COVID-19 passenger screening to reduce travel risk and translocation of disease.

Aviation passenger screening has been used worldwide to mitigate the translocation risk of SARS-CoV-2. We present a model that evaluates factors in screening strategies used in air travel and assess their relative sensitivity and importance in identifying infectious passengers. We use adapted Monte Carlo simulations to produce hypothetical disease timelines for the Omicron variant of SARS-CoV-2 for travelling passengers. Screening strategy factors assessed include having one or two RT-PCR and/or antigen tests prior to departure and/or post-arrival, and quarantine length and compliance upon arrival. One or more post-arrival tests and high quarantine compliance were the most important factors in reducing pathogen translocation. Screening that combines quarantine and post-arrival testing can shorten the length of quarantine for travelers, and variability and mean testing sensitivity in post-arrival RT-PCR and antigen tests decrease and increase with the greater time between the first and second post-arrival test, respectively. This study provides insight into the role various screening strategy factors have in preventing the translocation of infectious diseases and a flexible framework adaptable to other existing or emerging diseases. Such findings may help in public health policy and decision-making in present and future evidence-based practices for passenger screening and pandemic preparedness.

Cardiovascular Risk Assessment Among Adolescents and Youths Living With HIV: Evaluation of Electronic Health Record Findings and Implications.

BACKGROUND: The HIV epidemic remains a major public health concern, particularly among youths living with HIV. While the availability of antiretroviral therapy has significantly improved the health outcomes of people living with HIV, there is growing evidence that youths living with HIV may be at increased risk of cardiovascular disease. However, the underlying mechanisms linking HIV and cardiovascular disease among youths living with HIV remain poorly understood. One potential explanation is that HIV-related biomarkers, including detectable viral load (VL) and low cluster of differentiation 4 (CD4) lymphocyte counts, may contribute to increased cardiovascular risk. Despite the potential importance of these biomarkers, the relationship between HIV-related biomarkers and cardiovascular risk among youths living with HIV has been understudied. OBJECTIVE: To address this gap, we examined whether detectable VL and low CD4 lymphocyte counts, both of which are indications of unsuppressed HIV, were associated with cardiovascular risk among youths living with HIV. METHODS: We analyzed electronic health record data from 7 adolescent HIV clinics in the United States (813 youths living with HIV). We used multivariable linear regression to examine the relationship between detectable VL and CD4 lymphocyte counts of ≤200 and cardiovascular risk scores, which were adapted from the gender-specific Framingham algorithm. RESULTS: In our study, nearly half of the participants (366/766, 47.8%) had detectable VL, indicating unsuppressed HIV, while 8.6% (51/593) of them had CD4 lymphocyte counts of ≤200, suggesting weakened immune function. We found that those with CD4 lymphocyte counts of ≤200 had significantly higher cardiovascular risk, as assessed by Cardiac Risk Score2, than those with CD4 lymphocyte counts of >200 (P=.002). After adjusting for demographic and clinical factors, we found that for every 1000-point increase in VL copies/mL, the probability of having cardiovascular risk (Cardiac Risk Score2) increased by 38%. When measuring the strength of this connection, we observed a minor effect of VL on increased cardiovascular risk (ß=.134, SE 0.014; P=.006). We obtained similar results with Cardiac Risk Score1, but the effect of CD4 lymphocyte counts of ≤200 was no longer significant. Overall, our findings suggest that detectable VL is associated with increased cardiovascular risk among youths living with HIV, and that CD4 lymphocyte counts may play a role in this relationship as well. CONCLUSIONS: Our study highlights a significant association between unsuppressed HIV, indicated by detectable VL, and increased cardiovascular risk in youths living with HIV. These findings emphasize the importance of implementing interventions that address both VL suppression and cardiovascular risk reduction in this population. By tailoring interventions to meet the unique needs of youths, we can promote overall well-being throughout the HIV care continuum and across the life span. Ultimately, these efforts have the potential to improve the health outcomes and quality of life of youths living with HIV. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/11185.

Assessment of phthalic acid esters plasticizers in sediments of coastal Alabama, USA: Occurrence, source, and ecological risk.

Considering the ubiquitous occurrences and ecotoxicity of phthalates (PAEs), it is essential to understand their sources, distribution, and associated ecological risks of PAEs in sediments to assess the environmental health of estuaries and support effective management practices. This study provides the first comprehensive dataset on the occurrence, spatial variation, inventory, and potential ecological risk assessment of PAEs in surface sediments of commercially and ecologically significant estuaries in the southeastern United States, Mobile Bay and adjoining eastern Mississippi Sound. Fifteen PAEs were widely detected in the sediments of the study region, with total concentrations varying between 0.02 and 3.37 µg/g. The dominance of low-molecular-weight (LMW) PAEs (DEP, DBP and DiBP) relative to high-molecular-weight (HMW) PAEs (DEHP, DOP, DNP) indicates that residential activities have stronger impacts than industrial activities on PAE distributions. The total PAE concentrations displayed an overall decreasing trend with increasing bottom water salinity, with the maximum concentrations occurring near river mouths. These observations suggest that river inputs were an important pathway by which PAEs were transported to the estuary. Linear regression models identified sediment adsorption (measured by total organic carbon and median grain size) and riverine inputs (measured by bottom water salinity) as significant predictors for the concentrations of LMW and HMW PAEs. Estimated 5-year total inventories of sedimentary PAEs in Mobile Bay and the eastern Mississippi Sound were 13.82 tons and 1.16 tons, respectively. Risk assessment calculations suggest that LMW PAEs posed a medium-to-high risk to sensitive aquatic organisms, and DEHP posed a low or negligible risk to the aquatic organisms. The results of this study provide important information needed for establishing and implementing effective practices for monitoring and regulating plasticizer pollutants in estuaries.

Conservative nonsurgical treatment for cranial cruciate ligament disease can be an effective management strategy in cats based on validated owner-based subjective assessment in some cases.

OBJECTIVE: To describe long-term outcomes of cats managed medically for cranial cruciate ligament disease (CCLD) via a validated owner-based questionnaire. ANIMALS: 18 client-owned cats. PROCEDURES: Retrospective review of medical records at 2 tertiary referral hospitals was conducted for records of cats diagnosed with CCLD for which medical management was pursued. History, physical examination findings, and medical management strategies were recorded. Owner follow-up was obtained via phone call or an email correspondence interview using a 2-part questionnaire. Part 1 consisted of 5 multiple-choice questions evaluating short-term outcomes following initiation of medical management. Part 2 assessed long-term outcomes via the validated Feline Musculoskeletal Pain Index-short form metrology instrument. RESULTS: Mean follow-up time was 66.5 ± 46.7 months (range, 7 to 154 months). Medical management included oral analgesics, activity restriction, and joint supplements. Of the 18 cats, 13 (72%) were always able to bear weight or became weight bearing within a week following initiation of medical management, and 15 (83%) were reportedly clinically normal within 3 months of initiating medical management, with complete resolution of lameness occurring in less than 2 months in 12 of those cats. Long term, 17 of the 18 (94%) owners reported they felt that their cat had a good to excellent outcome with medical management. The mean Feline Musculoskeletal Pain Index-short form score of all cats was 0.29 ± 0.53 (range, 0 to 2.13). CLINICAL RELEVANCE: Based on owner follow-up, conservative, nonsurgical management of CCLD can be an effective and appropriate management strategy for some cats; however, some may be best treated with surgical stabilization.

Sexual Subcultures and HIV Prevention Methods: An Assessment of Condom Use, PrEP, and TasP Among Gay, Bisexual, and Other Men Who Have Sex with Men Using a Social and Sexual Networking Smartphone Application.

Despite being grouped together in epidemiological risk categories, gay, bisexual, and other men who have sex with men (GBM) are not a homogenous group. In addition to traditional segmentation along race, ethnicity, and socioeconomic status, many GBM also identify with sexual subcultural communities. Previous research has shown differences across a variety of health outcomes between these sexual subcultural communities. The purpose of this study was to determine whether HIV prevention practices among GBM differed according to sexual subcultural community. The study was conducted in collaboration with a popular social and sexual networking smartphone application company. A total of 23,577 GBM responded to the survey. A latent class analysis identified 6 distinct classes related to sexual subcultural community identification. We found significant differences across sociodemographic characteristics, HIV prevention practices, and condomless anal sex in the past 6 months related to sexual subculture identification. Findings suggest that sexual subcultural identity is related to decision-making around HIV prevention among GBM. Differences in HIV prevention strategies are likely a function of group norms, unique shared experiences among GBM identifying with a particular sexual subculture community, and sociodemographic characteristics associated with these groups. As such, sexual subculture identity should be considered in developing interventions and social marketing campaigns to increase uptake of biomedical HIV prevention tools among GBM. Identifying group norms and shared experiences related to HIV prevention practices among sexual subcultures is necessary to understand the role these identities play in lives of GBM, especially as it relates to their sexual health and well-being.

Racial and ethnic disparities in SARS-CoV-2 pandemic: analysis of a COVID-19 observational registry for a diverse US metropolitan population.

INTRODUCTION: Data on race and ethnic disparities for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection are limited. We analysed sociodemographic factors associated with higher likelihood of SARS-CoV-2 infection and explore mediating pathways for race and ethnic disparities in the SARS-CoV-2 pandemic. METHODS: This is a cross-sectional analysis of the COVID-19 Surveillance and Outcomes Registry, which captures data for a large healthcare system, comprising one central tertiary care hospital, seven large community hospitals and an expansive ambulatory/emergency care network in the Greater Houston area. Nasopharyngeal samples for individuals inclusive of all ages, races, ethnicities and sex were tested for SARS-CoV-2. We analysed sociodemographic (age, sex, race, ethnicity, household income, residence population density) and comorbidity (Charlson Comorbidity Index, hypertension, diabetes, obesity) factors. Multivariable logistic regression models were fitted to provide adjusted OR (aOR) and 95% CI for likelihood of a positive SARS-CoV-2 test. Structural equation modelling (SEM) framework was used to explore three mediation pathways (low income, high population density, high comorbidity burden) for the association between non-Hispanic black (NHB) race, Hispanic ethnicity and SARS-CoV-2 infection. RESULTS: Among 20 228 tested individuals, 1551 (7.7%) tested positive. The overall mean (SD) age was 51.1 (19.0) years, 62% were females, 22% were black and 18% were Hispanic. NHB and Hispanic ethnicity were associated with lower socioeconomic status and higher population density residence. In the fully adjusted model, NHB (vs non-Hispanic white; aOR, 2.23, CI 1.90 to 2.60) and Hispanic ethnicity (vs non-Hispanic; aOR, 1.95, CI 1.72 to 2.20) had a higher likelihood of infection. Older individuals and males were also at higher risk of infection. The SEM framework demonstrated a significant indirect effect of NHB and Hispanic ethnicity on SARS-CoV-2 infection mediated via a pathway including residence in densely populated zip code. CONCLUSIONS: There is strong evidence of race and ethnic disparities in the SARS-CoV-2 pandemic that are potentially mediated through unique social determinants of health.

An exploration of community partnerships, safety-net hospitals, and readmission rates.

OBJECTIVE: To compare hospital-community partnerships among safety-net hospitals relative to non-safety-net hospitals, and explore whether hospital-community partnerships are associated with reductions in readmission rates. DATA SOURCES: Data from four nationwide hospital-level datasets for 2015-2016, including American Hospital Association (AHA) annual survey, Hospital Inpatient Prospective Payment System (IPPS) data, CMS Hospital Compare, and County Health Rankings National (CHRN) data. STUDY DESIGN: We first examined how safety-net hospitals partner with nine different community providers, and how the overall and individual partnership patterns differ from those in non-safety-net hospitals. We then explored their association with 30-day readmission rates by diagnosis and hospital wide. DATA COLLECTION/EXTRACTION METHODS: We included 1979 hospitals across 50 US states. PRINCIPAL FINDINGS: Safety-net hospitals were more engaged in hospital-community partnerships, especially with local public health, local governments, social services, nonprofits, and insurance companies, relative to their non-safety-net peers. However, we found that such partnerships were not significantly related to reductions in readmission rates. The findings indicated that merely partnering with various community organizations may not be associated with readmission rate reduction. CONCLUSIONS: Before promoting partnerships with various community organizations for its own sake, further prospective, longitudinal, and evidence-based guidance derived from the study of hospital-community partnerships is needed to make meaningful recommendations aimed at readmission rate reduction in safety-net hospitals.

Using routine referral data for patients with knee and hip pain to improve access to specialist care.

BACKGROUND: Referral letters from primary care contain a large amount of information that could be used to improve the appropriateness of the referral pathway for individuals seeking specialist opinion for knee or hip pain. The primary aim of this study was to evaluate the content of the referral letters to identify information that can independently predict an optimal care pathway. METHODS: Using a prospective longitudinal design, a convenience sample of patients with hip or knee pain were recruited from orthopaedic, specialist general practice and advanced physiotherapy practitioner clinics. Individuals completed a Knee or hip Osteoarthritis Outcome Score at initial consultation and after 6 months. Participant demographics, body mass index, medication and co-morbidity data were extracted from the referral letters. Free text of the referral letters was mapped automatically onto the Unified Medical Language System to identify relevant clinical variables. Treatment outcomes were extracted from the consultation letters. Each outcome was classified as being an optimal or sub-optimal pathway, where an optimal pathway was defined as the one that results in the right treatment at the right time. Logistic regression was used to identify variables that were independently associated with an optimal pathway. RESULTS: A total of 643 participants were recruited, 419 (66.7%) were classified as having an optimal pathway. Variables independently associated with having an optimal care pathway were lower body mass index (OR 1.0, 95% CI 0.9 to 1.0 p = 0.004), named disease or syndromes (OR 1.8, 95% CI 1.1 to 2.8, p = 0.02) and taking pharmacologic substances (OR 1.8, 95% CI 1.0 to 3.3, p = 0.02). Having a single diagnostic procedure was associated with a suboptimal pathway (OR 0.5, 95% CI 0.3 to 0.9 p < 0.001). Neither Knee nor Hip Osteoarthritis Outcome scores were associated with an optimal pathway. Body mass index was found to be a good predictor of patient rated function (coefficient - 0.8, 95% CI -1.1, - 0.4 p < 0.001). CONCLUSION: Over 30% of patients followed sub-optimal care pathway, which represents potential inefficiency and wasted healthcare resource. A core data set including body mass index should be considered as this was a predictor of optimal care and patient rated pain and function.

Clinical and Economic Impact of Implementing OVIVA Criteria on Patients With Bone and Joint Infections in Outpatient Parenteral Antimicrobial Therapy.

The OVIVA study demonstrated noninferiority for managing bone and joint infections (BJIs) with oral antibiotics. We report that 79.7% of OPAT patients being treated for BJIs at our center would be eligible for oral antibiotics, saving a median (IQR) 19.5 IV-antibiotic days (8.5-37) and GBP 1234 (569-2594) per patient.

An assessment of the microbial community in an urban fringing tidal marsh with an emphasis on petroleum hydrocarbon degradative genes.

Small fringing marshes are ecologically important habitats often impacted by petroleum. We characterized the phylogenetic structure (16S rRNA) and petroleum hydrocarbon degrading alkane hydroxylase genes (alkB and CYP 153A1) in a sediment microbial community from a New Hampshire fringing marsh, using alkane-exposed dilution cultures to enrich for petroleum degrading bacteria. 16S rRNA and alkB analysis demonstrated that the initial sediment community was dominated by Betaproteobacteria (mainly Comamonadaceae) and Gammaproteobacteria (mainly Pseudomonas), while CYP 153A1 sequences predominantly matched Rhizobiales. 24 h of exposure to n-hexane, gasoline, dodecane, or dilution culture alone reduced functional and phylogenetic diversity, enriching for Gammaproteobacteria, especially Pseudomonas. Gammaproteobacteria continued to dominate for 10 days in the n-hexane and no alkane exposed samples, while dodecane and gasoline exposure selected for gram-positive bacteria. The data demonstrate that small fringing marshes in New England harbor petroleum-degrading bacteria, suggesting that petroleum degradation may be an important fringing marsh ecosystem function.

Outer Retinal Assessment Using Spectral-Domain Optical Coherence Tomography in Patients With Alzheimer's and Parkinson's Disease.

Purpose: To investigate outer retinal parameters among patients with various chronic neurodegenerative disorders by using spectral-domain coherence tomography (OCT) in a prospective cross-sectional cohort study. Methods: A total of 132 participants were enrolled following a comprehensive diagnostic evaluation with neurologic, neuropsychology, and magnetic resonance imaging volumetric evaluations. Participants were 50 years or older, either diagnosed with Alzheimer's disease (AD) dementia, amnestic mild cognitive impairment (MCI), non-AD dementia, Parkinson's disease (PD), or age- and sex-matched controls. All participants underwent a macular cube scan for both eyes by using the Cirrus 4000 HD-OCT (Zeiss, Oberkochen, Germany). The OCT image with the best quality was selected for further analysis. Outer retinal parameters including ellipsoid zone mapping and outer nuclear layer metrics were evaluated with a novel software platform. Results: One hundred twenty-four eyes of 124 participants with AD dementia (24 eyes), amnestic MCI (22 eyes), non-AD dementia (20 eyes), PD (22 eyes), and age- and sex-matched controls (36 eyes) were included in the analysis. Eight eyes were excluded either due to the presence of macular disease or poor quality of the OCT image. The mean ages of participants were 65.9 ± 8.9 years. The outer retinal thickness measures did not show any statistical significance between the groups. However, ellipsoid zone to retinal pigment epithelium volume correlated with cognitive testing scores in all study participants. Conclusions: There were no identifiable differences in the outer retinal metrics across neurodegenerative disease groups and controls. The relationship between the degree of cognitive impairment and ellipsoid zone to retinal pigment epithelium volume warrants further study.

Assessment of Administrative Medical Claims Data for Public Health Surveillance of Invasive Group A Streptococcal Necrotizing Fasciitis in Tennessee.

OBJECTIVE: Necrotizing fasciitis (NF) is a severe manifestation of invasive group A streptococcal (iGAS) infection. NF is a rapidly progressive infection of the subcutaneous tissues, including the fascia, and accurate diagnosis and prompt treatment are critical. Population-based surveillance is conducted for iGAS, including the severe manifestations of NF, by the federally funded Active Bacterial Core surveillance (ABCs) program. METHODS: We used administrative claims data from a large managed care organization in Tennessee to enhance the public health surveillance for NF iGAS. For the period 2003-2012, we identified cases of NF in Tennessee by searching the claims database for diagnostic codes indicating the diagnosis of NF. We compared these cases with cases detected in selected Tennessee counties by ABCs. RESULTS: Of 356 managed care patients with a diagnostic code indicating NF, we determined that 20 (6%) patients had been hospitalized with iGAS infection and, therefore, were likely to be true NF cases. Of these 20 patients, only 11 matched with patients identified by ABCs; nine patients had not been previously identified by ABCs. During the same time period, 54 patients with NF were ascertained by ABCs. CONCLUSION: Administrative claims data have the potential to augment disease surveillance but require a large investment in resources compared with the few NF cases identified.

Optic Nerve Assessment Using 7-Tesla Magnetic Resonance Imaging.

PURPOSE: The purpose of this study was to correlate high-resolution magnetic resonance imaging (MRI) and histologic findings in a case of juxtapapillary choroidal melanoma with clinical evidence of optic nerve invasion. METHODS: With institutional review board approval, an enucleated globe with choroidal melanoma and optic nerve invasion was imaged using a 7-tesla MRI followed by histopathologic evaluation. RESULTS: Optical coherence tomography, B-scan ultrasonography, and 1.5-tesla MRI of the orbit (1-mm sections) could not detect optic disc invasion. Ex vivo, 7-tesla MRI detected optic nerve invasion, which correlated with histopathologic features. CONCLUSIONS: Our case demonstrates the potential to document the existence of optic nerve invasion in the presence of an intraocular tumor, a feature that has a major bearing on decision making, particularly for consideration of enucleation.

Short Report. Audit of Conscious Sedation Provision in a Salaried Dental Service.

Clinical audit is a tool that may be used to improve the quality of care and outcomes for patients in a health care setting as well as a mechanism for clinicians to reflect on their performance. The audit described in this short report involved the collection and analysis of data related to the administration of 1,756 conscious sedations, categorised as standard techniques, by clinicians employed by an NHS Trust-based dental service during the year 2014. Data collected included gender, age and medical status of subject, the type of care delivered, the dose of drug administered and the quality of the achieved sedation and any sedation-related complications. This was the first time that a service-wide clinical audit had been undertaken with the objective of determining the safety and effectiveness of this aspect of care provision. Evaluation of the analysed data supported the perceived view that such care was being delivered satisfactorily. This on-going audit will collect data during year 2016 on the abandonment of clinical sessions, in which successful sedation had been achieved, due to the failure to obtain adequate local anaesthesia.

One-stage or two-stage revision surgery for prosthetic hip joint infection--the INFORM trial: a study protocol for a randomised controlled trial.

BACKGROUND: Periprosthetic joint infection (PJI) affects approximately 1% of patients following total hip replacement (THR) and often results in severe physical and emotional suffering. Current surgical treatment options are debridement, antibiotics and implant retention; revision THR; excision of the joint and amputation. Revision surgery can be done as either a one-stage or two-stage operation. Both types of surgery are well-established practice in the NHS and result in similar rates of re-infection, but little is known about the impact of these treatments from the patient's perspective. The main aim of this randomised controlled trial is to determine whether there is a difference in patient-reported outcome measures 18 months after randomisation for one-stage or two-stage revision surgery. METHODS/DESIGN: INFORM (INFection ORthopaedic Management) is an open, two-arm, multi-centre, randomised, superiority trial. We aim to randomise 148 patients with eligible PJI of the hip from approximately seven secondary care NHS orthopaedic units from across England and Wales. Patients will be randomised via a web-based system to receive either a one-stage revision or a two-stage revision THR. Blinding is not possible due to the nature of the intervention. All patients will be followed up for 18 months. The primary outcome is the WOMAC Index, which assesses hip pain, function and stiffness, collected by questionnaire at 18 months. Secondary outcomes include the following: cost-effectiveness, complications, re-infection rates, objective hip function assessment and quality of life. A nested qualitative study will explore patients' and surgeons' experiences, including their views about trial participation and randomisation. DISCUSSION: INFORM is the first ever randomised trial to compare two widely accepted surgical interventions for the treatment of PJI: one-stage and two-stage revision THR. The results of the trial will benefit patients in the future as the main focus is on patient-reported outcomes: pain, function and wellbeing in the long term. Patients state that these outcomes are more important than those that are clinically derived (such as re-infection) and have been commonly used in previous non-randomised studies. Results from the INFORM trial will also benefit clinicians and NHS managers by enabling the comparison of these key interventions in terms of patients' complication rates, health and social resource use and their overall cost-effectiveness. TRIAL REGISTRATION: Current controlled trials ISRCTN10956306 (registered on 29 January 2015); UKCRN ID 18159.

Outcomes and Resource Use of Sepsis-associated Stays by Presence on Admission, Severity, and Hospital Type.

OBJECTIVE: To establish a baseline for the incidence of sepsis by severity and presence on admission in acute care hospital settings before implementation of a broad sepsis screening and response initiative. METHODS: A retrospective cohort study using hospital discharge abstracts of 5672 patients, aged 18 years and above, with sepsis-associated stays between February 2012 and January 2013 at an academic medical center and 5 community hospitals in Texas. RESULTS: Sepsis was present on admission in almost 85% of cases and acquired in-hospital in the remainder. The overall inpatient death rate was 17.2%, but was higher in hospital-acquired sepsis (38.6%, medical; 29.2%, surgical) and Stages 2 (17.6%) and 3 (36.4%) compared with Stage 1 (5.9%). Patients treated at the academic medical center had a higher death rate (22.5% vs. 15.1%, P<0.001) and were more costly ($68,050±184,541 vs. $19,498±31,506, P<0.001) versus community hospitals. CONCLUSIONS: Greater emphasis is needed on public awareness of sepsis and the detection of sepsis in the prehospitalization and early hospitalization period. Hospital characteristics and case mix should be accounted for in cross-hospital comparisons of sepsis outcomes and costs.

Reductions in Sepsis Mortality and Costs After Design and Implementation of a Nurse-Based Early Recognition and Response Program.

BACKGROUND: Sepsis is a leading cause of death, but evidence suggests that early recognition and prompt intervention can save lives. In 2005 Houston Methodist Hospital prioritized sepsis detection and management in its ICU. In late 2007, because of marginal effects on sepsis death rates, the focus shifted to designing a program that would be readily used by nurses and ensure early recognition of patients showing signs suspicious for sepsis, as well as the institution of prompt, evidence-based interventions to diagnose and treat it. METHODS: The intervention had four components: organizational commitment and data-based leadership; development and integration of an early sepsis screening tool into the electronic health record; creation of screening and response protocols; and education and training of nurses. Twice-daily screening of patients on targeted units was conducted by bedside nurses; nurse practitioners initiated definitive treatment as indicated. Evaluation focused on extent of implementation, trends in inpatient mortality, and, for Medicare beneficiaries, a before-after (2008-2011) comparison of outcomes and costs. A federal grant in 2012 enabled expansion of the program. RESULTS: By year 3 (2011) 33% of inpatients were screened (56,190 screens in 9,718 unique patients), up from 10% in year 1 (2009). Inpatient sepsis-associated death rates decreased from 29.7% in the preimplementation period (2006-2008) to 21.1% after implementation (2009-2014). Death rates and hospital costs for Medicare beneficiaries decreased from preimplementation levels without a compensatory increase in discharges to postacute care. CONCLUSION: This program has been associated with lower inpatient death rates and costs. Further testing of the robustness and exportability of the program is under way.