UNC Health Research Articles

196. Increasing Bacteremia and Endovascular Infections due to Serratia marcescens: Implications for Evaluation and Treatment

Abstract Background While Serratia marcescens can cause bloodstream infections (BSI), endocarditis or other endovascular infections are historically rare and typically due to injection drug use (IDU). Given the rise in IDU nationwide, and limited evidence for managing non-HACEK gram-negative endocarditis, we examined trends in the epidemiology of Serratia BSI and characterized management strategies. Methods Our study was a retrospective analysis of adults admitted to UNC Health, a hospital network in North Carolina, from Apr 2014 to Mar 2021 with Serratia bacteremia. We used EMERSE, a program that searches free text in clinical notes, to identify those with ‘Serratia’ and either ‘bacteremia’ or ‘endocarditis’. This helped identify patients with microbiology obtained at outside hospitals. We performed chart review to confirm the Serratia BSI and collect demographic and clinical data. We tabulated yearly hospitalizations (Apr 1 to Mar 31), proportions of endovascular infections (endocarditis, cardiac device, vascular grafts), and described demographics and treatment approaches. Results We identified 97 patients by EMERSE and included 66 in analysis (Fig 1). 21 (32%) had endovascular infections and 21 (32%) overall were due to IDU (Table). Endovascular infections and BSIs increased over the period (Fig 2). Until 2018-2019, there were 0-10 Serratia BSIs yearly. In the final year, there were 37, 13 (37%) of which were endovascular infections. While we did not limit to S. marcescens, no other species were seen. 59/61 (97%) isolates with 3rd generation cephalosporin susceptibility reported were sensitive. 17/21 endovascular infections were endocarditis. 10/17 (59%) patients underwent valve replacement and 8/21 (38%) received dual antibiotic therapy for ≥ 6 weeks. Of the 10 attending infectious diseases follow-up visit, 6 were prescribed oral suppressive antibiotics after parenteral therapy. Figure 2. Serratia bloodstream infections (2014-2021) Table 1. Characteristics of Serratia bloodstream infections Conclusion Serratia BSI and endovascular infections are markedly increasing, with a large component due to IDU. Given the high proportion of endocarditis, echocardiography may be considered for patients with Serratia BSI, particularly those with IDU or prosthetic material. Further studies are needed to confirm this phenomenon and to establish evidence for optimal management of Serratia endocarditis. Disclosures Asher J. Schranz, MD, United HealthCare (Other Financial or Material Support, Spouse provides scientific review)

Judge rules against former employee

Case name: Wilson v. UNC Health Care System, No. 1:19CV1169 (M.D. N.C. 09/28/20).

Evaluation of Patient-Reported Delays and Affordability-Related Barriers to Care in Head and Neck Cancer.

ObjectiveTo examine the prevalence and predictors of patient-reported barriers to care among survivors of head and neck squamous cell carcinoma and the association with health-related quality of life (HRQOL) outcomes.Study DesignRetrospective cohort study.SettingOutpatient oncology clinic at an academic tertiary care center.MethodsData were obtained from the UNC Health Registry/Cancer Survivorship Cohort. Barriers to care included self-reported delays in care and inability to obtain needed care due to cost. HRQOL was measured with validated questionnaires: general (PROMIS) and cancer specific (FACT-GP).ResultsThe sample included 202 patients with head and neck squamous cell carcinoma with a mean age of 59.6 years (SD, 10.0). Eighty-two percent were male and 87% were White. Sixty-two patients (31%) reported at least 1 barrier to care. Significant predictors of a barrier to care in unadjusted analysis included age ≤60 years (P = .007), female sex (P = .020), being unmarried (P = .016), being uninsured (P = .047), and Medicaid insurance (P = .022). Patients reporting barriers to care had significantly worse physical and mental HRQOL on the PROMIS questionnaires (P < .001 and P = .002, respectively) and lower cancer-specific HRQOL on the FACT-GP questionnaire (P < .001), which persisted across physical, social, emotional, and functional domains. There was no difference in 5-year OS (75.3% vs 84.1%, P = .177) or 5-year CSS (81.6% vs 85.4%, P = .542) in patients with and without barriers to care.ConclusionDelay- and affordability-related barriers are common among survivors of head and neck cancer and appear to be associated with significantly worse HRQOL outcomes. Certain sociodemographic groups appear to be more at risk of patient-reported barriers to care.

Retrospective Study of Venous Thromboembolism Prophylaxis Dosing of Heparin in Adult Patients receiving Continuous Renal Replacement Therapy

Background: Appropriate chemical and/or mechanical venous thromboembolism prophylaxis is a high priority for clinicians. Unfortunately, there is little evidence-based guidance for clinical decision making for patients requiring both renal replacement therapy and VTE prophylaxis. The package insert for unfractionated heparin recommends 5000 units subcutaneously every 8 to 12 hours for VTE prophylaxis. Objective: The purpose of this study was to assess the two recommended dosing intervals and determine if there is a difference in terms of incidence of clotting or bleeding events. Methods: 159 patients were admitted to the UNC Health Care system between March 2014 and November 2019 and retrospectively screened for incidence of both the primary composite efficacy outcome (symptomatic or asymptomatic vascular event (VTE [DVT and PE]), ischemic event (stroke, TIA, or myocardial infarction), or death related to coagulopathy), the individual components of the composite outcome and the primary safety outcome. The results of the outcomes were then compared and analyzed using Fischer’s Exact test. Results: The two tailed p-values of the primary composite efficacy outcome (0.3517), the primary safety outcome (0.1571) and each of the composite outcomes (0.1556, 1.0000, 0.2297, respectively) showed no statistically significant difference. Conclusion: Results of this study show that there is no statistical difference between the dosing intervals of prophylactic UFH of every 8 to 12 hours, in terms of the incidence of VTE and major bleed events, for patients requiring CRRT. Suggesting that either interval is both efficacious and safe for the use of VTE prophylaxis.

Sheldon Peck (1941-2021) Secretary of the EHASO, 1995-2009.

Sheldon Peck (1941-2021) Secretary of the EHASO, 1995-2009.

Effect of government-issued state of emergency and reopening orders on cardiovascular hospitalizations during the COVID-19 pandemic

ObjectiveLittle is known about the effect of government-issued State of Emergency (SOE) and Reopening orders on health care behaviors. We aimed to determine the effect of SOE and Phase 1 of Reopening orders on hospitalizations for acute myocardial infarction (AMI) or acute decompensated heart failure (ADHF). MethodsHospitalizations for AMI and ADHF in the UNC Health system, which includes 10 hospitals in both urban and rural counties, were identified. An interrupted time series design was used to compare weekly hospitalization rates for eight weeks before the March 10th SOE declaration, eight weeks between the SOE order and Phase 1 of Reopening order, and the subsequent eight weeks. ResultsOverall, 3,792 hospitalizations for AMI and 7,223 for ADHF were identified. Rates before March 10th were stable. AMI/ADHF hospitalizations declined about 6% per week in both urban and rural hospitals from March 11th to May 5th. Larger declines in hospitalizations were seen in adults ≥65 years old (-8% per week), women (-7% per week), and White individuals (-6% per week). After the Reopening order, AMI/ADHF hospitalizations increased by 8% per week in urban centers and 9% per week in rural centers, including a significant increase in each demographic group. The decline and rebound in acute CV hospitalizations were most pronounced in the two weeks following the government orders. ConclusionsAMI and ADHF hospitalization rates closely correlated to SOE and Reopening orders. These data highlight the impact of public health measures on individuals seeking care for essential services; future policies may benefit from clarity regarding when individuals should present for care.

Implementation of Postoperative Standard Opioid Prescribing Schedules Reduces Opioid Prescriptions Without Change in Patient-reported Pain Outcomes

To implement Standard Opioid Prescribing Schedules (SOPS) based on opioid use following urologic surgeries and to evaluate how evidence-based prescribing schedules affect opioid use and patient reported outcomes. Patients who underwent urologic surgeries within 6 procedure subtypes at UNC Health during the 2 study time periods ("pre-SOPS": 7/2017-1/2018, "post-SOPS": 7/2018-1/2019) were invited to complete a survey analyzing postoperative opioid usage, storage and disposal, and patient reported outcomes (including pain interference using a validated questionnaire). A pharmacy database provided medication prescribing data and patient demographics. During the pre-SOPS time period, baseline outcomes were measured. Following the pre-SOPS period, usage amounts were analyzed and Standard Opioid Prescribing Schedules were developed to guide prescriptions during the post-SOPS period. Descriptive summary statistics and appropriate t test or r2 were calculated. A total of 438 patients within 6 procedure types completed the survey (pre-SOPS: 282 patients, post-SOPS: 156 patients). Pre-SOPS, patients were prescribed significantly more 5-mg oxycodone tablets than used (20.9 vs 7.8, P <.001). Post-SOPS, compared to pre-SOPS amounts, patients were prescribed significantly fewer tablets (12.7 vs 20.9, P <.001) and used fewer tablets (5.3 vs 7.8, P = .003). No difference was observed in pain interference (average t-score (standard deviation): 54.33 (10.9) pre-SOPS vs 55.89 (9.1) post-SOPS, P = .125) or patient satisfaction (95% pre-SOPS vs 94% post-SOPS). Adherence to data-driven postoperative opioid prescribing schedules reduce opioid prescriptions and use without compromising pain interference or patient satisfaction. These results have important implications for urologists' ability to decrease opioid prescriptions and fight the opioid epidemic.

EMBEDDING DEMENTIA-FRIENDLY TRAINING IN A HEALTH CARE SYSTEM

Alzheimer’s disease, the most common form of dementia, is now the 6th leading cause of death in the United States, affecting one in ten people over the age of 65. With our country’s rapidly aging population, and age being the primary known risk factor for dementia, the number of people with dementia is expected to increase from 5.8 million in 2019 to 14 million in 2050. People with dementia are hospitalized more often and have prolonged stays, poorer outcomes, higher costs, and increased readmission rates. Hospital employees have expressed the desire to have specialized training to learn how to more effectively communicate with and provide better care to patients with dementia to minimize adverse outcomes and increase patient satisfaction. To better address these identified patient and hospital employee needs, the University of North Carolina’s Center for Aging and Health (UNC CAH) is disseminating hospital-specific dementia-friendly training to four hospitals within the UNC Health Care System. The training is being delivered via online modules and follow-up didactic sessions to over 4,000 clinical and non-clinical staff who interact with patients. To monitor outcomes, pre and post training data is being collected on dementia patients’ length of stay, readmission rates, and falls. The pilot project was conducted in 2019, and results of the pilot will be presented in the poster. The dementia-friendly hospital training initiative will prepare hospitals to provide better care for people with dementia, which should lead to improved health outcomes and more positive experiences for patients, caregivers, and hospital employees.

211-LB: Developing "Gold Standard" Diagnoses for Type 1 and Type 2 Diabetes in Adults from Electronic Health Record Data

Type 1 (T1D) and type 2 (T2D) diabetes are distinct diseases, but most federal surveys used to monitor diabetes prevalence have not included questions on diabetes type. To design and validate survey questions that will distinguish between T1D and T2D in adults, we developed a survey sample in whom we first determined a "gold standard" for diabetes type from review of electronic health record (EHR) data. From &amp;gt;50,000 adult patients in the UNC Health Care System with diabetes, we assembled a sample of 2479 patients using a "strawman" definition based on diabetes-related diagnostic codes, laboratory results, and drugs. We stratified the sample using age, sex, race/ethnicity and crude diabetes type, oversampling T1D. For visits between 10/2014 and 9/2017, we collected clinical and demographic data including body mass index, diagnosis codes, medications, family history, and laboratory tests. We also abstracted chart notes, using trained personnel, to find additional information including diabetes duration and historical treatments. We created two models to determine diabetes type. The first was a decision tree, in which higher nodes sorted straightforward cases; lower nodes included more specific factors for those not categorized in higher nodes. The second was a weighted model, in which factors drawn from clinical or epidemiologic literature weighed weakly, moderately, or strongly in favor of or against each type of diabetes. The two models were 89% congruent for T1D and 96% congruent for T2D. An endocrinologist reviewed and determined type for the 10% of patients for which results of the two models were not congruent or for which neither was able to determine type. Overall, 70% of our sample has T2D, 27% has T1D, and 3% has indeterminate or other diabetes. We will use this sample to validate survey questions to determine type of diabetes. Such "gold standard" determinations may support validation of new and improved methods for measuring diabetes type among the adult population. Disclosure M. Kirkman: Research Support; Self; Bayer AG, Novo Nordisk A/S, Theracos, Inc. J.G. Nooney: None. S.R. Benoit: None. K.A. Bergamo: None. K.M. Bullard: None. J.R. Campione: None. R. Mardon: None. E. Pfaff: None. D.B. Rolka: None. S. Saydah: None. Funding Centers for Disease Control and Prevention

Benefits and Challenges of Linking Electronic Medical Record and Claims Data for Perinatal Research [28H

INTRODUCTION: To improve understanding of the postpartum health services received in the 90 days following delivery for mothers of medically fragile infants (MMFI) we linked electronic medical record (EMR) data to commercial insurance claims. METHODS: We conducted a retrospective cohort study of mothers delivering liveborn infants at North Carolina Women's Hospital between 7/1/2014 and 6/30/2016 (n=6849). We linked data from the UNC Health System Epic EMR to member encounters from a commercial insurance provider to measure prevalent conditions, health care utilization, and receipt of recommended services among MMFI compared with mothers of well babies. A list of mothers names with the payor on their delivery account (n=1687), birthdate, delivery date, procedure code for delivery, delivery location, subscriber ID, and billed provider was provided to an honest broker for matching. RESULTS: The honest broker identified members with enrollment and a childbirth-related procedure code during the study period (n=90,490) and applied context-based blocking and fuzzy matching on combinations of first and last name for a 97% match rate (n=1642). Having a finite time-period (a childbirth-related encounter date within 1-2 days of that mother's EMR delivery date) and adding anesthesia procedure codes contributed to a successful linkage. Changes in the mother's medical record number made it challenging to query EMR data on the same woman longitudinally. CONCLUSION: Linking claims to EMR data can elucidate women's health utilization in the early postpartum period by allowing ascertainment of encounters outside of the hospital. Additionally our findings have contributed to improved data quality initiatives in the hospital's EMR system.

739: Postpartum health service utilization by mothers of infants admitted to neonatal intensive care

Mothers of infants admitted to the neonatal intensive care unit (NICU) must recover from birth while attending to a critically ill infant. These mothers also have higher rates of chronic disease and perinatal complications than mothers of well babies (MWB). We sought to quantify postpartum health utilization by NICU mothers, compared with MWB. We conducted a retrospective cohort study of mothers delivering liveborn infants at North Carolina Women's Hospital between 7/1/2014 and 6/30/2016. MWB were defined as mothers of infants not admitted to the NICU. NICU mothers were defined as mothers with one or more infants admitted to the NICU. We further subtyped NICU mothers into two groups: Mothers of medically fragile infants (MMFI), defined as NICU length of stay ≥3 days, and mothers of transiently ill infants (MTII), defined as NICU stays <3 days. We ascertained postpartum health service utilization through encounter data recorded in the UNC Health System Epic Electronic Medical Record (EMR) between discharge from the birth hospitalization and 12 weeks postpartum. We used Poisson regression to compare encounter counts and by encounter type, adjusting for mode of delivery, race/ethnicity, payer status, and maternal age. When differences were found between NICU mothers and MWB, we further compared utilization for MMFI vs. MTII. During the study period, 6849 mothers met criteria for inclusion, of whom 5768 were MWB, 743 were MMFI, and 338 were MTII,. Of these 6849 women, 4349 had at least one encounter in the UNC system during the 12-week postpartum period, comprising 9540 encounters. In crude analyses, NICU mothers were more likely to experience each type of encounter, compared with MWB (Table). In adjusted analyses, utilization rates remained significantly higher for NICU mothers for all encounter types other than emergency room visits. Exclusion of women without any postpartum encounters in the UNC Health System did not materially change our results. When we compared MTII with MMFI, we found that MTII had higher rates of outpatient office visits (adj RR 1.29, 95% CI 1.07-1.55) and psychiatry visits (adj RR 1.63, 95% CI 1.13-2.35). Mothers of NICU infants utilize health care at a higher rate in the postpartum period, compared with MWB.

Social Relationships, Inflammation, and Cancer Survival.

Background: Social stressors, such as social relationship deficits, have been increasingly linked to chronic disease outcomes, including cancer. However, critical gaps exist in our understanding of the nature and strength of such links, as well as the underlying biological mechanisms relating social relationships to cancer progression and survival.Methods: Utilizing novel questionnaire and biomarker data from the UNC Health Registry/Cancer Survivorship Cohort, this study examines the associations between diverse measures of social support and mortality risk among individuals with cancer (N = 1,004). We further assess the role of multiple serum markers of inflammation, including high-sensitivity C-reactive protein (CRP), IL6, TNFα, and VEGF, as potential mediators in the social relationship-cancer link.Results: The findings revealed that one's appraisal of their social support was associated with cancer mortality, such that individuals reporting higher levels of social support satisfaction had lower mortality risk than individuals reporting lower levels of satisfaction. The amount of support received, on the other hand, was not predictive of cancer survival. We further found evidence that inflammatory processes may undergird the link between social support satisfaction and mortality among individuals with cancer, with individuals reporting higher levels of social support satisfaction having lower levels of CRP, IL6, and TNFα.Conclusions: These results provide new knowledge of the biosocial processes producing population disparities in cancer outcomes.Impact: Our study offers new insights for intervention efforts aimed at promoting social connectedness as a means for improving cancer survival. Cancer Epidemiol Biomarkers Prev; 27(5); 541-9. ©2018 AACR.

Quality improvement teams, super-users, and nurse champions: a recipe for meaningful use?

This study assessed whether having an electronic health record (EHR) super-user, nurse champion for meaningful use (MU), and quality improvement (QI) team leading MU implementation is positively associated with MU Stage 1 demonstration. Data on MU demonstration of 596 providers in 37 ambulatory care clinics came from the clinical data warehouse and administrative systems of UNC Health Care. We surveyed the 37 clinics about champions, super-users, and QI teams. We used generalized estimating equation methods with an independence working correlation matrix to account for clustering within clinics and to weight contributions from each clinic according to clinic size. Having a QI team lead MU implementation was significantly associated with MU demonstration (odds ratio, OR = 3.57, 95% CI, 1.83-6.96, P < .001, Table 2). Having neither a nurse champion nor an EHR super-user was significant. Our findings support the alignment of MU with QI efforts by having the QI team lead MU implementation.

Patient Portals: Who uses them? What features do they use? And do they reduce hospital readmissions?

Patient portals have demonstrated numerous benefits including improved patient-provider communication, patient satisfaction with care, and patient engagement. Recent literature has begun to illustrate how patients use selected portal features and an association between portal usage and improved clinical outcomes. This study sought to: (1) identify patient characteristics associated with the use of a patient portal; (2) determine the frequency with which common patient portal features are used; and (3) examine whether the level of patient portal use (non-users, light users, active users) is associated with 30-day hospital readmission. My UNC Chart is the patient portal for the UNC Health Care System. We identified adults discharged from three UNC Health Care hospitals with acute myocardial infarction, congestive heart failure, or pneumonia and classified them as active, light, or non-users of My UNC Chart. Multivariable analyses were conducted to compare across user groups; logistic regression was used to predict whether patient portal use was associated with 30-day readmission. Of 2,975 eligible patients, 83.4% were non-users; 8.6% were light users; and 8.0% were active users of My UNC Chart. The messaging feature was used most often. For patients who were active users, the odds of being readmitted within 30 days was 66% greater than patients who were non-users (p<0.05). There was no difference in 30-day readmission between non-users and light users. The vast majority of patients who were given an access code for My UNC Chart did not use it within 30 days of discharge. Of those who used the portal, active users had a higher odds of being readmitted within 30 days. Health care systems should consider strategies to: (1) increase overall use of patient portals and (2) target patients with the highest comorbidity scores to reduce hospital readmissions.

Survey of Emergency Department staff on disaster preparedness and training for Ebola virus disease.

In the domestic response to the outbreak of Ebola virus disease from 2013 to 2015, many US hospitals developed and implemented specialized training programs to care for patients with Ebola. This research reports on the effects of targeted training on Emergency Department (ED) staff's Ebola-related perceptions and attitudes. One hundred fifty-nine members of the UNC Health Care System ED staff participated in a voluntary cross-sectional, anonymous Web survey administered using a one-time "post then pre" design. Participants responded to questions about risk, roles, willingness to provide care, preparedness, and the contributions of media, training, or time to opinion change using a Likert agree-disagree scale. The authors conducted t test comparisons of Likert responses to pretraining and post-training attitudes about Ebola preparedness. The authors conducted multinomial logistic regression analyses of index scores of change and positivity of responses, controlling for the effects of independent variables. ED staff's opinions supported training; 73 percent felt all workers should receive Ebola education, 60 percent agreed all hospitals should prepare for Ebola, 66 percent felt UNC was better prepared, and 66 percent felt it had done enough to be ready for an Ebola case. Most staff (79 percent) said they had gotten more training for Ebola than for other disease outbreaks; 58 percent had experienced prior epidemics. After training, workers' attitudes were more positive about Ebola preparation including perceived risk of transmission, readiness and ability to manage a patient case, understanding team roles, and trust in both personal protective equipment and the hospital system's preparations (13 measures, p < 0.0001 to p < 0.001). Overall, total opinion indices also changed significantly over the training period (Mean Difference [MD] = 17.45, SD = 9.89) and in the intended positive direction (MD = 15.80, SD = 0.91, p < 0.0001). Positive change and overall change from pre to post were significantly associated with more hours of training (p = 0.003). Despite different occupations, mean scores were similar. Staff rated training most important and media least important, as the sources of change in their attitudes (p < 0.0001). These findings suggest that diseasespecific training for novel pathogens such as Ebola may result in positive staff perceptions of self-efficacy and occupational efficacy to treat potentially infected patients in the ED setting. Training, in this case, outweighed media content in changing staff perceptions of Ebola management.

The University of North Carolina's Health Care Pharmacy Assistance Progam.

UNC Health Care has a Pharmacy Assistance Program (PAP) that provides financial assistance to uninsured patients in North Carolina who need prescription medications. Despite significant investment in the program, little is known about the patients accessing it or the specific health care services they use. Our objectives were to describe the PAP population, to examine their use of prescription medications and health services, and to characterize changes in prescription medication use and expenditures from 2009 through 2011. We used a repeated cross-sectional study design, merging prescription claims with health records from Carolina Data Warehouse for Health, to measure use of prescription medications and use of inpatient, outpatient, and emergency department care by PAP participants. Prescription claims were grouped into therapeutic categories. We generated descriptive statistics for key variables to examine health service utilization from 2009 through 2011. From 2009 through 2011, PAP served 7,180 patients from 81 counties in North Carolina. PAP users received a mean of 23 prescriptions, at an average cost of $754 per recipient per year. An average of $2.93 million per year was spent on the program, with an 8% rise in spending from 2009 to 2011. Inpatient care and emergency department care were utilized by 30% and 31% of PAP users, respectively, and there was minimal change in these rates over 3 years. Data were limited to medications dispensed through PAP and to health services provided by UNC Health Care. With the state's decision to not expand Medicaid, PAP will continue to be an important resource for North Carolina's low income citizens.

Managing and Preventing Exposure Events from Inappropriately Reprocessed Endoscopes

Affiliation: 1. Department of Medicine, University of North Carolina at Chapel Hill, North Carolina; and Department of Hospital Epidemiology, UNC Health Care, Chapel Hill, North Carolina. Received March 21, 2012; accepted March 22, 2012; electronically published May 7, 2012. 2012 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2012/3307-0002$15.00. DOI: 10.1086/666339 Each year in the United States millions of invasive procedures are performed, including greater than 10,000,000 gastrointestinal endoscopic procedures (Table 1). All invasive procedures involve contact by a medical device or surgical instrument with a patient’s sterile tissue or mucous membranes. A major risk of all such procedures is the introduction of pathogens that can lead to infection. Failure to properly disinfect or sterilize equipment carries not only the risk associated with breach of host barriers but also the risk of personto-person transmission (eg, hepatitis B virus [HBV]) and transmission of environmental pathogens (eg, Pseudomonas aeruginosa). Proper disinfection and sterilization are essential for ensuring that medical and surgical instruments do not transmit pathogens to patients. More than 55 years ago, Spaulding devised a rational approach to disinfection and sterilization of patient care items or equipment. This classification scheme is so clear and logical it has been retained and refined and continues to be used when planning methods for disinfection and sterilization. Spaulding divided medical devices into 3 categories (ie, critical, semicritical, and noncritical) on the basis of the risk of infection involved in the use of the items. Critical devices are items that enter sterile tissue or the vascular system and include surgical instruments, implants, and intravenous or intra-arterial catheters. Items in this category should be purchased as sterile or should be sterilized by steam sterilization (preferred). Semicritical items are those that come into contact with mucous membranes or nonintact skin and include gastrointestinal endoscopes, bronchoscopes, laryngoscope blades and handles, and diaphragm-fitting rings. These medical devices should be free of all microorganisms (ie, mycobacteria, fungi, viruses, and bacteria), although small numbers of bacterial spores may be present. The minimal requirement for semicritical items is high-level disinfection using Food and Drug Administration (FDA)–cleared highlevel chemical disinfectants. Noncritical items are those that come into contact with intact skin but not mucous membranes (eg, bedpans, blood-pressure cuffs, and bed rails). Such items should undergo low-level disinfection after use when shared by different patients. The Spaulding classification provides an excellent guide for disinfection and sterilization of medical devices, but it should be noted that the scheme is an oversimplification, and preventing transmission of infection by medical devices may require additional modifications. Multiple studies in many countries have documented a lack of compliance with established guidelines for disinfection and sterilization. Failure to comply with scientifically based guidelines has led to numerous outbreaks. Preventing and managing potential outbreaks when there is a breach in established methods of disinfection and sterilization is complex, may consume substantial amounts of personnel time and expense, and may lead to legal problems. In this issue of Infection Control and Hospital Epidemiology, Holodniy et al describe the management of 4 potential outbreaks in Veterans Affairs medical centers (VAMCs), all resulting from failure to follow established guidelines for cleaning and disinfecting endoscopes. The breaches in disinfection led to 9,879 patients being tested in look-back programs for possible acquisition of human immunodeficiency virus (HIV), HBV, and hepatitis C virus (HCV). This excellent article raises a number of important issues. First, what is the frequency of outbreaks and pseudo-outbreaks related to endoscopy? The incidence of infection associated with endoscopy has been reported to be very low (about 1 case per 1.8 million procedures). However, as noted by Holodniy and colleagues, this number may be an underestimate because outbreaks may be unrecognized or never reported. The prolonged incubation period of the key bloodborne viruses (ie, HIV, HBV, and HCV) and the fact that initial infection may be asymptomatic would make detection of an infection from an endoscopic procedure difficult. Fur-

Immunization for Vaccine-Preventable Diseases: Why Aren’t We Protecting Our Students?

Affiliations: 1. Department of Medicine, University of North Carolina, Chapel Hill, North Carolina; 2. Department of Hospital Epidemiology, UNC Health Care, Chapel Hill, North Carolina; 3. Department of Preventive Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee. Received June 29, 2011; accepted July 1, 2011; electronically published July 22, 2011. 2011 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2011/3209-0012$15.00. DOI: 10.1086/661791 Despite major advances in the prevention and treatment of infectious diseases, infections still remain a common reason for admission to US hospitals. Healthcare personnel (HCP) are at risk for acquiring infections from patients and, if they are infected, transmitting infections to patients. The risk of acquisition of an infectious disease during the care of a patient is a major reason physicians have been held in such high regard by the public. While this risk can be minimized by adherence to infection control guidelines, it cannot be entirely eliminated. For example, more than 20% of persons who acquired severe acute respiratory syndrome (SARS) were healthcare workers. In Vietnam, Canada, and Singapore, healthcare workers accounted for 57%, 43%, and 41% of SARS patients, respectively. Protection of HCP from acquisition of infectious diseases can be achieved by adherence to established infection control guidelines to include the following: (1) assuring that HCP are immune to vaccine-preventable diseases; (2) strict adherence to standard precautions when providing patient care, especially the performance of hand hygiene before and after patient care; (3) rapid evaluation and appropriate isolation of patients with potentially communicable diseases; (4) proper use of personal protective equipment, such as masks, N-95 respirators, eye protection, and gowns, for patients with potentially communicable diseases; and (5) evaluation of personnel with exposure to communicable diseases for receipt of postexposure prophylaxis (eg, pertussis). Immunity to vaccine-preventable diseases for which transmission has been shown in healthcare facilities is recommended by the Centers for Disease Control and Prevention (CDC), the Healthcare Infection Control Practices Advisory Committee, the Advisory Committee on Immunization Practices (ACIP), and the American Academy of Pediatrics. Failure to assure immunity to vaccine-preventable diseases had led to large institutional outbreaks in healthcare facilities, morbidity and mortality among hospitalized patients, and even morbidity and mortality among HCP. HCP not only have become infected with vaccine-preventable diseases through patient care but also have served to initiate or propagate hospital outbreaks. The CDC and ACIP in recent publications have replaced the term “healthcare workers” with “healthcare personnel” specifically to indicate that all persons providing patient care should be immunized, including healthcare facility employees (eg, nurses and environmental service workers), physicians (who are often independent contractors), students, volunteers, and contract workers. All HCP should be immune to measles, mumps, rubella, varicella, pertussis, and influenza. Immunity should be demonstrated by all HCP providing service in the medical facility, not just those providing direct patient care, as all of the diseases just listed are transmitted by the droplet or airborne routes and hence unimmunized HCP, if infected, could transmit infection to their colleagues or patients via close contact or in common areas (eg, cafeteria or gift shop). HCP with potential exposure to blood or contaminated fluids must be offered hepatitis B vaccine per regulations from the US Occupational Health and Safety Administration. Healthcare facilities should screen HCP prior to providing service in the healthcare facility for immunity by using current recommendations (Table 1). Unimmunized HCP should be immunized with the appropriate vaccines unless there is a medical contraindication. Religious and personal objections to vaccines should be accepted only if required by local and state regulations or laws, as susceptible HCP pose a substantial risk to the well-being of their patients. HCP should be provided vaccines that are recommended for adults, such as human papilloma virus, herpes zoster, and pneumococcal vaccines, or referred to their local medical provider. In special circumstances, HCP or laboratory personnel should be offered immunization with other vaccines, includ-

Surprising evidence of pelvic growth (widening) after skeletal maturity

Following an increase in length and width during childhood and adolescence, skeletal growth is generally assumed to stop. This study investigates the influence of aging on the dimensions of the pelvis and the L4 lumbar vertebra during adulthood. The dimensions of the pelvis, L4 vertebra, and femoral heads were calculated for 246 patients who had received pelvic and abdominal Computed Tomography scans from the UNC Health Care System. Linear regression analysis determined the significance of relationships between age and width of the pelvis. There was a strong correlation between increasing patient age and increasing width of the pelvis at the trochanters, (0.333 mm/year of age p<0.0001), at the iliac wings, (0.371 mm/year of age p < 0.0002), and between the femoral heads, indicating that the bony pelvis widens over 20 mm between the ages of 20 and 80. The pelvic inlet did not enlarge over time while the distance between the hips and the femoral head diameter did significantly increase. The height of L4 did not increase over time, but the L4 width did increase. These correlations were seen in both genders. Surprisingly, our results suggest that the pelvis and L4 vertebra increase in width after skeletal maturity and cessation of longitudinal growth.

UNC Health Systems and Blue Cross and Blue Shield of North Carolina Patient-Centered Medical Home Collaborative

UNC Health Systems and Blue Cross and Blue Shield of North Carolina have entered into a joint venture that is designed to improve patient outcomes and experience and to control medical costs for patients with chronic conditions. This commentary reviews the impetus for, and the anticipated outcomes of, the model practice.