Factors associated with uptake of guideline-recommended cardiovascular implantable electronic device management: a nationwide, retrospective cohort study.

Clinical guidelines recommend device removal for cardiovascular implantable electronic device (CIED) infection management. In this retrospective, nationwide cohort, 60.8% of CIED infections received guideline-concordant care. One-year mortality was higher among those without procedural management (25% vs 16%). Factors associated with receipt of device procedures included pocket infections and positive microbiology.

Engaging patients in antimicrobial stewardship: co-designed educational tool to improve periprocedural care through de-implementation of guideline-discordant antimicrobial use.

Effective de-implementation models often include replacement of an ineffective practice with an alternative. We co-developed patient education materials as a replacement strategy for inappropriate post-procedural antibiotics in cardiac device procedures. Lessons learned and developed materials may be used to promote infection prevention in other periprocedural settings.

A Novel Informatics Tool to Detect Periprocedural Antibiotic Allergy Adverse Events for Near Real-time Surveillance to Support Audit and Feedback.

Importance: Standardized processes for identifying when allergic-type reactions occur and linking reactions to drug exposures are limited. Objective: To develop an informatics tool to improve detection of antibiotic allergic-type events. Design, Setting, and Participants: This retrospective cohort study was conducted from October 1, 2015, to September 30, 2019, with data analyzed between July 1, 2021, and January 31, 2022. The study was conducted across Veteran Affairs hospitals among patients who underwent cardiovascular implantable electronic device (CIED) procedures and received periprocedural antibiotic prophylaxis. The cohort was split into training and test cohorts, and cases were manually reviewed to determine presence of allergic-type reaction and its severity. Variables potentially indicative of allergic-type reactions were selected a priori and included allergies entered in the Veteran Affair's Allergy Reaction Tracking (ART) system (either historical [reported] or observed), allergy diagnosis codes, medications administered to treat allergic reactions, and text searches of clinical notes for keywords and phrases indicative of a potential allergic-type reaction. A model to detect allergic-type reaction events was iteratively developed on the training cohort and then applied to the test cohort. Algorithm test characteristics were assessed. Exposure: Preprocedural and postprocedural prophylactic antibiotic administration. Main Outcomes and Measures: Antibiotic allergic-type reactions. Results: The cohort of 36 344 patients included 34 703 CIED procedures with antibiotic exposures (mean [SD] age, 72 [10] years; 34 008 [98%] male patients); median duration of postprocedural prophylaxis was 4 days (IQR, 2-7 days; maximum, 45 days). The final algorithm included 7 variables: entries in the Veteran Affair's hospitals ART, either historic (odds ratio [OR], 42.37; 95% CI, 11.33-158.43) or observed (OR, 175.10; 95% CI, 44.84-683.76); PheCodes for "symptoms affecting skin" (OR, 8.49; 95% CI, 1.90-37.82), "urticaria" (OR, 7.01; 95% CI, 1.76-27.89), and "allergy or adverse event to an antibiotic" (OR, 11.84, 95% CI, 2.88-48.69); keyword detection in clinical notes (OR, 3.21; 95% CI, 1.27-8.08); and antihistamine administration alone or in combination (OR, 6.51; 95% CI, 1.90-22.30). In the final model, antibiotic allergic-type reactions were identified with an estimated probability of 30% or more; positive predictive value was 61% (95% CI, 45%-76%); and sensitivity was 87% (95% CI, 70%-96%). Conclusions and Relevance: In this retrospective cohort study of patients receiving periprocedural antibiotic prophylaxis, an algorithm with a high sensitivity to detect incident antibiotic allergic-type reactions that can be used to provide clinician feedback about antibiotic harms from unnecessarily prolonged antibiotic exposures was developed.

Promoting de-implementation of inappropriate antimicrobial use in cardiac device procedures by expanding audit and feedback: protocol for hybrid III type effectiveness/implementation quasi-experimental study.

BACKGROUND: Despite a strong evidence base and clinical guidelines specifically recommending against prolonged post-procedural antimicrobial use, studies indicate that the practice is common following cardiac device procedures. Formative evaluations conducted by the study team suggest that inappropriate antimicrobial use may be driven by information silos that drive provider belief that antimicrobials are not harmful, in part due to lack of complete feedback about all types of clinical outcomes. De-implementation is recognized as an important area of research that can lead to reductions in unnecessary, wasteful, or harmful practices, such as excess antimicrobial use following cardiac device procedures; however, investigations into strategies that lead to successful de-implementation are limited. The overarching hypothesis to be tested in this trial is that a bundle of implementation strategies that includes audit and feedback about direct patient harms caused by inappropriate prescribing can lead to successful de-implementation of guideline-discordant care. METHODS: We propose a hybrid type III effectiveness-implementation stepped-wedge intervention trial at three high-volume, high-complexity VA medical centers. The main study intervention (an informatics-based, real-time audit-and-feedback tool) was developed based on learning/unlearning theory and formative evaluations and guided by the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) Framework. Elements of the bundled and multifaceted implementation strategy to promote appropriate prescribing will include audit-and-feedback reports that include information about antibiotic harms, stakeholder engagement, patient and provider education, identification of local champions, and blended facilitation. The primary study outcome is adoption of evidence-based practice (de-implementation of inappropriate antimicrobial use). Clinical outcomes (cardiac device infections, acute kidney injuries and Clostridioides difficile infections) are secondary. Qualitative interviews will assess relevant implementation outcomes (acceptability, adoption, fidelity, feasibility). DISCUSSION: De-implementation theory suggests that factors that may have a particularly strong influence on de-implementation include strength of the underlying evidence, the complexity of the intervention, and patient and provider anxiety and fear about changing an established practice. This study will assess whether a multifaceted intervention mapped to identified de-implementation barriers leads to measurable improvements in provision of guideline-concordant antimicrobial use. Findings will improve understanding about factors that impact successful or unsuccessful de-implementation of harmful or wasteful healthcare practices. TRIAL REGISTRATION: ClinicalTrials.gov NCT05020418.

The impact of school opening model on SARS-CoV-2 community incidence and mortality.

The role that traditional and hybrid in-person schooling modes contribute to the community incidence of SARS-CoV-2 infections relative to fully remote schooling is unknown. We conducted an event study using a retrospective nationwide cohort evaluating the effect of school mode on SARS-CoV-2 cases during the 12 weeks after school opening (July-September 2020, before the Delta variant was predominant), stratified by US Census region. After controlling for case rate trends before school start, state-level mitigation measures and community activity level, SARS-CoV-2 incidence rates were not statistically different in counties with in-person learning versus remote school modes in most regions of the United States. In the South, there was a significant and sustained increase in cases per week among counties that opened in a hybrid or traditional mode versus remote, with weekly effects ranging from 9.8 (95% confidence interval (CI) = 2.7-16.1) to 21.3 (95% CI = 9.9-32.7) additional cases per 100,000 persons, driven by increasing cases among 0-9 year olds and adults. Schools can reopen for in-person learning without substantially increasing community case rates of SARS-CoV-2; however, the impacts are variable. Additional studies are needed to elucidate the underlying reasons for the observed regional differences more fully.

The Impact of School Opening Model on SARS-CoV-2 Community Incidence and Mortality: A Nationwide Cohort Study.

The role that in-person schooling contributes to community incidence of SARS-CoV-2 infections and deaths remains unknown. We conducted an event study evaluating the effect of in-person school on SARS-CoV-2 cases and deaths per 100,000 persons during the 12-weeks following school opening, stratified by US Census region. There was no impact of in-person school opening and COVID-19 deaths. In most regions, COVID-19 incidence rates were not statistically different in counties with in-person versus remote school modes. However, in the South, there was a significant and sustained increase in cases per week among counties that opened for in-person learning versus remote learning, with weekly effects ranging from 7.8 (95% CI: 1.2-14.5) to 18.9 (95% CI: 7.9-29.9) additional cases per 100,000, driven by increases among 0-9 year olds and adults.

Effectiveness of 3 Versus 6 ft of Physical Distancing for Controlling Spread of Coronavirus Disease 2019 Among Primary and Secondary Students and Staff: A Retrospective, Statewide Cohort Study.

BACKGROUND: National and international guidelines differ about the optimal physical distancing between students for prevention of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission; studies directly comparing the impact of ≥3 versus ≥6 ft of physical distancing policies in school settings are lacking. Thus, our objective was to compare incident cases of SARS-CoV-2 in students and staff in Massachusetts public schools among districts with different physical distancing requirements. State guidance mandates masking for all school staff and for students in grades 2 and higher; the majority of districts required universal masking. METHODS: Community incidence rates of SARS-CoV-2, SARS-CoV-2 cases among students in grades K-12 and staff participating in-person learning, and district infection control plans were linked. Incidence rate ratios (IRRs) for students and staff members in traditional public school districts with ≥3 versus ≥6 ft of physical distancing were estimated using log-binomial regression; models adjusted for community incidence are also reported. RESULTS: Among 251 eligible school districts, 537 336 students and 99 390 staff attended in-person instruction during the 16-week study period, representing 6 400 175 student learning weeks and 1 342 574 staff learning weeks. Student case rates were similar in the 242 districts with ≥3 versus ≥6 ft of physical distancing between students (IRR, 0.891; 95% confidence interval, .594-1.335); results were similar after adjustment for community incidence (adjusted IRR, 0.904; .616-1.325). Cases among school staff in districts with ≥3 versus ≥6 ft of physical distancing were also similar (IRR, 1.015, 95% confidence interval, .754-1.365). CONCLUSIONS: Lower physical distancing requirements can be adopted in school settings with masking mandates without negatively affecting student or staff safety.