Etiology and utility of hospital-onset bacteremia as a safety metric for targeted harm reduction.

BACKGROUND: Hospital acquired infections (HAIs) are a major driver of morbidity and cost in health systems. Central line-associated bloodstream infections (CLABSIs) require intensive surveillance and review. All-cause hospital-onset bacteremia (HOB) may be a simpler reporting metric, correlates with CLABSI, and is viewed positively by HAI experts. Despite the ease in the collection, the proportion of HOBs that are actionable and preventable is unknown. Moreover, quality improvement strategies targeting it may be more challenging. In this study, we describe the bedside provider-perceived sources of HOB in order to provide insight into this new metric as a target for HAI prevention. METHODS: All cases of HOBs in 2019 from an academic tertiary care hospital were retrospectively reviewed. Information was collected to assess provider-perceived etiology and associated clinical factors (microbiology, severity, mortality, and management). HOB was categorized as preventable or not preventable based on the perceived source from the care team and management decisions. Preventable causes included device-associated bacteremias, pneumonias, surgical complications, and contaminated blood cultures. RESULTS: Of the 392 instances of HOB, 56.0% (n = 220) had episodes that were determined not preventable by providers. Excluding blood culture contaminates, the most common cause of preventable HOB was secondary to CLABSIs (9.9%, n = 39). Of the HOBs that were not preventable, the most common sources were gastrointestinal and abdominal (n = 62), neutropenic translocation (n = 37), and endocarditis (n = 23). Patients with HOB were generally medically complex with an average Charlson comorbidity index of 4.97. This translated into a higher average length of stay (29.23 vs 7.56, P < .001) and higher inpatient mortality (odds ratio 8.3, confidence interval [6.32-10.77]) when compared to admissions without HOB. CONCLUSIONS: The majority of HOBs were not preventable and the HOB metric may be a marker of a sicker patient population making it a less actionable target for quality improvement. Standardization across the patient mix is important if the metric becomes linked to reimbursement. If the HOB metric were to be used in lieu of CLABSI, large tertiary care health systems that house sicker patients may be unfairly financially penalized for caring for more medically complex patients.

Discharges against medical advice: time to take another look. A retrospective review of discharges against medical advice focused on prevention.

BACKGROUND: Discharges against medical advice (DAMA) increase the risk of death. METHODS: We retrieved DAMA from five hospitals within a large health system and reviewed 10% of DAMA from the academic site between 2016 and 2021. RESULTS: DAMA increased at the onset of the pandemic. Patients who discharged AMA multiple times accounted for a third of all DAMA. Detailed review was completed for 278 patients who discharged AMA from the academic site. In this sample, women comprised 52% of those who discharged AMA multiple times. Relative to the proportion of all discharges from the academic site during the study period, Black patients were overrepresented among DAMA (21% vs. 34%, p < .05). Patients with multiple AMA discharges were younger, more likely to be unmarried, or have substance use disorders (SUD) than those who discharged AMA once. The most common reason for requesting premature discharge noted in n = 77, 28% of instances was related to patient obligations outside the hospital. Hospital policies and procedures contributed in n = 29, 10% of instances. Reasons for requesting premature discharge and documentation of key safety processes were similar by gender and race however the sample may be underpowered to detect differences. Capacity was evaluated in 109 (39%). Among those who consumed alcohol (n = 81 (29%)) or had SUDs (n = 112 (40%)), information on the amount or timing of last use was missing in n = 39 (48%) and n = 74 (66%), respectively. Critical tools to manage illness were provided in 45 (16%) of DAMA reviewed. CONCLUSIONS: Drivers of AMA discharge may differ by AMA discharge frequency. Recognition of the common reasons for requesting premature discharge may help destigmatize AMA discharges and also identifies early assessments by social work colleagues as an important prevention strategy. Opportunities also exist in anticipating and preventing withdrawal symptoms and in revising hospital practices that contribute to DAMA.

Two-step algorithm-based Clostridioides difficile testing as a tool for antibiotic stewardship.

OBJECTIVES: Diagnosis of Clostridium difficile infection (CDI) can be challenging due to high colonization rates. Unlike PCR-only testing, two-step algorithm testing (that includes toxin and PCR) may help differentiate colonization from active infection, but it is unknown if this type of testing impacts treatment decisions. We examined the association between changing CDI diagnostic methods, the way the testing results were displayed, and the rates of CDI-specific treatment. METHODS: We performed a retrospective analysis of positive C. difficile cases over 2 years, a year preceding and following our institution's transition from PCR to two-step testing. During the PCR period, results were displayed in the electronic medical record as 'positive'. In the two-step period, positive results were either displayed as 'likely colonized' or 'toxin positive'. Rates of CDI-specific therapy and adverse patient outcomes (30-day mortality and intensive care unit admission) were compared among the three groups. RESULTS: A total of 610 patients had positive results over the study period. Of the 354 patients in the PCR group, 329 (93%) were treated with CDI-specific therapy. Of the 142 patients in the likely colonized group, 59 (42%) were treated. All 114 patients in the toxin-positive group were treated. Multivariate analysis of patients who were PCR positive or likely colonized showed that tests sent in the two-step era were less likely to be associated with treatment for CDI (odds ratio 0.05, 95% CI 0.03-0.09). DISCUSSION: We found a correlation between changing the type of test and the way the results were displayed and reduction in CDI-specific antibiotic use without restricting clinician diagnostic ordering.

Changing the culture of urine culturing: Utilizing Agile Implementation to improve diagnostic stewardship in the ICU.

Over diagnosis of catheter-associated urinary tract infection (CAUTI) contributes to unnecessary and excessive antibiotic use, selection for resistant organisms, increased risk for Clostridiodes difficile infections, as well as a false elevation in CAUTI rates. Utilizing agile implementation to implement a urine culture algorithm achieved statistically significant reduction in CAUTI rates in a critical care unit resulting in sustainment and spread throughout the system.

Utilizing a real-time discussion approach to improve the appropriateness of Clostridioides difficile testing and the potential unintended consequences of this strategy.

We report electronic medical record interventions to reduce Clostridioides difficile testing risk 'alert fatigue.' We used a behavioral approach to diagnostic stewardship and observed a decrease in the number of tests ordered of ~4.5 per month (P < .0001). Although the number of inappropriate tests decreased during the study period, delayed testing increased.