Identification of distinct symptom profiles in patients with gynecologic cancers using a pre-specified symptom cluster.

PURPOSE: Pain, fatigue, sleep disturbance, and depression are four of the most common symptoms in patients with gynecologic cancer. The purposes were to identify subgroups of patients with distinct co-occurring pain, fatigue, sleep disturbance, and depression profiles (i.e., pre-specified symptom cluster) in a sample of patients with gynecologic cancer receiving chemotherapy and assess for differences in demographic and clinical characteristics, as well as the severity of other common symptoms and QOL outcomes among these subgroups. METHODS: Patients completed symptom questionnaires prior to their second or third cycle of chemotherapy. Latent profile analysis was used to identify subgroups of patients using the pre-specified symptom cluster. Parametric and nonparametric tests were used to evaluate for differences between the subgroups. RESULTS: In the sample of 233 patients, two distinct latent classes were identified (i.e., low (64.8%) and high (35.2%)) indicating lower and higher levels of symptom burden. Patients in high class were younger, had child care responsibilities, were unemployed, and had a lower annual income. In addition, these women had a higher body mass index, a higher comorbidity burden, and a lower functional status. Patients in the high class reported higher levels of anxiety, as well as lower levels of energy and cognitive function and poorer quality of life scores. CONCLUSIONS: This study identified a number of modifiable and non-modifiable risk factors associated with membership in the high class. Clinicians can use this information to refer patients to dieticians and physical therapists for tailored interventions.

Barriers, facilitators, and opportunities for Doctor of Nursing Practice engagement in translational research.

BACKGROUND: Little is known about how Doctor of Nursing Practice (DNP) graduates apply translational research competencies in the practice setting. PURPOSE: This qualitative descriptive study aimed to explore the barriers, facilitators, and opportunities for engaging in translational research among DNPs in practice. METHODS: We conducted semi-structured interviews with 11 DNPs working within an 8-hospital health system from November 2020 through July 2021. DISCUSSION: We identified four themes related to barriers (invisibility of the DNP degree and skillset; lack of role clarity and organizational structure for DNPs; lack of time for engagement in translational research; lack of support for engagement in translational research), one theme related to facilitators (encouragement from colleagues and supervisors), and two themes related to opportunities (DNP education promotes recognition of nurse role in translational research; DNPs are interested in role expansion to include translational research). CONCLUSION: DNPs have the interest and training to engage in translational research but face structural barriers to doing so.

Immune-Related Adverse Events Among COVID-19-Vaccinated Patients With Cancer Receiving Immune Checkpoint Blockade.

BACKGROUND: Whether COVID-19 vaccination and the associated immune response increases susceptibility to immune-related adverse events (irAEs) among patients treated with immune checkpoint inhibition (ICI) remains unknown. Short-term follow-up can assess the safety of concurrent administration of the vaccine and ICI treatment. METHODS: We conducted an electronic health record analysis of a cohort of 408 patients with cancer receiving ICI therapy and who were vaccinated for COVID-19 between January 16 and March 27, 2021. Patients were seen in follow-up for 90 days from the day of the first dose in this single-institution tertiary care center. We evaluated the incidence of irAEs and the frequency of each event type and grade among patients who experienced an irAE. We also evaluated the incidence of irAEs in patients who began a new immunotherapy agent after vaccination. RESULTS: Among 408 patients with cancer receiving ICI therapy (median age, 71 years; 217 [53%] male), administration of a COVID-19 mRNA vaccine within 90 days of ICI treatment was not associated with an increased incidence of irAEs. A total of 27 (7%) patients experienced a new irAE within the observation period. Among patients with previous irAEs from ICIs (n=54), 3 (6%) experienced a recurrent irAE, and of those initiating a new immunotherapy (n=52), 9 (17%) experienced an irAE. No excess risk of COVID-19 diagnosis was seen in this subset of patients receiving ICI therapy, and no breakthrough COVID-19 cases were seen after full COVID-19 vaccination. CONCLUSIONS: These findings should reassure providers that COVID-19 vaccination during ICI therapy is safe and efficacious.

Factors Associated With Burnout Among Nurses Providing Direct Patient Care During the COVID-19 Pandemic.

OBJECTIVE: This study aimed to identify factors associated with burnout in nurses and nurses' opinions regarding interventions to promote well-being during crisis conditions such as those experienced during the COVID-19 pandemic. BACKGROUND: Burnout among nurses is prevalent under usual conditions and may increase during crises such as COVID-19. METHODS: Researchers conducted a survey of 1103 frontline nurses in a single New York City hospital during the first (spring 2020) and second (fall 2020/winter 2021) local waves of COVID-19. RESULTS: Burnout prevalence increased from 45% to 52% between the first and second wave. Younger age, female gender, posttraumatic stress, anxiety or depressive symptoms, history of burnout, feeling less valued by hospital leadership, less informed of responsibilities, less certain about duration of enhanced workload, and prepared by prepandemic experience were predictive of burnout in multivariable analyses. CONCLUSIONS: Although some identified risk factors for burnout were nonmodifiable, others may be modifiable by hospital leadership.

Readmission Rates in Stroke Patients with and without Infections: Incidence and Risk Factors.

BACKGROUND: Stroke patients are at increased risk for acquiring infections in the hospital and risk of readmission. We aimed to examine whether an infection acquired during the initial stroke admission contributes to increased risk of readmission and infection during readmission. METHODS: We performed a retrospective cohort study incorporating all adult ischemic stroke patients from three New York City hospitals from 2006 to 2016. A validated computer algorithm defined infections based on electronically-available laboratory culture data. Multivariable logistic regression was used to evaluate the crude and adjusted association of infections present on admission (IPOA) and healthcare-associated infections (HAI) with 60-day readmissions, and infection during readmission. RESULTS: Among the 10,436 stroke patients, 17% had infections during initial admission of which 52% were IPOA and 48% were HAI. The risk of readmission was significantly higher for those with HAIs (OR = 1.40; 95% CI: 1.20-1.64) and IPOA (OR = 1.26; 95% CI: 1.09-1.47). The presence of infection during the 60-day readmission was also independently predicted by HAI (OR = 3.27; 95% CI: 2.60-4.12) and IPOA (OR = 2.54; 95% CI: 2.01-3.22). Patients with a Gram-negative infection were not at higher odds for readmission compared to patients with a Gram-positive infection (OR 1.07, 95%CI 0.81-1.42). CONCLUSION: Among stroke patients, HAI and IPOA were predictors of readmission within 60 days and infection during readmission.

Improved 30-Day Heart Failure Readmissions Following Implementation of an Advanced Cardiovascular Education (ACE) Academy.

BACKGROUND: Heart failure readmissions are common, though some are preventable through evidence-based management. LOCAL PROBLEM: Despite outperforming national benchmarks for 30-day readmissions, compliance with an evidence-based institutional heart failure management pathway was inconsistent. The purpose of this project was to reduce 30-day heart failure readmission rates through an educational intervention and an electronic health record (EHR) redesign. METHODS: The cardiac services nursing leadership team conducted an education and documentation needs assessment to identify knowledge gaps and practical barriers to effective utilization of evidence-based interventions for heart failure management. INTERVENTIONS: This intervention included an Advanced Cardiovascular Education (ACE) Academy and an EHR workflow redesign for clinical and supportive nursing staff. RESULTS: The 30-day heart failure readmission rates reduced immediately following the intervention, and rates continued to decrease over a 3-year follow-up. CONCLUSIONS: Even among hospitals outperforming national benchmarks, 30-day heart failure readmissions can be reduced and sustained with enhanced education and EHR redesign.

Loneliness and symptom burden in oncology patients during the COVID-19 pandemic.

BACKGROUND: Loneliness and social isolation are significant public health problems that are being exacerbated during the coronavirus disease 2019 pandemic. Little is known about the associations between loneliness and symptom burden in oncology patients before and during the pandemic. Study purposes include determining the prevalence of loneliness in a sample of oncology patients; evaluating for differences in demographic, clinical, and symptom characteristics between lonely and nonlonely patients; and determining which demographic, clinical, and symptom characteristics were associated with membership in the lonely group. METHODS: A convenience sample (n = 606) completed online surveys that evaluated the severity of loneliness, social isolation, and common symptoms (ie, anxiety, depression, fatigue, sleep disturbance, cognitive dysfunction, and pain) in oncology patients. Parametric and nonparametric tests were used to evaluate for differences in scores between the lonely and nonlonely groups. Logistic regression analysis was used to determine risk factors for membership in the loneliness group. RESULTS: Of the 606 patients, 53.0% were categorized in the lonely group. The lonely group reported higher levels of social isolation, as well as higher symptom severity scores for all of the symptoms evaluated. In the multivariate model, being unmarried, having higher levels of social isolation, as well as higher levels of anxiety and depressive symptoms were associated with membership in the lonely group. CONCLUSIONS: Study findings suggest that a significant number of oncology patients are experiencing loneliness, most likely as a result of mandate social distancing and isolation procedures. The symptom burden of these patients is extremely high and warrants clinical evaluation and interventions.

Oncology patients' perceptions of and experiences with COVID-19.

PURPOSE: No information is available on cancer patients' knowledge of and experiences with COVID-19. We undertook an evaluation of differences in COVID-19 symptom occurrence rates, COVID-19 testing rates, clinical care activities, knowledge of COVID-19, and use of mitigation procedures between patients who were and were not receiving active cancer treatment. METHODS: Patients enrolled were > 18 years of age; had a diagnosis of cancer; and were able to complete the emailed study survey online. RESULTS: Of the 174 patients who participated, 27.6% (n = 48) were receiving active treatment, 13.6% were unemployed because of COVID-19, 12.2% had been tested for COVID-19, and 0.6% had been hospitalized for COVID-19. Patients who were not on active treatment reported a higher mean number of COVID-19 symptoms (3.1 (± 4.2) versus 1.9 (± 2.6)), and patients who reported a higher number of COVID-19 symptoms were more likely to be tested. Over 55% of the patients were confident that their primary care provider could diagnose COVID-19, and the majority of the patients had high levels of adherence with the use of precautionary measures (e.g., social distancing, use of face coverings). CONCLUSION: The high level of COVID-19 symptoms and the significant overlap of COVID-19 and cancer-related symptoms pose challenges for clinicians who are assessing and triaging oncology patients for COVID-19 testing. For patients on active treatment, clinicians face challenges with how to assess and manage symptoms that, prior to COVID-19, would be ascribed to acute toxicities associated with cancer treatments or persistent symptoms in cancer survivors.

Willing But Not Quite Ready: Nurses' Knowledge, Attitudes, and Practices of Research in an Academic Healthcare System.

OBJECTIVE: To describe nurses' research knowledge, attitudes, and practices within an academic hospital system. BACKGROUND: Hospitals are investing in research resources to meet Magnet® goals and advance the science of nursing, but nurses' specific needs for support are not well characterized and may vary by setting. METHODS: We conducted an anonymous online survey of RNs at an academic hospital system in 2019-2020 using the validated Nurses' Knowledge, Attitudes, and Practices of Research Survey. RESULTS: Respondents (N = 99) indicated high willingness to engage in research-related tasks but low or moderate knowledge of and ability to perform them. Knowledge, attitudes, and practices of research increased with level of education, although gaps between willingness to engage versus knowledge and ability persisted even among doctorally prepared nurses. CONCLUSIONS: Research support for clinical nurses should leverage enthusiasm for research and focus on developing and applying specific practical skills, even among nurses with advanced degrees.

Safety of Inactivated Influenza Vaccine in Cancer Patients Receiving Immune Checkpoint Inhibitors.

BACKGROUND: Cancer patients are at a higher risk for developing influenza (flu)- related complications. It is unclear if the flu vaccine exacerbates immune events in patients treated with immune checkpoint inhibitors (ICIs). METHODS: We conducted an institutional review board-IRB-approved retrospective review of advanced cancer patients on ICIs who received the flu vaccine during three 3 consecutive seasons: 2014-2015, 2015-2016, and 2016-2017. The primary outcome assessed was any "new onset" immune-related adverse event (IRAE). A subset analysis of vaccinated patients newly treated with anti-programmed cell death protein 1 (PD-1) agents (nivolumab or pembrolizumab) was conducted to assess overall IRAE rates for comparison with published clinical trials. RESULTS: During the three 3 seasons, 370 patients met criteria for ICI and vaccination within ~ twoapproximately 2 months (65 days). The most common underlying cancers were lung (46%) and melanoma (19%); 61% of patients received an anti-PD-1 agent only. In the entire cohort, 20% experienced an IRAE (any grade); incidence of grade 3 or 4 toxicity was 8%. No grade 5 events occurred. In the subset of 170 patients newly treated with anti-PD-1 agents, the overall IRAE rate was 18% and, grade 3/4 events occurred in 7.6%. Influenza was diagnosed in 2 patients. CONCLUSIONS: No increase in incidence or severity of IRAEs was detected in patients on ICIs who received the inactivated influenza vaccine within ~ approximately 2 months of ICI. For newly treated patients on anti-PDI-1 agents, IRAE rates were comparable to those from published clinical trials and did not vary with order of administration. Routine seasonal flu vaccination is encouraged in patients on ICIs.

Novel Strategies for Predicting Healthcare-Associated Infections at Admission: Implications for Nursing Care.

BACKGROUND: Accurate, real-time models to predict hospital adverse events could facilitate timely and targeted interventions to improve patient outcomes. Advances in computing enable the use of supervised machine learning (SML) techniques to predict hospital-onset infections. OBJECTIVES: The purpose of this study was to trial SML methods to predict urinary tract infections (UTIs) during inpatient hospitalization at the time of admission. METHODS: In a large cohort of adult hospitalizations in three New York City acute care facilities (N = 897,344), we used two SML methods-neural networks and decision trees-to predict having a hospital-onset UTI using data available and accessible on the first day of admission at healthcare facilities in the United States. RESULTS: Performance for both neural network and decision tree models were superior compared to logistic regression methods. The decision tree model had a higher sensitivity compared to neural network, but a lower specificity. DISCUSSION: SML methods show potential for automated accurate UTI risk stratification using electronic data routinely available at admission; this could relieve nurses from the burden of having to complete and document additional risk assessment forms in the electronic medical record. Future studies should pilot and test interventions linked to the risk stratification results, such as short nursing educational modules or alerts triggered for high-risk patients.

Evaluation of the joint nurse scientist role across academia and practice.

BACKGROUND: Mapped with the guiding principles of academic-practice partnerships (APPs) outlined by the American Association of Colleges of Nursing and the American Organization for Nursing Leadership, a joint nurse scientist role between a nursing school and acute care facility at a large academic health center was developed and characterized by a PhD-prepared nurse appointed in a research role across organizations. To date, eight faculty are now appointed across the School and four health systems. PURPOSE: Describe outcomes, facilitators and vulnerabilities of the joint nurse scientist role. METHODS: Review of administrative records. DISCUSSION: Outcomes include the 1) conduct and dissemination of joint research, 2) translation of evidence into practice, 3) development of educational programs for health system nurses, 4) scholarly activities among health system nurses, and 5) improved visibility and valuation of the PhD-prepared nurse. Role facilitators include those previously reported for APPs, the joint nurse scientists' ability to broker opportunities across settings, and the evolving nature of the role. Role vulnerabilities pertain to the negotiation of workload, promotion, and institutional priorities. CONCLUSION: The joint nurse scientist role fosters shared scholarly successes across academia and service.

The Association Between the Frequency of Interruptions in Antibiotic Exposure and the Risk of Health Care-Associated Clostridiodes difficile Infection.

BACKGROUND: Although antibiotic use is an established risk factor for health care-associated Clostridiodes difficile infection, estimates of the association between infection and antibiotic use vary, depending upon how antibiotic exposure is measured. OBJECTIVES: The purpose of this study was to explore the association between the frequency of interruptions in antibiotic exposure and the risk of health care-associated C difficile infection. METHODS: A retrospective chart review cohort study was conducted of all inpatients between 2011and 2016 from a single academic health center who received at least 1 dose of a systemic antibacterial for a cumulative duration of >3 days and ≤30 days. The measures of antibiotic exposure examined were duration-cumulative total calendar days of antibiotics therapy-and continuity-the frequency of interruptions in antibiotic exposure that was defined as the number of antibiotic treatment courses. RESULTS: A total of 52,445/227,967 (23%) patients received antibacterial therapy for >3 days and ≤30 days during their hospitalization. Of these, 1161 out of 52,445 (2.21%) were patients with health care-associated C difficile infection. An adjusted multivariable logistic regression analysis revealed that the risk of C difficile increased with longer cumulative days (odds ratio = 2.7; comparison of >12 days to ≤5 days) and fewer interruptions of antibiotic treatment (odds ratio = 0.78; comparison of >3 discrete antibiotic treatment courses to 1 course or continuous antibiotic treatment course; all P values < 0.05). CONCLUSIONS: For patients who received the same number of cumulative days of therapy, the patients who had more frequently interrupted courses of antibiotic therapy were less likely to experience health care-associated C difficile infection. (Curr Ther Res Clin Exp. 2020; 81:XXX-XXX).

Comparison of Measures to Predict Mortality and Length of Stay in Hospitalized Patients.

BACKGROUND: Patient risk adjustment is critical for hospital benchmarking and allocation of healthcare resources. However, considerable heterogeneity exists among measures. OBJECTIVES: The performance of five measures was compared to predict mortality and length of stay (LOS) in hospitalized adults using claims data; these include three comorbidity composite scores (Charlson/Deyo age-comorbidity score, V W Elixhauser comorbidity score, and V W Elixhauser age-comorbidity score), 3 M risk of mortality (3 M ROM), and 3 M severity of illness (3 M SOI) subclasses. METHODS: Binary logistic and zero-truncated negative binomial regression models were applied to a 2-year retrospective dataset (2013-2014) with 123,641 adult inpatient admissions from a large hospital system in New York City. RESULTS: All five measures demonstrated good to strong model fit for predicting in-hospital mortality, with C-statistics of 0.74 (95% confidence interval [CI] [0.74, 0.75]), 0.80 (95% CI [0.80, 0.81]), 0.81(95% CI [0.81, 0.82]), 0.94 (95% CI [0.93, 0.94]), and 0.90 (95% CI [0.90, 0.91]) for Charlson/Deyo age-comorbidity score, V W Elixhauser comorbidity score, V W Elixhauser age-comorbidity score, 3 M ROM, and 3 M SOI, respectively. The model fit statistics to predict hospital LOS measured by the likelihood ratio index were 0.3%, 1.2%, 1.1%, 6.2%, and 4.3%, respectively. DISCUSSION: The measures tested in this study can guide nurse managers in the assignment of nursing care and coordination of needed patient services and administrators to effectively and efficiently support optimal nursing care.

Concurrent Detection of Bacterial Pathogens in Hospital Roommates.

BACKGROUND: Some nurse-driven interventions have successfully reduced rates of healthcare-associated infections, though incidence remains unacceptably high. Bacterial contamination in patient rooms may be a source of exposure for patients and thus a target for future interventions; however, few studies have investigated the role of the patient room on organism acquisition. OBJECTIVES: The purpose of this study was to determine the incidence of concurrent detection of bacterial pathogens among patients sharing a hospital room. METHODS: We performed a retrospective network analysis using electronic administrative and clinical data collected from all patients admitted in 2006 through 2012 to four New York City hospitals, totaling 2,065 beds within 183 inpatient units. A computerized algorithm identified concurrent organism detection among roommates, defined as two patients who shared a room on at least 1 day and had a first positive culture for the same organism within 3 days following cohabitation. RESULTS: In total, 741,271 patient admissions were included. The algorithm identified 373 concurrent detection events: 158 (42%) in which the patients' first positive cultures were drawn after they were no longer sharing a room but within 3 days of cohabitation, 144 (39%) in which the patients' first positive cultures were drawn while they were still sharing a room but on different days, and 71 (19%) in which the patients' first positive cultures were drawn while they were sharing a room on the same day. DISCUSSION: Methods to improve environmental decontamination should be included as part of a comprehensive approach to infection prevention in hospitals. Nurses have an important role to play in the planning and implementation of interventions to reduce bioburden in the patient environment.

Behavioral Interventions to Reduce Infections in Pediatric Long-term Care Facilities: The Keep It Clean for Kids Trial.

Children in pediatric long-term care facilities (pLTCF) represent a highly vulnerable population and infectious outbreaks occur frequently, resulting in significant morbidity, mortality, and resource use. The purpose of this quasi-experimental trial using time series analysis was to assess the impact of a 4-year theoretically based behavioral intervention on infection prevention practices and clinical outcomes in three pLTCF (288 beds) in New York metropolitan area including 720 residents, ages 1 day to 26 years with mean lengths of stay: 7.9-33.6 months. The 5-pronged behavioral intervention included explicit leadership commitment, active staff participation, work flow assessments, training staff in the World Health Organization "'five moments of hand hygiene (HH)," and electronic monitoring and feedback of HH frequency. Major outcomes were HH frequency, rates of infections, number of hospitalizations associated with infections, and outbreaks. Mean infection rates/1000 patient days ranged from 4.1-10.4 pre-intervention and 2.9-10.0 post-intervention. Mean hospitalizations/1000 patient days ranged from 2.3-9.7 before and 6.4-9.8 after intervention. Number of outbreaks/1000 patient days per study site ranged from 9-24 pre- and 9-18 post-intervention (total = 95); number of cases/outbreak ranged from 97-324 (total cases pre-intervention = 591 and post-intervention = 401). Post-intervention, statistically significant increases in HH trends occurred in one of three sites, reductions in infections in two sites, fewer hospitalizations in all sites, and significant but varied changes in the numbers of outbreaks and cases/outbreak. Modest but inconsistent improvements occurred in clinically relevant outcomes. Sustainable improvements in infection prevention in pLTCF will require culture change; increased staff involvement; explicit administrative support; and meaningful, timely behavioral feedback.

Assessing Intensity of Nursing Care Needs Using Electronically Available Data.

Although previous research has confirmed that nurse staffing affects patient outcomes, some potentially important factors have not been accounted for in tools to assess relationships between staffing and outcomes. The aim of this project was to develop and test a Nursing Intensity of Care Index using electronically available data from 152 072 patient discharges from three hospitals. Initially, 1765 procedure codes were reviewed; 69 were confirmed as directly increasing nursing workload by at least 15 minutes per shift. Two research staff independently reviewed a random sample of 5 patient days to assess interrater reliability with complete scoring agreement. To assess face validity, eight nurse clinician experts reviewed factors included in the Nursing Intensity of Care Index to assess the accuracy of the nursing time estimates in the tool. To examine concurrent validity, Nursing Intensity of Care Index scores for a random sample of 28 patients from four clinical units were compared with assessments made by a unit-based clinical nurse (low/medium/high intensity) for the same patients on the same day with a Spearman correlation of 0.94. In preliminary testing, data for the Nursing Intensity of Care Index, which accurately reflect nursing care intensity, can be obtained electronically in real time. The next steps will be a discrete-event simulation model and large-scale field trials.

Hand-hygiene practices and observed barriers in pediatric long-term care facilities in the New York metropolitan area.

OBJECTIVE: To describe hand-hygiene practices in pediatric long-term care (pLTC) facilities and to identify observed barriers to, and potential solutions for, improved infection prevention. DESIGN: Observational study using (i) the World Health Organization's '5 Moments for Hand Hygiene' validated observation tool to record indications for hand hygiene and adherence; and (ii) individual logs of subjective impressions of behavioral and/or systemic barriers witnessed during direct observation. SETTING: Staff in three pLTC facilities (284 beds total) were observed by two trained nurses 1 day a week for 3 weeks in February and March 2015. PARTICIPANTS: Direct providers of health, therapeutic and rehabilitative care, and other staff responsible for social and academic activities for children with complex, chronic medical conditions. MAIN OUTCOME MEASURES: Hand-hygiene indications, adherence and barriers. RESULTS: Hand hygiene was performed for 40% of the 847 indications observed and recorded. Adherence increased at one site and decreased in the other two sites during the study period. Adherence appeared to be influenced by individuals' knowledge, attitudes, beliefs and work setting. CONCLUSIONS: Poor hand-hygiene adherence was observed overall. Specific barriers were identified, which suggest a contextual approach to the interpretation of results indicated in this uniquely challenging setting. We offer some practical suggestions for overcoming those barriers or mitigating their effect. Ultimately, an adaptation of the '5 Moments for Hand Hygiene' may be necessary to improve infection prevention in pLTC.

Visualization of Data Regarding Infections Using Eye Tracking Techniques.

OBJECTIVE: To evaluate ease of use and usefulness for nurses of visualizations of infectious disease transmission in a hospital. DESIGN: An observational study was used to evaluate perceptions of several visualizations of data extracted from electronic health records designed using a participatory approach. Twelve nurses in the master's program in an urban research-intensive nursing school participated in May 2015. METHODS: A convergent parallel mixed method was used to evaluate nurses' perceptions on ease of use and usefulness of five visualization conveying trends in hospital infection transmission applying think-aloud, interview, and eye-tracking techniques. FINDINGS: Subjective data from the interview and think-aloud techniques indicated that participants preferred the traditional line graphs in simple data representation due to their familiarity, clarity, and easiness to read. An objective quantitative measure of eye movement analysis (444,421 gaze events) identified a high degree of participants' attention span in infographics in all three scenarios. All participants responded with the correct answer within 1 min in comprehensive tests. CONCLUSIONS: A user-centric approach was effective in developing and evaluating visualizations for hospital infection transmission. For the visualizations designed by the users, the participants were easily able to comprehend the infection visualizations on both line graphs and infographics for simple visualization. The findings from the objective comprehension test and eye movement and subjective attitudes support the feasibility of integrating user-centric visualization designs into electronic health records, which may inspire clinicians to be mindful of hospital infection transmission. Future studies are needed to investigate visualizations and motivation, and the effectiveness of visualization on infection rate. CLINICAL RELEVANCE: This study designed visualization images using clinical data from electronic health records applying a user-centric approach. The design insights can be applied for visualizing patient data in electronic health records.