients remains unknown. Methods: Patients were included if they were admitted to 1 of 2 intensive care units (ICUs) for &gt;12 hours between December 1, 2010, and January 31, 2016. During this period at the University of Virginia Hospital, there was ongoing patient acquisition of multiple species producing Klebsiella pneumoniae carbapenemase (KPC) as well as consistent perirectal KPC surveillance. In January 2014, to eliminate CPE-colonized sinks, the sink drains and traps in one of the ICUs (ie, the “intervention unit”) were exchanged followed by varied chemical mitigations to prevent recolonization. In another ICU, the same chemical mitigations were performed but without plumbing replacement (ie, the “control unit”). Acquisition of KPC-producing S. marcescens was defined as colonization or infection &gt;12 hours after admission to either unit. To control for increases in patient-to-patient transmission, acquisition of methicillin-resistant Staphylococcus aureus (MRSA) was evaluated in the intervention unit during the same period and was defined as new colonization or infection with MRSA &gt;12 hours after unit admission but within 21 days of last unit exposure. Results: For the postintervention period, risk of S. marcescens acquisition was increased (RR, 2.85; 95% CI, 1.24–6.58; P = .01) in the intervention unit compared to the control unit. In the intervention unit, the risk of S. marcescens acquisition increased in the postintervention period compared to the preintervention period (RR, 6.26; 95% CI, 2.59–15.1; P &lt; .0001). There was no change in MRSA acquisition in the intervention unit representing consistent patient-to-patient infection prevention (RR, 0.95; 95% CI, 0.61–1.48; P = .81). S. marcescens isolates were noted to be highly clonal. Conclusions: Exposure to the intervention unit following plumbing replacement was associated with increased relative risk of acquisition of KPC-producing S. marcescens. This increased risk was not observed in the control unit, which had only chemical plumbing interventions. There was no concomitant increase in patient-to-patient MRSA transmission. The disturbance of the wastewater environment through the plumbing replacement intervention may have led to the unintended consequence of more KPC-producing S. marcescens acquisition.Disclosures: None