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Exposure investigations are labor intensive and vulnerable to recall bias. We developed an algorithm to identify healthcare personnel (HCP) interactions from the electronic health record (EHR), and we evaluated its accuracy against conventional exposure investigations. The EHR algorithm identified every known transmission and used ranking to produce a manageable contact list.
Central-line–associated bloodstream infection (CLABSI) surveillance in home infusion therapy is necessary to track efforts to reduce infections, but a standardized, validated, and feasible definition is lacking. We tested the validity of a home-infusion CLABSI surveillance definition and the feasibility and acceptability of its implementation.
Mixed-methods study including validation of CLABSI cases and semistructured interviews with staff applying these approaches.
This study was conducted in 5 large home-infusion agencies in a CLABSI prevention collaborative across 14 states and the District of Columbia.
From May 2021 to May 2022, agencies implemented a home-infusion CLABSI surveillance definition, using 3 approaches to secondary bloodstream infections (BSIs): National Healthcare Safety Program (NHSN) criteria, modified NHSN criteria (only applying the 4 most common NHSN-defined secondary BSIs), and all home-infusion–onset bacteremia (HiOB). Data on all positive blood cultures were sent to an infection preventionist for validation. Surveillance staff underwent semistructured interviews focused on their perceptions of the definition 1 and 3–4 months after implementation.
Interrater reliability scores overall ranged from κ = 0.65 for the modified NHSN criteria to κ = 0.68 for the NHSN criteria to κ = 0.72 for the HiOB criteria. For the NHSN criteria, the agency-determined rate was 0.21 per 1,000 central-line (CL) days, and the validator-determined rate was 0.20 per 1,000 CL days. Overall, implementing a standardized definition was thought to be a positive change that would be generalizable and feasible though time-consuming and labor intensive.
The home-infusion CLABSI surveillance definition was valid and feasible to implement.
Access to patient information may affect how home-infusion surveillance staff identify central-line–associated bloodstream infections (CLABSIs). We characterized information hazards in home-infusion CLABSI surveillance and identified possible strategies to mitigate information hazards.
Qualitative study using semistructured interviews.
Setting and participants:
The study included 21 clinical staff members involved in CLABSI surveillance at 5 large home-infusion agencies covering 13 states and the District of Columbia. Methods: Interviews were conducted by 1 researcher. Transcripts were coded by 2 researchers; consensus was reached by discussion.
Data revealed the following barriers: information overload, information underload, information scatter, information conflict, and erroneous information. Respondents identified 5 strategies to mitigate information chaos: (1) engage information technology in developing reports; (2) develop streamlined processes for acquiring and sharing data among staff; (3) enable staff access to hospital electronic health records; (4) use a single, validated, home-infusion CLABSI surveillance definition; and (5) develop relationships between home-infusion surveillance staff and inpatient healthcare workers.
Information chaos occurs in home-infusion CLABSI surveillance and may affect the development of accurate CLABSI rates in home-infusion therapy. Implementing strategies to minimize information chaos will enhance intra- and interteam collaborations in addition to improving patient-related outcomes.
Physical distancing among healthcare workers (HCWs) is an essential strategy in preventing HCW-to-HCWs transmission of severe acute respiratory coronavirus virus 2 (SARS-CoV-2).
To understand barriers to physical distancing among HCWs on an inpatient unit and identify strategies for improvement.
Qualitative study including observations and semistructured interviews conducted over 3 months.
A non–COVID-19 adult general medical unit in an academic tertiary-care hospital.
HCWs based on the unit.
We performed a qualitative study in which we (1) observed HCW activities and proximity to each other on the unit during weekday shifts July–October 2020 and (2) conducted semi-structured interviews of HCWs to understand their experiences with and perspectives of physical distancing in the hospital. Qualitative data were coded based on a human-factors engineering model.
We completed 25 hours of observations and 20 HCW interviews. High-risk interactions often occurred during handoffs of care at shift changes and patient rounds, when HCWs gathered regularly in close proximity for at least 15 minutes. Identified barriers included spacing and availability of computers, the need to communicate confidential patient information, and the desire to maintain relationships at work.
Physical distancing can be improved in hospitals by restructuring computer workstations, work rooms, and break rooms; applying visible cognitive aids; adapting shift times; and supporting rounds and meetings with virtual conferencing. Additional strategies to promote staff adherence to physical distancing include rewarding positive behaviors, having peer leaders model physical distancing, and encouraging additional safe avenues for social connection at a safe distance.
Background: Patients with a penicillin/aminopenicillin (PCN) allergy label are more likely to receive non–β-lactam antibiotics and to experience worse clinical outcomes. Given that nurses are often first to interact with patients, we pilot tested a nurse-driven quality improvement initiative to improve PCN allergy documentation and increase β-lactam use. Methods: We conducted a before-and-after study on a labor and delivery unit at The Johns Hopkins Hospital (JHH) from May 2018 to September 2019. Patients aged 18 years with a PCN allergy were included. The intervention included (1) the use of an algorithm developed by the antimicrobial stewardship team to assist nurses in obtaining accurate PCN allergy histories (Fig. 1), (2) identification of a nurse champion to facilitate implementation of the algorithm, and (3) in-person education by a stewardship physician regarding the importance and impact of adequate PCN allergy documentation on clinical outcomes. Readmissions were counted as separate encounters. The primary outcome was improved allergy documentation (either fewer blank documentations, nonspecified rash reactions, drug intolerance documentations (eg, isolated nausea), documentation of signs and symptoms of anaphylaxis not specified as such). The secondary outcome was β-lactam use. Categorical variables were compared using the 2 test and continuous variables were compared with the Student t test. Severe allergic reactions were defined as anaphylaxis, severe skin reactions (eg, Stevens-Johnson syndrome), and organ involvement (eg, hepatitis). Results: Overall, 382 patient admissions were included, 305 in the preintervention (May 2018 to May 2019) and 77 in the postintervention period (June 2019 to September 2019). Mean age and length-of-stay were 30 years and 4 days, respectively, for both periods. The proportion of admitted patients with a PCN allergy label was 8% and 7% for pre- and postintervention periods. Documentation findings in the pre- and postintervention periods respectively were as follows: blank documentation 11% and 12% (P = .89), documentation of specified rashes 0.6% and 1.3% (P = .56), documentation of drug intolerance 11% and 8% (P = .39), documentation of reactions that were indicative of anaphylaxis but not documented specifically as anaphylaxis 8% and 13% (P = .20). Among patients with a documented PCN allergy who received antibiotics, 83 of 177 (47%) and 27 of 43 (63%) received β-lactams (P = .01) in the pre- and postintervention periods, with cefazolin being the antibiotic most commonly used in both periods. Conclusions: Nursing education and an algorithm did not result in significant improvements in PCN allergy documentation in the 3 months after implementation. More data collection is planned to assess the impact of the intervention.
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