Crisis resolution teams (CRTs) offer brief, intensive home treatment for people experiencing mental health crisis. CRT implementation is highly variable; positive trial outcomes have not been reproduced in scaled-up CRT care.

To evaluate a 1-year programme to improve CRTs’ model fidelity in a non-masked, cluster-randomised trial (part of the Crisis team Optimisation and RElapse prevention (CORE) research programme, trial registration number: ISRCTN47185233).

Fifteen CRTs in England received an intervention, informed by the US Implementing Evidence-Based Practice project, involving support from a CRT facilitator, online implementation resources and regular team fidelity reviews. Ten control CRTs received no additional support. The primary outcome was patient satisfaction, measured by the Client Satisfaction Questionnaire (CSQ-8), completed by 15 patients per team at CRT discharge (n = 375). Secondary outcomes: CRT model fidelity, continuity of care, staff well-being, in-patient admissions and bed use and CRT readmissions were also evaluated.

All CRTs were retained in the trial. Median follow-up CSQ-8 score was 28 in each group: the adjusted average in the intervention group was higher than in the control group by 0.97 (95% CI −1.02 to 2.97) but this was not significant (P = 0.34). There were fewer in-patient admissions, lower in-patient bed use and better staff psychological health in intervention teams. Model fidelity rose in most intervention teams and was significantly higher than in control teams at follow-up. There were no significant effects for other outcomes.

The CRT service improvement programme did not achieve its primary aim of improving patient satisfaction. It showed some promise in improving CRT model fidelity and reducing acute in-patient admissions.

None.

Hospitalized patients placed in isolation due to a carrier state or infection with resistant or highly communicable organisms report higher rates of anxiety and loneliness and have fewer physician encounters, room entries, and vital sign records. We hypothesized that isolation status might adversely impact patient experience as reported through Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys, particularly regarding communication.

Retrospective analysis of HCAHPS survey results over 5 years.

A 1,165-bed, tertiary-care, academic medical center.

Patients on any type of isolation for at least 50% of their stay were the exposure group. Those never in isolation served as controls.

Multivariable logistic regression, adjusting for age, race, gender, payer, severity of illness, length of stay and clinical service were used to examine associations between isolation status and “top-box” experience scores. Dose response to increasing percentage of days in isolation was also analyzed.

Patients in isolation reported worse experience, primarily with staff responsiveness (help toileting 63% vs 51%; adjusted odds ratio [aOR], 0.77; P = .0009) and overall care (rate hospital 80% vs 73%; aOR, 0.78; P < .0001), but they reported similar experience in other domains. No dose-response effect was observed.

Isolated patients do not report adverse experience for most aspects of provider communication regarded to be among the most important elements for safety and quality of care. However, patients in isolation had worse experiences with staff responsiveness for time-sensitive needs. The absence of a dose-response effect suggests that isolation status may be a marker for other factors, such as illness severity. Regardless, hospitals should emphasize timely staff response for this population.

To determine which healthcare worker (HCW) roles and patient care activities are associated with acquisition of vancomycin-resistant Enterococcus (VRE) on HCW gloves or gowns after patient care, as a surrogate for transmission to other patients.

Prospective cohort study.

Medical and surgical intensive care units at a tertiary-care academic institution.

VRE-colonized patients on Contact Precautions and their HCWs.

Overall, 94 VRE-colonized patients and 469 HCW–patient interactions were observed. Research staff recorded patient care activities and cultured HCW gloves and gowns for VRE before doffing and exiting patient room.

VRE were isolated from 71 of 469 HCWs’ gloves or gowns (15%) following patient care. Occupational/physical therapists, patient care technicians, nurses, and physicians were more likely than environmental services workers and other HCWs to have contaminated gloves or gowns. Compared to touching the environment alone, the odds ratio (OR) for VRE contamination associated with touching both the patient (or objects in the immediate vicinity of the patient) and environment was 2.78 (95% confidence interval [CI], 0.99–0.77) and the OR associated with touching only the patient (or objects in the immediate vicinity) was 3.65 (95% CI, 1.17–11.41). Independent risk factors for transmission of VRE to HCWs were touching the patient’s skin (OR, 2.18; 95% CI, 1.15–4.13) and transferring the patient into or out of bed (OR, 2.66; 95% CI, 1.15–6.43).

Patient contact is a major risk factor for HCW contamination and subsequent transmission. Interventions should prioritize contact precautions and hand hygiene for HCWs whose activities involve touching the patient.

To determine the feasibility and value of developing a regional antibiogram for community hospitals.

Multicenter retrospective analysis of antibiograms.

A total of 20 community hospitals in central and eastern North Carolina and south central Virginia participated in this study.

We combined antibiogram data from participating hospitals for 13 clinically relevant gram-negative pathogen–antibiotic combinations. From this combined antibiogram, we developed a regional antibiogram based on the mean susceptibilities of the combined data.

We combined a total of 69,778 bacterial isolates across 13 clinically relevant gram-negative pathogen–antibiotic combinations (median for each combination, 1100; range, 174–27,428). Across all pathogen–antibiotic combinations, 69% of local susceptibility rates fell within 1 SD of the regional mean susceptibility rate, and 97% of local susceptibilities fell within 2 SD of the regional mean susceptibility rate. No individual hospital had >1 pathogen–antibiotic combination with a local susceptibility rate >2 SD of the regional mean susceptibility rate. All hospitals’ local susceptibility rates were within 2 SD of the regional mean susceptibility rate for low-prevalence pathogens (<500 isolates cumulative for the region).

Small community hospitals frequently cannot develop an accurate antibiogram due to a paucity of local data. A regional antibiogram is likely to provide clinically useful information to community hospitals for low-prevalence pathogens.

Infect Control Hosp Epidemiol 2018;39:718–722

To analyze whether electronically available comorbid conditions are risk factors for Centers for Disease Control and Prevention (CDC)-defined, hospital-onset Clostridium difficile infection (CDI) after controlling for antibiotic and gastric acid suppression therapy use.

Patients aged ≥18 years admitted to the University of Maryland Medical Center between November 7, 2015, and May 31, 2017.

Comorbid conditions were assessed using the Elixhauser comorbidity index. The Elixhauser comorbidity index and the comorbid condition components were calculated using the International Classification of Disease, Tenth Revision, Clinical Modification (ICD-10-CM) codes extracted from electronic medical records. Bivariate associations between CDI and potential covariates for multivariable regression, including antibiotic use, gastric acid suppression therapy use, as well as comorbid conditions, were estimated using log binomial multivariable regression.

After controlling for antibiotic use, age, proton-pump inhibitor use, and histamine-blocker use, the Elixhauser comorbidity index was a significant risk factor for predicting CDI. There was an increased risk of 1.26 (95% CI, 1.19–1.32) of having CDI for each additional Elixhauser point added to the total Elixhauser score.

An increase in Elixhauser score is associated with CDI. Our study and other studies have shown that comorbid conditions are important risk factors for CDI. Electronically available comorbid conditions and scores like the Elixhauser index should be considered for risk-adjustment of CDC CDI rates.

Infect Control Hosp Epidemiol 2018;39:297–301

To identify predictors of treatment for urinary tract infections (UTI) among patients undergoing total hip (THA) or knee (TKA) arthroplasties and to assess an intervention based on these predictors.

We conducted a retrospective cohort study of 200 consecutive patients undergoing THA/TKA between February 21, 2011, and June 30, 2011, to identify predictors of treatment for UTI and a prospective cohort study of 50 patients undergoing these procedures between May 21, 2012, and July 17, 2012, to assess the association of signs or symptoms and UTI treatment. We then conducted a before-and-after study to assess whether implementing an intervention affected the frequency of treatment for UTI before or after THA/TKA.

The orthopedics department of a university health center.

Patients undergoing THA or TKA.

Surgeons revised their UTI screening and treatment practices.

Positive leukocyte esterase (P<.0001; P<.0001) and urine white blood cell count>5 (P=.01; P=.01) were associated with preoperative or postoperative UTI treatment. In the prospective study, 12 patients (24%) had signs and symptoms consistent with UTI. The number of patients treated for presumed UTI decreased 80.2% after the surgeons changed their practices, and surgical site infection (SSI) rates, including prosthetic joint infections (PJIs), did not increase.

Urine leukocyte esterase and white blood cell count were the strongest predictors of treatment for UTI before or after THA/TKA. The intervention was associated with a significant decrease in treatment for UTI, and SSI/PJI rates did not increase.

Infect Control Hosp Epidemiol 2017;38:281–286

Converging evidence suggests that subjective cognitive concerns (SCC) are associated with biomarker evidence of Alzheimer's disease (AD) prior to objective clinical impairment. However, the sensitivity of SCC reports in early AD may be biased by demographic factors. Here, we sought to investigate whether age, education, and sex influence the relationship between SCC and amyloid (Aβ) burden.

In this cross-sectional study, we examined 252 clinically normal (CN) individuals (57.7% females) enrolled in the Harvard Aging Brain Study, ages 63–90 years (mean 73.7±6) with 6–20 years of education (mean 15.8±3). SCC was assessed as a composite score comprising three questionnaires. Cortical Aβ burden was assessed with Pittsburgh compound B positron emission tomography imaging. A series of linear regression models assessed the potential modifying role of demographic variables with respect to Aβ burden and SCC. A post-hoc mediation model was implemented to further understand the relationship between Aβ burden and SCC via their relationship with education.

Age (β = −0.84, p = 0.36) and sex (β = −0.55, p = 0.22) did not modify the relationship between SCC and Aβ burden. Fewer years of education was correlated with greater SCC (r = −0.12, p = 0.05), but the relationship between Aβ burden and SCC was stronger in those with more education (β = 1.16, p < 0.05). A partial mediation effect was found of Aβ burden on SCC via education (b = −0.12, 95% CI [−0.31, −0.02]).

These findings suggest that the association between SCC and Aβ burden becomes stronger with greater educational attainment. Thus, SCC may be of particular importance in highly educated CN individuals harboring amyloid pathology.

Social relationships can impact youths’ eating and physical activity behaviours; however, the best strategies for intervening in the social environment are unknown. The objectives of the present study were to provide in-depth information on the social roles that youths’ parents and friends play related to eating and physical activity behaviours and to explore the impact of other social relationships on youths’ eating and physical activity behaviours.

Convergent parallel mixed-methods design.

Low-income, African American, food desert neighbourhoods in Baltimore City, MD, USA.

Data were collected from 297 youths (53 % female, 91 % African American, mean age 12·3 (sd 1·5) years) using structured questionnaires and combined with in-depth interviews from thirty-eight youths (42 % female, 97 % African American, mean age 11·4 (sd 1·5) years) and ten parents (80 % female, 50 % single heads of house, 100 % African American).

Combined interpretation of the results found that parents and caregivers have multiple, dynamic roles influencing youths’ eating and physical activity behaviours, such as creating health-promoting rules, managing the home food environment and serving as a role model for physical activity. Other social relationships have specific, but limited roles. For example, friends served as partners for physical activity, aunts provided exposure to novel food experiences, and teachers and doctors provided information related to eating and physical activity.

Obesity prevention programmes should consider minority youths’ perceptions of social roles when designing interventions. Specifically, future research is needed to test the effectiveness of intervention strategies that enhance or expand the supportive roles played by social relationships.