A Common Longitudinal Intensive Care Unit data Format (CLIF) to enable multi-institutional federated critical illness research.

Background: Critical illness, or acute organ failure requiring life support, threatens over five million American lives annually. Electronic health record (EHR) data are a source of granular information that could generate crucial insights into the nature and optimal treatment of critical illness. However, data management, security, and standardization are barriers to large-scale critical illness EHR studies. Methods: A consortium of critical care physicians and data scientists from eight US healthcare systems developed the Common Longitudinal Intensive Care Unit (ICU) data Format (CLIF), an open-source database format that harmonizes a minimum set of ICU Data Elements for use in critical illness research. We created a pipeline to process adult ICU EHR data at each site. After development and iteration, we conducted two proof-of-concept studies with a federated research architecture: 1) an external validation of an in-hospital mortality prediction model for critically ill patients and 2) an assessment of 72-hour temperature trajectories and their association with mechanical ventilation and in-hospital mortality using group-based trajectory models. Results: We converted longitudinal data from 94,356 critically ill patients treated in 2020-2021 (mean age 60.6 years [standard deviation 17.2], 30% Black, 7% Hispanic, 45% female) across 8 health systems and 33 hospitals into the CLIF format, The in-hospital mortality prediction model performed well in the health system where it was derived (0.81 AUC, 0.06 Brier score). Performance across CLIF consortium sites varied (AUCs: 0.74-0.83, Brier scores: 0.06-0.01), and demonstrated some degradation in predictive capability. Temperature trajectories were similar across health systems. Hypothermic and hyperthermic-slow-resolver patients consistently had the highest mortality. Conclusions: CLIF facilitates efficient, rigorous, and reproducible critical care research. Our federated case studies showcase CLIF's potential for disease sub-phenotyping and clinical decision-support evaluation. Future applications include pragmatic EHR-based trials, target trial emulations, foundational multi-modal AI models of critical illness, and real-time critical care quality dashboards.

Early Deep Sedation Practices Worsened During the Pandemic Among Adult Patients Without COVID-19: A Retrospective Cohort Study.

BACKGROUND: There is substantial evidence that patients with COVID-19 were treated with sustained deep sedation during the pandemic. However, it is unknown whether such guideline-discordant care had spillover effects to patients without COVID-19. RESEARCH QUESTION: Did patterns of early deep sedation change during the pandemic for patients on mechanical ventilation without COVID-19? STUDY DESIGN AND METHODS: We used electronic health record data from 4,237 patients who were intubated without COVID-19. We compared sedation practices in the first 48 h after intubation across prepandemic (February 1, 2018, to January 31, 2020), pandemic (April 1, 2020, to March 31, 2021), and late pandemic (April 1, 2021, to March 31, 2022) periods. RESULTS: In the prepandemic period, patients spent an average of 13.0 h deeply sedated in the first 48 h after intubation. This increased 1.9 h (95% CI, 1.0-2.8) during the pandemic period and 2.9 h (95% CI, 2.0-3.8) in the late pandemic period. The proportion of patients that spent over one-half of the first 48 h deeply sedated was 18.9% in the prepandemic period, 22.3% during the pandemic period, and 25.9% during the late pandemic period. Ventilator-free days decreased during the pandemic, with a subdistribution hazard ratio of being alive without mechanical ventilation at 28 days of 0.87 (95% CI, 0.79-0.95) compared with the prepandemic period. Tracheostomy placement increased during the pandemic period compared with the prepandemic period (OR, 1.41; 95% CI, 1.08-1.82). In the medical ICU, early deep sedation increased 2.5 h (95% CI, 0.6-4.4) during the pandemic period and 4.9 h (95% CI, 3.0-6.9) during the late pandemic period, compared with the prepandemic period. INTERPRETATION: We found that among patients on mechanical ventilation without COVID-19, sedation use increased during the pandemic. In the subsequent year, these practices did not return to prepandemic standards.

Association of Visitor Contact Precautions With Estimated Hospital-Onset Clostridioides difficile Infection Rates in Acute Care Hospitals.

Importance: Visitor contact precautions (VCPs) are commonly used to reduce the transmission of Clostridioides difficile at health care institutions. Implementing VCPs requires considerable personnel and personal protective equipment resources. However, it is unknown whether VCPs are associated with reduced hospital-onset C difficile infection (HO-CDI) rates. Objective: To estimate the association between VCPs and HO-CDI rates using simulation modeling. Design, Setting, and Participants: This simulation study, conducted between July 27, 2020, and August 11, 2020, used an established agent-based simulation model of C difficile transmission in a 200-bed acute care adult hospital to estimate the association between VCPs and HO-CDI while varying assumptions about factors such as patient susceptibility, behavior, and C difficile transmission. The model simulated hospital activity for 1 year among a homogeneous, simulated adult population. Interventions: No VCP use vs ideal use of VCPs under different hospital configurations. Main Outcomes and Measures: The rate of HO-CDI per 10 000 patient-days according to the Centers for Disease Control and Prevention's definition of HO-CDI. Results: With use of the simulation model, the baseline rate of HO-CDI was 7.94 10 000 patient-days (95% CI, 7.91-7.98 per 10 000 patient-days) with no VCP use compared with 7.97 per 10 000 patient-days (95% CI, 7.93-8.01 per 10 000 patient-days) with ideal VCP use. Visitor contact precautions were not associated with a reduction of more than 1% in HO-CDI rates in any of the tested scenarios and hospital settings. Independently increasing the hand-hygiene compliance of the average health care worker and environmental cleaning compliance by no more than 2% each was associated with greater HO-CDI reduction compared with all other scenarios, including VCPs. Conclusions and Relevance: In this simulation study, the association between VCPs and HO-CDI was minimal, but improvements in health care worker hand hygiene and environmental cleaning were associated with greater reductions in estimated HO-CDI. Hospitals may achieve a higher rate of reduction for HO-CDI by focusing on making small improvements in compliance with interventions other than VCP.

Effects of Recreational Marijuana Legalization on College Students: A Longitudinal Study of Attitudes, Intentions, and Use Behaviors.

PURPOSE: As legal recreational marijuana use expands rapidly across the U.S., there is growing concern that this will lead to higher rates of use among college-aged young adults. Given the limited research addressing this issue, a longitudinal study was conducted to evaluate the effects of legalizing recreational use on the attitudes, intentions, and marijuana use behaviors of college students in two different legalization contexts, Washington State and Wisconsin. METHODS: Survey data assessing marijuana attitudes, intentions, and use behavior were collected from 2011 to 2016 on a longitudinal cohort of 338 students at two large public universities in Washington and Wisconsin. Time series analyses were conducted to evaluate postlegalization changes in ever use, 28-day use, and mean attitude and intention-to-use scores in Washington state, using Wisconsin participants as the control group. RESULTS: Ever use, attitude, and intention-to-use scores did not change significantly more in Washington after legalization than in Wisconsin. However, among prior users, the proportion using in the last 28 days rose faster in Washington after legalization that it did in Wisconsin (p < .001). CONCLUSIONS: The findings suggest that legalization had the greatest effects on current marijuana users, who are surrounded by a climate that is increasingly supportive of its use.

Evaluation of the Cost-effectiveness of Infection Control Strategies to Reduce Hospital-Onset Clostridioides difficile Infection.

Importance: Clostridioides difficile infection is the most common hospital-acquired infection in the United States, yet few studies have evaluated the cost-effectiveness of infection control initiatives targeting C difficile. Objective: To compare the cost-effectiveness of 9 C difficile single intervention strategies and 8 multi-intervention bundles. Design, Setting, and Participants: This economic evaluation was conducted in a simulated 200-bed tertiary, acute care, adult hospital. The study relied on clinical outcomes from a published agent-based simulation model of C difficile transmission. The model included 4 agent types (ie, patients, nurses, physicians, and visitors). Cost and utility estimates were derived from the literature. Interventions: Daily sporicidal cleaning, terminal sporicidal cleaning, health care worker hand hygiene, patient hand hygiene, visitor hand hygiene, health care worker contact precautions, visitor contact precautions, C difficile screening at admission, and reduced intrahospital patient transfers. Main Outcomes and Measures: Cost-effectiveness was evaluated from the hospital perspective and defined by 2 measures: cost per hospital-onset C difficile infection averted and cost per quality-adjusted life-year (QALY). Results: In this agent-based model of a simulated 200-bed tertiary, acute care, adult hospital, 5 of 9 single intervention strategies were dominant, reducing cost, increasing QALYs, and averting hospital-onset C difficile infection compared with baseline standard hospital practices. They were daily cleaning (most cost-effective, saving $358 268 and 36.8 QALYs annually), health care worker hand hygiene, patient hand hygiene, terminal cleaning, and reducing intrahospital patient transfers. Screening at admission cost $1283/QALY, while health care worker contact precautions and visitor hand hygiene interventions cost $123 264/QALY and $5 730 987/QALY, respectively. Visitor contact precautions was dominated, with increased cost and decreased QALYs. Adding screening, health care worker hand hygiene, and patient hand hygiene sequentially to the daily cleaning intervention formed 2-pronged, 3-pronged, and 4-pronged multi-intervention bundles that cost an additional $29 616/QALY, $50 196/QALY, and $146 792/QALY, respectively. Conclusions and Relevance: The findings of this study suggest that institutions should seek to streamline their infection control initiatives and prioritize a smaller number of highly cost-effective interventions. Daily sporicidal cleaning was among several cost-saving strategies that could be prioritized over minimally effective, costly strategies, such as visitor contact precautions.

A systematic review of the effectiveness of cohorting to reduce transmission of healthcare-associated C. difficile and multidrug-resistant organisms.

BACKGROUND: Cohorting of patients and staff is a control strategy often used to prevent the spread of infection in healthcare institutions. However, a comprehensive evaluation of cohorting as a prevention approach is lacking. METHODS: We performed a systematic review of studies that used cohorting as part of an infection control strategy to reduce hospital-acquired infections. We included studies published between 1966 and November 30, 2019, on adult populations hospitalized in acute-care hospitals. RESULTS: In total, 87 studies met inclusion criteria. Study types were quasi-experimental "before and after" (n = 35), retrospective (n = 49), and prospective (n = 3). Case-control analysis was performed in 7 studies. Cohorting was performed with other infection control strategies in the setting of methicillin-resistant Staphylococcus aureus (MRSA, n = 22), Clostridioides difficile infection (CDI, n = 6), vancomycin-resistant Enterococcus (VRE, n = 17), carbapenem-resistant Enterobacteriaceae infections (CRE, n = 22), A. baumannii (n = 15), and other gram-negative infections (n = 5). Cohorting was performed either simultaneously (56 of 87, 64.4%) or in phases (31 of 87, 35.6%) to help contain transmission. In 60 studies, both patients and staff were cohorted. Most studies (77 of 87, 88.5%) showed a decline in infection or colonization rates after a multifaceted approach that included cohorting as part of the intervention bundle. Hand hygiene compliance improved in approximately half of the studies (8 of 15) during the respective intervention. CONCLUSION: Cohorting of staff, patients, or both is a frequently used and reasonable component of an enhanced infection control strategy. However, determining the effectiveness of cohorting as a strategy to reduce transmission of MDRO and C. difficile infections is difficult, particularly in endemic situations.

Reducing C. difficile in children: An agent-based modeling approach to evaluate intervention effectiveness.

OBJECTIVE: Clostridioides difficile infection (CDI) is rapidly increasing in children's hospitals nationwide. Thus, we aimed to compare the effectiveness of 9 infection prevention interventions and 6 multiple-intervention bundles at reducing hospital-onset CDI and asymptomatic C. difficile colonization. DESIGN: Agent-based simulation model of C. difficile transmission. SETTING: Computer-simulated, 80-bed freestanding, tertiary-care pediatric hospital, including 8 identical wards with 10 single-bed patient rooms each. PARTICIPANTS: The model includes 5 distinct agent types: patients, visitors, caregivers, nurses, and physicians. INTERVENTIONS: Daily and terminal environmental disinfection, screening at admission, reduced intrahospital patient transfers, healthcare worker (HCW), visitor, and patient hand hygiene, and HCW and visitor contact precautions. RESULTS: The model predicted that daily environmental disinfection with sporicidal product, combined with screening for asymptomatic C. difficile at admission, was the most effective 2-pronged infection prevention bundle, reducing hospital-onset CDI by 62.0% and asymptomatic colonization by 88.4%. Single-intervention strategies, including daily disinfection, terminal disinfection, asymptomatic screening at admission, HCW hand hygiene, and patient hand hygiene, as well as decreasing intrahospital patient transfers, all also reduced both hospital-onset CDI and asymptomatic colonization in the model. Visitor hand hygiene and visitor and HCW contact precautions were not effective at reducing either measure. CONCLUSIONS: Hospitals can achieve substantial reduction in hospital-onset CDIs by implementing a small number of highly effective interventions.

An in-room observation study of hand hygiene and contact precaution compliance for Clostridioides difficile patients.

Using an innovative, covert, in-room observer method to evaluate infection control practices for patients with Clostridioides difficile infection, we found no difference between physician and nursing hand hygiene compliance and contact precaution usage. There was also no diurnal variation in hand hygiene practices, but decreased contact precaution usage at night. Conversely, hospital-wide data from overt observations collected over the same time period showed significantly higher hand hygiene compliance among nurses than physicians.

Effect of Lactobacillus rhamnosus HN001 on carriage of Staphylococcus aureus: results of the impact of probiotics for reducing infections in veterans (IMPROVE) study.

BACKGROUND: Infection by Staphylococcus aureus (S. aureus) is a major cause of morbidity and mortality. Colonization by S. aureus increases the risk of infection. Little is known about decolonization strategies for S. aureus beyond antibiotics, however probiotics represent a promising alternative. A randomized controlled trial was conducted to determine the efficacy of Lactobacillus rhamnosus (L. rhamnosus) HN001 in reducing carriage of S. aureus at multiple body sites. METHODS: One hundred thirteen subjects, positive for S. aureus carriage, were recruited from the William S. Middleton Memorial Medical Center, Madison, WI, USA, and randomized by initial site of colonization, either gastrointestinal (GI) or extra-GI, to 4-weeks of oral L. rhamnosus HN001 probiotic, or placebo. Nasal, oropharyngeal, and axillary/groin swabs were obtained, and serial blood and fecal samples were collected. Differences in prevalence of S. aureus carriage at the end of the 4-weeks of treatment were assessed. RESULTS: The probiotic and placebo groups were similar in age, gender, and health history at baseline. S. aureus colonization within the stool samples of the extra-GI group was 15% lower in the probiotic than placebo group at the endpoint of the trial. Those in the probiotic group compared to the placebo group had 73% reduced odds (OR 0.27, 95% CI 0.07-0.98) of methicillin-susceptible S. aureus presence, and 83% reduced odds (OR 0.17, 95% CI 0.04-0.73) of any S. aureus presence in the stool sample at endpoint. CONCLUSION: Use of daily oral L. rhamnosus HN001 reduced odds of carriage of S. aureus in the GI tract, however it did not eradicate S. aureus from other body sites. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01321606 . Registered March 21, 2011.