Polymorphic cis- and trans-regulation of human gene expression.

Expression levels of human genes vary extensively among individuals. This variation facilitates analyses of expression levels as quantitative phenotypes in genetic studies where the entire genome can be scanned for regulators without prior knowledge of the regulatory mechanisms, thus enabling the identification of unknown regulatory relationships. Here, we carried out such genetic analyses with a large sample size and identified cis- and trans-acting polymorphic regulators for about 1,000 human genes. We validated the cis-acting regulators by demonstrating differential allelic expression with sequencing of transcriptomes (RNA-Seq) and the trans-regulators by gene knockdown, metabolic assays, and chromosome conformation capture analysis. The majority of the regulators act in trans to the target (regulated) genes. Most of these trans-regulators were not known to play a role in gene expression regulation. The identification of these regulators enabled the characterization of polymorphic regulation of human gene expression at a resolution that was unattainable in the past.

Electronic health record solutions to reduce central line-associated bloodstream infections by enhancing documentation of central line insertion practices, line days, and daily line necessity.

BACKGROUND: Central line-associated bloodstream infections (CLABSIs) continue to cause preventable morbidity and mortality, but methods for tracking and ensuring consistency of CLABSI-prevention activities remain underdeveloped. METHODS: We created an integrated electronic health record solution to prompt sterile central venous catheter (CVC) insertion, CVC tracking, and timely line removal. The system embedded central line insertion practices (CLIP) elements in inserter procedure notes, captured line days and new lines, matching each with its CLIP form and feeding back compliance, and enforced daily documentation of line necessity in physician progress notes. We examined changes in CLIP compliance and form submission, number of new line insertions captured, and necessary documentation. RESULTS: Standard reporting of CLIP compliance, which measures compliance per CLIP form received, artificially inflated CLIP compliance relative to compliance measured using CVC placements as the denominator; for example, 99% per CLIP form versus 55% per CVC placement. This system established a higher threshold for CLIP compliance using this denominator. Identification of CVCs increased 35%, resulting in a decrease in CLABSI rates. The system also facilitated full compliance with daily documentation of line necessity. CONCLUSIONS: Integrated electronic health records systems can help realize the full benefit of CLABSI prevention strategies by promoting, tracking, and raising the standard for best practices behavior.

Automated tracking and ordering of precautions for multidrug-resistant organisms.

BACKGROUND: The transmission and infection risk associated with multidrug-resistant organism (MDRO) carriers necessitates surveillance and tracking to provide proper contact precautions. As MDROs increase in scope, automated electronic health record (EHR) systems may help with surveillance demands. METHODS: We created a system for MDROs and Clostridium difficile tracking that automated the following 3 main surveillance and tracking activities: monitoring of microbiology results and initiation of chart-based flags, ordering of contact precautions on admission, and ensuring appropriate removal of precautions. RESULTS: Automation saved 43 infection preventionist hours per 1,000 admissions, in addition to previously unquantified hours spent reviewing MDRO history for every admission. Automatic retiring of certain MDRO flags ensured removal of contact precautions after a specified time. A point-prevalence assessment for eligibility for discontinuation found that all precautions were appropriate, with none eligible for removal. By integrating microbiology data, EHR tracking flags, and automated orders, this system assured rapid and comprehensive placement of patients into contact precautions without requiring oversight by infection prevention personnel. CONCLUSION: We show that automated systems embedded within EHRs can ensure tracking and application of appropriate contact precautions while simultaneously producing tremendous time savings for infection prevention programs.

Electronic solutions to enhance tracking and compliance with mandatory influenza vaccination for all hospital staff.

In implementing a hospital mandatory influenza vaccination policy, we developed an automated, real-time tracking and reminder system. Of 6,957 policy-covered individuals automatically identified, automated reminders left only 5 requiring counseling. This decreased Occupational Health workload in contacting noncompliant individuals and hosting vaccination events while simultaneously facilitating a 96% vaccination rate.