Background: The purpose of this study was to find out the relationship between appropriateness of antibiotic prescription and clinical outcomes in patients with community-acquired acute pyelonephritis (CA-APN). Methods: A multicenter prospective cohort study was performed in 8 Korean hospitals from September 2017 to August 2018. All hospitalized patients aged ≥19 years diagnosed with CA-APN at admission were recruited. Pregnant women and patients with insufficient data were excluded. In addition, patients with prolonged hospitalization due to medical problems that were not associated with APN treatment were excluded. The appropriateness of empirical and definitive antibiotics was divided into “optimal,” “suboptimal,” and “inappropriate,” and optimal and suboptimal were regarded as appropriate antibiotic use. The standard for the classification of empirical antibiotics was defined reflecting the Korean national guideline for the antibiotic use in urinary tract infection 2018. The standards for the classification of definitive antibiotics were defined according to the result of in vitro susceptibility tests of causative organisms. Clinical outcomes including clinical failure (mortality or recurrence) rate, hospitalization days, and medical costs were compared between patients who were prescribed antibiotics appropriately and those who were prescribed them inappropriately. Results: In total, 397 and 318 patients were eligible for the analysis of the appropriateness of empirical and definitive antibiotics, respectively. Of these, 10 (2.5%) and 18 (5.7%) were inappropriately prescribed empirical and definitive antibiotics, respectively, and 28 (8.8%) were prescribed either empirical or definitive antibiotics inappropriately. Patients who were prescribed empirical antibiotics appropriately showed a lower mortality rate (0 vs 10%; P = .025), shorter hospitalization days (9 vs 12.5 days; P = .014), and lower medical costs (US$2,333 vs US$4,531; P = .007) compared to those who were prescribed empirical antibiotics “inappropriately.” In comparison, we detected no significant differences in clinical outcomes between patients who were prescribed definitive antibiotics appropriately and those who were prescribed definitive antibiotics inappropriately. Patients who were prescribed both empirical and definitive antibiotics appropriately showed a lower clinical failure rate (0.3 vs 7.1%; P = .021) and shorter hospitalization days (9 vs 10.5 days; P = .041) compared to those who were prescribed either empirical or definitive antibiotics inappropriately. Conclusions: Appropriate use of antibiotics leads patients with CA-APN to better clinical outcomes including fewer hospitalization days and lower medical costs.

Funding: No

Disclosures: None

Table 1.

Table 2.

The coronavirus disease 2019 (COVID-19) pandemic has influenced current infection control practices in the healthcare setting. We surveyed 74 hospitals in Japan regarding changes in their infection control practices or policies between 2020 and the present. We found that the current hospital infection control practices for COVID-19 are adequate.

Background: Although there has been a significant reduction in central-line–associated bloodstream infection (CLABSI) rates in the past decade with the implementation of evidence-based practices, an estimated 30,100 CLABSI occur each year in acute-care facilities. CLABSIs are associated with increased length of stay, cost, morbidity, and mortality, and they are preventable. In this study, we assessed the impact of a multidisciplinary team approach on CLABSI rates at a 319-bed teaching hospital in northwestern Ohio. Methods: In this before-and-after retrospective study, we compared the CLABSI rate per 1,000 central-line days, standardized infection ratio (SIR), and standardized utilization ratio (SUR) in the preintervention period (January 1, 2016, to December 31, 2018) to those of the intervention period (January 1, 2019, to December 31, 2020). Despite hospital-wide nursing education focusing on central-line maintenance in 2017, our SIR and SUR remained above the national benchmark. Starting in August 2018, we began to focus on insertion practices and physician education. An infection preventionist observed resident central-line insertion training and noted that there was no emphasis on infection prevention measures. There was a best practice knowledge gap. Thus, the indications for central-line use were updated, the insertion checklist was standardized, and the vascular access policy was revised to limit femoral and internal jugular vein use. Infection prevention training was provided to all providers involved in central-line insertions. Nurses were tasked with observing insertion of every central line and stopping the procedure if there is was an observed break in sterile technique. A central-line report listing indications and duration was developed and was sent to the nursing directors who assessed daily need with providers and prompted removal of unnecessary lines. The infection prevention medical director provided CLABSI prevention education to providers. Results: The CLABSI rate per 1,000 central-line days decreased from 0.90 in the preintervention period to 0.34 in the postintervention period, resulting in a 62% reduction in CLABSI rate. The SIR decreased from 0.886 to 0.323 (p-value <0.05), yielding a 64% reduction. The SUR also decreased from 1.156 to 0.874 (p-value <0.001) with a 24% reduction. Conclusion: A multidisciplinary team-approach with emphasis on standardized insertion checklist to ensure adherence to sterile technique and prompt removal of unnecessary central lines, and physician insertion training focusing on IP practices may potentially reduce CLABSI rates.

Funding: No

Disclosures: None

Group Name: Working Group on Neonatal Infectious Diseases of the Section of Neonatology of the Dutch Paediatric Society

Background: Central-line–associated bloodstream infections (CLABSIs) are a main focus of infection prevention and control initiatives in neonatal care. Standardized surveillance of neonatal CLABSI enables intra- and interfacility comparisons, which can contribute to quality improvement. To date, there is no national registration system for CLABSI in neonatal care in the Netherlands. Across neonatal intensive care units (NICUs), several different sets of CLABSI criteria and surveillance methods are used for local monitoring of CLABSI incidence rates. To achieve standardized CLABSI surveillance, we conducted a consensus procedure with regard to nationwide neonatal CLABSI surveillance criteria. Method: A modified Delphi consensus procedure for the development of nationwide neonatal CLABSI surveillance criteria was performed between January 2016 and January 2017 in the Netherlands. An expert panel was formed by members of the Working Group on Neonatal Infectious Diseases of the Section of Neonatology of the Dutch Paediatric Society. The consensus procedure consisted of 3 expert panel rounds. Figure 1 shows a detailed description of the consensus procedure. Result: The expert panel achieved consensus on Dutch neonatal CLABSI surveillance criteria, which are summarized in Figure 2. Neonatal CLABSI is defined as a bloodstream infection occurring >72 hours after birth, associated with an indwelling central venous or arterial line and laboratory confirmed by 1 or more blood cultures. In addition, the blood culture finding should not be related to an infection at another site and one of the following criteria can be applied: (1) a bacterial or fungal pathogen is identified from 1 or more blood cultures; (2) the patient has clinical symptoms of sepsis and (2A) a common commensal is identified in 2 separate blood cultures or (2B) a common commensal is identified by 1 blood culture and C-reactive protein (CRP) level is >10 mg/L in the first 36 hours following blood culture collection. Conclusion: The newly developed Dutch neonatal CLABSI surveillance criteria are concise, are specific to the neonatal population, and comply with a single blood-culture policy in actual neonatal clinical practice. International agreement upon neonatal CLABSI surveillance criteria is needed to identify best practices for infection prevention and control.

Funding: No

Disclosures: None

Figure 1.

Figure 2.

In 829 hospital encounters for patients with COVID-19, 73.2% included orders for antibiotics; however, only 1.8% had respiratory cultures during the first 3 hospital days isolating bacteria. Case–control analysis of 30 patients and 96 controls found that each antibiotic day increased the risk of isolating multidrug-resistant gram-negative bacteria (MDR-GNB) in respiratory cultures by 6.5%.

Group Name: CDC Prevention Epicenters Program Background: Reverse-transcriptase polymerase chain reaction (RT-PCR) tests are the reference standard for diagnosing SARS-CoV-2 infection, but false positives can occur and viral RNA may persist for weeks-to-months following recovery. Isolating such patients increases pressure on limited hospital resources and may impede care. Therefore, we quantified the percentage of patients who tested positive by RT-PCR yet were unlikely to be infectious and could be released from isolation. Methods: We prospectively identified all adults hospitalized at Brigham and Women’s Hospital (Boston, MA) who tested positive for SARS-CoV-2 by RT-PCR (primarily Hologic Panther Fusion or Cepheid Xpert platforms) between December 24, 2020, and January 24, 2021. Each case was assessed by infection control staff for possible discontinuation of isolation using an algorithm that incorporated the patient’s prior history of COVID-19, current symptoms, RT-PCR cycle threshold (Ct) values, repeat RT-PCR testing at least 24 hours later, and SARS-CoV-2 serologies (Figure 1). Results: Overall, 246 hospitalized patients (median age, 66 years [interquartile range, 50–74]; 131 [53.3%] male) tested positive for SARS-CoV-2 by RT-PCR during the study period. Of these, 201 (81.7%) were deemed new diagnoses of active disease on the basis of low Ct values and/or progressive symptoms. Moreover, 44 patients (17.9%) were deemed noninfectious: 35 (14.2%) had prior known resolved infections (n = 21) or unknown prior infection but positive serology (n = 14), high Ct values on initial testing, and negative or stably high Ct values on repeat testing. Also, 5 (2.0%) had recent infection but >10 days had passed since symptom onset and they were clinically improving. In addition, 4 (1.6%) results were deemed false positives based on lack of symptoms and at least 1 negative repeat RT-PCR test (Figure 2). One patient was asymptomatic with Ct value <35 but was discharged before further testing could be obtained. Among the 44 noninfectious patients, isolation was discontinued a median of 3 days (IQR, 2–4) after the first positive test. We did not identify any healthcare worker infections attributable to early discontinuation of isolation in these patients. Conclusions: During the winter COVID-19 second surge in Massachusetts, nearly 1 in 5 hospitalized patients who tested positive for SARS-CoV-2 by RT-PCR were deemed noninfectious and eligible for discontinuation of precautions. Most of these cases were consistent with residual RNA from prior known or undiagnosed infections. Active assessments of SARS-CoV-2 RT-PCR tests by infection control practitioners using clinical data, Ct values, repeat tests, and serologies can safely validate the release many patients from isolation and thereby conserve resources and facilitate patient care.

Funding: No

Disclosures: None

Figure 1.

Figure 2.

Background: During the COVID-19 pandemic, public-health decision makers have increasingly relied on hospitalization forecasts that are routinely provided, accurate, and based on timely input data to inform pandemic planning. In North Carolina, we adapted an existing agent-based model (ABM) to produce 30-day hospitalization forecasts of COVID-19 and non–COVID-19 hospitalizations for use by public-health decision makers. We sought to continually improve model speed and accuracy during forecasting. Methods: The geospatially explicit ABM included movement of agents (ie, patients) among 104 short-term acute-care hospitals, 10 long-term acute-care hospitals, 421 licensed nursing homes, and the community in North Carolina. Agents were based on a synthetic population of North Carolina residents (ie, >10.4 million agents). We assigned SARS-CoV-2 infections to agents according to county-level susceptible, exposed, infectious, recovered (SEIR) models informed by reported COVID-19 cases by county. Agents’ COVID-19 severity and probability of hospitalization were determined using agent-specific characteristics (eg, age, comorbidities). During May 2020–December 2020, we produced weekly 30-day forecasts of intensive care unit (ICU) and non-ICU bed occupancy for COVID-19 agents and non–COVID-19 agents statewide and by region under a range of SARS-CoV-2 effective reproduction numbers. During the reporting period, we identified optimizations for faster results turnaround. We evaluated the incorporation of real-time hospital-level occupancy data at model initialization on forecast accuracy using mean absolute percent error (MAPE). Results: During May 2020–December 2020, we provided 31 weekly reports of 30-day hospitalization forecasts with a 1-day turnaround time. Reports included (1) raw and smoothed 7-day average values for 42 model output variables; (2) static visuals of ICU and non-ICU bed demand and capacity; and (3) an interactive Tableau workbook of hospital demand variables. Identifying code efficiencies reduced a single model runtime from ~100 seconds to 28 seconds. The use of cloud computing reduced simulation runtime from ~20 hours to 15 minutes. Across forecasts, the average MAPEs were 21.6% and 7.1% for ICU and non-ICU bed demand, respectively. By incorporating hospital-level occupancy data, we reduced the average MAPE to 6.5% for ICU bed demand and 3.9% for non-ICU bed demand, indicating improved accuracy. Conclusions: We adapted an ABM and continually improved it during COVID-19 forecasting by optimizing code and computing resources and including real-time hospital-level occupancy data. Planned SEIR model updates for enhanced forecasts include the addition of compartments for undocumented infections and recoveries as well as permission of reinfection from recovered compartments.

Funding: No

Disclosures: None

A policy mandating the completion of an online learning module for healthcare workers intending to decline influenza immunization was associated with a nearly 25% relative increase in immunization and significant reduction in healthcare-associated influenza. In the absence of mandatory vaccination, this model may help to augment severe acute respiratory coronavirus virus 2 (SARS-CoV-2) vaccine efforts.

Surgical site infections (SSIs) are associated with readmissions, reoperations, increased cost of care, and overall morbidity and mortality risk. The National Healthcare Safety Network (NHSN) and the National Surgical Quality Improvement Program (NSQIP) have developed an array of metrics to monitor hospital-acquired complications. The only metric collected by both is SSI, but performance as benchmarked against peer hospitals is often discordant between the 2 systems. In this commentary, we outline the differences between these 2 surveillance systems as they relate to this potential for discordance.

Background: In 2019, according to the Centers for Disease Control and Prevention, carbapenem-resistant Enterobacteriaceae (CRE), had cost the lives of >35,000 patients, particularly the most virulent plasmid-mediated New Delhi metallo-β-lactamase (NDM). Although healthcare systems normally have strict surveillance and infection control measures for CRE, the rapid emergence of novel SAR-CoV-2 and COVID-19 led to a shortage of personal protective equipment (PPE) and medical supplies. As a result, routine infection practices, such as contact precautions, were violated. Studies have shown this depletion and shift in resources compromised the control of infections such CRE leading to rising horizontal transmission. Method: A retrospective study was conducted at a tertiary healthcare system in Detroit, Michigan, to determine the impact of PPE shortages during the COVID-19 pandemic on NDM infection rates. The following periods were established during 2020 based on PPE availability: (1) pre-PPE shortage (January–June), (2) PPE shortage (July–October), and (3) post-PPE shortage (November–December). Rates of NDM per 10,000 patient days were compared between periods using the Wilcoxon signed rank-sum test. Isolates were confirmed resistant by NDM by molecular typing performed by the Michigan State Health Department. Patient characteristics were gathered by medical chart review and patient interviews by telephone. Results: Overall, the average rate of NDM infections was 1.82 ±1.5 per 10,000 patient days. Rates during the PPE shortage were significantly higher, averaging 3.6 ±1.1 cases per 10,000 patient days (P = .02). During this time, several infections occurred within patients on the same unit and/or patients with same treating team, suggesting possible horizontal transmission. Once PPE stock was replenished and isolation practices were reinstated, NDM infection rates decreased to 0.77 ±1.1 per 10,000 patient days. Conclusion: Control of CRE requires strategic planning with active surveillance, antimicrobial constructs, and infection control measures. The study illustrates that in times of crisis, such as the COVID-19 pandemic, the burden of effective infection control requires much more multidisciplinary efforts to prevent unintentional lapses in patient safety. A swift response by the state and local health departments at a tertiary-care healthcare center conveyed a positive mitigation of the highest clinical threats and decreased horizontal transmission of disease.

Funding: No

Disclosures: None

Figure 1.

Background: Coronavirus disease 2019 (COVID-19) has demonstrated a variety of presentations and clinical complications, among them coinfection of pneumonia with the mold Aspergillus spp. Patients at risk for invasive disease include transplant recipients and those with prolonged neutropenia, immune disorders, cystic fibrosis, and steroid use. There have been recent descriptions of coronavirus disease–associated pulmonary aspergillosis (CAPA). An outbreak investigation into a cluster of Aspergillus fumigatus infections in a health system intensive care unit uncovered a community-onset (CO) increase in CAPA. Methods: A multidisciplinary outbreak investigation was conducted evaluating sources of contamination, completion of construction projects, and changes in clinical processes. Retrospective chart review was done for the prior 18 months and incidence density rates for Aspergillus infections from June 2019 through December 2020 were calculated per 10,000 patient days, stratified by unit, specimen source, and coinfection with COVID-19. Data were linked with all positive and negative COVID-19 tests performed by the health system’s regional laboratory from March to December 2020. Healthcare-onset (HO) classification was based on infections identified ≥7 days after admission. Statistical analysis was calculated with significance at p < 0.05. Results: Over the last 18 months, 82 patients were identified positive with Aspergillus cultures; of which 10 (12%) met CAPA definitions. Aspergillus fumigatus was the most common species and accounted for 62% of samples, followed by Aspergillus niger (17%). Median rates of HO Aspergillosis were 0.45 cases per 10,000 patient days, whereas the median total rates of infection were 1.97 cases per 10,000 patient days. Rates of CAPA coincided with COVID-19 hospitalization rates. In the spring and fall, surges of COVID-19, the rate ratio of CAPA to COVID hospitalized infections per 10,000 patient days, ranged from 0.006 to 0.015. Once CAPA infections were adjusted for, rates of CO Aspergillus remained high, whereas HO cases suggested baseline acquisition. Conclusion: This study outlines rates of CO aspergillosis as well as CAPA rates coinciding with the healthcare system’s spring and fall surges of COVID-19 hospitalizations. Despite the determination that this was not a hospital-acquired cluster, the investigation revealed some areas for opportunity in construction processes along with maintaining coverage of all patient supplies to reduce the risk of contamination.

Funding: No

Disclosures: None

Figure 1.

Antimicrobial prescribing and the associated discipline of antimicrobial stewardship have inherent ethical and moral dimensions. We contend that the explicit, formal application of ethical principles and frameworks can strengthen and further justify the value of antimicrobial stewardship programs and their work. To illustrate the value of this process, we highlight 3 ethical scenarios that antimicrobial stewardship programs regularly encounter at the prescriber, institutional, and societal levels, and we analyze these scenarios using the Beauchamp and Childress biomedical ethics framework.

Background: COVID-19 in hospitalized patients may be the result of community acquisition or in-hospital transmission. Molecular epidemiology can help confirm hospital COVID-19 transmission and outbreaks. We describe large COVID-19 clusters identified in our hospital and apply molecular epidemiology to confirm outbreaks. Methods: The University of Iowa Hospitals and Clinics is an 811-bed academic medical center. We identified large clusters involving patients with hospital onset COVID-19 detected during March–October 2020. Large clusters included ≥10 individuals (patients, visitors, or HCWs) with a laboratory confirmed COVID-19 diagnosis (RT-PCR) and an epidemiologic link. Epidemiologic links were defined as hospitalization, work, or visiting in the same unit during the incubation or infectious period for the index case. Hospital onset was defined as a COVID-19 diagnosis ≥14 days from admission date. Admission screening has been conducted since May 2020 and serial testing (every 5 days) since July 2020. Nasopharyngeal swab specimens were retrieved for viral whole-genome sequencing (WGS). Cluster patients with a pairwise difference in ≤5 mutations were considered part of an outbreak. WGS was performed using Oxford Nanopore Technology and protocols from the ARTIC network. Results: We identified 2 large clusters involving patients with hospital-onset COVID-19. Cluster 1: 2 hospital-onset cases were identified in a medical-surgical unit in June 2020. Source and contact tracing revealed 4 additional patients, 1 visitor, and 13 employees with COVID-19. Median age for patients was 62 (range, 38–79), and all were male. In total, 17 samples (6 patients, 1 visitor, and 10 HCWs) were available for WGS. Cluster 2: A hospital-onset case was identified via serial testing in a non–COVID-19 intensive care unit in September 2020. Source investigation, contact tracing, and serial testing revealed 3 additional patients, and 8 HCWs. One HCW also had a community exposure. Patient median age was 60 years (range, 48–68) and all were male. In total, 11 samples (4 patients and 7 HCWs) were sequenced. Using WGS, cluster 1 was confirmed to be an outbreak: WGS showed 0–5 mutations in between samples. Cluster 2 was also an outbreak: WGS showed less diversity (0–3 mutations) and ruled out the HCW with a community exposure (20 mutations of difference). Conclusion: Whole-genome sequencing confirmed the outbreaks identified using classic epidemiologic methods. Serial testing allowed for early outbreak detection. Early outbreak detection and implementation of control measures may decrease outbreak size and genetic diversity.

Funding: No

Disclosures: None

Figure 1.

Background: The approval of the first SARS-COV-2 vaccines for COVID-19 were accompanied by unprecedented efforts to provide vaccination to healthcare workers and first responders. More information about vaccine uptake in this group is needed to better refine and target educational messaging. Methods: HCA Healthcare used federal guidance and internal experience to create a systemwide mass vaccination strategy. A closed point-of-dispensing (POD) model was developed and implemented. The previously developed enterprise-wide emergency operations strategy was adapted and implemented, which allowed for rapid development of communications and operational processes. A tiering strategy based on recommendations from the National Academies was used in conjunction with human resources data to determine vaccine eligibility for the first phase of vaccination. A comprehensive data and reporting strategy was built to connect human resources and vaccine consent data for tracking vaccination rates across the system. Results: Vaccination of employed and affiliated colleagues began December 15, 2020, and was made available based on state-level release of tiers. Within the first 6 weeks, in total, 203,544 individuals were eligible for vaccine based on these criteria. Of these, 181,282 (89.1%) consented to and received vaccine, 19,788 (9.7%) declined, and 2,474 (1.2%) indicated that they had already been vaccinated. Of those eligible, the highest acceptance of vaccine was among the job codes of specialists and professionals (n = 7,914 total, 100% consent), providers (n = 23,335, 99.6%,), and physicians (n = 3,218, 98.4%). Vaccine was most likely to be declined among job codes of clerical and other administrative (n = 12,889 total, 80.1% consent), clinical specialists and professionals (n = 22,853, 81.0%,) and aides, orderlies and technicians (n = 17,803, 82.6%,). Registered nurses made up the largest eligible population (n = 56,793), and 89.5% of those eligible consented to receive vaccination. Average age among those who consented was slightly older (48.3 years) than those that declined (44.7 years), as was length of employment tenure (6.9 vs 5.0 years). Conclusion: A large-scale, closed POD, mass vaccination program was able to vaccinate nearly 200,000 healthcare workers for SARS-CoV-2 in 6 weeks. This program was implemented in acute-care sites across 20 different US states, and it was able to meet the various state-level requirements for management of processes, product, and required reporting. The development of a standardized strategy and custom, centralized monitoring and reporting facilitated insight into the characteristics of early vaccine adopters versus those who decline vaccination. These data can aid in the refining and targeting of educational materials and messaging about the SARS-CoV-2 vaccine.

Funding: No

Disclosures: None

Recognition of antibiotic stewardship programs (ASPs) as essential components of quality health care has dramatically increased in the past decade. The value of ASPs has been further reinforced during the coronavirus disease 2019 (COVID-19) pandemic because these programs were instrumental in monitoring antibiotic use, assessing emerging COVID-19 therapies, and coordinating implementation of monoclonal antibody infusions and vaccinations. ASPs are now required across hospital settings as a condition of participation for the Centers for Medicare and Medicaid Services and for accreditation by The Joint Commission. In the 2019 National Healthcare Safety Network annual survey, almost 89% of hospitals met the Seven Core Elements for ASPs defined by the Centers for Disease Control and Prevention. More than 61% of programs were co-led by physicians and pharmacists, evidence of the leadership role of both groups. ASPs employ many strategies to improve prescribing. Core interventions of preauthorization for targeted antibiotics, prospective audit and feedback, and development of local treatment guidelines have been supplemented with numerous emerging strategies. Diagnostic stewardship, optimizing duration of therapy, promoting appropriate conversion from intravenous to oral therapy, monitoring at transitions of care and hospital discharge, implementing stewardship initiatives in the outpatient setting, and increasing use of telemedicine are approaches being adopted across hospital settings. As a core function for medical facilities, ASP leaders must ensure that antibiotic use and ASP interventions promote optimal and equitable care. The urgency of success becomes progressively greater as complex patterns of antibiotic resistance continue to emerge, exacerbated by unpredictable factors such as a worldwide pandemic.

Background: High-level disinfection (HLD) of semicritical instruments in a multispecialty ambulatory care network has the potential for increased risk due to the decentralized instrument reprocessing and lack of a sterile processing department. Attention to HLD practices is an important part of device-borne outbreak prevention. Method: An HLD database was developed to identify specific departments and locations where HLD occurred across a 30-medical practice ambulatory care network in eastern Massachusetts, which included otolaryngology, urology, endoscopy, and obstetrics/gynecology departments. Based on qualitative feedback from managers and reprocessing staff, this database centralized information that included the supply inventory including manufacturer and model information, HLD methodology, standard work, and listing of competency evaluations. The infection control team then led audits to directly observe compliance with instrument reprocessing and a monthly-driven HLD calendar was developed to enforce annual competencies. Result: The results of the audits demonstrated variability across departments with gaps in precleaning, transportation of used instruments, the dilution of enzymatic cleaner, and maintenance of quality control logs. Given the uniqueness of shape and size of various ambulatory locations, proper storage and separation between clean and dirty spaces were common pitfalls. Auditing also revealed different levels of staff understanding of standard work and variable inventory management. Centralized education sessions held jointly by the infection control team and various manufacturers for the reprocessing staff helped to create and reinforce best practices. Conclusion: Decentralized HLD that occurs across multiple ambulatory care sites led to gaps in instrument reprocessing and unique challenges due to variable geography of sites, physical space constraints, and an independent approach to procuring medical supplies. Through the auditing and feedback of all areas that perform HLD, an effective and sustainable strategy was created to ensure practice improvement. Streamlining standard work, seeking direct input from frontline staff, and collective educational events were critical to our success in the ambulatory setting.

Funding: No

Disclosures: None