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Background:Clostridioides difficile infection (CDI) is the most common healthcare-associated infection (HAI) in the United States. Healthcare facility-onset (HO) CDI reporting is a laboratory-identified (LabID) event and does not rely on symptoms. Inappropriate testing can lead to overdiagnosis in patients who are colonized, especially in those receiving promotility agents. Approximately 45% of HO-CDI cases at our institution occurred in the setting of laxative use in 2019. We assessed the effectiveness of an electronic medical record (EMR) “hard stop” in reducing inappropriate CDI testing and its impact on HO-CDI rates. Methods: We conducted a pre–post quasi-experimental retrospective study comparing test order rates per 1,000 patient days, CDI rate per 1,000 patient days, and standardized infection ratio (SIR) in the preintervention period (January 2018–December 2019) to the intervention period (April 2020–September 2021), at a 5-hospital healthcare system in southeastern Michigan. In February 2020, we implemented a hard stop in Epic that was triggered >3 days after admission for the following criteria: patients <1 year of age; repeated testing within 7 days, and receipt of promotility agents within 48 hours. After discontinuing the promotility agents for at least 48 hours, providers were allowed to place an order if diarrhea persisted. The medical director of infection prevention and control or designee had the ability to override the hard stop when deemed necessary after reviewing the case upon provider request. All orders expired after 24 hours if a specimen was not collected. We retrospectively reviewed the number of overrides after the intervention to determine the positivity rate. Results: Our CDI rates per 1,000 patient days were 3.21 in the preintervention period and 1.48 in the postintervention period, a 54% reduction (Fig. 1). The test order rates were 119.4 in the preintervention period and 87.7 in the postintervention period, a 26.5% reduction (Fig. 2). The SIR decreased from 0.542 in the preintervention period to 0.361 in the postintervention period, a 33% reduction (95% CI, 0.54–0.82; P = .0001). After the intervention, 299 patients had an override. Of these, samples from 218 patients (72.9%) were negative, 50 orders (16.7%) were cancelled, and 28 samples (9%) were positive. Conclusions: Diagnostic stewardship, utilizing an electronic hard stop, was effective in reducing inappropriate C. difficile testing in the setting of promotility agents without delaying diagnosis of HO-CDI. This strategy combined with standard best practices can significantly reduce HO-CDI rates.
Funding: None
Disclosures: None
New care paradigms are required to enable remote life-saving interventions (RLSIs) in extreme environments such as disaster settings. Informatics may assist through just-in-time expert remote-telementoring (RTM) or video-modelling (VM). Currently, RTM relies on real-time communication that may not be reliable in some locations, especially if communications fail. Neither technique has been extensively developed however, and both may be required to be performed by inexperienced providers to save lives. A pilot comparison was thus conducted.
Procedure-naïve Search-and-Rescue Technicians (SAR-Techs) performed a tube-thoracostomy (TT) on a surgical simulator, randomly allocated to RTM or VM. The VM group watched a pre-prepared video illustrating TT immediately prior, while the RTM group were remotely guided by an expert in real-time. Standard outcomes included success, safety, and tube-security for the TT procedure.
There were no differences in experience between the groups. Of the 13 SAR-Techs randomized to VM, 12/13 (92%) placed the TT successfully, safely, and secured it properly, while 100% (11/11) of the TT placed by the RTM group were successful, safe, and secure. Statistically, there was no difference (P = 1.000) between RTM or VM in safety, success, or tube security. However, with VM, one subject cut himself, one did not puncture the pleura, and one had barely adequate placement. There were no such issues in the mentored group. Total time was significantly faster using RTM (P = .02). However, if time-to-watch was discounted, VM was quicker (P = .000).
Random evaluation revealed both paradigms have attributes. If VM can be utilized during “travel-time,” it is quicker but without facilitating “trouble shooting.” On the other hand, RTM had no errors in TT placement and facilitated guidance and remediation by the mentor, presumably avoiding failure, increasing safety, and potentially providing psychological support. Ultimately, both techniques appear to have merit and may be complementary, justifying continued research into the human-factors of performing RLSIs in extreme environments that are likely needed in natural and man-made disasters.
Controlling bleeding early in the prehospital and military setting is an extremely important and life-saving skill. Wound clamping is a newly introduced technique that may augment both the effectiveness and logistics of wound packing with any gauze product. As these devices may be inadvertently removed, the potential consequences of such were examined in a simulated, extreme, inadvertent disengagement.
The wound clamp used was an iTClamp (Innovative Trauma Care; Edmonton, Alberta, Canada) that was applied and forcefully removed (skin-pull) from the skin of both a human cadaver and swine. Sixty skin-pull tests were sequentially performed to measure the pull weight required to remove the device, any potential skin and device damage, how the device failed, and if the device could be re-applied.
Observations of the skin revealed that other than the expected eight small needle holes from device application, no other damage to the skin was sustained in 98.3% of cases. Conversely, of the 60 devices pulled, 93.3% of the devices sustained no damage and all could be re-applied. Four (6.7%) of the devices remained in place despite a maximum pull weight >22lbF (pound-force). The mean pull weights for pin bar pull were (lbF): vertical 9.2 (SD=5.0); perpendicular 2.5 (SD=1.7); and parallel 5.3 (SD=3.1). For the encompassed pull position group, mean pull weights were (lbF): vertical 5.7 (SD=2.3); perpendicular 3.0 (SD=2.5); and parallel 14.5 (SD=3.5). The overall mean for all groups was 6.7 (SD=5.2). The two main reasons that the iTClamp was pulled off were because the friction lock let go or the needles slipped out of one side of the skin due to the angle of the pull.
Inadvertent, forcible removal of the iTClamp created essentially no skin damage seen when the wound clamp was forcibly removed from either cadaver or swine models in a variety of positions and directions. Thus, the risks of deployment in operational environments do not seem to be increased.
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