US Healthcare Facilities Research Articles

Clusters of emerging multidrug-resistant organisms in US health care facilities during the initial months of the SARS-CoV-2 pandemic

Outbreaks of emerging multidrug-resistant organisms (eMDROs), including carbapenem-resistant Enterobacterales, carbapenem-resistant Acinetobacter baumannii, and Candida auris, have been reported among severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) patients. We describe eMDRO clusters in SARS-CoV-2 units and associated infection control (IC) practices early in the SARS-CoV-2 pandemic. We conducted a retrospective survey of a convenience sample of health departments in 11 states to describe clusters of eMDROs that began before November 1, 2020 and involved SARS-CoV-2 units. Cluster characteristics and IC practices during the cluster period were assessed using a standardized outbreak report form, and descriptive analyses were performed. Overall, 18 eMDRO clusters (10 carbapenem-resistant Enterobacterales, 6 Cauris, 1 carbapenem-resistant Pseudomonas aeruginosa, and 1 carbapenem-resistant A baumannii) in 18 health care facilities involving 397 patients were reported from 10 states. During the cluster period, 60% of facilities reported a shortage of isolation gowns, 69% extended use of gowns, and 67% reported difficulty obtaining preferred disinfectants. Reduced frequency of hand hygiene audits was reported in 85% of acute care hospitals during the cluster period compared with before the pandemic. Changes in IC practices and supply shortages were identified in facilities with eMDRO outbreaks during the SARS-CoV-2 pandemic and might have contributed to eMDRO transmission.

Hospital mortality and length of stay associated with Enterobacterales positive blood cultures: a multicenter analysis.

Delayed time to antimicrobial susceptibility results can impact patients' outcomes. Our study evaluated the impact of susceptibility turnaround time (TAT) and inadequate empiric antibacterial therapy (IET) in patients with bloodstream infections (BSI) caused by Enterobacterales (ENT) species on in-hospital mortality and length of stay (LOS). This retrospective, multicenter investigation which included 29,570 blood ENT-positive admissions across 161 US healthcare facilities evaluated the association between antimicrobial susceptibility testing (AST) TAT, carbapenem susceptibility, and empiric therapy on post-BSI in-hospital mortality and LOS following an ENT BSI event in adult patients. After adjusting for outcomes covariates, post-BSI in-hospital mortality was significantly higher for patients in the IET vs adequate empiric therapy (AET) group [odds ratio (OR): 1.61 (95% CI: 1.32, 1.98); P < 0.0001], and when AST TAT was >63 h [OR:1.48 (95% CI: 1.16, 1.90); P = 0.0017]. Patients with carbapenem non-susceptible (carb-NS) ENT BSI had significantly higher LOS (16.6 days, 95% CI: 15.6, 17.8) compared to carbapenem susceptible (carb-S, 12.2 days, 95% CI: 11.8, 12.6), (P < 0.0001). Extended AST TAT was significantly associated with longer LOS for TAT of 57-65 h and >65 h (P = 0.005 and P< 0.0001, respectively) compared to TAT ≤42 h (reference). Inadequate empiric therapy (IET), carb-NS, and delayed AST TAT are significantly associated with adverse hospital outcomes in ENT BSI. Workflows that accelerate AST TAT for ENT BSIs and facilitate timely and adequate therapy may reduce post-BSI in-hospital mortality rate and LOS.IMPORTANCEFor patients diagnosed with bloodstream infections (BSI) caused by Enterobacterales (ENT), delayed time to antimicrobial susceptibility (AST) results can significantly impact in-hospital mortality and hospital length of stay. However, this relationship between time elapsed from blood culture collection to AST results has only been assessed, to date, in a limited number of publications. Our study focuses on this important gap using retrospective data from 29,570 blood ENT-positive admissions across 161 healthcare facilities in the US as we believe that a thorough understanding of the dynamic between AST turnaround time, adequacy of empiric therapy, post-BSI event mortality, and hospital length of stay will help guide effective clinical management and optimize outcomes of patients with ENT infections.

Candida auris screening practices at healthcare facilities in the United States: An Emerging Infections Network survey.

We surveyed members of the Emerging Infections Network about Candida auris screening practices at US healthcare facilities. Only 37% of respondents reported conducting screening; among these, 75% reported detection of at least 1 C. auris case in the last year. Increased screening could improve C. auris detection and prevent spread.

GSK will license Scynexis antifungal

GSK is beefing up its infectious disease portfolio with an antifungal from Scynexis. For $90 million up front and possible milestone-based payments up to $503 million, the pharma giant will get the rights to commercialize and further develop Scynexis’s antifungal Brexafemme (ibrexafungerp). The small-molecule treatment is approved by the US Food and Drug Administration to treat vulvovaginal candidiasis (VVC) and to reduce the incidence of recurrent VVC. It’s the first and only oral antifungal approved for both indications, according to the firms. Notably, the companies say ibrexafungerp has also shown activity against Candida auris , which is currently spreading through US health-care facilities. C. auris has been responsible for severe illness in people who are hospitalized, and it is frequently resistant to multiple commonly used antifungals, the US Centers for Disease Control and Prevention says . Ibrexafungerp is also in Phase 3 trials to treat invasive candidiasis , which is

Sensitivity of National Healthcare Safety Network definitions to capture healthcare-associated transmission identified by whole-genome sequencing surveillance.

The National Healthcare Safety Network (NHSN) definitions are critical for standardizing healthcare-associated infection surveillance in US healthcare facilities. However, their use in accurately detecting healthcare-associated transmission (HAT) has not been measured. Using whole-genome sequencing surveillance data, we show that the NHSN has a sensitivity of 44.4% in detecting HAT.

Stethoscope Hygiene, Workflow, and Patient Safety: The Crux of Healthcare Associated Infections

Background: Alcohol based hand cleaners are installed throughout almost every health care facility in support of hand hygiene. However, despite numerous attempts, no study has ever demonstrated this strategy is effective for the stethoscope, which carries the same pathogens. Recently, a touch free disposable barrier stethoscope diaphragm system became available (The Disk Cover; Aseptiscope, Inc, San Diego, CA). Our objective was to perform a pilot feasibility trial to evaluate the impressions and perceived workflow consequences of its installation in the clinical environment. Patients and Methods: Beginning in 2020, we performed a volunteer survey given to aseptic stethoscope diaphragm barrier users in multiple US healthcare facilities. A 10-question survey was presented on an iPad near the aseptic barrier dispenser, which was usually located in the patient’s exam room, to be available immediately after the practitioner completed their examination, which included the use of the stethoscope barrier. This evaluation was considered as a quality improvement project and was exempt from IRB approval. For this analysis, only one survey per practitioner was included. Data presented as means (standard deviation). Results: Overall 147 surveys obtained from seven institutions geographically distributed across the US, shortly after placement of the Disk Cover system in the patient care environment. Responses were generally positive, and included ease of use (93.5% rated easy or very easy), comparison to a disposable stethoscope (100% as similar to, improved over, or significant improvement), work-flow changes (63.9% improvement, 97.6% no impact or improved) and perceived effect on patient safety (93.5% felt patient safety was improved or significantly improved). Conclusions: The use of a touch-free aseptic stethoscope barrier system was reported as easy to use, superior to a disposable stethoscope, and was an improvement to practitioner workflow and perceived patient safety

Epidemiology and outcomes of culture-positive bloodstream pathogens prior to and during the SARS-CoV-2 pandemic: a multicenter evaluation

BackgroundBloodstream infections (BSIs) are an important cause of morbidity and mortality in hospitalized patients. We evaluate incidence of community- and hospital-onset BSI rates and outcomes before and during the SARS-CoV-2 pandemic.MethodsWe conducted a retrospective cohort study evaluating patients who were hospitalized for ≥ 1 day with discharge or death between June 1, 2019, and September 4, 2021, across 271 US health care facilities. Community- and hospital-onset BSI and related outcomes before and during the SARS-CoV-2 pandemic, including intensive care admission rates, and overall and ICU-specific length of stay (LOS) was evaluated. Bivariate correlations were calculated between the pre-pandemic and pandemic periods overall and by SARS-CoV-2 testing status.ResultsOf 5,239,692 patient admissions, there were 20,113 community-onset BSIs before the pandemic (11.2/1000 admissions) and 39,740 (11.5/1000 admissions) during the pandemic (P ≤ 0.0062). Corresponding rates of hospital-onset BSI were 2,771 (1.6/1000 admissions) and 6,864 (2.0/1000 admissions; P < 0.0062). Compared to the pre-pandemic period, rates of community-onset BSI were higher in patients who tested negative for SARS-CoV-2 (15.8/1000 admissions), compared with 9.6/1000 BSI admissions among SARS-CoV-2-positive patients. Compared with patients in the pre-pandemic period, SARS-CoV-2-positive patients with community-onset BSI experienced greater ICU admission rates (36.6% vs 32.8%; P < 0.01), greater ventilator use (10.7% vs 4.7%; P < 0.001), and longer LOS (12.2 d vs 9.1 d; P < 0.001). Rates of hospital-onset BSI were higher in the pandemic vs the pre-pandemic period (2.0 vs 1.5/1000; P < 0.001), with rates as high a 7.3/1000 admissions among SARS-CoV-2-positive patients. Compared to the pre-pandemic period, SARS-CoV-2-positive patients with hospital-onset BSI had higher rates of ICU admission (72.9% vs 55.4%; P < 0.001), LOS (34.8 d vs 25.5 d; P < 0.001), and ventilator use (52.9% vs 21.5%; P < 0.001). Enterococcus species, Staphylococcus aureus, Klebsiella pneumoniae, and Candida albicans were more frequently detected in the pandemic period.Conclusions and relevanceThis nationally representative study found an increased risk of both community-onset and hospital-onset BSI during the SARS-CoV-2 pandemic period, with the largest increased risk in hospital-onset BSI among SARS-CoV-2-positive patients. SARS-CoV-2 positivity was associated with worse outcomes.

Stethoscope hygiene, workflow, and patient safety: The crux of healthcare-associated infections

Objective: We evaluated the impressions and perceived workflow consequences following installation of a touch-free aseptic stethoscope barrier dispenser in the clinical environment. Methods: Beginning in 2020, we conducted a volunteer survey of aseptic stethoscope diaphragm barrier (AseptiScope, San Diego, CA) users in multiple departments at 7 US healthcare facilities. A 10-question survey was presented on an iPad near the aseptic barrier dispenser, which was usually located in the patient exam room, to be available immediately after the practitioner completed their examination, which included the use of the stethoscope barrier. This evaluation was considered a quality improvement project and was exempt from institutional review board approval. For this analysis, only 1 survey per practitioner was included. Results: Overall, 147 surveys were obtained from 7 institutions geographically distributed across the United States, immediately after placement of the DiskCover system in the patient care environment. Responses were generally positive and included ease of use (95.2% rated easy or very easy), comparison to a disposable stethoscope (97.9% as similar to, improved over, or significant improvement), workflow changes (53.7% improvement, 97.3% no impact, or improved), and perceived effect on patient safety (90.3% felt that patient safety was improved or significantly improved). Conclusions: The use of a touch-free aseptic stethoscope barrier system was reported to be easy to use, superior to a disposable stethoscope, and an improvement to practitioner workflow and perceived patient safety.Funding: AseptiScope, Inc.Disclosures: None

Suspected Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-COV-2) Reinfections: Incidence, Predictors, and Healthcare Use Among Patients at 238 US Healthcare Facilities, 1 June 2020 to 28 February 2021.

In a retrospective cohort study, among 131 773 patients with previous coronavirus disease 2019 (COVID-19), reinfection with severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) was suspected in 253 patients (0.2%) at 238 US healthcare facilities between 1 June 2020 and 28 February 2021. Women displayed a higher cumulative reinfection risk. Healthcare burden and illness severity were similar between index and reinfection encounters.

Using Low-Heat Decontamination to Allow N95 and PPE Reuse During the COVID-19 Pandemic

Background: US healthcare facilities experienced significant personal protective equipment (PPE) shortages, including N95 masks, in the spring and summer of 2020. The Centers for Disease Control and Prevention issued guidance for extended use, reprocessing, and reuse of N95s. Eskenazi Health (EH) implemented a program to reprocess N95s and other PPE on-site using low-heat decontamination (LHD). EH considered large-scale and small-scale ultraviolet (UV), hydrogen peroxide vapor, and LHD for on-site reprocessing of N95s. All of these methods allowed up to 3 reprocessing cycles according to most literature available at the time. However, each method differed in feasibility and acceptability to staff. EH chose to implement LHD based on both considerations. Methods: Numerous small-group meetings were held in April 2020 to determine the feasibility and acceptability of N95 reprocessing methods. Staff wanted a method that was easy for the end user, had quick turnaround, and allowed them to retrieve their own N95s. They favored a method that could be used for all PPE. EH had deployed numerous small UV machines that individuals could use for N95s. The UV machines could not be scaled up easily. To scale up, a multidisciplinary team comprising infection prevention, biomedical engineering, and sterile processing representatives reviewed available methods and implemented LHD. Biomedical engineers determined that existing blanket warmers could be reprogrammed and repurposed for low-heat decontamination. Food warmers were also available but were not needed. Biomedical engineers reprogrammed the blanket warmers to 70°C and developed a wicking system using a towel and water tray to maintain humidity; decontamination took 30 minutes. Testing runs determined that both N95s and eye protection tolerated LHD without apparent damage. Infection prevention staff developed a workflow in which staff deposited all PPE in a paper bag; the PPE bag was centrally reprocessed, marked (Figure 1), and returned to designated locations (Figure 2) for staff to retrieve their original PPE. Sterile processing staff facilitated the reprocessing workflow, and elective surgeries were canceled during the COVID-19 surge. Results: From April 20, 2020, to July 19, 2020, 7,512 units were decontaminated with LHD. If each N95 was sterilized thrice (4 uses per N95), then LHD reduced the need to purchase 22,536 N95s. Restarting elective surgeries decreased staff and support from sterile processing; the space was needed for other purposes; and N95 availability increased. All of these factors led to the discontinuation of LHD. Conclusions: LHD enables reprocessing of N95s and other PPE using existing assets. LHD is advantageous because of scalability and the capacity to provide staff with their own reprocessed PPE.Funding: NoDisclosures: None

A mixed-method approach to tailor the implementation of a participatory Total Worker Health® program

PurposeTotal Worker Health® (TWH) programs, which represent a holistic approach for advancing worker safety, health and well-being, require an employer to adapt programmatic coordination and employee involvement in program design and delivery. Organizational readiness for such measures requires competencies in leadership, communication, subject expertise and worker participation. In the absence of documented methods for TWH readiness assessment, the authors developed a process to prospectively identify implementation facilitators and barriers that may be used to strengthen organizational competencies and optimize the organizational “fit” in advance.Design/methodology/approachThe mixed-method baseline assessment instruments comprised an online organizational readiness survey and a key leader interview; these were administered with key organizational and labor leaders in five US healthcare facilities. Findings about organizational resources, skills available and potential implementation barriers were summarized in a stakeholder feedback report and used to strengthen readiness and tailor implementation to the organizational context.FindingsThe research team was able to leverage organizational strengths such as leaders' commitment and willingness to address nontraditional safety topics to establish new worker-led design teams. Information about program barriers (staff time and communication) enabled the research team to respond with proactive tailoring strategies such as training on participant roles, extending team recruitment time and providing program communication tools and coaching.Originality/valueA new method has been developed for prospective organizational readiness assessment to implement a participatory TWH program. The authors illustrate its ability to identify relevant organizational features to guide institutional preparation and tailor program implementation.

New Approaches to Colonization Screening in Response to Emerging Antimicrobial Resistance

Background: The capacity to monitor the emergence of carbapenemase-producing organisms (CPO) is critical in limiting transmission. CPO-colonized patients can be identified by screening rectal specimens for carbapenemase genes and the Cepheid GeneXpert Carba-R (XCR), the only FDA-approved test, is limited to 5 carbapenemase genes and cannot identify the bacterial species. Objective: We describe the development and validation of culture-based methods for the detection of CPO in rectal cultures (RCs) and nonrectal cultures (NRCs) of tracheal aspirate and axilla-groin swabs. Methods: Colonization screening was performed at 3 US healthcare facilities; specimens of RC swabs and NRC ESwabs were collected. Each specimen was inoculated to a MacConkey broth enrichment tube for overnight incubation then were subcultured to MacConkey agar with meropenem and ertapenem 10 µg disks (BEMA) and CHROMagar KPC (KCHR) or CHROMagar Acinetobacter (ACHR). All media were evaluated for the presence of carbapenem-resistant organisms; suspect colonies were screened by real-time PCR for the most common carbapenemase genes. MALDI-TOF was performed for species identification. BEMA, a previously validated method, was the comparator for 52 RCs; clinical culture (CC) served as the comparator method for 66 NRCs. Select CPO-positive and -negative specimens underwent reproducibility testing. Results: Among 56 patients undergoing colonization screening, 12 (21%) carried a CPO. Only 1 patient had CPO solely from RC. Also, 6 patients had both CPO-positive RC and NRC, and 5 patients only had a CPO-positive NRC. Of the latter, 4 had a CPO-positive tracheal specimen, and 1 had a positive culture from both tracheal and axilla-groin specimens. Sensitivity of BEMA (70%) for NRC was lower than for KCHR (96%) and ACHR (88 %) for all specimens. All methods showed a specificity of 100% and reproducibility of 92%. The detected CPO included OXA-23–positive Acinetobacter baumannii, NDM-positive Escherichia coli, KPC-positive Pseudomonas aeruginosa and 4 genera of KPC-positive Enterobacteriaceae. Conclusions:The addition of nonrectal specimens and use of selective media contributed to increased sensitivity and enhanced identification of CPO-colonized patients. Positive cultures were equally distributed among the 3 specimen types. The addition of the nonrectal specimens resulted in the identification of more colonized patients. The culture-based method was successful in detecting an array of different CPOs and target genes, including genes not detected by the Carba-R assay (eg, blaOXA-23-like). Enhanced isolation and characterization of CPOs will be key in aiding epidemiologic investigations and strengthening targeted guidance for containment strategies.Funding: NoneDisclosures: We discuss the drug combination aztreonam-avibactam and acknowledge that this drug combination is not currently FDA approved.

Implementation of Surgical Site Infection (SSI) Gap Analysis and Data Visualization Dashboards to Drive Organizational Change

Background: Surgical site infections (SSIs) are a major healthcare quality issue; they lead to increased morbidity and mortality rates. They also prolong the length of stay and increase the cost to the patient and the healthcare system. Depending on the procedure, the risk of death is 2 to 11 times greater for patients with an SSI than for patients without an SSI. Additionally, the financial burden and patient burden is considerable; it ranks as the most common and costly of hospital-acquired infections (HAIs) and can extend a patient’s length of stay by 11.2 days. The risk of developing an SSI is affected by multiple factors at the patient, operative, and institutional levels. Methods: A Midwestern healthcare system conducted a review of the recommended best-practice guidelines that are currently accepted as the standards of care in US healthcare facilities. A gap analysis instrument for colorectal SSI prevention was drafted and reviewed for content validity and accuracy by field experts. Hospital infection preventionists worked in conjunction with operating room leaders to disseminate the survey to staff. Responses were collected from June 5 to June 30, 2019. Concurrently, the system infection preventionist team developed a standardized SSI dashboard template that could be used at the hospital, regional, and system level to visualize SSI infection counts, standardized infection ratios (SIRs) as well as procedure count data. These dashboard reports are updated and distributed on a monthly basis to each hospital’s campus executive team and other leaders. Federal- and state-required procedures were included and additional procedures were included based on hospital risk. Results: In total, 35 responses were recorded from 8 ministries across the system. Infection preventionists, operating room directors, physicians, nurses, and surgical technologists were represented among the respondents. The following areas were identified areas for improvement: use of chlorhexidine gluconate (CHG) bathing kit, mechanical bowel preparation with preoperative oral antibiotics, hair removal practices, use of fascial wound protector, maintenance of patients’ blood glucose levels, glove and gown changing procedures, and use of antimicrobial-coated sutures. The development and distribution of the SSI dashboard increased awareness and knowledge of SSIs by hospital and system-level leaders. Conclusions: The implementation of both the gap analysis and dashboard reports improved the awareness areas needed for improvement and knowledge of the burden of SSIs. These findings will drive discussions within the hospitals and at the system-level to implement evidence-based practice to improve care and decrease infections as well as guide the development of SSI patient care bundles.Funding: NoneDisclosures: None

Mycobacterial Testing Trends, United States, 2009-20151.

We studied 31 US healthcare facilities to characterize trends in mycobacterial testing. During 2009–2015, testing for acid-fast bacilli increased 3.2% annually, and prevalence of pathogenic nontuberculous mycobacteria increased 4.5% annually. These increases were highest for subpopulations at high risk of infection, including older women, Asians, and patients with concurrent conditions.

Availability of personal protective equipment and infection prevention supplies during the first month of the COVID-19 pandemic: A national study by the APIC COVID-19 task force

BackgroundSARS-CoV-2, the virus that causes COVID-19 disease was first discovered in China in December, 2019. The disease quickly spread globally, with the first US case identified in January, 2020; it was declared a pandemic on March 11, 2020. Soon after, anecdotal reports indicated that many US hospitals and healthcare facilities were running low on personal protective equipment (PPE) and supplies.MethodsAn online survey was administered to all Association for Professionals in Infection Control and Epidemiology members in March, 2020 to assess access to PPE, hand hygiene products, and disinfection supplies.ResultsIn all, 1,201 infection preventionists participated. Participants reported running a bit low to almost being out of all PPE types. More had sufficient gloves (63.4%) compared to all other PPE types (P < .001 for all). Face shields and N95 respirators were the least available (13.6% and 18.2% had sufficient supplies, respectively; p < .001 for all). Many (66.9%) had sufficient hand soap, but far fewer had sufficient hand sanitizer (29.5%, X2 = 211.1, P < .001). Less than half (45.4%, n = 545) had sufficient disinfection supplies.ConclusionsMany US healthcare facilities had very low amounts of PPE, hand hygiene products, and disinfection supplies early on during the pandemic. A lack of these supplies can lead to occupational exposures and illness as well as healthcare-associated transmission of COVID-19 and other diseases.

US public health resources for coronavirus disease 2019 that are relevant to allergy-immunology

US public health resources for coronavirus disease 2019 that are relevant to allergy-immunology

Invasive Candidiasis Species Distribution and Trends, United States, 2009-2017.

Invasive candidiasis (IC) is a growing concern among US healthcare facilities. A large-scale study evaluating incidence and trends of IC in the United States by species and body site is needed to understand the distribution of infection. An electronic medical record database was used to calculate incidence and trends of IC in the United States by species and infection site from 2009 through 2017. Hospital incidence was calculated using total unique inpatient hospitalizations in hospitals reporting at least 1 Candida case as the denominator. IC incidence trends were assessed using generalized estimating equations with exchangeable correlation structure to fit Poisson regression models, controlling for changes in hospital characteristics and case mix over time. Candida albicans remains the leading cause of IC in the United States, followed by Candida glabrata. The overall incidence of IC was 90/100 000 patients, which did not change significantly over time. There were no changes in incidence among C. albicans, C. glabrata, C. parapsilosis, or C. tropicalis; the incidence of other Candida spp. as a whole increased 7.2% annually. While there was no change in candidemia 2009-2017, abdominal and nonabdominal sterile site IC increased significantly. Nonbloodstream IC is increasing in the United States. Understanding the epidemiology of IC should facilitate improved management of infected patients.

Caregiver-Reported Barriers to Quality End-of-Life Care in Dementia With Lewy Bodies: A Qualitative Analysis.

This study investigated barriers to quality end-of-life (EOL) care in the context of dementia with Lewy bodies (DLB), one of the most common degenerative dementias in the United States. The study consisted of telephone interviews with caregivers and family members of individuals who died with DLB in the last 5 years. Interviews used a semi-structured questionnaire. Investigators employed a qualitative descriptive approach to analyze interview transcripts and identify common barriers to quality EOL care. Thirty participants completed interviews. Reported barriers to quality EOL experiences in DLB pertained to the DLB diagnosis itself and factors relating to the US health-care system, facilities, hospice, and health-care providers (physicians and staff). Commonly reported barriers included lack of recognition and knowledge of DLB, lack of education regarding what to expect, poor coordination of care and communication across health-care teams and circumstances, and difficulty accessing health-care resources including skilled nursing facility placement and hospice. Many identified themes were consistent with published barriers to quality EOL care in dementia. However, DLB-specific EOL considerations included diagnostic challenges, lack of knowledge regarding DLB and resultant prescribing errors, difficulty accessing resources due to behavioral changes in DLB, and waiting to meet Medicare dementia hospice guidelines. Improving EOL experiences in DLB will require a multifaceted approach, starting with improving DLB recognition and provider knowledge. More research is needed to improve recognition of EOL in DLB and factors that drive quality EOL experiences.

Health information technology:Fallacies and Sober realities – Redux A homage to Bentzi Karsh and Robert Wears

Since the publication of “Health Information Technology: Fallacies and Sober Realities” in 2010, health information technology (HIT) has become nearly ubiquitous in US healthcare facilities. Yet, HIT has yet to achieve its putative benefits of higher quality, safer, and lower cost care. There has been variable but largely marginal progress at addressing the 12 HIT fallacies delineated in the original paper. Here, we revisit several of the original fallacies and add five new ones. These fallacies must be understood and addressed by all stakeholders for HIT to be a positive force in achieving the high value healthcare system the nation deserves. Foundational cognitive and human factors engineering research and development continue to be essential to HIT development, deployment, and use.

Blood transfusion preparedness for mass casualty incidents: Are we truly ready?

Mass casualty incidents (MCI) are high profile contributors to the number of annual trauma-related deaths in the United States. A critical aspect of MCI care is the ability to provide blood components in sufficient types and quantities to prevent deaths due to hemorrhage. For transfusions to play an optimal role in the prevention of trauma-related hemorrhagic death, including MCI, there appears to be a very tight time window after injury to initiate transfusion therapy. In order to meet this tight window, blood components of appropriate numbers and quantities must be immediately available. Currently, it is questionable whether standing blood inventories at US healthcare facilities are sufficient to appropriately meet the transfusion needs of a surge of MCI victims. Previous models of blood supply adequacy have focused on the availability of red blood cells, and the ability to move blood components quickly from blood suppliers to impacted healthcare facilities. These models have not considered the adequacy of other critically necessary blood components, such as platelets. A recent simulation of blood product demand after MCI showed that, in order to meet the defined RBC needs of 100 percent of casualties, a hospital would need 13-14 units in inventory per casualty. This simulation did not evaluate requirements for platelets and plasma, which would likely be extensive. Meeting balanced resuscitation demands in the timeframe necessary to minimize the number of preventable hemorrhagic deaths is probably not realistically achievable for most healthcare facilities in the United States. Alternative approaches to treat hemorrhage are likely necessary to solve this problem.