A Technology-Enabled Solution to Manage Referrals to Hospice and Palliative Care Beds: The Ottawa SMART System as a Case Study.

Ottawa has a 31-bed palliative care unit (PCU) and two residential adult hospices (total 19 beds). In 2013, we initiated a project to improve the referral and triage processes to these beds. Previously, there were two separate paper-based systems with duplication, inefficiencies, delays and inappropriate patient placements. The multipronged approach included clarifying the respective roles of the PCU and hospices, creating a single referral and triage office and developing an e-platform. We leveraged technology that was available in the public-funded system. This paper describes the development processes, lessons learned, and the final system, referred to as System to Manage Access, Referrals and Triage (SMART).

Severe diarrhea caused by cholera toxin-producing vibrio cholerae serogroup O75 infections acquired in the southeastern United States.

BACKGROUND: From 2003 through 2007, Vibrio cholerae serogroup O75 strains possessing the cholera toxin gene were isolated from 6 patients with severe diarrhea, including 3 in Georgia, 2 in Alabama, and 1 in South Carolina. These reports represent the first identification of V. cholerae O75 as a cause of illness in the United States. V. cholerae O75 was isolated from a water sample collected from a pond in Louisiana in 2004. Subsequently, 3 V. cholerae isolates from Louisiana (2 from patients with diarrhea in 2000 and 1 from a water sample collected in 1978) that had been previously reported as serogroup O141 were also discovered to be serogroup O75. RESULTS: All 8 patients who were infected with V. cholerae O75 were adults who became ill after consuming seafood; 2 had eaten raw oysters traced back to the Gulf Coast of the United States. All 10 isolates possessed the cholera toxin gene and were susceptible to 10 antimicrobials. One clinical isolate and 1 environmental (water) isolate had the same pulsed-field gel electrophoresis pattern; 4 clinical isolates shared a common pulsed-field gel electrophoresis pattern. CONCLUSIONS: The occurrence of these cases over many years and the concurrent identification of V. cholerae O75 in water from a Gulf Coast state suggest that these strains may survive for long periods in this environment. The patients' exposure histories suggest that infection can be acquired from consumption of raw oysters from the Gulf Coast. Clinicians and public health authorities should be vigilant for the occurrence of new toxigenic serogroups of V. cholerae that are capable of causing severe diarrhea.

An outbreak of enterotoxigenic Escherichia coli associated with sushi restaurants in Nevada, 2004.

BACKGROUND: In August and November 2004, 2 clusters of diarrhea cases occurred among patrons of 2 affiliated sushi restaurants (sushi restaurant A and sushi restaurant B) in Nevada. In August 2004, a stool sample from 1 ill sushi restaurant A patron yielded enterotoxigenic Escherichia coli (ETEC). In December 2004, we investigated a third cluster of diarrhea cases among sushi restaurant B patrons. METHODS: We defined a case as diarrhea in a person who ate at sushi restaurant B from 3 December through 13 December 2004. Control subjects were individuals who dined with case patients but did not become ill. Duplex polymerase chain reaction was used to detect genes coding for heat-stable and heat-labile enterotoxins of ETEC. RESULTS: One-hundred thirty patrons of sushi restaurant B reported illness; we enrolled 36 case patients and 29 control subjects. The diarrhea-to-vomiting prevalence ratio among patients was 4.5. Illness was associated with consumption of butterfly shrimp (estimated odds ratio, 7.2; 95% confidence interval, 1.1 to infinity). The implicated food was distributed to many restaurants, but only sushi restaurant B patrons reported diarrhea. We observed poor food-handling and hand hygiene practices at sushi restaurant B. Stool samples from 6 of 7 ill patrons and 2 of 27 employees who denied illness yielded ETEC. CONCLUSIONS: ETEC was identified as the etiologic agent of a large foodborne outbreak at a sushi restaurant in Nevada. Poor food-handling practices and infected foodhandlers likely contributed to this outbreak. Although ETEC is a well-documented cause of domestic foodborne outbreaks, few laboratories can test for it. Earlier recognition of ETEC infections may prevent subsequent outbreaks from occurring.

Epidemic diarrhea due to enterotoxigenic Escherichia coli.

BACKGROUND: In June 1998, we investigated one of the largest foodborne outbreaks of enterotoxigenic Escherichia coli gastroenteritis reported in the United States. METHODS: We conducted cohort studies of 11 catered events to determine risk factors for illness. We used stool cultures, polymerase chain reaction, and serologic tests to determine the etiologic agent, and we conducted an environmental inspection to identify predisposing conditions and practices at the implicated establishment. RESULTS: During 5-7 June, the implicated delicatessen catered 539 events attended by >16,000 people. Our epidemiological study of 11 events included a total of 612 attendees. By applying the median prevalence of illness (20%) among events with ill attendees to the total number of events with any ill attendees, we estimate that at least 3300 persons may have developed gastroenteritis during this outbreak. Multiple food items (potato salad, macaroni salad, egg salad, and watermelon) were associated with illness, all of which required extensive handling during preparation. Enterotoxigenic Escherichia coli serotype O6:H16 producing heat-labile and heat-stable toxins was isolated from the stool specimens from 11 patients. Eight patients with positive stool culture results, 11 (58%) of 19 other symptomatic attendees, and 0 (0%) of 17 control subjects had elevated serum antibody titers to E. coli O6 lipopolysaccharide. The delicatessen had inadequate hand-washing supplies, inadequate protection against back siphonage of wastewater in the potable water system, a poorly draining kitchen sink, and improper food storage and transportation practices. CONCLUSIONS: In the United States, where enterotoxigenic Escherichia coli is an emerging cause of foodborne disease, enterotoxigenic Escherichia coli should be suspected in outbreaks of gastroenteritis when common bacterial or viral enteric pathogens are not identified.

An Outbreak of Vibrio cholerae O1 infections on Ebeye Island, Republic of the Marshall Islands, associated with use of an adequately chlorinated water source.

In December 2000, physicians in the Republic of the Marshall Islands reported the first known outbreak of Vibrio cholerae O1 infection (biotype El Tor, serotype Ogawa) from this country. In a matched case-control study on Ebeye Island, patients with cholera (n=53) had greater odds than persons without cholera (n=104) to have drunk adequately chlorinated water collected from a US military installation on neighboring Kwajalein Island and transported back to Ebeye (matched odds ratio [MOR], 8.0; P=.01). Transporting or storing drinking water in a water cooler with a spout and a tight-fitting lid was associated with reduced odds of illness (MOR, 0.24; P<.01), as was drinking bottled water (MOR, 0.08; P<.01), boiled water (MOR, 0.47; P=.02), or water flavored with powdered drink mixes (MOR, 0.18; P<.01). No cases of cholera were reported among Kwajalein residents. This outbreak highlights the critical importance of handling and storing drinking water safely, especially during outbreaks of gastrointestinal illness.

Enterotoxin-producing Escherichia coli O169:H41, United States.

From 1996 to 2003, 16 outbreaks of enterotoxigenic Escherichia coli (ETEC) infections in the United States and on cruise ships were confirmed. E. coli serotype O169:H41 was identified in 10 outbreaks and was the only serotype in 6. This serotype was identified in 1 of 21 confirmed ETEC outbreaks before 1996.