Reducing Clostridioides difficile Infections in a Medical Intensive Care Unit: A Multimodal Quality Improvement Initiative.

BACKGROUND: Clostridioides difficile (C. diff) infection causes significant morbidity for hospitalized patients. A large medical intensive care unit had an increase in C. diff infection rates. OBJECTIVES: The aim of this project was to reduce the C. diff polymerase chain reaction (PCR) test positivity rate and the rate of C. diff PCR tests ordered. Rates were compared between preintervention (July 2017 to December 2019) and postintervention (January 2021 to December 2022) timeframes. METHODS: Unit leadership led a robust quality improvement project, including use of quality improvement tools such as A3, Gemba walks, and plan-do-study-act cycles. Interventions were tailored to the barriers identified, including standardization of in-room supply carts; use of single-packaged oral care kits; new enteric precautions signage; education to staff, providers, and visitors; scripting for patients and visitors; and use of a C. diff testing algorithm. Statistical process control charts were used to assess for improvements. RESULTS: The average rate of C. diff PCR test positivity decreased from 34.9 PCR positive tests per 10 000 patient days to 12.3 in the postintervention period, a 66% reduction. The average rate of PCR tests ordered was 28 per 1000 patient days in the preintervention period; this decreased 44% to 15.7 in the postintervention period. DISCUSSION: We found clinically significant improvements in the rate of C. diff infection and PCR tests ordered as a result of implementing tailored interventions in a large medical intensive care unit. Other units should consider using robust quality improvement methods and tools to conduct similar initiatives to reduce patient harm and improve care and outcomes.

Generative Artificial Intelligence as a Tool for Teaching Communication in Nutrition and Dietetics Education-A Novel Education Innovation.

Although effective communication is fundamental to nutrition and dietetics practice, providing novice practitioners with efficacious training remains a challenge. Traditionally, human simulated patients have been utilised in health professions training, however their use and development can be cost and time prohibitive. Presented here is a platform the authors have created that allows students to interact with virtual simulated patients to practise and develop their communication skills. Leveraging the structured incorporation of large language models, it is designed by pedagogical content experts and comprises individual cases based on curricula and student needs. It is targeted towards the practice of rapport building, asking of difficult questions, paraphrasing and mistake making, all of which are essential to learning. Students appreciate the individualised and immediate feedback based on validated communication tools that encourage self-reflection and improvement. Early trials have shown students are enthusiastic about this platform, however further investigations are required to determine its impact as an experiential communication skills tool. This platform harnesses the power of artificial intelligence to bridge the gap between theory and practice in communication skills training, requiring significantly reduced costs and resources than traditional simulated patient encounters.

Oral interview in place of traditional objective structured clinical examinations for assessing placement readiness in nutrition and dietetics education.

AIM: Objective structured clinical examinations have long been used in dietetics education. This observational study aims to describe the development, deployment, feasibility and validity of assessment using an oral interview in place of traditional objective structured clinical examinations, and to determine the ability of this assessment to identify students who are either not ready for placement or may require early support and/or remediation. METHODS: Student assessment data were collected over a two-and-a-half-year period and used to test the predictive ability of an oral interview to determine dietetic placement outcomes and highlight a need for early remediation. Descriptive statistics as well as a between-group one-way ANOVA was used to describe results. RESULTS: A total of 169 students participated in the oral interview and subsequent medical nutrition therapy placement over the study period. Significant differences in oral interview score were seen between students who passed placement and students who passed with remediation or those who failed. Oral interview performance was able to predict placement outcome, yet required less resources than traditional objective structured clinical examinations. CONCLUSION: An oral interview may provide the same utility as the objective structured clinical examination in dietetics education .

Prevalence, risk factors, and clinical outcomes of vitamin C deficiency in adult hospitalized patients in high-income countries: a scoping review.

BACKGROUND: Assessment for vitamin C deficiency (VCD) is rarely undertaken in an acute hospital setting in high-income countries. However, with growing interest in VCD in community settings, there is emerging evidence investigating the prevalence and impact of VCD during hospitalization. OBJECTIVES: In this scoping review, the prevalence of VCD in adult hospitalized patients is explored, patient characteristics are described, and risk factors and clinical outcomes associated with VCD are identified. METHODS: A systematic scoping review was conducted in accordance with the PRISMA-ScR framework. The Ovid MEDLINE, Ovid Embase, Scopus, CINAHL Plus, Allied and Complementary Medicine Database, and the Cochrane Library databases were searched for interventional, comparative, and case-series studies that met eligibility criteria, including adult hospital inpatients in high-income countries, as defined by the Organization for Economic Co-operation and Development, that reported VCD prevalence using World Health Organization reference standards. These standards define VCD deficiency as plasma or serum vitamin C level <11.4 µmol/L, wholeblood level <17 µmol/L, or leukocytes <57 nmol/108 cells. RESULTS: Twenty-three articles were included, representing 22 studies. The cumulative prevalence of VCD was 27.7% (n = 2494; 95% confidence interval [CI], 21.3-34.0). High prevalence of VCD was observed in patients with severe acute illness and poor nutritional status. Scurvy was present in 48% to 62% of patients with VCD assessed in 2 studies (n = 71). Being retired (P = 0.015) and using excessive amounts of alcohol and tobacco (P = 0.0003) were independent risk factors for VCD (n = 184). Age was not conclusively associated with VCD (n = 631). Two studies examined nutrition associations (n = 309); results were inconsistent. Clinical outcomes for VCD included increased risk of frailty (adjusted odds ratio, 4.3; 95%CI, 1.33-13.86; P = 0.015) and cognitive impairment (adjusted odds ratio, 2.93; 95%CI, 1.05-8.19, P = 0.031) (n = 160). CONCLUSIONS: VCD is a nutritional challenge facing the healthcare systems of high-income countries. Research focused on early identification and treatment of patients with VCD is warranted. SYSTEMATIC REVIEW REGISTRATION: Open Science Framework ( https://doi.org/10.17605/OSF.IO/AJGHX ).

Packaged hospital food appears safe and feasible to reuse.

AIM: To determine the safety, operational feasibility and environmental impact of collecting unopened non-perishable packaged hospital food items for reuse. METHODS: This pilot study tested packaged foods from an Australian hospital for bacterial species, and compared this to acceptable safe limits. A waste management strategy was trialled (n = 10 days) where non-perishable packaged foods returning to the hospital kitchen were collected off trays, and the time taken to do this and the number and weight of packaged foods collected was measured. Data were extrapolated to estimate the greenhouse gasses produced if they were disposed of in a landfill. RESULTS: Microbiological testing (n = 66 samples) found bacteria (total colony forming units and five common species) on packaging appeared to be within acceptable limits. It took an average of 5.1 ± 10.1 sec/tray to remove packaged food items from trays returning to the kitchen, and an average of 1768 ± 19 packaged food items were per collected per day, equating to 6613 ± 78 kg/year of waste which would produce 19 tonnes/year of greenhouse gasses in landfill. CONCLUSIONS: A substantial volume of food items can be collected from trays without significantly disrupting current processes. Collecting and reusing or donating non-perishable packaged food items that are served but not used within hospitals is a potential strategy to divert food waste from landfill. This pilot study provides initial data addressing infection control and feasibility concerns. While food packages in this hospital appear safe, further research with larger samples and testing additional microbial species is recommended.

Public support for policies to regulate flavoured tobacco and e-cigarette products in rural California.

INTRODUCTION: Flavoured tobacco control policy exemptions and electronic cigarette products may contribute to increased youth access and tobacco use disparities. METHODS: We assessed public support among California Central Valley residents for four policies to regulate flavoured tobacco products and e-cigarettes. The probability-based, multimode survey was conducted with English-speaking and Spanish-speaking registered voters (n=845) across 11 counties between 13 and 18 August 2020. Weighted logistic regression analyses measured odds of policy support, adjusting for predictor variables (attitudes and beliefs) and covariates. RESULTS: The weighted sample was 50% female and predominantly Latino (30%) or non-Hispanic white (46%); 26% had a high school education or less, and 22% an annual household income

In Situ Simulation for Adoption of New Technology to Improve Sepsis Care in Rural Emergency Departments.

OBJECTIVES: The aims of the study were to evaluate whether in situ (on-site) simulation training is associated with increased telemedicine use for patients presenting to rural emergency departments (EDs) with severe sepsis and septic shock and to evaluate the association between simulation training and telehealth with acute sepsis bundle (SEP-1) compliance and mortality. METHODS: This was a quasi-experimental study of patients presenting to 2 rural EDs with severe sepsis and/or septic shock before and after rollout of in situ simulation training that included education on sepsis management and the use of telehealth. Unadjusted and adjusted analyses were conducted to describe the association of simulation training with sepsis process of care markers and with mortality. RESULTS: The study included 1753 patients, from 2 rural EDs, 629 presented before training and 1124 presented after training. There were no differences in patient characteristics between the 2 groups. Compliance with several SEP-1 bundle components improved after training: antibiotics within 3 hours, intravenous fluid administration, repeat lactic acid assessment, and vasopressor administration. The use of telemedicine increased from 2% to 5% after training. Use of telemedicine was associated with increases in repeat lactic acid assessment and reassessment for septic shock. We did not demonstrate an improvement in mortality across either of the 2 group comparisons. CONCLUSIONS: We demonstrate an association between simulation and improved care delivery. Implementing an in situ simulation curriculum in rural EDs was associated with a small increase in the use of telemedicine and improvements in sepsis process of care markers but did not demonstrate improvement in mortality. The small increase in telemedicine limited conclusions on its impact.

Applying the social ecological framework to enhance wellness for student veterans.

ObjectiveTo increase campus-wide wellness for student service members/veterans (SSM/Vs), student services professionals, healthcare providers, and faculty collaborated to implement the Social Ecological Framework (SEF) over a three-year project.ParticipantsOne thousand six hundred and seventy eight SSM/Vs enrolled at a medium-sized doctoral granting institution with high-research activity (R2). SSM/Vs were directly and indirectly impacted through a series of initiatives, including stigma reduction efforts, wellness promotion, faculty training, therapeutic services, and peer-advising.MethodsData collection included student success measures such as retention, student satisfaction/feedback, peer-advising meetings, psychotherapy sessions, TBI screenings, and growth measures from a mental health stigma scale.ResultsA significant increase in therapy sessions conducted at the Wellness Center, increased faculty trainings, new and strengthened partnerships, and an increase in SSM/V retention.ConclusionsResults suggest that collaborative efforts applying the SEF can create improved educational conditions and outcomes for SSM/Vs. A review of SSM/V wellness literature and suggestions for other campuses are offered.

A novel in situ simulation framework for introduction of a new technology: the 3-Act-3-Debrief model.

BACKGROUND: New technologies for clinical staff are typically introduced via an "in-service" that focuses on knowledge and technical skill. Successful adoption of new healthcare technologies is influenced by multiple other factors as described by the Consolidated Framework in Implementation Research (CFIR). A simulation-based introduction to new technologies provides opportunity to intentionally address specific factors that influence adoption. METHODS: The new technology proposed for adoption was a telehealth cart that provided direct video communication with electronic intensive care unit (eICU) staff for a rural Emergency Department (ED). A novel 3-Act-3-Debrief in situ simulation structure was created to target predictive constructs from the CFIR and connect debriefing to specific workflows. The structure and content of the simulation in relation to the framework is described. Participants completed surveys pre-simulation/post-simulation to measure change in their readiness to adopt the new technology. RESULTS: The scenario was designed and pilot tested before implementation at two rural EDs. There were 60 interprofessional participants across the 2 sites, with 58 pre-simulation and 59 post-simulation surveys completed. The post-simulation mean ratings for each readiness measure (feasibility, quality, resource availability, role clarity, staff receptiveness, and tech usability) increased significantly as a result of the simulation experience. CONCLUSIONS: A novel 3-stage simulation-debriefing structure positively targets factors influencing the adoption of new healthcare technologies.

The Equivalence of Video Self-review Versus Debriefing After Simulation: Can Faculty Resources Be Reallocated?

INTRODUCTION: Traditional simulation debriefing is both time- and resource-intensive. Shifting the degree of primary learning responsibility from the faculty to the learner through self-guided learning has received greater attention as a means of reducing this resource intensity. The aim of the study was to determine if video-assisted self-debriefing, as a form of self-guided learning, would have equivalent learning outcomes compared to standard debriefing. METHODS: This randomized cohort study consisting of 49 PGY-1 to -3 emergency medicine residents compared performance after video self-assessment utilizing an observer checklist versus standard debriefing for simulated emergency department procedural sedation (EDPS). The primary outcome measure was performance on the second EDPS scenario. RESULTS: Independent-samples t-test found that both control (standard debrief) and intervention (video self-assessment) groups demonstrated significantly increased scores on Scenario 2 (standard-t(40) = 2.20, p < 0.05; video-t(45) = 3.88, p < 0.05). There was a large and significant positive correlation between faculty and resident self-evaluation (r = 0.70, p < 0.05). There was no significant difference between faculty and residents self-assessment mean scores (t(24) = 1.90, p = 0.07). CONCLUSIONS: Residents receiving feedback on their performance via video-assisted self-debriefing improved their performance in simulated EDPS to the same degree as with standard faculty debriefing. Video-assisted self-debriefing is a promising avenue for leveraging the benefits of simulation-based training with reduced resource requirements.