Disinfection of central venous access device needleless connectors: A human factors analysis

OBJECTIVE

Evidence-based central-line-associated bloodstream infection (CLABSI) prevention guidelines recommend the use of an antiseptic scrub to disinfect needleless connectors before device access. Guideline noncompliance may render disinfection ineffective. The goal of this study was to observe needleless-connector disinfection practices and to identify perceived facilitators and barriers to best practices of needleless-connector access.

METHODS

A human factors mixed-methods study involving nursing focus groups of perceived barriers and facilitators and clinical observations of compliance with instructions and protocols for use of 3.15% chlorhexidine gluconate/70% isopropyl alcohol (CHG/IPA) and 70% isopropyl alcohol (IPA) antisepsis products for central venous access device (CVAD) needleless-connector disinfection was conducted in intensive care units (ICUs) at 2 academic medical centers.

RESULTS

Access to the antiseptic product and lesser workload were identified as best-practice facilitators. Barriers were the time required per needleless-connector access and knowledge deficits. Of the 48 observed access events, 77% resulted in needleless-connector disinfection. The observed mean needleless-connector scrubbing times when using IPA were substantially below the recommended time. Drying time after product use was negligible.

CONCLUSIONS

Lack of access to the disinfection product, emergency situations, and high workload were barriers to needleless-connector disinfection. Observed scrubbing and drying times were shorter than recommended, especially for IPA wipes. These needleless-connector disinfection deficits may increase the risk of CLABSI. Ongoing education and periodic competency evaluation of needleless-connector disinfection, improvement of supply management, and staffing workload are required to imbed and sustain best practices. Further study involving a larger sample size in diverse patient populations is warranted.

Severe acute respiratory coronavirus virus 2 (SARS-CoV-2) RNA and viable virus contamination of hospital emergency department surfaces and association with patient coronavirus disease 2019 (COVID-19) status and aerosol-generating procedures

Emergency departments are high-risk settings for severe acute respiratory coronavirus virus 2 (SARS-CoV-2) surface contamination. Environmental surface samples were obtained in rooms with patients suspected of having COVID-19 who did or did not undergo aerosol-generating procedures (AGPs). SARS-CoV-2 RNA surface contamination was most frequent in rooms occupied by coronavirus disease 2019 (COVID-19) patients who received no AGPs.

A mixed-methods evaluation on the efficacy and perceptions of needleless connector disinfectants

OBJECTIVE

Optimizing needleless connector hub disinfection practice is a key strategy in central-line-associated bloodstream infection (CLABSI) prevention. In this mixed-methods evaluation, 3 products with varying scrub times were tested for experimental disinfection followed by a qualitative nursing assessment of each.

METHODS

Needleless connectors were inoculated with varying concentrations of Staphylococcus epidermidis, Pseudomonas aeruginosa, and Staphylococcus aureus followed by disinfection with a 70% isopropyl alcohol (IPA) wipe (a 15-second scrub time and a 15-second dry time), a 70% IPA cap (a 10-second scrub time and a 5-second dry time), or a 3.15% chlorhexidine gluconate with 70% IPA (CHG/IPA) wipe (a 5-second scrub time and a 5-second dry time). Cultures of needleless connectors were obtained after disinfection to quantify bacterial reduction. This was followed by surveying a convenience sample of nursing staff with intensive care unit assignments at an academic tertiary hospital on use of each product.

RESULTS

All products reduced overall bacterial burden when compared to sterile water controls, however the IPA and CHG/IPA wipes were superior to the IPA caps when product efficacy was compared. Nursing staff noted improved compliance with CHG/IPA wipes compared with the IPA wipes and the IPA caps, with many preferring the lesser scrub and dry times required for disinfection.

CONCLUSION

Achieving adequate bacterial disinfection of needleless connectors while maximizing healthcare staff compliance with scrub and dry times may be best achieved with a combination CHG/IPA wipe.

Analysis of Failure Rates for COVID-19 Entrance Screening at a US Academic Medical Center

This quality improvement study analyzes the rate of failures in entrance screening for COVID-19 among individuals entering a large academic medical center.

1919. Implementation of Hydrogen Peroxide Vapor (HPV) Decontamination of N95 Respirators for Reuse During COVID-19 Pandemic

Background

To ensure an adequate supply of N95 respirators in response to the global shortages caused by the COVID-19 pandemic, we evaluated and implemented hydrogen peroxide vapor (HPV) to reprocess disposable N95 respirators. Previous work performed by our team showed that HPV was effective in eradicating viable viruses from experimentally contaminated N95 respirators and that they retained their breathability and filtering efficiency for 3 cycles of HPV disinfection.

Methods

A multidisciplinary team worked by performing experiments and PDSA cycles to develop the ultimate process. Key processes and stakeholders were identified and engaged in operations decisions.

Results

The respirator reprocessing program was successfully implemented. One of the critical components for its success was the implementation of a Personal Protective Equipment (PPE) liaison program which was developed to create a process and local, unit-level champion for the collection of used N95s and to educate the staff on the program and provide guidance per the hospitals’ PPE policy. A courier system was implemented for the collection, transport and delivery of bulk containers of respirators between facilities. Facility Services designed and constructed a centralized respirator reprocessing center to include a receiving location, a negative pressure decontamination area to sort and stage the respirators on racks, two HPV reprocessing rooms and a clean room to receive the reprocessed N95s and to repackage and label for distribution. Standard operating procedures, staff training and competencies, and logs for documentation were created.

Within 18 weeks (March 13, 2020 through July 2020), nearly 32,000 N95 respirators were reprocessed and packaged for redistribution utilizing the 2 HPV disinfection rooms and 5 full time employees. As built, there was capacity to reprocess 5,000 respirators per day and evaluated by the U. S. Food and Drug Administration (FDA) led to the issue of an Emergency Use Authorization.

Conclusion

This scalable program enabled YNHHS to ensure an adequate supply of respirators for the safety of staff during the COVID-19 pandemic and global shortages of PPE. A multidisciplinary team and leadership commitment to provide resources for space and personnel were critical for program success.

Disclosures

All Authors: No reported disclosures.

Disinfection of Virtual Reality Devices in Health Care Settings: In Vitro Assessment and Survey Study

BACKGROUND

Virtual reality (VR) devices are increasingly used in health care settings. The use among patients has the potential to unintentionally transmit pathogens between patients and hospital staff. No standard operating procedure for disinfection exists to ensure safe use between patients.

OBJECTIVE

This study aims to determine the efficacy of disinfectants on VR devices in order to ensure safe use in health care settings.

METHODS

Three types of bacteria were inoculated onto porous and nonporous surfaces of 2 VR devices: the Meta Oculus Quest and Meta Oculus Quest 2. Disinfection was performed using either isopropyl alcohol or alcohol-free quaternary ammonium wipes. A quantitative culture was used to assess the adequacy of disinfection. A survey was separately sent out to VR device technicians at other pediatric health care institutes to compare the methods of disinfection and how they were established.

RESULTS

Both products achieved adequate disinfection of the treated surfaces; however, a greater log-kill was achieved on nonporous surfaces than on the porous surfaces. Alcohol performed better than quaternary ammonium on porous surfaces. The survey respondents reported a wide variability in disinfection processes with only 1 person reporting an established standard operating procedure.

CONCLUSIONS

Disinfection can be achieved through the use of either isopropyl alcohol or quaternary ammonium products. Porous surfaces showed lesser log-kill rates than the nonporous surfaces, indicating that the use of an added barrier may be of benefit and should be a point of future research. Given the variability in the disinfection process across health care systems, a standard operating procedure is proposed.

Pilot study of using thermal imaging to assess hand hygiene technique

BACKGROUND

Currently, there is no standard method for assessing hand hygiene (HH) technique. We explored the use of thermal imaging to determine if alcohol-based sanitizer (ABHS) has been applied to fingertips and thumbs, areas often missed by healthcare personnel.

METHODS

A FLIR thermal camera attached to an iPhone with FLIR app was used to obtain thermal images of volunteers' dominant hand before and after performing HH with an ABHS. Temperature readings of the mid-palm area, and tips of 3rd finger and thumb were recorded before and at multiple time points after hand hygiene.

RESULTS

In 11 of 12 volunteers, thermal images revealed significant decreases in mid-palm, finger and thumb temperatures after performing HH (P < .01 for all sites), confirming visual assessment of coverage. When HH was performed without including the thumb, a lack of colorimetric change in the thumb was visible. For persons with "cold" fingers at baseline, assessing ABHS coverage of the fingers was more difficult.

CONCLUSIONS

Thermal imaging of HH performance shows promise for assessing HH technique. Additional studies involving a larger number of persons under varying conditions are needed to establish if thermal imaging can be a practical modality for teaching or monitoring HH technique.

Comparison of traditional instruction versus nontraditional learning to improve trainee knowledge of urine culture practices in catheterized patients

We surveyed trainees about their urine culture practices and assessed the impact of an educational intervention delivered electronically and in-person. Trainee scores improved across all levels of training and across all questions on the post-intervention survey, but there was no difference in scores by mode of education (P=0.91).

Models for an Ultraviolet-C Research and Development Consortium

The development of an international, precompetitive, collaborative, ultraviolet (UV) research consortium is discussed as an opportunity to lay the groundwork for a new UV commercial industry and the supply chain to support this industry. History has demonstrated that consortia can offer promising approaches to solve many common, current industry challenges, such as the paucity of data regarding the doses of ultraviolet-C (UV-C, 200 nm to 280 nm) radiation necessary to achieve the desired reductions in healthcare pathogens and the ability of mobile disinfection devices to deliver adequate doses to the different types of surfaces in a whole-room environment. Standard methods for testing are only in the initial stages of development, making it difficult to choose a specific UV-C device for a healthcare application. Currently, the public interest in UV-C disinfection applications is elevated due to the spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes the respiratory coronavirus disease 19 (COVID-19). By channeling the expertise of different UV industry stakeholder sectors into a unified international consortium, innovation in UV measurements and data could be developed to support test methods and standards development for UV healthcare equipment. As discussed in this paper, several successful examples of consortia are applicable to the UV industry to help solve these types of common problems. It is anticipated that a consortium for the industry could lead to UV applications for disinfection becoming globally prolific and commonplace in residential, work, business, and school settings as well as in transportation (bus, rail, air, ship) environments. Aggressive elimination of infectious agents by UV-C technologies would also help to reduce the evolution of antibiotic-resistant bacteria.

Development and Application of a Polydimethylsiloxane-Based Passive Air Sampler to Assess Personal Exposure to SARS-CoV-2

Exhaled respiratory droplets and aerosols can carry infectious viruses and are an important mode of transmission for COVID-19. Recent studies have been successful in detecting airborne SARS-CoV-2 RNA in indoor settings using active sampling methods. The cost, size, and maintenance of these samplers, however, limit their long-term monitoring ability in high-risk transmission areas. As an alternative, passive samplers can be small, lightweight, and inexpensive and do not require electrical power or maintenance for continual operation. Integration of passive samplers into wearable designs can be used to better understand personal exposure to the respiratory virus. This study evaluated the use of a polydimethylsiloxane (PDMS)-based passive sampler to assess personal exposure to aerosol and droplet SARS-CoV-2. The rate of uptake of virus-laden aerosol on PDMS was determined in lab-based rotating drum experiments to estimate time-weighted averaged airborne viral concentrations from passive sampler viral loading. The passive sampler was then embedded in a wearable clip design and distributed to community members across Connecticut to surveil personal SARS-CoV-2 exposure. The virus was detected on clips worn by five of the 62 participants (8%) with personal exposure ranging from 4 to 112 copies of SARS-CoV-2 RNA/m3, predominantly in indoor restaurant settings. Our findings demonstrate that PDMS-based passive samplers may serve as a useful exposure assessment tool for airborne viral exposure in real-world high-risk settings and provide avenues for early detection of potential cases and guidance on site-specific infection control protocols that preempt community transmission.

Hydrogen peroxide vapor decontamination of N95 respirators for reuse

OBJECTIVE

The coronavirus disease 2019 (COVID-19) pandemic has led to global shortages of N95 respirators. Reprocessing of used N95 respirators may provide a higher filtration crisis alternative, but whether effective sterilization can be achieved for a virus without impairing respirator function remains unknown. We evaluated the viricidal efficacy of Bioquell vaporized hydrogen peroxide (VHP) on contaminated N95 respirators and tested the particulate particle penetration and inhalation and exhalation resistance of respirators after multiple cycles of VHP.

METHODS

For this study, 3M 1870 N95 respirators were contaminated with 3 aerosolized bacteriophages: T1, T7, and Pseudomonas phage phi-6 followed by 1 cycle of VHP decontamination using a BQ-50 system. Additionally, new and unused respirators were sent to an independent laboratory for particulate filter penetration testing and inhalation and exhalation resistance after 3 and 5 cycles of VHP.

RESULTS

A single VHP cycle resulted in complete eradication of bacteriophage from respirators (limit of detection 10 PFU). Respirators showed acceptable limits for inhalation/exhalation resistance after 3 and 5 cycles of VHP. Respirators demonstrated a filtration efficiency >99 % after 3 cycles, but filtration efficiency fell below 95% after 5 cycles of HPV.

CONCLUSION

Bioquell VHP demonstrated high viricidal activity for N95 respirators inoculated with aerosolized bacteriophages. Bioquell technology can be scaled for simultaneous decontamination of a large number of used but otherwise intact respirators. Reprocessing should be limited to 3 cycles due to concerns both about impact of clinical wear and tear on fit, and to decrement in filtration after 3 cycles.

Hydrogen peroxide vapor decontamination of N95 respirators for reuse

OBJECTIVE

The coronavirus disease 2019 (COVID-19) pandemic has led to global shortages of N95 respirators. Reprocessing of used N95 respirators may provide a higher filtration crisis alternative, but whether effective sterilization can be achieved for a virus without impairing respirator function remains unknown. We evaluated the viricidal efficacy of Bioquell vaporized hydrogen peroxide (VHP) on contaminated N95 respirators and tested the particulate particle penetration and inhalation and exhalation resistance of respirators after multiple cycles of VHP.

METHODS

For this study, 3M 1870 N95 respirators were contaminated with 3 aerosolized bacteriophages: T1, T7, and Pseudomonas phage phi-6 followed by 1 cycle of VHP decontamination using a BQ-50 system. Additionally, new and unused respirators were sent to an independent laboratory for particulate filter penetration testing and inhalation and exhalation resistance after 3 and 5 cycles of VHP.

RESULTS

A single VHP cycle resulted in complete eradication of bacteriophage from respirators (limit of detection 10 PFU). Respirators showed acceptable limits for inhalation/exhalation resistance after 3 and 5 cycles of VHP. Respirators demonstrated a filtration efficiency >99 % after 3 cycles, but filtration efficiency fell below 95% after 5 cycles of HPV.

CONCLUSION

Bioquell VHP demonstrated high viricidal activity for N95 respirators inoculated with aerosolized bacteriophages. Bioquell technology can be scaled for simultaneous decontamination of a large number of used but otherwise intact respirators. Reprocessing should be limited to 3 cycles due to concerns both about impact of clinical wear and tear on fit, and to decrement in filtration after 3 cycles.

An outbreak of SARS-CoV-2 on a transplant unit in the early vaccination era

Solid organ transplant recipients are at increased risk of COVID-19 associated morbidity and mortality. We describe the first nosocomial outbreak investigation on an immunocompromised inpatient unit aided by SARS-CoV-2 whole genome sequencing. Two patients were identified as potential index cases; one presented with diarrhea and the other tested positive on hospital day 18 after developing hypoxemia and subsequently testing positive for SARS-CoV-2. Following identification of the SARS-CoV-2 cluster, the unit was closed to new admissions, and the remaining patients and staff members underwent surveillance SARS-CoV-2 testing. Four additional patients and four staff members tested positive for SARS-CoV-2. Asymptomatic patients with COVID-19 were treated with bamlanivimab and all were alive at discharge. The unit was then re-opened with no additional positives reported since the initial outbreak. Preventing SARS-CoV-2 outbreaks in transplant units poses unique challenges as patients may have atypical presentations of COVID-19. Immunocompromised patients who test positive for SARS-CoV-2 while asymptomatic may benefit from monoclonal antibody therapy to prevent disease progression. All hospital staff members working with immunocompromised patients should be promptly encouraged to receive SARS-CoV-2 vaccination. This article is protected by copyright. All rights reserved.

Risk Communication After Health Care Exposures: An Experimental Vignette Survey With Patients

Purpose. We investigated how health care systems should communicate with patients about possible exposures to blood-borne pathogens that may have occurred during their care. Our goal was to determine how best to communicate uncertain risk information in a way that would minimize harm to patients, maintain their trust, and encourage patients to seek follow-up treatment. Methods. Participants (N = 1103) were randomized to receive one of six vignette surveys; 997 (98.4%) responded. All vignettes described the same event, but differed by risk level and recommendations (lower risk v. higher risk) and by communication mode (telephone, letter, social media). We measured participants’ perceived risk of blood-borne infection, trust in the health care system, and shared decision making about next clinical steps. Open-ended questions were analyzed using grounded thematic analysis. Results. When the vignette requested patients to undergo testing and practice certain health behaviors (higher risk), participants’ likelihood of seeking follow-up testing for blood-borne pathogens and their understanding of health issues increased. Perceived trust was unaffected by risk level or communication processes. Qualitative data indicated a desire for telephone communication from providers known to the patient. Limitations. It is not clear whether higher risk language or objective risk levels in vignettes motivated patients’ behavioral intentions. Conclusion. Using higher risk language when disclosing large-scale adverse events increased participants’ willingness to seek follow-up care. Implications. Health care organizations’ disclosures should focus on the next steps to take after health care exposures. This communication should involve helping patients to understand their personal health issues better, make them feel that they know which steps to take following the receipt of this information, and encouraging them to seek follow-up infectious disease testing in order to better take care of themselves.

Universal SARS-CoV-2 Testing of Emergency Department Admissions Increases Emergency Department Length of Stay

Study objective

Our institution experienced a change in SARS-CoV-2 testing policy as well as substantial changes in local COVID-19 prevalence, allowing for a unique examination of the relationship between SARS-CoV-2 testing and emergency department (ED) length of stay.

Methods

This was an observational interrupted time series of all patients admitted to an academic health system between March 15, 2020, and September 30, 2020. Given testing limitations from March 15 to April 24, all patients receiving SARS-CoV-2 tests were symptomatic. On April 24, testing was expanded to all ED admissions. The primary and secondary outcomes were ED length of stay and number needed to test to obtain a positive, respectively.

Results

A total of 70,856 patients were cared for in the EDs during the 7-month period. The testing change increased admission length of stay by 1.89 hours (95% confidence interval 1.39 to 2.38). The number needed to test was 2.5 patients and was highest yield on April 1, 2020, when the state positivity rate was 39.7%; however, the number needed to test exceeded 170 patients by Sept 1, 2020, at which point the state positivity rate was 0.5%.

Conclusion

Although universal SARS-CoV-2 testing of ED admissions may meaningfully support mitigation and containment efforts, the clinical cost of testing all admissions amid low community positivity is notable. In our system, universal ED SARS-CoV-2 testing was associated with a 24% increase in admission length of stay alongside the detection of only 1 positive case every other day. Given the known harms and risks of ED boarding and crowding, solutions must be developed to support regular operational flow while balancing infection prevention needs.

Inpatient Capacity Management during COVID-19 Pandemic: The Yale New Haven Hospital Capacity Expansion Experience

The 2019 SARS-CoV2 virus presented a capacity demand scenario for Yale New Haven Hospital. The response was created with a focus on clinical needs, but was also driven by the unique characteristics of the buildings within our institution. These physical characteristics were considered in the response as a safety measure as little was known about the transmissibility risk in the acute hospital setting of SARS-CoV2 at the time of response. The lessons learned in capacity expansion to meet the potentially catastrophic demand for acute care services due to a novel, poorly understood pathogen are discussed here.

Ultraviolet Radiation Technologies and Healthcare-Associated Infections: Standards and Metrology Needs

The National Institute of Standards and Technology (NIST) hosted an international workshop on ultraviolet-C (UV-C) disinfection technologies on January 14-15, 2020, in Gaithersburg, Maryland, in collaboration with the International Ultraviolet Association (IUVA). This successful public event, as evidenced by the participation of more than 150 attendees, with 65% from the ultraviolet technology industry, was part of an ongoing collaborative effort between NIST and the IUVA and its affiliates to examine the measurement and standards needs for pathogen abatement with UV-C in the healthcare whole-room environment. Prior to and since this event, stakeholders from industry, academia, government, and public health services have been collaboratively engaged with NIST to accelerate the development and use of accurate measurements and models for UV-C disinfection technologies and facilitate technology transfer. The workshop served as an open forum to continue this discussion with a technical focus centered on the effective design, use, and implementation of UV-C technologies for the prevention and treatment of healthcare-associated infections (HAIs) in complex hospital settings. These settings include patient rooms, operating rooms, common staging areas, ventilation systems, personal protective equipment, and tools for the reprocessing and disinfecting of instruments or devices used in medical procedures, such as catheters and ventilators. The critical need for UV-C technologies for disinfection has been amplified by the outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes coronavirus disease 2019 (COVID-19), stimulating an even greater emphasis on identifying testing and performance metrology needs. This paper discusses these topics based on the international workshop and community activities since the workshop, including a public World-Wide-Web-based seminar with more than 500 registered attendees on September 30, 2020; an international conference on UV-C technologies for air and surface disinfection, December 8-9, 2020; and a webinar on returning to normalcy with the use of UV-C technologies, April 27 and 29, 2021. This article also serves as an introduction to a special section of the Journal of Research of the National Institute of Standards and Technology, where full papers address recent technical, noncommercial, UV-C technology and pathogen-abatement investigations. The set of papers provides keen insights from the vantage points of medicine and industry. Recent technical developments, successes, and needs in optics and photonics, radiation physics, biological efficacy, and the needs of future markets in UV-C technologies are described to provide a concise compilation of the community's efforts and the state of the field. Standards needs are identified and discussed throughout this special section. This article provides a summary of the essential role of standards for innovation and implementation of UV-C technology for improved patient care and public health.

Perspectives and Recommendations Regarding Standards for Ultraviolet-C Whole-Room Disinfection in Healthcare

Patient well-being must be the driving force for determining standards for disinfection systems based on ultraviolet-C (UV-C) radiation. Reductions of inoculated bacteria on carriers is the optimal method of validating a UV-C-emitting system. We make specific, evidence-based recommendations regarding room description, organism selection, carrier material, quantity, orientations, and locations. Criteria for a satisfactory performance are discussed. Adoption of these requirements will ensure that devices intended for room disinfection provide the greatest chances for prevention of environmentally derived healthcare-associated infections.

From implementation to sustainment: A large-scale adverse event disclosure support program generated through embedded research in the Veterans Health Administration

In 2008, the Veterans Health Administration published a groundbreaking policy on disclosing large-scale adverse events to patients in order to promote transparent communication in cases where harm may not be obvious or even certain. Without embedded research, the evidence on whether or not implementation of this policy was generating more harm than good among Veteran patients was unknown. Through an embedded research-operations partnership, we conducted four research projects that led to the development of an evidence-based large-scale disclosure toolkit and disclosure support program, and its implementation across VA healthcare. Guided by the Consolidated Framework for Implementation Research, we identified specific activities corresponding to planning, engaging, executing, reflecting and evaluating phases in the process of implementation. These activities included planning with operational leaders to establish a shared research agenda; engaging with stakeholders to discuss early results, establishing buy-in of our efforts and receiving feedback; joining existing operational teams to execute the toolkit implementation; partnering with clinical operations to evaluate the toolkit during real-time disclosures; and redesigning the toolkit to meet stakeholders' needs. Critical lessons learned for implementation success included a need for stakeholder collaboration and engagement, an organizational culture involving a strong belief in evidence, a willingness to embed researchers in clinical operation activities, allowing for testing and evaluation of innovative practices, and researchers open to constructive feedback. At the conclusion of the research, VA operations worked with the researchers to continue to support efforts to spread, scale-up and sustain toolkit use across the VA healthcare system, with the final goal to establish long-term sustainability.

Accuracy of Computable Phenotyping Approaches for SARS-CoV-2 Infection and COVID-19 Hospitalizations from the Electronic Health Record

Objective:

Real-world data have been critical for rapid-knowledge generation throughout the COVID-19 pandemic. To ensure high-quality results are delivered to guide clinical decision making and the public health response, as well as characterize the response to interventions, it is essential to establish the accuracy of COVID-19 case definitions derived from administrative data to identify infections and hospitalizations.

Methods:

Electronic Health Record (EHR) data were obtained from the clinical data warehouse of the Yale New Haven Health System (Yale, primary site) and 3 hospital systems of the Mayo Clinic (validation site). Detailed characteristics on demographics, diagnoses, and laboratory results were obtained for all patients with either a positive SARS-CoV-2 PCR or antigen test or ICD-10 diagnosis of COVID-19 (U07.1) between April 1, 2020 and March 1, 2021. Various computable phenotype definitions were evaluated for their accuracy to identify SARS-CoV-2 infection and COVID-19 hospitalizations.

Results:

Of the 69,423 individuals with either a diagnosis code or a laboratory diagnosis of a SARS-CoV-2 infection at Yale, 61,023 had a principal or a secondary diagnosis code for COVID-19 and 50,355 had a positive SARS-CoV-2 test. Among those with a positive laboratory test, 38,506 (76.5%) and 3449 (6.8%) had a principal and secondary diagnosis code of COVID-19, respectively, while 8400 (16.7%) had no COVID-19 diagnosis. Moreover, of the 61,023 patients with a COVID-19 diagnosis code, 19,068 (31.2%) did not have a positive laboratory test for SARS-CoV-2 in the EHR. Of the 20 cases randomly sampled from this latter group for manual review, all had a COVID-19 diagnosis code related to asymptomatic testing with negative subsequent test results. The positive predictive value (precision) and sensitivity (recall) of a COVID-19 diagnosis in the medical record for a documented positive SARS-CoV-2 test were 68.8% and 83.3%, respectively. Among 5,109 patients who were hospitalized with a principal diagnosis of COVID-19, 4843 (94.8%) had a positive SARS-CoV-2 test within the 2 weeks preceding hospital admission or during hospitalization. In addition, 789 hospitalizations had a secondary diagnosis of COVID-19, of which 446 (56.5%) had a principal diagnosis consistent with severe clinical manifestation of COVID-19 (e.g., sepsis or respiratory failure). Compared with the cohort that had a principal diagnosis of COVID-19, those with a secondary diagnosis had a more than 2-fold higher in-hospital mortality rate (13.2% vs 28.0%, P<0.001). In the validation sample at Mayo Clinic, diagnosis codes more consistently identified SARS-CoV-2 infection (precision of 95%) but had lower recall (63.5%) with substantial variation across the 3 Mayo Clinic sites. Similar to Yale, diagnosis codes consistently identified COVID-19 hospitalizations at Mayo, with hospitalizations defined by secondary diagnosis code with 2-fold higher in-hospital mortality compared to those with a primary diagnosis of COVID-19.

Conclusions:

COVID-19 diagnosis codes misclassified the SARS-CoV-2 infection status of many people, with implications for clinical research and epidemiological surveillance. Moreover, the codes had different performance across two academic health systems and identified groups with different risks of mortality. Real-world data from the EHR can be used to in conjunction with diagnosis codes to improve the identification of people infected with SARS-CoV-2.

Mass severe acute respiratory coronavirus 2 (SARS-CoV-2) testing of asymptomatic healthcare personnel

Mass asymptomatic SARS-CoV-2 nucleic acid amplified testing of healthcare personnel (HCP) was performed at a large tertiary health system. A low period-prevalence of positive HCP was observed. Of those who tested positive, half had mild symptoms in retrospect. HCP with even mild symptoms should be isolated and tested.

COVID-19 Outbreak and Hospital Air Quality: A Systematic Review of Evidence on Air Filtration and Recirculation

The outbreak of SARS-CoV-2 has made us all think critically about hospital indoor air quality and the approaches to remove, dilute, and disinfect pathogenic organisms from the hospital environment. While specific aspects of the coronavirus infectivity, spread, and routes of transmission are still under rigorous investigation, it seems that a recollection of knowledge from the literature can provide useful lessons to cope with this new situation. As a result, a systematic literature review was conducted on the safety of air filtration and air recirculation in healthcare premises. This review targeted a wide range of evidence from codes and regulations, to peer-reviewed publications, and best practice standards. The literature search resulted in 394 publications, of which 109 documents were included in the final review. Overall, even though solid evidence to support current practice is very scarce, proper filtration remains one important approach to maintain the cleanliness of indoor air in hospitals. Given the rather large physical footprint of the filtration system, a range of short-term and long-term solutions from the literature are collected. Nonetheless, there is a need for a rigorous and feasible line of research in the area of air filtration and recirculation in healthcare facilities. Such efforts can enhance the performance of healthcare facilities under normal conditions or during a pandemic. Past innovations can be adopted for the new outbreak at low-to-minimal cost.

Tracking smell loss to identify healthcare workers with SARS-CoV-2 infection

INTRODUCTION

Healthcare workers (HCW) treating COVID-19 patients are at high risk for infection and may also spread infection through their contact with vulnerable patients. Smell loss has been associated with SARS-CoV-2 infection, but it is unknown whether monitoring for smell loss can be used to identify asymptomatic infection among high risk individuals. In this study we sought to determine if tracking smell sensitivity and loss using an at-home assessment could identify SARS-CoV-2 infection in HCW.

METHODS AND FINDINGS

We performed a prospective cohort study tracking 473 HCW across three months to determine if smell loss could predict SARS-CoV-2 infection in this high-risk group. HCW subjects completed a longitudinal, behavioral at-home assessment of olfaction with household items, as well as detailed symptom surveys that included a parosmia screening questionnaire, and real-time quantitative polymerase chain reaction testing to identify SARS-CoV-2 infection. Our main measures were the prevalence of smell loss in SARS-CoV-2-positive HCW versus SARS-CoV-2-negative HCW, and timing of smell loss relative to SARS-CoV-2 test positivity. SARS-CoV-2 was identified in 17 (3.6%) of 473 HCW. HCW with SARS-CoV-2 infection were more likely to report smell loss than SARS-CoV-2-negative HCW on both the at-home assessment and the screening questionnaire (9/17, 53% vs 105/456, 23%, P < .01). 6/9 (67%) of SARS-CoV-2-positive HCW reporting smell loss reported smell loss prior to having a positive SARS-CoV-2 test, and smell loss was reported a median of two days before testing positive. Neurological symptoms were reported more frequently among SARS-CoV-2-positive HCW who reported smell loss compared to those without smell loss (9/9, 100% vs 3/8, 38%, P < .01).

CONCLUSIONS

In this prospective study of HCW, self-reported changes in smell using two different measures were predictive of SARS-CoV-2 infection. Smell loss frequently preceded a positive test and was associated with neurological symptoms.

Critical Care Nursing: A Key Constraint to COVID-19 Response and Healthcare Now and in the Future

This article discusses the crucial role and dearth of critical care nurses in the United States highlighted during the COVID-19 pandemic. This challenge of sufficient critical care nursing resources existed before the pandemic, but now concern is heightened by the need for such crucial healthcare providers now and in the future. We present strategies to address the gap, as well as challenges inherent in the suggested approaches. The discussion is relevant as nurse leaders adapt to COVID-19 and other novel challenges in the future.

493. Clinical and Epidemiological Features of Healthcare Workers Detected with Coronavirus Disease

Background

Data early in the SARS-CoV-2 pandemic suggested frontline healthcare workers (HCW) may account for 10–20% of all infections. CDC estimated 600,000 infections in HCWs. Symptom screening is a strategy to prevent healthcare-associated transmission. This method may not identify asymptomatic or pre-symptomatic carriers.

Methods

We conducted a prospective cohort study in asymptomatic or minimally symptomatic healthcare workers in a 1541-bed academic medical center. Although recruitment began in designated COVID-19 units, we expanded to all HCWs providing care to hospitalized patients during the pandemic. Data was gathered on demographics, work area in the hospital and daily questionnaires were sent listing symptoms of SARS-CoV-2. Protocol included twice weekly self-collected nasopharyngeal swab and saliva for SARS-CoV-2 N1 and N2.Those with positive PCR result, underwent telephone survey to assess symptomatology and severity of illness.

Results

A total 525 HCWs began the study protocol and 16 were identified as PCR positive. Samples included concordant saliva and NP samples on 9 (56%), exclusively NP samples on 5 (31%) and 2 (12%) HCWs were positive by saliva PCR only. Majority were female, and all were nursing staff; with 19% reported not working in a designated COVID-19 unit. During the course of this active surveillance, universal masking was mandated in the institution. Rhinorrhea and headache were reported by 6 (38%), 5 (31%) reported cough and 3 (19%) developed myalgia. Changes in smell and taste preceded the positive PCR test in 2 (12%). One HCW reported developing a fever with acute illness. All were notified about their PCR positive status by institution’s occupational health department and self-isolated to monitor for symptoms.

Conclusion

The spectrum of disease in this HCW cohort is similar to mild disease in the community. Due to high incidence of asymptomatic or mildly symptomatic HCWs, active surveillance with routine testing proves be beneficial to prevent hospital transmission of SARS-CoV-2. Universal masking significantly decreased the HCW positive rate in our study, underscoring the need for universal efforts to mitigate healthcare-associated transmission with self-monitoring, face mask use, and other infection prevention behaviors like hand hygiene.

Disclosures

All Authors: No reported disclosures

456. Implementing an At-Home Smell Test for Early Assessment of COVID-19 in High-Risk Healthcare Workers

Background

Smell loss has been recognized as an important, and potentially early, sign of COVID-19. However, to date smell loss has only been assessed in retrospective, COVID+ cohorts, and largely through self-report. The objective of this study was to implement a daily standardized behavioral test of smell sensitivity in healthcare workers (HCW) to capture changes in smell sensitivity over time and to assess whether these changes occur prior to positive COVID test.

Methods

The study enrolled 500 high-risk COVID-negative HCW during the COVID-19 epidemic in Connecticut, beginning March 28, 2020 (80% F, mean age 38, 58% nurses). Initially, HCW received a daily symptom questionnaire with parosmia screening questions. On April 23 we introduced the “Jiffy”, a daily at-home psychophysical test of smell sensitivity, where olfactory stimuli are sampled and rated for perceived intensity. SARS-CoV-2 infection was tested every three days by PCR of nasopharyngeal swabs or saliva.

Screening Questionnaire for Parosmia

The “Jiffy” Survey and Test

Results

Of the first 500 enrolled HCW, 376 HCW (75%) completed the Jiffy 4528 times (mean 12 times/HCW). 17/500 HCW (3.4%) had a COVID+ test, of which 9/17 (53%) reported smell loss through the Jiffy or the daily symptom survey. 6/9 (67%) reported smell loss that preceded or was concurrent with a COVID+ test. 8/17 COVID+ HCW completed the Jiffy, with 5/8 (63%) reporting reductions in smell versus 42/368 (11%) COVID- HCW (OR=13, 95% CI: 2.4–85, p=.001). COVID+ HCW rated their greatest reduction in smell sensitivity as slight (40%) and severe (60%), versus slight (88%) and moderate (12%) in COVID- HCW. 16/17 COVID+ HCW completed a daily symptom survey (mean 14 times/HCW), with 8/16 (50%) ever reporting parosmia versus 90/466 (19%) of COVID- HCW (OR=4.2, 95% CI: 1.3–13, p=.007). Overall, parosmia was the first reported symptom in 3/13 (23%) COVID+ HCW who reported symptoms.

Smell Changes in COVID+ and COVID- HCW Reported in the “Jiffy” Test

Smell Changes in COVID+ and COVID- HCW Reported in Daily Symptom Questionnaire

Smell Changes among COVID+ HCW by Day, Relative to Day of Positive PCR Test

Conclusion

We conducted a prospective study of smell testing in a population at high risk for COVID-19 using two parallel approaches. Our results demonstrate the feasibility of at-home smell testing for assessing parosmia during COVID-19, in some cases even prior to a positive PCR result. Given the urgent need for widespread, low-cost, non-invasive testing for COVID-19, we are now developing an easy-to-use app to distribute this survey more widely to high-risk populations.

Disclosures

Julian J. Weiss, BA, Nothing to disclose

68. Active Monitoring of a Healthcare Worker Cohort During the COVID-19 Epidemic

Background

Initial CDC recommendations for passive monitoring of COVID-19 related symptoms among staff may not be sufficient in preventing the introduction and transmission of SARS-CoV-2 in healthcare settings. We therefore implemented active monitoring for SARS-CoV-2 infection in healthcare workers (HCWs) at an academic medical center during the COVID-19 epidemic in northeast US.

Methods

We recruited a cohort of HCWs at Yale New Haven Hospital who worked in COVID-19 units and did not have COVID-19 related symptoms between March 28 and June 1, 2020. During follow-up, participants provided daily information on symptoms by responding to a web-based questionnaire, self-administered nasopharyngeal (NP) and saliva specimens every 3 days, and blood specimens every 14 days. We performed SARS-CoV-2 RT-PCR and an anti-spike protein IgM and IgG ELISA to identify virological and serological-confirmed infection, respectively.

Results

We enrolled 525 (13%) amongst 4,136 HCW of whom daily information on symptoms and NP, saliva, and blood specimens were obtained for 66% (of 13208), 42% (or 1977), 44% (of 2071) and 65% (of 1099), respectively, of the follow-up measurement points. We identified 16 (3.0% of 525) HCWs with PCR-confirmed SARS-CoV-2 infection and an additional 12 (2.3% of 525) who were not tested by PCR or had negative PCR results but had serological evidence of infection. The overall cumulative incidence of SARS-CoV-2 infection was 5.3% (28 of 525) amongst HCWs. Cases were not identified by hospital protocols for passive staff self-monitoring for symptoms. Amongst 16 PCR-confirmed cases, 9 (56%) of the 16 PCR-confirmed HCW had symptoms during or after the date of initial detection. We did not identify an epidemiological link between the 28 confirmed cases.

Conclusion

We found that a significant proportion (5.3%) of HCWs were infected with SARS-CoV-2 during the COVID-19 epidemic. In the setting of universal PPE use, infections were possibly acquired in the community rather than stemming from patient-HCW or HCW-HCW transmission. Passive monitoring of symptoms is inadequate in preventing introductions of SARS-CoV-2 into the healthcare setting due to asymptomatic and oligosymptomatic presentations.

Disclosures

All Authors: No reported disclosures

Performance analysis of portable HEPA filters and temporary plastic anterooms on the spread of surrogate coronavirus

The outbreak of COVID-19, and its current resurgence in the United States has resulted in a shortage of isolation rooms within many U.S. hospitals admitting COVID-19-positive cases. As a result, hospital systems, especially those at an epicenter of this outbreak, have initiated task forces to identify and implement various approaches to increase their isolation capacities. This paper describes an innovative temporary anteroom in addition to a portable air purifier unit to turn a general patient room into an isolation space. Using an aerosolization system with a surrogate oil-based substance, we evaluated the effectiveness of the temporary plastic anteroom and the portable air purifier unit. Moreover, the optimal location of the portable unit, as well as the effect of negative pressurization and door opening on the containment of surrogate aerosols were assessed. Results suggested that the temporary anteroom alone could prevent the migration of nearly 98% of the surrogate aerosols into the adjacent corridor. Also, it was shown that the best location of a single portable air purifier unit is inside the isolation room and near the patient's bed. The outcome of this paper can be widely used by hospital facilities managers when attempting to retrofit a general patient room into an airborne infection isolation room.

Tracking Smell Loss to Identify Healthcare Workers with SARS-CoV-2 Infection

BACKGROUND

Healthcare workers (HCW) treating COVID-19 patients are at high risk for infection and may also spread infection through their contact with vulnerable patients. Smell loss has been associated with SARS-CoV-2 infection, but it is unknown whether monitoring for smell loss can be used to identify asymptomatic infection among high risk individuals, like HCW.

METHODS

We performed a prospective cohort study, tracking 473 HCW across three months to determine if smell loss could predict SARS-CoV-2 infection in this high-risk group. HCW subjects completed a longitudinal, novel behavioral at-home assessment of smell function with household items, as well as detailed symptom surveys that included a parosmia screening questionnaire, and RT-qPCR testing to identify SARS-CoV-2 infection.

RESULTS

SARS-CoV-2 was identified in 17 (3.6%) of 473 HCW. Among the 17 infected HCW, 53% reported smell loss, and were more likely to report smell loss than COVID-negative HCW on both the at-home assessment and the screening questionnaire (P < .01). 67% reported smell loss prior to having a positive SARS-CoV-2 test, and smell loss was reported a median of two days before testing positive. Neurological symptoms were reported more frequently among COVID-positive HCW who reported smell loss (P < .01).

CONCLUSIONS

In this prospective study of HCW, self-reported changes in smell using two different measures were predictive of COVID-19 infection. Smell loss frequently preceded a positive test and was associated with neurological symptoms.

Clinical impact of rapid influenza PCR in the adult emergency department on patient management, ED length of stay, and nosocomial infection rate

BACKGROUND

Seasonal influenza causes significant morbidity and mortality and incurs large economic costs. Influenza like illness is a common presenting concern to Emergency Departments (ED), and optimizing the diagnosis of influenza in the ED has the potential to positively affect patient management and outcomes. Therapeutic guidelines have been established to identify which patients most likely will benefit from anti-viral therapy.

OBJECTIVES

We assessed the impact of rapid influenza PCR testing of ED patients on laboratory result generation and patient management across two influenza seasons.

METHODS

A pre-post study was performed following a multifaceted clinical redesign including the implementation of rapid influenza PCR at three diverse EDs comparing the 2016-2017 and 2017-2018 influenza seasons. Testing parameters including turn-around-time and diagnostic efficiency were measured along with rates of bed transfers, hospital-acquired (HA) influenza, and ED length of stay (LOS).

RESULTS

More testing of discharged patients was performed in the post-intervention period, but influenza rates were the same. Identification of influenza-positive patients was significantly faster, and there was faster and more appropriate prescription of anti-influenza medication. There were no differences in bed transfer rates or HA influenza, but ED LOS was reduced by 74 minutes following clinical redesign.

CONCLUSIONS

Multifaceted clinical redesign to optimize ED workflow incorporating rapid influenza PCR testing can be successfully deployed across different ED environments. Adoption of rapid influenza PCR can streamline testing and improve antiviral stewardship and ED workflow including reducing LOS. Further study is needed to determine if other outcomes including bed transfers and rates of HA influenza can be affected by improved testing practices.

Obstetricians on the Coronavirus Disease 2019 (COVID-19) Front Lines and the Confusing World of Personal Protective Equipment

As health care systems struggle to maintain adequate supplies of personal protective equipment, there is confusion and anxiety among obstetricians and others about how to best protect themselves, their coworkers, and their patients. Although use of personal protective equipment is a critical strategy to protect health care personnel from coronavirus disease 2019 (COVID-19), other strategies also need to be implemented on labor and delivery units to reduce the risk of health care-associated transmission, including screening of all pregnant women who present for care (case identification), placing a mask on and rapidly isolating ill pregnant women, and minimizing the number of personnel who enter the room of an ill patient (physical distancing). Although the mechanism of transmission of COVID-19 is not known with certainty, current evidence suggests that COVID-19 is transmitted primarily through respiratory droplets. Therefore, strict adherence to hand hygiene and consistent use of recommended personal protective equipment are cornerstones for reducing transmission. In addition, it is critical that health care professionals receive training on and practice correct donning (putting on) and doffing (removing) of personal protective equipment and avoid touching their faces as well as their facial protection to minimize self-contamination.

Coast-to-Coast Spread of SARS-CoV-2 during the Early Epidemic in the United States

The novel coronavirus SARS-CoV-2 was first detected in the Pacific Northwest region of the United States in January 2020, with subsequent COVID-19 outbreaks detected in all 50 states by early March. To uncover the sources of SARS-CoV-2 introductions and patterns of spread within the United States, we sequenced nine viral genomes from early reported COVID-19 patients in Connecticut. Our phylogenetic analysis places the majority of these genomes with viruses sequenced from Washington state. By coupling our genomic data with domestic and international travel patterns, we show that early SARS-CoV-2 transmission in Connecticut was likely driven by domestic introductions. Moreover, the risk of domestic importation to Connecticut exceeded that of international importation by mid-March regardless of our estimated effects of federal travel restrictions. This study provides evidence of widespread sustained transmission of SARS-CoV-2 within the United States and highlights the critical need for local surveillance.

•

Connecticut’s COVID-19 outbreak resulted from multiple domestic virus introductions

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SARS-CoV-2 genomic data indicate that coast-to-coast spread occurred in the United States

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Risk of introduction by domestic air travel exceeded international travel in March

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Restrictions on international travel did not significantly alter risk estimates

Coast-to-coast spread of SARS-CoV-2 in the United States revealed by genomic epidemiology

Since its emergence and detection in Wuhan, China in late 2019, the novel coronavirus SARS-CoV-2 has spread to nearly every country around the world, resulting in hundreds of thousands of infections to date. The virus was first detected in the Pacific Northwest region of the United States in January, 2020, with subsequent COVID-19 outbreaks detected in all 50 states by early March. To uncover the sources of SARS-CoV-2 introductions and patterns of spread within the U.S., we sequenced nine viral genomes from early reported COVID-19 patients in Connecticut. Our phylogenetic analysis places the majority of these genomes with viruses sequenced from Washington state. By coupling our genomic data with domestic and international travel patterns, we show that early SARS-CoV-2 transmission in Connecticut was likely driven by domestic introductions. Moreover, the risk of domestic importation to Connecticut exceeded that of international importation by mid-March regardless of our estimated impacts of federal travel restrictions. This study provides evidence for widespread, sustained transmission of SARS-CoV-2 within the U.S. and highlights the critical need for local surveillance.

2385. Evaluating the Antibiotic Risk for Clostridioides difficile Infection (CDI): Comparing Piperacillin/Tazobactam to Cefepime and Ceftazidime

Background

Clostridioides difficile infection (CDI) is a common healthcare-associated infection (HAI). Past studies have revealed that anti-pseudomonal cephalosporins such as cefepime (FEP) and ceftazidime (CTZ) are associated with a higher CDI risk than β-lactam/β-lactamase inhibitors (BLBLI) such as piperacillin/tazobactam (PTZ). However, there is limited data evaluating the comparative healthcare-associated CDI (HA-CDI) risk associated with BLBLI and anti-pseudomonal cephalosporin therapy.

Methods

An observational cohort study was performed with patients who received PTZ, FEP, or CTZ at Yale New Haven Hospital and Bridgeport Hospital from February 1, 2013 to June 1, 2018. Patients who received ≥ 3 days of PTZ, FEP, or CTZ therapy were included. Patients under the age of 18, those admitted to oncology, transplant, or pediatric units, and those with < 2 or ≥ 120 days of hospital admission were excluded. Multivariate logistic regression models were constructed to control and to adjust for underlying comorbidities.

Results

A total of 11,909 patient encounters met the study criteria. The median patient-days of therapy for both the PTZ and FEP/CTZ groups was 4 days (Table 1). FEP/CTZ exposure was associated with a higher CDI risk than PTZ exposure (P = 0.03) (Figure 1) even with higher C. difficile testing frequency in the PTZ group (P < 0.001) (Table 1). Using a multivariate logistic regression model controlling for high-risk antibiotic therapy (ciprofloxacin, clindamycin, ertapenem, meropenem, moxifloxacin), acid suppression therapy (famotidine, lansoprazole, pantoprazole), sex, Charlson comorbidity index score, age, and duration of hospital admission, FEP/CTZ exposure was independently associated with a higher CDI risk than PTZ exposure (Table 2) (Table 3).

Conclusion

FEP/CTZ exposure was associated with a higher CDI risk than PTZ exposure. PTZ may be associated with a higher risk for non-CDI antibiotic-associated diarrhea which may lead to an increased frequency of testing for CDI. The findings from this study may justify additional antibiotic stewardship efforts to limit the use of empiric FEP/CTZ therapy.

Disclosures

All authors: No reported disclosures.

Knowledge and Practices of Physicians and Nurses Related to Urine Cultures in Catheterized Patients: An Assessment of Adherence to IDSA Guidelines

Background

A positive urine culture often drives initiation of antimicrobials even in the absence of symptoms. Our objectives were to evaluate the knowledge and practice patterns related to ordering urine cultures in patients with indwelling urinary catheters.

Methods

We performed chart reviews of catheter-associated urinary tract infections (CAUTIs) at our academic health care system between October 1, 2015, and September 30, 2017, to assess practice patterns related to the assessment of potential CAUTIs. Following this, we surveyed physicians and nurses about indications for ordering urine cultures in catheterized patients between January 11, 2018, and April 17, 2018. The accuracy of these indications was assessed based on Infectious Diseases Society of America CAUTI and asymptomatic bacteriuria guidelines.

Results

On chart review, we identified 184 CAUTIs in 2 years. In 159 episodes (86%), urine cultures were ordered inappropriately. In 114 episodes (62%), CAUTI criteria were met by “pan-culturing” rather than symptom-directed testing. Twenty cases (11%) experienced partial or delayed management of other infections, drug adverse events, and Clostridioides difficile infections (CDIs). On our survey, we received 405 responses, for a response rate of 45.3%. Mean scores varied by occupation and level of training. Nurses were more likely than physicians to consider change in appearance (61% vs 23%; P < .05) and odor (74% vs 42%; P < .05) of urine as indications to order urine cultures.

Conclusions

Our data reveal specific knowledge gaps among physicians and nurses related to ordering urine cultures in catheterized patients. The practice of pan-culturing and inappropriate urine culture orders may contribute to overdiagnosis of surveillance CAUTIs, delay in diagnosis of alternative infections, and excess CDIs.

Conversion of a Conference Room into a Low-Acuity Inpatient Medical Unit: A Creative Response to Influenza-Related Surge

The 2017-2018 influenza season was associated with high demand for both emergency department (ED) care and inpatient acute care for influenza-like illness (ILI). This high demand resulted in increased numbers of inpatients and ED patients, including prolonged ED length of stay. A large, urban, academic medical center in a cold-weather region was limited in its ability to expand its footprint to create de novo locations of care, such as temporary outbuildings or tents. As such, a large conference room was rapidly converted and placed in service as a temporary inpatient unit for adults requiring inpatient admission. LOGISTICS AND IMPLEMENTATION: The logistical, infection prevention, safety, information technology, staffing, and other concerns of creating a clinical environment during a high demand scenario is challenging. However, the lessons learned in this study are reproducible despite the complexity of this issue. CONCLUSION: This is believed to be the first published account of successful conversion of a nonclinical area to an operational clinical unit in response to a surge in demand for hospital care and admission. This may be a valid option for hospitals of all sizes as part of a surge or disaster plan.

Innovative Approaches to Combat Healthcare-Associated Infections Using Efficacy Standards Developed Through Industry and Federal Collaboration

Nation-wide, healthcare-associated infections (HAIs) infect one in every 25 hospital patients, account for more than 100,000 deaths and increase medical costs by around $96-147B, each year. Ultraviolet-C (UV-C) antimicrobial devices are shown to reduce the incidence of many of these HAIs by 35% or more, through the deactivation of the pathogen's DNA chain following irradiation with a wavelength of ~254 nm. This irradiation does not kill the cells, per se but effectively prevents the cells from multiplying. Clinical case reductions of 30-70% in Clostridium difficile (C. diff.) have been reported with similar results for methicillin-resistant Staphylococcus aureus (MRSA), and others. The methodology works, but, the adoption of UV-C technology by the healthcare industry has been sporadic. This is largely due to the lack of definitive knowledge and uniform performance standards or measures for efficacy to help healthcare managers make informed, credible investment decisions. The leveling of the playing field with scientifically certifiable data of the efficacy of antimicrobial devices will enhance acceptance by the healthcare industry and public, at large, as well as facilitate science-based decision making. The National Institute of Standards and Technology (NIST) has engaged with the International Ultra Violet Association (IUVA) and its member companies and affiliates to explore ways to develop needed standards, determine appropriate testing protocols, and transfer the technology to help to reduce these inharmonious market conditions. Collaborative efforts are underway to develop science-based answers to the healthcare industry's questions surrounding standards and measures of device disinfection efficacy, as well as reliability, operations and durability. These issues were recently discussed at the IUVA 2018 America's Conference in Redondo Beach, CA in several panel sessions. A major output of the sessions was the formation of a formal IUVA Working Group for the development of antimicrobial standards and initiatives for the healthcare industry. The goal of this working group is to provide global guidance, with specific programs and deliverables, on the use of UV technologies and standards to combat HAIs and to further the stated aims of the IUVA on its outreach to the healthcare industry. This paper reviews the strong collaboration between NIST and its industry partners pursuing the development of standards, guidelines and guidance documents related to healthcare applications that include standard methods for validating performance of UV devices and test guidelines for efficacy measurements. In addition, an overview of the issues, problems, and a summary of the needs confronting future growth and success of the UV industry in the Nation's healthcare application space is provided.

Criteria to Screen Molecular Tests for the Diagnosis of Herpes Simplex Virus in the Central Nervous System have no Propensity to Harm

Objectives:

Investigators have ruled out herpes simplex virus (HSV) infection without the detection of herpes simplex deoxyribonucleic acid in cerebrospinal fluid (CSF) (i.e., HSV polymerase chain reaction [PCR]) by laboratory (normal CSF white blood cell count and protein) and clinical criteria (age ≥2 years, no history of human immunodeficiency virus or solid-organ transplant). Compared to HSV PCR of all samples, the algorithm saves money in test costs and may decrease exposure to acyclovir by illustrating the low probability that the patient has HSV. Concern exists that algorithm use may cause harm through alteration of empiric acyclovir treatment in patients with true HSV central nervous system infection.

Methods:

All Department of Veterans Affair's patients with a positive HSV PCR of the CSF between 2000 and 2013 were identified and their medical records reviewed to determine the extent and possible impact of omitted HSV PCR testing by the algorithm.

Results:

Of 6357 total results, 101 patients had a positive CSF HSV PCR in the study period. Among the positive CSF HSV PCR results, the algorithm excluded 7 (7%) from PCR testing. Record review indicated these seven patients not tested by the algorithm with a positive CSF HSV PCR were considered by their attending physician not to have active HSV.

Conclusion:

The algorithm to screen HSV tests had no propensity to harm.

Intended and unintended effects of large-scale adverse event disclosure: a controlled before-after analysis of five large-scale notifications

BACKGROUND AND OBJECTIVE

How patients respond to being notified of a large-scale adverse event (LSAE), such as improper sterilisation of medical equipment that exposes them to bloodborne pathogens, is not well known. The objective of this study was to determine, using administrative data, the intended and unintended consequences of patient notification following a LSAE.

METHODS

We examined five LSAEs where patients may have been inadvertently exposed to hepatitis C virus (HCV), HIV, and hepatitis B virus (HBV). A total of 9638 cases were identified at five Department of Veteran Affairs (VA) medical facilities between 2009 and 2012. We identified controls at the same facility prior to the exposure period and at neighbouring facilities (n=45,274). Difference-in-differences models were used with Veterans Health Administration (VHA) and Medicare data to examine infectious disease testing rates and subsequent utilisation patterns.

RESULTS

Receipt of a LSAE notification was associated with a 73.2, 76.8 and 77.1 adjusted percentage point increase for HCV, HIV and HBV testing, respectively (all p<0.001). Compared with white patients, African-American patients were significantly less likely to return to VHA for follow-up testing. Patients exposed to a dental LSAE reduced their use of preventive and restorative dental care over the subsequent year, but they eventually came back to VHA for dental services 18-months post exposure.

CONCLUSIONS

The majority of patients notified of a LSAE responded by getting tested for HCV, HIV and HBV, although there remains room for improvement. Potential exposure to a LSAE was associated with increased odds of subsequently using non-VA facilities, but the size and timing of the shift depended on the type of care.

Evaluating the implementation of a national disclosure policy for large-scale adverse events in an integrated health care system: identification of gaps and successes

Background

Many healthcare organizations have developed disclosure policies for large-scale adverse events, including the Veterans Health Administration (VA). This study evaluated VA’s national large-scale disclosure policy and identifies gaps and successes in its implementation.

Methods

Semi-structured qualitative interviews were conducted with leaders, hospital employees, and patients at nine sites to elicit their perceptions of recent large-scale adverse events notifications and the national disclosure policy. Data were coded using the constructs of the Consolidated Framework for Implementation Research (CFIR).

Results

We conducted 97 interviews. Insights included how to handle the communication of large-scale disclosures through multiple levels of a large healthcare organization and manage ongoing communications about the event with employees. Of the 5 CFIR constructs and 26 sub-constructs assessed, seven were prominent in interviews. Leaders and employees specifically mentioned key problem areas involving 1) networks and communications during disclosure, 2) organizational culture, 3) engagement of external change agents during disclosure, and 4) a need for reflecting on and evaluating the policy implementation and disclosure itself. Patients shared 5) preferences for personal outreach by phone in place of the current use of certified letters. All interviewees discussed 6) issues with execution and 7) costs of the disclosure.

Conclusions

CFIR analysis reveals key problem areas that need to be addresses during disclosure, including: timely communication patterns throughout the organization, establishing a supportive culture prior to implementation, using patient-approved, effective communications strategies during disclosures; providing follow-up support for employees and patients, and sharing lessons learned.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1903-7) contains supplementary material, which is available to authorized users.

Organizational factors associated with Health Care Provider (HCP) influenza campaigns in the Veterans health care system: a qualitative study

Background

It is an important goal to vaccinate a high proportion of health care providers (HCPs) against influenza, to prevent transmission to patients. Different aspects of how a HCP vaccination campaign is conducted may be linked to different vaccination rates. We sought to characterize organizational factors and practices that were associated with vaccination campaign success among six sites within the Veterans Health Administration, where receipt of flu-vaccination is voluntary.

Method

We conducted a total of 31 telephone interviews with key informants who were involved with HCP flu vaccination campaigns at three sites with high-vaccination rates and three sites with low-vaccination rates. We compared the organization and management of the six sites’ campaigns using constant comparison methods, characterzing themes and analyzing data iteratively.

Results

Three factors distinguished sites with high flu vaccination rates from those with low vaccination rates. 1) High levels of executive leadership involvement: demonstrating visible support, fostering new ideas, facilitating resources, and empowering flu team members; 2) Positive flu team characteristics: high levels of collaboration, sense of campaign ownership, sense of empowerment to meet challenges, and adequate time and staffing dedicated to the campaign; and 3) Several concrete strong practices emerged: advance planning, easy access to the vaccine, ability to track employee vaccination status, use of innovative methods to educate staff, and use of audit and feedback to promote targeted efforts to reach unvaccinated employees.

Conclusion

Successful HCP flu campaigns shared several recognizable characteristics, many of which are amenable to adoption or emulation by programs hoping to improve their vaccination rates.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1462-y) contains supplementary material, which is available to authorized users.

Are current screening protocols for chronic hepatitis B virus infection adequate?

Chronic hepatitis B virus (HBV) infection screening usually includes only HBV surface antigen (HBsAg) testing; HBV core and surface antibody (anti-HBc, anti-HBs) assays, indicating resolved infection and immunity, are not routinely performed. Yet, serum HBV DNA is measurable in approximately 10% of HBsAg-negative/anti-HBc-positive cases, representing occult HBV infection (OBI). Patient blood samples from 2 Veterans Affairs medical center look-back investigations were screened for HBV infection using HBsAg enzyme immunoassays. Supplementary testing included anti-HBc and anti-HBs enzyme immunoassays. For anti-HBc-positive samples, HBV DNA testing was performed. Background OBI prevalence was further estimated at these 2 facilities based on HBV serology testing results from 1999-2012. Finally, a literature review was performed to determine OBI prevalence in the published literature. Of 1887 HBsAg-negative cohort patients, 98 (5.2%) were anti-HBc positive/anti-HBs negative; and 175 (9.3%), anti-HBc positive/anti-HBs positive. Six of 273 were HBV DNA positive, representing 0.3% of the total tested and 2.2% who were anti-HBc positive/anti-HBs negative or anti-HBc positive/anti-HBs positive. Among 32,229 general population veterans at these 2 sites who had any HBV testing, 4/108 (3.7%) were HBV DNA positive, none of whom were part of the cohort. In 129 publications with HBsAg-negative patients, 1817/1,209,426 (0.15%) had OBI. However, excluding blood bank studies with greater than 1000 patients, the OBI rate increased to 1800/17,893 (10%). OBI is not rare and has implications for transmission and disease detection. HBsAg testing alone is insufficient for detecting all chronic HBV infections. These findings may impact blood donation, patient HBV screening, follow-up protocols for patients assumed to have cleared the infection, and initiation of immunosuppression in patients with distant or undetected HBV.

Building strong research partnerships between public health and researchers: a VA case study

We are in a new era of partner-based implementation research, and we need clear strategies for how to navigate this new era. Drawing on principles from community-based participatory research, the Clinical Public Health group of the Department of Veterans Affairs and the HIV/Hepatitis Quality Enhancement Research Initiative (HHQUERI) forged a longstanding partnership that has improved the care of Veterans with Human Immunodeficiency Virus (HIV) and Hepatitis C Virus. An exemplar HIV testing project epitomizes this partnership and is discussed in terms of the lessons learned as a result of our high level of collaboration around design, analysis, implementation, and dissemination across projects over the past several years. Lessons learned through this partnered testing program involve respecting different time horizons among the partners, identifying relevant research questions for both parties, designing flexible studies, engaging all partners throughout the research, and placing an emphasis on relationship building at all times. These lessons and strategies can benefit others conducting partner-based research both within the Veterans Health Administration (VA) and in other integrated healthcare systems.

Improving healthcare systems' disclosures of large-scale adverse events: a Department of Veterans Affairs leadership, policymaker, research and stakeholder partnership

BACKGROUND

The Department of Veterans Affairs (VA) mandates disclosure of large-scale adverse events to patients, even if risk of harm is not clearly present. Concerns about past disclosures warranted further examination of the impact of this policy.

OBJECTIVE

Through a collaborative partnership between VA leaders, policymakers, researchers and stakeholders, the objective was to empirically identify critical aspects of disclosure processes as a first step towards improving future disclosures.

DESIGN

Semi-structured interviews were conducted with participants at nine VA facilities where recent disclosures took place.

PARTICIPANTS

Ninety-seven stakeholders participated in the interviews: 38 employees, 28 leaders (from facilities, regions and national offices), 27 Veteran patients and family members, and four congressional staff members.

APPROACH

Facility and regional leaders were interviewed by telephone, followed by a two-day site visit where employees, patients and family members were interviewed face-to-face. National leaders and congressional staff also completed telephone interviews. Interviews were analyzed using rapid qualitative assessment processes. Themes were mapped to the stages of the Crisis and Emergency Risk Communication model: pre-crisis, initial event, maintenance, resolution and evaluation.

KEY RESULTS

Many areas for improvement during disclosure were identified, such as preparing facilities better (pre-crisis), creating rapid communications, modifying disclosure language, addressing perceptions of harm, reducing complexity, and seeking assistance from others (initial event), managing communication with other stakeholders (maintenance), minimizing effects on staff and improving trust (resolution), and addressing facilities' needs (evaluation).

CONCLUSIONS

Through the partnership, five recommendations to improve disclosures during each stage of communication have been widely disseminated throughout the VA using non-academic strategies. Some improvements have been made; other recommendations will be addressed through implementation of a large-scale adverse event disclosure toolkit. These toolkit strategies will enable leaders to provide timely and transparent information to patients and families, while reducing the burden on employees and the healthcare system during these events.