Characterizing Patients Presenting on Hospital Admission with Central Line-Associated Bloodstream Infections: A Multicenter Study

BACKGROUND

There are no systematic measures of central line-associated bloodstream infections (CLABSIs) in patients maintaining central venous catheters (CVCs) outside acute care hospitals. To improve understanding of the burden of CLABSIs outside acute care hospitals, we characterized patients with CLABSI present on hospital admission (POA).

METHODS

Retrospective cross-sectional analysis of patients with CLABSI-POA in three health systems covering eleven hospitals across Maryland, Washington DC, and Missouri from November 2020 to October 2021. CLABSI-POA was defined using an adaptation of the acute care CLABSI definition. Patient demographics, clinical characteristics, and outcomes were collected via chart review. Cox proportional hazard analysis was used to assess factors associated with all-cause mortality within 30 days.

RESULTS

461 patients were identified as having CLABSI-POA. CVCs were most commonly maintained in home infusion therapy (32.8%) or oncology clinics (31.2%). Enterobacterales were the most common etiologic agent (29.2%). Recurrent CLABSIs occurred in a quarter of patients (25%). Eleven percent of patients died during the hospital admission. Among CLABSI-POA patients, mortality risk increased with age (versus ages <20: ages 20-44 years: HR: 11.21, 95% CI: 1.46-86.22; ages 45-64: HR: 20.88, 95% CI: 2.84-153.58; at least 65 years of age: HR: 22.50, 95% CI: 2.98-169.93), and lack of insurance (HR: 2.46; 95% CI: 1.08-5.59), and decreased with CVC removal (HR: 0.57, 95% CI: 0.39-0.84).

CONCLUSION

CLABSI-POA is associated with significant in-hospital mortality. Surveillance is required to understand the burden of CLABSI in the community to identify targets for CLABSI prevention initiatives outside acute care settings.

Orthopoxvirus-Specific T-Cell Responses in Convalescent Mpox Patients

Orthopoxvirus-specific T-cell responses were analyzed in 10 patients who had recovered from Mpox including 7 people with human immunodeficiency virus (PWH). Eight participants had detectable virus-specific T-cell responses, including a PWH who was not on antiretroviral therapy and a PWH on immunosuppressive therapy. These 2 participants had robust polyfunctional CD4+ T-cell responses to peptides from the 121L vaccinia virus (VACV) protein. T-cells from 4 of 5 HLA-A2-positive participants targeted at least 1 previously described HLA-A2-restricted VACV epitope, including an epitope targeted in 2 participants. These results advance our understanding of immunity in convalescent Mpox patients.

Implementing and validating a home-infusion central-line-associated bloodstream infection surveillance definition

OBJECTIVE

Central-line-associated bloodstream infection (CLABSI) surveillance in home infusion therapy is necessary to track efforts to reduce infections, but a standardized, validated, and feasible definition is lacking. We tested the validity of a home-infusion CLABSI surveillance definition and the feasibility and acceptability of its implementation.

DESIGN

Mixed-methods study including validation of CLABSI cases and semistructured interviews with staff applying these approaches.

SETTING

This study was conducted in 5 large home-infusion agencies in a CLABSI prevention collaborative across 14 states and the District of Columbia.

PARTICIPANTS

Staff performing home-infusion CLABSI surveillance.

METHODS

From May 2021 to May 2022, agencies implemented a home-infusion CLABSI surveillance definition, using 3 approaches to secondary bloodstream infections (BSIs): National Healthcare Safety Program (NHSN) criteria, modified NHSN criteria (only applying the 4 most common NHSN-defined secondary BSIs), and all home-infusion-onset bacteremia (HiOB). Data on all positive blood cultures were sent to an infection preventionist for validation. Surveillance staff underwent semistructured interviews focused on their perceptions of the definition 1 and 3-4 months after implementation.

RESULTS

Interrater reliability scores overall ranged from κ = 0.65 for the modified NHSN criteria to κ = 0.68 for the NHSN criteria to κ = 0.72 for the HiOB criteria. For the NHSN criteria, the agency-determined rate was 0.21 per 1,000 central-line (CL) days, and the validator-determined rate was 0.20 per 1,000 CL days. Overall, implementing a standardized definition was thought to be a positive change that would be generalizable and feasible though time-consuming and labor intensive.

CONCLUSIONS

The home-infusion CLABSI surveillance definition was valid and feasible to implement.

A Bundle of the Top 10 OPAT Publications in 2022

Outpatient parenteral antimicrobial therapy (OPAT) has become more common in clinical settings. Correspondingly, OPAT-related publications have also increased; the objective of this article was to summarize clinically meaningful OPAT-related publications in 2022. Seventy-five articles were initially identified, with 54 being scored. The top 20 OPAT articles published in 2022 were reviewed by a group of multidisciplinary OPAT clinicians. This article provides a summary of the "top 10" OPAT publications of 2022.

The need to expand the infection prevention workforce in home infusion therapy

Infection prevention and surveillance training approaches for home infusion therapy have not been well defined. We interviewed home infusion staff who perform surveillance activities about barriers to and facilitators for central line-associated bloodstream infection (CLABSI) surveillance and identified barriers to training in CLABSI surveillance. Our findings show a lack of formal surveillance training for staff. This gap can be addressed by adapting existing training resources to the home infusion setting.

Controlling the chaos: Information management in home-infusion central-line-associated bloodstream infection (CLABSI) surveillance

Objectives

Access to patient information may affect how home-infusion surveillance staff identify central-line-associated bloodstream infections (CLABSIs). We characterized information hazards in home-infusion CLABSI surveillance and identified possible strategies to mitigate information hazards.

Design

Qualitative study using semistructured interviews.

Setting and participants

The study included 21 clinical staff members involved in CLABSI surveillance at 5 large home-infusion agencies covering 13 states and the District of Columbia. Methods: Interviews were conducted by 1 researcher. Transcripts were coded by 2 researchers; consensus was reached by discussion.

Results

Data revealed the following barriers: information overload, information underload, information scatter, information conflict, and erroneous information. Respondents identified 5 strategies to mitigate information chaos: (1) engage information technology in developing reports; (2) develop streamlined processes for acquiring and sharing data among staff; (3) enable staff access to hospital electronic health records; (4) use a single, validated, home-infusion CLABSI surveillance definition; and (5) develop relationships between home-infusion surveillance staff and inpatient healthcare workers.

Conclusions

Information chaos occurs in home-infusion CLABSI surveillance and may affect the development of accurate CLABSI rates in home-infusion therapy. Implementing strategies to minimize information chaos will enhance intra- and interteam collaborations in addition to improving patient-related outcomes.

Duration of antibiotics through care transitions: A quality improvement initiative

Antibiotic resistance is increasing worldwide and can be largely attributed to excess antibiotic use. At our institution, 75% of patients were prescribed excess antibiotic days and total duration of therapy was appropriate in only 24.5% of cases per the reviewers. Choice of antibiotic was appropriate in 70.4% of cases.

965. Prevalence and Drivers of Burnout Among Antimicrobial Stewardship Personnel in the United States: A Cross-Sectional Study

Background

Although antimicrobial stewardship (AS) personnel are faced with occupational stressors that may contribute to burnout, little is known about the degree to which they experience this work-related syndrome. Our objective was to characterize the prevalence of, and identify factors associated with, burnout among AS personnel practicing in United States (US) hospitals.

Methods

We conducted a cross-sectional survey in October-December 2021. AS personnel (physicians and pharmacists) were approached via email through four US-based professional organizations. Respondents self-administered a questionnaire measuring demographics, AS program structure, resources, and organizational climate. Burnout was measured using the Maslach Burnout Inventory, a 22-item validated instrument with three subscales. Burnout was defined as a dichotomous outcome based on the presence of high scores on the emotional exhaustion subscale along with either a high depersonalization score or low professional accomplishment score. Descriptive statistics and logistic regression analyses were performed.

Results

A total of 259 AS personnel completed the questionnaire. The majority of respondents were pharmacists (n=201; 78.2%), female (n=166; 64.3%) and worked in a teaching hospital (n=212, 84.1%). The median age was 36 (IQR, 32-41). Thirty-six percent (n=94 of 259) of respondents met the definition for burnout. There were no significant differences in burnout by respondent demographics or professional role. Significant drivers of burnout (P&lt; 0.05) identified in univariable regression modeling included feeling as if AS is not an institutional priority, that hospital leadership is unsupportive of AS, prescriber resistance to AS recommendations is common, having unsupportive infectious diseases or pharmacy colleagues, the AS team does not work well together, and AS work is not intellectually stimulating.

Conclusion

Over one third of AS personnel in our sample met predefined standardized criteria for burnout. Contextual aspects of the work environment, including leadership, unsupportive peer climate and conflict were associated with burnout. There is a need to address factors that contribute to burnout in AS personnel to ensure an engaged workforce and to minimize turnover.

Disclosures

Jason Newland, MD, AHRQ: Grant/Research Support|Merck: Grant/Research Support|NIH: Grant/Research Support|PEW Charitable Trust: Grant/Research Support|Pfizer: Grant/Research Support.

2053. The Need to Expand the Infection Prevention Workforce in Home Infusion Therapy

Background

Infection preventionists who perform surveillance for central line-associated bloodstream infections (CLABSIs) in hospitals receive training in application of rigorous surveillance definitions. However, in the home infusion setting where CLABSIs also occur, the approach for training and methods to perform surveillance has not been well defined.

Objective

In this qualitative study, we sought to characterize how home infusion surveillance staff are trained in CLABSI surveillance and to identify barriers to CLABSI surveillance in the home infusion setting.

Methods

We interviewed 21 surveillance staff members of five non-profit home infusion agencies covering portions of thirteen states and Washington, DC across the Mid-Atlantic, Northeast, and Midwest. Interview questions were developed using the Systems Engineering in Patient Safety (SEIPS) 2.0 framework. Data were analyzed both inductively and deductively by two team members. These interviews are part of a larger study, some of whose findings have been previously discussed in prior publications. Data specific to training home infusion surveillance staff in CLABSI surveillance are presented (Table 1).

Results

Many of the CLABSI surveillance staff had received no formal training in CLABSI surveillance. Instead, many either learned on the job (often from predecessors who also had not been formally trained), drew from previous clinical experience, perused online resources, or attended conferences. A lack of (1) resources for learning, (2) formal training offered by their agencies, and (3) awareness of professional development resources were identified as barriers to CLABSI surveillance training in the home infusion setting.

Conclusion

Our findings indicate a current lack of formal training in CLABSI surveillance for staff performing CLABSI surveillance in home infusion therapy. The home infusion surveillance workforce can be strengthened by providing home infusion-specific standardized training, perhaps through adaptations of resources used for training surveillance staff in other settings.

Disclosures

Sara E. Cosgrove, MD, Basilea: Member of Infection Adjudication Committee.

A framework for implementing antibiotic stewardship in ambulatory care: Lessons learned from the Agency for Healthcare Research and Quality Safety Program for Improving Antibiotic Use

Antibiotic overuse is common in ambulatory care settings, underscoring the importance of outpatient antibiotic stewardship to ensure safe and effective antibiotic prescription. In response to this need, the Agency for Healthcare Research and Quality (AHRQ) developed the AHRQ Safety Program for Improving Antibiotic Use in Ambulatory Care. The Safety Program successfully assisted 389 outpatient practices across the United States to establish ambulatory antibiotic stewardship. Herein, we have used lessons learned from the AHRQ Safety Program to describe a step-by-step framework to assist practices with establishing antibiotic stewardship in the outpatient setting. Steps include obtaining support from practice leadership; establishing an antibiotic stewardship team; garnering support from practice members; determining how to access antibiotic prescribing data; building communication skills around antibiotic use in the practice; implementing educational content around an infectious syndrome; monitoring antibiotic prescription data; and implementing a sustainability plan.

Assessment of Changes in Visits and Antibiotic Prescribing During the Agency for Healthcare Research and Quality Safety Program for Improving Antibiotic Use and the COVID-19 Pandemic

IMPORTANCE

The Agency for Healthcare Research and Quality (AHRQ) Safety Program for Improving Antibiotic Use aimed to improve antibiotic prescribing in ambulatory care practices by engaging clinicians and staff to incorporate antibiotic stewardship into practice culture, communication, and decision-making. Little is known about implementation of antibiotic stewardship in ambulatory care practices.

OBJECTIVE

To examine changes in visits and antibiotic prescribing during the AHRQ Safety Program.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study evaluated a quality improvement intervention in ambulatory care throughout the US in 389 ambulatory care practices from December 1, 2019, to November 30, 2020.

EXPOSURES

The AHRQ Safety Program used webinars, audio presentations, educational tools, and office hours to engage stewardship leaders and clinical staff to address attitudes and cultures that challenge judicious antibiotic prescribing and incorporate best practices for the management of common infections.

MAIN OUTCOMES AND MEASURES

The primary outcome of the Safety Program was antibiotic prescriptions per 100 acute respiratory infection (ARI) visits. Data on total visits and ARI visits were also collected. The number of visits and prescribing rates from baseline (September 1, 2019) to completion of the program (November 30, 2020) were compared.

RESULTS

Of 467 practices enrolled, 389 (83%) completed the Safety Program; of these, 292 (75%) submitted complete data with 6 590 485 visits to 5483 clinicians. Participants included 82 (28%) primary care practices, 103 (35%) urgent care practices, 34 (12%) federally supported practices, 39 (13%) pediatric urgent care practices, 21 (7%) pediatric-only practices, and 14 (5%) other practice types. Visits per practice per month decreased from a mean of 1624 (95% CI, 1317-1931) at baseline to a nadir of 906 (95% CI, 702-1111) early in the COVID-19 pandemic (April 2020), and were 1797 (95% CI, 1510-2084) at the end of the program. Total antibiotic prescribing decreased from 18.2% of visits at baseline to 9.5% at completion of the program (-8.7%; 95% CI, -9.9% to -7.6%). Acute respiratory infection visits per practice per month decreased from baseline (n = 321) to a nadir of 76 early in the pandemic (May 2020) and gradually increased through completion of the program (n = 239). Antibiotic prescribing for ARIs decreased from 39.2% at baseline to 24.7% at completion of the program (-14.5%; 95% CI, -16.8% to -12.2%).

CONCLUSIONS AND RELEVANCE

In this study of US ambulatory practices that participated in the AHRQ Safety Program, significant reductions in the rates of overall and ARI-related antibiotic prescribing were noted, despite normalization of clinic visits by completion of the program. The forthcoming AHRQ Safety Program content may have utility in ambulatory practices across the US.

A Bundle of the Top 10 OPAT Publications in 2021

As outpatient parenteral antimicrobial therapy (OPAT) becomes more common, it may be difficult to stay current with recent related publications. A group of multidisciplinary OPAT clinicians reviewed and ranked all OPAT publications published in 2021. This article provides a high-level summary of the OPAT manuscripts that were voted the “top 10” publications of 2021.

A task analysis of central line-associated bloodstream infection (CLABSI) surveillance in home infusion therapy

BACKGROUND

Barriers for home infusion therapy central line associated bloodstream infection (CLABSI) surveillance have not been elucidated and are needed to identify how to support home infusion CLABSI surveillance. We aimed to (1) perform a goal-directed task analysis of home infusion CLABSI surveillance, and (2) describe barriers to, facilitators for, and suggested strategies for successful home infusion CLABSI surveillance.

METHODS

We conducted semi-structured interviews with team members involved in CLABSI surveillance at 5 large home infusion agencies to explore work systems used by members of the agency for home infusion CLABSI surveillance. We analyzed the transcribed interviews qualitatively for themes.

RESULTS

Twenty-one interviews revealed 8 steps for performing CLABSI surveillance in home infusion therapy. Major barriers identified included the need for training of the surveillance staff, lack of a standardized definition, inadequate information technology support, struggles communicating with hospitals, inadequate time, and insufficient clinician engagement and leadership support.

DISCUSSION

Staff performing home infusion CLABSI surveillance need health system resources, particularly leadership and front-line engagement, access to data, information technology support, training, dedicated time, and reports to perform tasks.

CONCLUSIONS

Building home infusion CLABSI surveillance programs will require support from home infusion leadership.

Implementing a Toolkit to Improve the Education of Patients on Home-based Outpatient Parenteral Antimicrobial Therapy (OPAT)

BACKGROUND

Patients discharged to the home on home-based outpatient parenteral antimicrobial therapy (OPAT) perform their own infusions and catheter care; thus, they require high-quality training to improve safety and the likelihood of treatment success. This article describes the study team's experience piloting an educational toolkit for patients on home-based OPAT.

METHODS

An OPAT toolkit was developed to address barriers such as unclear communication channels, rushed instruction, safe bathing with an intravenous (IV) catheter, and lack of standardized instructions. The research team evaluated the toolkit through interviews with home infusion nurses implementing the intervention, surveys of 20 patients who received the intervention, and five observations of the home infusion nurses delivering the intervention to patients and caregivers.

RESULTS

Of surveyed patients, 90.0% were comfortable infusing medications at the time of discharge, and 80.0% with bathing with the IV catheter. While all practiced on equipment, 75.0% used the videos and the paper checklists. Almost all (95.0%) were satisfied with their training, and all were satisfied with managing their IV catheters at home. The videos were considered very helpful, particularly as reference. Overall, nurses adjusted training to patient characteristics and modified the toolkit over time. Shorter instruction forms were more helpful than longer instruction forms.

CONCLUSION

Developing a toolkit to improve the education of patients on home-based OPAT has the potential to improve the safety of and experience with home-based OPAT.

The Voice of the Patient: Patient Roles in Antibiotic Management at the Hospital-to-Home Transition

OBJECTIVE

Our objective was to characterize tasks required for patient-performed antibiotic medication management (MM) at the hospital-to-home transition, as well as barriers to and strategies for patient-led antibiotic MM. Our overall goal was to understand patients' role in managing antibiotics at the hospital-to-home transition.

METHODS

We performed a qualitative study including semistructured interviews with health care workers and contextual inquiry with patients discharged home on oral antibiotics. The setting was one academic medical center and one community hospital. Participants included 37 health care workers and 16 patients. We coded interview transcripts and notes from contextual inquiry and developed themes.

RESULTS

We identified 6 themes involving barriers or strategies for antibiotic MM. We identified dissonance between participant descriptions of the ease of antibiotic MM at the hospital-to-home transition and their experience of barriers. Similarly, patients did not always recognize when they were experiencing side effects. Lack of access to follow-up care led to unnecessarily long antibiotic courses. Instructions about completing antibiotics were not routinely provided. However, patients typically did not question the need for the prescribed antibiotic.

CONCLUSIONS

There are many opportunities to improve patient-led antibiotic MM at the hospital-to-home transition. Mismatches between patient perceptions and patient experiences around antibiotic MM at the hospital-to-home transition provide opportunities for health system improvement.

Coronavirus disease 2019 (COVID-19) research agenda for healthcare epidemiology

This SHEA white paper identifies knowledge gaps and challenges in healthcare epidemiology research related to coronavirus disease 2019 (COVID-19) with a focus on core principles of healthcare epidemiology. These gaps, revealed during the worst phases of the COVID-19 pandemic, are described in 10 sections: epidemiology, outbreak investigation, surveillance, isolation precaution practices, personal protective equipment (PPE), environmental contamination and disinfection, drug and supply shortages, antimicrobial stewardship, healthcare personnel (HCP) occupational safety, and return to work policies. Each section highlights three critical healthcare epidemiology research questions with detailed description provided in supplementary materials. This research agenda calls for translational studies from laboratory-based basic science research to well-designed, large-scale studies and health outcomes research. Research gaps and challenges related to nursing homes and social disparities are included. Collaborations across various disciplines, expertise and across diverse geographic locations will be critical.

The case for wearable proximity devices to inform physical distancing among healthcare workers

Objective

Despite the importance of physical distancing in reducing SARS-CoV-2 transmission, this practice is challenging in healthcare. We piloted use of wearable proximity beacons among healthcare workers (HCWs) in an inpatient unit to highlight considerations for future use of trackable technologies in healthcare settings.

Materials and Methods

We performed a feasibility pilot study in a non-COVID adult medical unit from September 28 to October 28, 2020. HCWs wore wearable proximity beacons, and interactions defined as <6 feet for ≥5 s were recorded. Validation was performed using direct observations.

Results

A total of 6172 close proximity interactions were recorded, and with the removal of 2033 false-positive interactions, 4139 remained. The highest proportion of interactions occurred between 7:00 Am–9:00 Am. Direct observations of HCWs substantiated these findings.

Discussion

This pilot study showed that wearable beacons can be used to monitor and quantify HCW interactions in inpatient settings.

Conclusion

Technology can be used to track HCW physical distancing.

Physical distancing, or social distancing, is important in preventing COVID-19. It is hard for healthcare workers (HCWs) to physically distance at work. We tested a device (proximity beacon) that HCWs could wear to measure their distance from each other among HCWs on a medical unit. The device measured any time HCWs were within 6 feet of each other for at least 5 s. We watched HCWs who were close to each other. The devices and our observations showed that 7:00 Am—9:00 Am was the highest risk time for not physically distancing. This study shows that wearable devices can be a tool to monitor HCWs physical distancing on a hospital unit.

161. The Agency for Healthcare Research and Quality (AHRQ) Safety Program for Improving Antibiotic Use: Antibiotic Stewardship Intervention in 389 United States Ambulatory Practices during the COVID-19 Pandemic

Background

The AHRQ Safety Program for Improving Antibiotic Use aimed to improve antibiotic use by engaging clinicians and staff to incorporate antibiotic stewardship (AS) into practice culture, communication, and decision making. We report on changes in visits and antibiotic prescribing in AHRQ Safety Program ambulatory practices during the COVID-19 pandemic.

Methods

The Safety Program used webinars, audio presentations, educational tools, and office hours to engage clinician champions and staff leaders to: (a) address attitudes and culture that pose challenges to judicious antibiotic prescribing and (b) incorporate best practices for the management of common infections into their workflow using the Four Moments of Antibiotic Decision Making framework. Total visits (in-person and virtual), acute respiratory infection (ARI) visits, and antibiotic prescribing data were collected. Using linear mixed models to account for random effects of participating practices and repeated measurements of outcomes within practices over time, data from the pre-intervention period (September-November 2019) and the Ambulatory Care Safety Program (December 2019-November 2020) were compared.

Results

Of 467 practices enrolled, 389 (83%) completed the program, including 162 primary care practices (42%; 23 [6%] pediatric), 160 urgent care practices (41%; 40 [10%] pediatric), and 49 federally-supported practices (13%). 292 practices submitted complete data for analysis, including 6,590,485 visits. Visits/practice-month declined March-May 2020 but gradually returned to baseline by program end (Figure 1). Total antibiotic prescribing declined by 9 prescriptions/100 visits (95% CI: -10 to -8). ARI visits/practice-month declined significantly in March-May 2020, then increased but remained below baseline by program end (Figure 2). ARI-related antibiotic prescriptions decreased by 15/100 ARI visits by program end (95% CI: -17 to -12). The greatest reduction was in penicillin class prescriptions with a reduction of 7/100 ARI visits by program end (95% CI: -9 to -6).

Conclusion

During the COVID-19 pandemic, a national ambulatory AS program was associated with declines in overall and ARI-related antibiotic prescribing.

Disclosures

Pranita Tamma, MD, MHS, Nothing to disclose Sara E. Cosgrove, MD, MS, Basilea (Individual(s) Involved: Self): Consultant Jeffrey A. Linder, MD, MPH, FACP, Amgen (Shareholder)Biogen (Shareholder)Eli Lilly (Shareholder)

162. Duration of Antibiotics Through Care Transitions: A Quality Improvement Initiative

Background

Antibiotic resistance is increasing worldwide, largely driven by excessive antibiotic use. Antibiotic stewardship (AS) interventions have traditionally focused on acute care, long-term care, and ambulatory settings. However, as patients transition from one care setting to another, AS interventions should address antibiotic orders (agent, dose, duration) between the hospital and the home. The purpose of this study is to determine the appropriateness of a total course of antibiotics, including inpatient and outpatient prescriptions, to aid in prioritizing AS interventions.

Methods

A single-center, retrospective study was performed to evaluate antibiotic duration for adult patients discharged from a large quaternary-care academic hospital. All antibiotic prescribing data, including pre-admission, during admission, and after hospital discharge, as well as information on indication, was collected from the electronic medical record. Descriptive statistics were used to summarize the data collected.

Results

196 patients were included in the study. There were 100 instances of disagreement on antibiotic indication between the discharge summary and reviewer. However, 70% of patients were discharged on an appropriate antibiotic. The majority of patients (75%) were prescribed excess antibiotic days beyond guideline recommended total duration, and 68% of patients did not have appropriate duration of antibiotics post-discharge. Of those with excess duration, 31% were prescribed penicillins, 23% were prescribed cephalosporins, and 20% were prescribed trimethoprim/sulfamethoxazole. Excess antibiotic duration was associated most commonly with an unknown diagnosis (23%), a skin and soft tissue infection diagnosis (16%), and antibiotic prophylaxis (12%).

Conclusion

The results of this study showed that patients were often prescribed excess antibiotics at discharge, and the total duration of antibiotics from pre-admission to post-discharge were prolonged beyond guideline-recommended duration. Understanding the total duration of antibiotic prescription, including post-discharge and pre-admission durations, is key in assessing risk from antibiotics and targeting AS interventions.

Disclosures

Kate Dzintars, PharmD, Nothing to disclose

Antibiotic stewardship in direct-to-consumer telemedicine: translating interventions into the virtual realm

Direct-to-consumer (DTC) telemedicine is an increasingly popular modality for delivery of medical care via a virtual platform. As most DTC telemedicine visits focus on infection-related complaints, there is growing concern about the magnitude of antibiotic use associated with this setting. However, there is limited scholarship regarding adapting and implementing antibiotic stewardship principles in this setting as most efforts have been focused on hospitals with more recent work in long-term care facilities and primary care settings. We discuss utilizing the core elements for outpatient antibiotic stewardship as a framework for DTC antibiotic stewardship efforts moving forward.

Empowering nurses and residents to improve telemetry stewardship in the academic care setting

AIMS AND OBJECTIVES

Inappropriate use of telemetry frequently occurs in the inpatient, non-intensive care unit setting. Telemetry practice standards have attempted to guide appropriate use and limit the overuse of this important resource with limited success. Clinical-effectiveness studies have thus far not included care settings in which resident-physicians are the primary caregivers.

METHODS

We implemented two interventions on general internal medicine units of an academic hospital. The first intervention, or nurse-discontinuation protocol, allowed nurses to trigger the discontinuation of telemetry once the appropriate duration had passed according to practice standards. The second intervention, or physician-discontinuation protocol, instituted a best-practice advisory that notified the resident-physician via the electronic medical record when the appropriate telemetry duration for each patient had elapsed and suggested termination of telemetry. Data collection spanned 8 months following the implementation of the nurse-discontinuation protocol and 12 months following the physician-discontinuation protocol.

RESULTS

During the control period, the average time spent on telemetry was 86.29 hours/patient/month. During the nurse-discontinuation protocol, patients spent, on average, 70.86 hours/patient/month on telemetry. During the physician-discontinuation protocol, patients spent, on average, 81.6 hours/patient/month on telemetry. During the nurse-discontinuation protocol, there was no significant change in the likelihood that a patient was placed on telemetry throughout their admission when compared with the control period. During the physician-discontinuation protocol, there was a significant decrease of 56.1% in the likelihood that a patient would be put on telemetry when compared with the control time period.

CONCLUSIONS

These findings expand our understanding of telemetry use in the academic care setting in which trainees serve as the primary caregivers. Furthermore, these findings represent an important addition to the telemetry and patient monitoring literature by demonstrating the impact that nurse-managed protocols can have on telemetry use and by highlighting effective strategies to improve telemetry use by physicians in training.

Delayed Rise of Oral Fluid Antibodies, Elevated BMI, and Absence of Early Fever Correlate With Longer Time to SARS-CoV-2 RNA Clearance in a Longitudinally Sampled Cohort of COVID-19 Outpatients

BACKGROUND

Sustained molecular detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA in the upper respiratory tract (URT) in mild to moderate coronavirus disease 2019 (COVID-19) is common. We sought to identify host and immune determinants of prolonged SARS-CoV-2 RNA detection.

METHODS

Ninety-five symptomatic outpatients self-collected midturbinate nasal, oropharyngeal (OP), and gingival crevicular fluid (oral fluid) samples at home and in a research clinic a median of 6 times over 1-3 months. Samples were tested for viral RNA, virus culture, and SARS-CoV-2 and other human coronavirus antibodies, and associations were estimated using Cox proportional hazards models.

RESULTS

Viral RNA clearance, as measured by SARS-CoV-2 reverse transcription polymerase chain reaction (RT-PCR), in 507 URT samples occurred a median (interquartile range) 33.5 (17-63.5) days post-symptom onset. Sixteen nasal-OP samples collected 2-11 days post-symptom onset were virus culture positive out of 183 RT-PCR-positive samples tested. All participants but 1 with positive virus culture were negative for concomitant oral fluid anti-SARS-CoV-2 antibodies. The mean time to first antibody detection in oral fluid was 8-13 days post-symptom onset. A longer time to first detection of oral fluid anti-SARS-CoV-2 S antibodies (adjusted hazard ratio [aHR], 0.96; 95% CI, 0.92-0.99; P = .020) and body mass index (BMI) ≥25 kg/m2 (aHR, 0.37; 95% CI, 0.18-0.78; P = .009) were independently associated with a longer time to SARS-CoV-2 viral RNA clearance. Fever as 1 of first 3 COVID-19 symptoms correlated with shorter time to viral RNA clearance (aHR, 2.06; 95% CI, 1.02-4.18; P = .044).

CONCLUSIONS

We demonstrate that delayed rise of oral fluid SARS-CoV-2-specific antibodies, elevated BMI, and absence of early fever are independently associated with delayed URT viral RNA clearance.

Failure modes and effects analysis to improve transitions of care in patients discharged on outpatient parenteral antimicrobial therapy

PURPOSE

To identify barriers to safe and effective completion of outpatient parenteral antimicrobial therapy (OPAT) in patients discharged from an academic medical center and to develop targeted solutions to potentially resolve or improve the identified barriers.

SUMMARY

A failure modes and effects analysis (FMEA) was conducted by a multidisciplinary OPAT task force to evaluate the processes for patients discharged on OPAT to 2 postdischarge dispositions: (1) home and (2) skilled nursing facility (SNF). The task force created 2 process maps and identified potential failure modes, or barriers, to the successful completion of each step. Thirteen and 10 barriers were identified in the home and SNF process maps, respectively. Task force members created 5 subgroups, each developing solutions for a group of related barriers. The 5 areas of focus included (1) the OPAT electronic order set, (2) critical tasks to be performed before patient discharge, (3) patient education, (4) patient follow-up and laboratory monitoring, and (5) SNF communication. Interventions involved working with information technology to update the electronic order set, bridging communication and ensuring completion of critical tasks by creating an inpatient electronic discharge checklist, developing patient education resources, planning a central OPAT outpatient database within the electronic medical record, and creating a pharmacist on-call pager for SNFs.

CONCLUSION

The FMEA approach was helpful in identifying perceived barriers to successful transitions of care in patients discharged on OPAT and in developing targeted interventions. Healthcare organizations may reproduce this strategy when completing quality improvement planning for this high-risk process.

Delayed rise of oral fluid antibodies, elevated BMI, and absence of early fever correlate with longer time to SARS-CoV-2 RNA clearance in an longitudinally sampled cohort of COVID-19 outpatients

Background

Sustained molecular detection of SARS-CoV-2 RNA in the upper respiratory tract (URT) in mild to moderate COVID-19 is common. We sought to identify host and immune determinants of prolonged SARS-CoV-2 RNA detection.

Methods

Ninety-five outpatients self-collected mid-turbinate nasal, oropharyngeal (OP), and gingival crevicular fluid (oral fluid) samples at home and in a research clinic a median of 6 times over 1-3 months. Samples were tested for viral RNA, virus culture, and SARS-CoV-2 and other human coronavirus antibodies, and associations were estimated using Cox proportional hazards models.

Results

Viral RNA clearance, as measured by SARS-CoV-2 RT-PCR, in 507 URT samples occurred a median (IQR) 33.5 (17-63.5) days post-symptom onset. Sixteen nasal-OP samples collected 2-11 days post-symptom onset were virus culture positive out of 183 RT-PCR positive samples tested. All participants but one with positive virus culture were negative for concomitant oral fluid anti-SARS-CoV-2 antibodies. The mean time to first antibody detection in oral fluid was 8-13 days post-symptom onset. A longer time to first detection of oral fluid anti-SARS-CoV-2 S antibodies (aHR 0.96, 95% CI 0.92-0.99, p=0.020) and BMI ≥ 25kg/m ² (aHR 0.37, 95% CI 0.18-0.78, p=0.009) were independently associated with a longer time to SARS-CoV-2 viral RNA clearance. Fever as one of first three COVID-19 symptoms correlated with shorter time to viral RNA clearance (aHR 2.06, 95% CI 1.02-4.18, p=0.044).

Conclusions

We demonstrate that delayed rise of oral fluid SARS-CoV-2-specific antibodies, elevated BMI, and absence of early fever are independently associated with delayed URT viral RNA clearance.

The Clinical Course of COVID-19 in the Outpatient Setting: A Prospective Cohort Study

BACKGROUND

Outpatient coronavirus disease 2019 (COVID-19) has been insufficiently characterized. To determine the progression of disease and determinants of hospitalization, we conducted a prospective cohort study.

METHODS

Outpatient adults with positive reverse transcription polymerase chain reaction results for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) were recruited by phone between April 21 and July 23, 2020, after receiving outpatient or emergency department testing within a large health network in Maryland, United States. Symptoms were collected by participants on days 0, 3, 7, 14, 21, and 28, and portable pulse oximeter oxygen saturation (SaO2), heart rate, and temperature were collected for 15 consecutive days. Baseline demographics, comorbid conditions, and vital signs were evaluated for risk of subsequent hospitalization using negative binomial and logistic regression.

RESULTS

Among 118 SARS-CoV-2-infected outpatients, the median age (interquartile range [IQR]) was 56.0 (50.0-63.0) years, and 50 (42.4%) were male. Among individuals in the first week of illness (n = 61), the most common symptoms included weakness/fatigue (65.7%), cough (58.8%), headache (45.6%), chills (38.2%), and anosmia (27.9%). Participants returned to their usual health a median (IQR) of 20 (13-38) days from symptom onset, and 66.0% of respondents were at their usual health during the fourth week of illness. Over 28 days, 10.9% presented to the emergency department and 7.6% required hospitalization. The area under the receiver operating characteristics curve for the initial home SaO2 for predicting subsequent hospitalization was 0.86 (95% CI, 0.73-0.99).

CONCLUSIONS

Symptoms often persisted but uncommonly progressed to hospitalization among outpatients with COVID-19. Home SaO2 may be a helpful tool to stratify risk of hospitalization.

Prevalence of Co-infection at the Time of Hospital Admission in COVID-19 Patients, A Multicenter Study

BACKGROUND

Bacterial infections may complicate viral pneumonias. Recent reports suggest that bacterial co-infection at time of presentation is uncommon in coronavirus disease 2019 (COVID-19); however, estimates were based on microbiology tests alone. We sought to develop and apply consensus definitions, incorporating clinical criteria to better understand the rate of co-infections and antibiotic use in COVID-19.

METHODS

A total of 1016 adult patients admitted to 5 hospitals in the Johns Hopkins Health System between March 1, 2020, and May 31, 2020, with COVID-19 were evaluated. Adjudication of co-infection using definitions developed by a multidisciplinary team for this study was performed. Both respiratory and common nonrespiratory co-infections were assessed. The definition of bacterial community-acquired pneumonia (bCAP) included proven (clinical, laboratory, and radiographic criteria plus microbiologic diagnosis), probable (clinical, laboratory, and radiographic criteria without microbiologic diagnosis), and possible (not all clinical, laboratory, and radiographic criteria met) categories. Clinical characteristics and antimicrobial use were assessed in the context of the consensus definitions.

RESULTS

Bacterial respiratory co-infections were infrequent (1.2%); 1 patient had proven bCAP, and 11 (1.1%) had probable bCAP. Two patients (0.2%) had viral respiratory co-infections. Although 69% of patients received antibiotics for pneumonia, the majority were stopped within 48 hours in patients with possible or no evidence of bCAP. The most common nonrespiratory infection was urinary tract infection (present in 3% of the cohort).

CONCLUSIONS

Using multidisciplinary consensus definitions, proven or probable bCAP was uncommon in adults hospitalized due to COVID-19, as were other nonrespiratory bacterial infections. Empiric antibiotic use was high, highlighting the need to enhance antibiotic stewardship in the treatment of viral pneumonias.

Engaging Patients and Caregivers in a Transdisciplinary Effort to Improve Outpatient Parenteral Antimicrobial Therapy

We worked with patients, caregivers, and healthcare workers to prioritize barriers and propose solutions to outpatient parenteral antimicrobial therapy (OPAT) care. Unclear communication channels, rushed instruction, safe bathing with an intravenous catheter, and lack of standardized instructions were highly ranked barriers. Outpatient parenteral antimicrobial therapy programs should focus on mitigating barriers to OPAT care.

Which Patients Discharged to Home-Based Outpatient Parenteral Antimicrobial Therapy Are at High Risk of Adverse Outcomes?

Background

Patients increasingly receive home-based outpatient parenteral antimicrobial therapy (OPAT). Understanding which patients might be at higher risk of complications is critical in effectively triaging resources upon and after hospital discharge.

Methods

A prospective cohort of patients discharged from 1 of 2 academic medical centers in Baltimore, Maryland, between March 2015 and December 2018 were consented and randomly divided into derivation and validation cohorts for development of a risk score for adverse OPAT outcomes. Data from the derivation cohort with the primary outcome of a serious adverse outcome (infection relapse, serious adverse drug event, serious catheter complication, readmission, or death) were analyzed to derive the risk score equation using logistic regression, which was then validated in the validation cohort for performance of predicting a serious adverse outcome.

Results

Of 664 patients in the total cohort, half (332) experienced a serious adverse outcome. The model predicting having a serious adverse outcome included type of catheter, time on OPAT, using a catheter for chemotherapy, using a catheter for home parenteral nutrition, being treated for septic arthritis, being on vancomycin, being treated for Enterococcus, being treated for a fungal infection, and being treated empirically. A score ≥2 on the serious adverse outcome score had a 94.0% and 90.9% sensitivity for having a serious adverse outcome in the derivation and validation cohorts, respectively.

Conclusions

A risk score can be implemented to detect who may be at high risk of serious adverse outcomes, but all patients on OPAT may require monitoring to prevent or detect adverse events.

In Full Flow: Left Ventricular Assist Device Infections in the Modern Era

With the rising prevalence of heart disease in the United States, there is increasing reliance on durable mechanical circulatory support (MCS) to treat patients with end-stage heart failure. Left ventricular assist devices (LVADs), the most common form of durable MCS, are implanted mechanical pumps that connect to an external power source through a transcutaneous driveline. First-generation LVADs were bulky, pulsatile pumps that were frequently complicated by infection. Second-generation LVADs have an improved design, though infection remains a common and serious complication due to the inherent nature of implanted MCS. Infections can affect any component of the LVAD, with driveline infections being the most common. LVAD infections carry significant morbidity and mortality for LVAD patients. Therefore, it is paramount for the multidisciplinary team of clinicians caring for these patients to be familiar with this complication. We review the epidemiology, prevention, diagnosis, treatment, and outcomes of LVAD infections.

The inconvincible patient: how clinicians perceive demand for antibiotics in the outpatient setting

BACKGROUND

Perceived patient demand for antibiotics drives unnecessary antibiotic prescribing in outpatient settings, but little is known about how clinicians experience this demand or how this perceived demand shapes their decision-making.

OBJECTIVE

To identify how clinicians perceive patient demand for antibiotics and the way these perceptions stimulate unnecessary prescribing.

METHODS

Qualitative study using semi-structured interviews with clinicians in outpatient settings who prescribe antibiotics. Interviews were analyzed using conventional and directed content analysis.

RESULTS

Interviews were conducted with 25 clinicians from nine practices across three states. Patient demand was the most common reason respondents provided for why they prescribed non-indicated antibiotics. Three related factors motivated clinically unnecessary antibiotic use in the face of perceived patient demand: (i) clinicians want their patients to regard clinical visits as valuable and believe that an antibiotic prescription demonstrates value; (ii) clinicians want to avoid negative repercussions of denying antibiotics, including reduced income, damage to their reputation, emotional exhaustion, and degraded relationships with patients; (iii) clinicians believed that certain patients are impossible to satisfy without an antibiotic prescription and felt that efforts to refuse antibiotics to such patients wastes time and invites the aforementioned negative repercussions. Clinicians in urgent care settings were especially likely to describe being motivated by these factors.

CONCLUSION

Interventions to improve antibiotic use in the outpatient setting must address clinicians' concerns about providing value for their patients, fear of negative repercussions from denying antibiotics, and the approach to inconvincible patients.

Antibiotic Stewardship for Older Adults in Ambulatory Care Settings: Addressing an Unmet Challenge

Inappropriate antibiotic use is common in older adults (aged >65 y), and they are particularly vulnerable to serious antibiotic-associated adverse effects such as cardiac arrhythmias, delirium, aortic dissection, drug-drug interactions, and Clostridioides difficile. Antibiotic prescribing improvement efforts in older adults have been primarily focused on inpatient and long-term care settings. However, the ambulatory care setting is where the vast majority of antibiotic prescribing to older adults occurs. To help improve the clinical care of older adults, we review drivers of antibiotic prescribing in this population, explore systems aspects of ambulatory care that can create barriers to optimal antibiotic use, discuss existing stewardship interventions, and provide guidance on priority areas for future inquiry. J Am Geriatr Soc 68:244-249, 2020.

2018 Infectious Diseases Society of America Clinical Practice Guideline for the Management of Outpatient Parenteral Antimicrobial Therapy

A panel of experts was convened by the Infectious Diseases Society of America (IDSA) to update the 2004 clinical practice guideline on outpatient parenteral antimicrobial therapy (OPAT) [1]. This guideline is intended to provide insight for healthcare professionals who prescribe and oversee the provision of OPAT. It considers various patient features, infusion catheter issues, monitoring questions, and antimicrobial stewardship concerns. It does not offer recommendations on the treatment of specific infections. The reader is referred to disease- or organism-specific guidelines for such support.

2018 Infectious Diseases Society of America Clinical Practice Guideline for the Management of Outpatient Parenteral Antimicrobial Therapy

A panel of experts was convened by the Infectious Diseases Society of America to update the 2004 clinical practice guideline on outpatient parenteral antimicrobial therapy (OPAT) [1]. This guideline is intended to provide insight for healthcare professionals who prescribe and oversee the provision of OPAT. It considers various patient features, infusion catheter issues, monitoring questions, and antimicrobial stewardship concerns. It does not offer recommendations on the treatment of specific infections. The reader is referred to disease- or organism-specific guidelines for such support.

Roles and Role Ambiguity in Patient- and Caregiver-Performed Outpatient Parenteral Antimicrobial Therapy

BACKGROUND

Complicated medical therapies traditionally performed in acute care hospitals are increasingly moving to the home, requiring patients and informal caregivers to perform complicated medical tasks. For example, in outpatient parenteral antimicrobial therapy (OPAT), patients and caregivers perform antimicrobial infusions and venous catheter care. The objective of this study was to characterize patient understanding of patient, caregiver, and health care worker roles in OPAT and barriers to fulfilling these roles, with the goal of understanding how to best support patients and their caregivers.

METHODS

A qualitative study using 40 semistructured telephone interviews and 20 contextual inquiries of patients and caregivers performing OPAT tasks was performed. Eligible participants were discharged from two academic medical centers on OPAT. Interview transcripts and notes from contextual inquiry were coded based on a human factors engineering model.

RESULTS

Four main roles are described: communicator, advocate, learner-trainer, and lay health care worker doing "high-skilled tasks." Patients and caregivers experienced role ambiguity about OPAT task performance at the time of hospital discharge. Patients noted that their health care workers experienced role ambiguity as well, particularly regarding who was managing their care. Patients and caregivers used role transitions to achieve workload management, in which patients and caregivers transitioned OPAT tasks or non-OPAT tasks from one person to another.

CONCLUSION

Clear delineation of roles in complicated home-based medical therapies and training of all who may perform these tasks could improve the safety and quality of home-based care.

1978. Statements about Antibiotic Side-Effects and Patient Desire for Unnecessary Antibiotics

Background

Antibiotic resistance is a global health emergency fueled in part by non-indicated use of antibiotics. Current public education campaigns primarily focus on the risks of global antibiotic resistance or society-wide adverse impacts of antibiotic misuse. There has been little research into what messages have the greatest impact on patient requests for non-indicated antibiotics.

Methods

We administered a survey at a primary care clinic in August 2018. Participants rated 18 statements about potential harm from antibiotics on how that statement changed their likelihood to request antibiotics for an upper respiratory tract infection (URI) on an 11-point Likert scale. These included 8 statements about potential harm to the individual, 4 statements about potential harm to contacts of the individual, and 6 statements about resistance or the societal impact of antibiotic misuse. Before and after the survey, participants rated how likely they were to request antibiotics for a URI.

Results

Of 1150 adult patients in clinic over the 6 days of the survey, 250 completed the survey. Statements about potential harm to the individual decreased patient likelihood to request antibiotics more than statements about societal impacts of antibiotic misuse. (P < 0.001). Statements about potential harm to contacts of the patient also decreased patient likelihood to request antibiotics more than statements about resistance or societal impacts of antibiotic misuse (P < 0.001). Statements discussing antibiotic resistance were less likely to impact patient likelihood to request antibiotics than statements not mentioning antibiotic resistance (P < 0.001). All statements decreased patient likelihood to request antibiotics. Overall likelihood to request antibiotics decreased after the survey (from 5.3 pre- to 3.1 post-survey, P < 0.001).

Conclusion

Statements about how potential harm of antibiotics to the individual had a greater impact than statements about resistance or societal impact of antibiotics. Our results suggest that when dissuading patients from requesting non-indicated antibiotics, providers and public health campaigns focus on the potential harm of antibiotics to the individual patient rather than on antibiotic resistance or societal impacts.

Disclosures

All authors: No reported disclosures.

1063. A Healthcare Worker-Informed Approach to the Hospital-to-Home Transition on Oral Antibiotics

Background

Improved antibiotic decision-making during the hospital-to-home transition is an important but under-addressed target for antimicrobial stewardship. This study aims to provide a healthcare worker-informed approach to characterize prescriber antibiotic decision-making and patient medication management at discharge to identify barriers to and strategies for antibiotic stewardship during the hospital-to-home transition.

Methods

Semi-structured interviews were conducted at an academic medical center with relevant stakeholders including house staff (n = 10), nurses (n = 2), nurse practitioners (n = 5), inpatient pharmacists (n = 4), and discharge coordinators (n = 2). Interviews focused on challenges to antibiotic decision-making and patient medication management at discharge. Transcripts were independently coded and analyzed by two physicians using the constant comparative method.

Results

We identified four main barriers to antibiotic decision-making at hospital discharge: (1) uncertainty over antibiotic choice (due to lack of microbiology data), (2) pressure to discharge, (3) lack of control over antibiotic decision-making (attending-led decision with little room for input), and (4) lack of awareness of cost and insurance coverage. We also identified challenges to patient medication management specific to patient education: (1) role ambiguity around who provides education and (2) lack of education to patients around side effects. To improve antibiotic decision-making, prescribers relied heavily on institutional guidelines and interaction with experts in informing antibiotic choices, and used multidisciplinary approaches to verify antibiotic cost and availability. Five strategies to improve medication management were proposed: (1) assessing patient health literacy when providing instructions, (2) an in-hospital trial of the oral antibiotic to ensure tolerance, (3) ensuring the patient leaves the hospital with the antibiotic in hand, (4) care coordination after discharge, and (5) close follow-up with prescribers after discharge.

Conclusion

Our findings identify barriers to discharge antibiotic decision-making and medication management that allow for targeted interventions to improve antibiotic decision-making during the hospital-to-home transition.

Disclosures

Sara E. Cosgrove, MD, MS, Basilea: Consultant; Theravance: Consultant.

Rates of and Risk Factors for Adverse Drug Events in Outpatient Parenteral Antimicrobial Therapy

Background

To better monitor patients on outpatient parenteral antimicrobial therapy (OPAT), we need an improved understanding of risk factors for and timing of OPAT-associated adverse drug events (ADEs).

Methods

We analyzed a prospective cohort of patients on OPAT discharged from 2 academic medical centers. Patients underwent chart abstraction and a telephone survey. Multivariable analyses estimated adjusted incident rate ratios (aIRR) between clinical and demographic risk factors and clinician-determined clinically significant ADEs. Descriptive data were used to present patient-reported ADEs.

Results

Of 339 patients enrolled in the study, 18.0% experienced an ADE (N = 65), of which 49 were significant (14.5%, 2.24/1000 home-OPAT days). Patients with longer courses of therapy had lower rates of ADEs compared with patients treated for 0-13 days (14-27 days: aIRR, 0.44; 95% confidence interval [CI], 0.20-0.99; at least 28 days: aIRR, 0.11; 95% CI, 0.056-0.21). Risk factors for ADEs included female gender and receipt of daptomycin or vancomycin, while treatment for uncomplicated bacteremia and empiric treatment were associated with lower rates of ADEs.

Conclusions

OPAT-related ADEs were common and often occurred within 2 weeks of hospital discharge. Patients on OPAT should be monitored more closely for ADEs, including clinical assessment and laboratory monitoring, especially within the first weeks after hospital discharge and particularly among women and patients who receive vancomycin.

Perspectives of United States-based Infectious Diseases Physicians on Outpatient Parenteral Antimicrobial Therapy Practice

BACKGROUND

While outpatient parenteral antimicrobial therapy (OPAT) is generally considered safe, patients are at risk for complications and thus require close monitoring. The purpose of this study is to determine how OPAT programs are structured and how United States-based infectious diseases (ID) physicians perceive barriers to safe OPAT care.

METHODS

We queried members of the Emerging Infections Network (EIN) between November and December 2018 about practice patterns and barriers to providing OPAT.

RESULTS

672 members of the EIN (50%) responded to the survey. Seventy-five percent of respondents were actively involved in OPAT, although only 37% of respondents reported ID consultation was mandatory for OPAT. The most common location for OPAT care was at home with home-health support, followed by post-acute-care facilities. Outpatient and inpatient ID physicians were identified as being responsible for monitoring laboratory results (73% and 54% of respondents, respectively), but only 36% had a formal OPAT program. The majority of respondents reported a lack of support in data analysis (80%), information technology (66%), financial assistance (65%), and administrative assistance (60%). Perceived amount of support did not differ significantly across employment models. Inability to access laboratory results in a timely manner, lack of leadership awareness of OPAT value, and failure to communicate with other providers administering OPAT were reported as the most challenging aspects of OPAT care.

CONCLUSION

ID providers are highly involved in OPAT, but only a third of respondents have a dedicated OPAT program. Lack of financial and institutional support are perceived as significant barriers to providing safe OPAT care.

It's Complicated: Patient and Informal Caregiver Performance of Outpatient Parenteral Antimicrobial Therapy-Related Tasks

Outpatient parenteral antimicrobial therapy (OPAT) requires patients and caregivers to infuse antimicrobials through venous catheters (VCs) in the home. The objective of this study was to perform a patient-centered goal-directed task analysis to identify what is required for successful completion of OPAT. The authors performed 40 semi-structured patient interviews and 20 observations of patients and caregivers performing OPAT-related tasks. Six overall goals were identified: (1) understanding and developing skills in OPAT, (2) receiving supplies, (3) medication administration and VC maintenance, (4) preventing VC harm while performing activities of daily living, (5) managing when hazards lead to failures, and (6) monitoring status. The authors suggest that patients and caregivers use teach-back, take formal OPAT classes, receive visual and verbal instructions, use cognitive aids, learn how to troubleshoot, and receive clear instructions to address areas of uncertainty. Addressing these goals is essential to ensuring the safety of and positive experiences for our patients.

Improving daily patient room cleaning: an observational study using a human factors and systems engineering approach

Background

While playing a critical role in preventing healthcare-associated infections, patient room cleaning is often unsatisfactorily performed. To improve patient room cleaning, a human factors and systems engineering (HFSE) approach is needed to understand the complex cleaning process and associated work system factors.

Purpose

We conducted an observational study to assess the performance of environmental care (EVC) associates during daily patient room cleaning and identify work system factors influencing their performance.

Methods

This study was conducted in eight adult medicine inpatient units at a large urban academic medical center. An HFSE researcher shadowed 10 day-shift EVC associates performing daily patient room cleanings and used a semi-structured observation form to collect quantitative data (e.g., duration of room cleaning, orders for surface cleaning) and qualitative data (e.g., challenges to patient room cleaning). Descriptive statistics (e.g., median, interquartile range) were reported for cleaning performance, and bivariate and regression analyses were conducted to identify factors influencing cleaning performance. We also performed link analyses of the workflow of EVC associates and qualitative analyses of observer notes to identify challenges to daily patient room cleaning.

Results

We observed 89 patient room cleanings. Median duration of cleaning a room was 14 minutes, and median percentage of surfaces cleaned in a room was 63%. High-touch surfaces that were frequently missed during daily cleaning included the bedrails, telephone, patient and visitor chairs, and cabinet. Work system factors that could influence cleaning performance included the type of unit, the presence of the patient and family members in the room, cleaning patterns and orders of EVC associates, and interruptions EVC associates encountered while cleaning.

Conclusions

Daily patient room cleaning was influenced by a number of work system factors. To improve daily patient room cleaning, multifaceted interventions are needed to address these system-level factors.

Health-Related Quality of Life in Outpatient Parenteral Antimicrobial Therapy

Health-related quality of life (HRQoL) in outpatient parenteral antimicrobial therapy (OPAT) has not been well characterized in the United States. In an OPAT cohort, the short-form-12’s median physical component score and mental component score were 40.3 and 54.4, respectively. HRQoL measures could be helpful in studies of OPAT cost-effectiveness.