Machine-Aided Bridge Deck Crack Condition State Assessment Using Artificial Intelligence.

The Federal Highway Administration (FHWA) mandates biannual bridge inspections to assess the condition of all bridges in the United States. These inspections are recorded in the National Bridge Inventory (NBI) and the respective state's databases to manage, study, and analyze the data. As FHWA specifications become more complex, inspections require more training and field time. Recently, element-level inspections were added, assigning a condition state to each minor element in the bridge. To address this new requirement, a machine-aided bridge inspection method was developed using artificial intelligence (AI) to assist inspectors. The proposed method focuses on the condition state assessment of cracking in reinforced concrete bridge deck elements. The deep learning-based workflow integrated with image classification and semantic segmentation methods is utilized to extract information from images and evaluate the condition state of cracks according to FHWA specifications. The new workflow uses a deep neural network to extract information required by the bridge inspection manual, enabling the determination of the condition state of cracks in the deck. The results of experimentation demonstrate the effectiveness of this workflow for this application. The method also balances the costs and risks associated with increasing levels of AI involvement, enabling inspectors to better manage their resources. This AI-based method can be implemented by asset owners, such as Departments of Transportation, to better serve communities.

Differentiating severe and non-severe lower respiratory tract illness in patients hospitalized with influenza: Development of the Influenza Disease Evaluation and Assessment of Severity (IDEAS) scale.

BACKGROUND: Experimental studies have shown that vaccination can reduce viral replication to attenuate progression of influenza-associated lower respiratory tract illness (LRTI). However, clinical studies are conflicting, possibly due to use of non-specific outcomes reflecting a mix of large and small airway LRTI lacking specificity for acute lung or organ injury. METHODS: We developed a global ordinal scale to differentiate large and small airway LRTI in hospitalized adults with influenza using physiologic features and interventions (PFIs): vital signs, laboratory and radiographic findings, and clinical interventions. We reviewed the literature to identify common PFIs across 9 existing scales of pneumonia and sepsis severity. To characterize patients using this scale, we applied the scale to an antiviral clinical trial dataset where these PFIs were measured through routine clinical care in adults hospitalized with influenza-associated LRTI during the 2010-2013 seasons. RESULTS: We evaluated 12 clinical parameters among 1020 adults; 210 (21%) had laboratory-confirmed influenza, with a median severity score of 4.5 (interquartile range, 2-8). Among influenza cases, median age was 63 years, 20% were hospitalized in the prior 90 days, 50% had chronic obstructive pulmonary disease, and 22% had congestive heart failure. Primary influencers of higher score included pulmonary infiltrates on imaging (48.1%), heart rate ≥110 beats/minute (41.4%), oxygen saturation <93% (47.6%) and respiratory rate >24 breaths/minute (21.0%). Key PFIs distinguishing patients with severity < or ≥8 (upper quartile) included infiltrates (27.1% vs 90.0%), temperature ≥ 39.1°C or <36.0°C (7.1% vs 27.1%), respiratory rate >24 breaths/minute (7.9% vs 47.1%), heart rate ≥110 beats/minute (29.3% vs 65.7%), oxygen saturation <90% (14.3% vs 31.4%), white blood cell count >15,000 (5.0% vs 27.2%), and need for invasive or non-invasive mechanical ventilation (2.1% vs 15.7%). CONCLUSION: We developed a scale in adults hospitalized with influenza-associated LRTI demonstrating a broad distribution of physiologic severity which may be useful for future studies evaluating the disease attenuating effects of influenza vaccination or other therapeutics.

Socioeconomic Position and the Incidence, Severity, and Clinical Outcomes of Hospitalized Patients With Community-Acquired Pneumonia.

OBJECTIVES: The influence of socioeconomic disparities on adults with pneumonia is not well understood. The objective of our study was to evaluate the relationship between community-level socioeconomic position, as measured by an area deprivation index, and the incidence, severity, and outcomes among adults with community-acquired pneumonia (CAP). METHODS: This was an ancillary study of a population-based, prospective cohort study of patients hospitalized with CAP in Louisville, Kentucky, from June 1, 2013, through May 31, 2015. We used a race-specific, block group-level area deprivation index as a proxy for community-level socioeconomic position and evaluated it as a predictor of CAP incidence, CAP severity, early clinical improvement, 30-day mortality, and 1-year mortality. RESULTS: The cohort comprised 6349 unique adults hospitalized with CAP. CAP incidence per 100 000 population increased significantly with increasing levels of area deprivation, from 303 in tertile 1 (low deprivation), to 467 in tertile 2 (medium deprivation), and 553 in tertile 3 (high deprivation) (P < .001). Adults in medium- and high-deprivation areas had significantly higher odds of severe CAP (tertile 2 odds ratio [OR] = 1.2 [95% confidence interval (CI), 1.06-1.39]; tertile 3 OR = 1.4 [95% CI, 1.18-1.64] and 1-year mortality (tertile 2 OR = 1.3 [95% CI, 1.11-1.54], tertile 3 OR = 1.3 [95% CI, 1.10-1.64]) than adults in low-deprivation areas. CONCLUSIONS: Compared with adults residing in low-deprivation areas, adults residing in high-deprivation areas had an increased incidence of CAP, and they were more likely to have severe CAP. Beyond 30 days of care, we identified an increased long-term mortality for persons in high-deprivation areas. Community-level socioeconomic position should be considered an important factor for research in CAP and policy decisions.

Adults Hospitalized With Pneumonia in the United States: Incidence, Epidemiology, and Mortality.

BACKGROUND: Understanding the burden of community-acquired pneumonia (CAP) is critical to allocate resources for prevention, management, and research. The objectives of this study were to define incidence, epidemiology, and mortality of adult patients hospitalized with CAP in the city of Louisville, and to estimate burden of CAP in the US adult population. METHODS: This was a prospective population-based cohort study of adult residents in Louisville, Kentucky, from 1 June 2014 to 31 May 2016. Consecutive hospitalized patients with CAP were enrolled at all adult hospitals in Louisville. The annual population-based CAP incidence was calculated. Geospatial epidemiology was used to define ecological associations among CAP and income level, race, and age. Mortality was evaluated during hospitalization and at 30 days, 6 months, and 1 year after hospitalization. RESULTS: During the 2-year study, from a Louisville population of 587499 adults, 186384 hospitalizations occurred. A total of 7449 unique patients hospitalized with CAP were documented. The annual age-adjusted incidence was 649 patients hospitalized with CAP per 100000 adults (95% confidence interval, 628.2-669.8), corresponding to 1591825 annual adult CAP hospitalizations in the United States. Clusters of CAP cases were found in areas with low-income and black/African American populations. Mortality during hospitalization was 6.5%, corresponding to 102821 annual deaths in the United States. Mortality at 30 days, 6 months, and 1 year was 13.0%, 23.4%, and 30.6%, respectively. CONCLUSIONS: The estimated US burden of CAP is substantial, with >1.5 million unique adults being hospitalized annually, 100000 deaths occurring during hospitalization, and approximately 1 of 3 patients hospitalized with CAP dying within 1 year.

Cost effectiveness of adherence to IDSA/ATS guidelines in elderly patients hospitalized for Community-Aquired Pneumonia.

BACKGROUND: Adherence to guidelines for the treatment of hospitalized elderly patients with community-acquired pneumonia (CAP) has been associated with improved clinical outcomes. This study evaluated the cost-effectiveness of adherence to guidelines for the treatment of CAP in an elderly hospitalized patient cohort. METHODS: Data from an international, multicenter observational study for patients age 65 years or older hospitalized with CAP from 2001 to 2007 were used to estimate transition probabilities for a multi-state Markov model traversing multiple health states during hospitalization for CAP. Empiric antibiotic therapy was classified as adherent, over-treated, and under-treated according to 2007 Infectious Disease Society of America/American Thoracic Society IDSA/ATS guidelines. Utilities were estimated from an expert panel of active clinicians. Costs were estimated from a tertiary referral hospital and adjusted for inflation to 2013 US dollars. Costs, utilities, and transition probabilities were all modeled using probability distributions to handle their inherit uncertainty. Cost-effectiveness analysis was based on the first 14 days of hospitalization. Patients admitted to the intensive care unit (ICU) were analyzed separately from those admitted to the ward. Sensitivity analyses with regards to time frame (out to 30 days hospitalization), cost estimates, and willingness to pay values were performed. RESULTS: The model parameters were estimated using data from 1635 patients (1438 admitted to the ward and 197 admitted to the ICU). For the ward model, adherence to antibiotic guidelines was the dominant strategy and associated with lower costs (-$1379 and -$799) and improved quality of life compared to over- and under-treatment. In the ICU model, however, adherence to guidelines was associated with greater costs (+$13,854 and + $3461 vs. over- and under-treatment, respectively) and lower quality of life. Acceptance rates across the willingness to pay ranges evaluated were 42-48 % for guideline adherence on the ward and 61-64 % for over-treatment on the ICU. Results were robust over sensitivity analyses concerning cost and utility estimates. CONCLUSIONS: While adherence to antibiotic guidelines was the most cost-effective strategy for elderly patients hospitalized with CAP and admitted to the ward, in the ICU over-treatment of patients relative to the guidelines was the most cost-effective strategy.

The value of ready-to-use disinfectant wipes: compliance, employee time, and costs.

Cleaning and disinfection practices of environmental surfaces are critical interventions for reducing health care-associated infections. We studied the value of ready-to-use cleaning and disinfection wipes compared with the traditional towel and bucket method. When using ready-to-use wipes, we found compliance to be significantly higher, a more rapid cleaning and disinfection process, and potential cost savings. Facilities should consider these products when making environmental services product selections.

Development and implementation of a performance improvement project in adult intensive care units: overview of the Improving Medicine Through Pathway Assessment of Critical Therapy in Hospital-Acquired Pneumonia (IMPACT-HAP) study.

INTRODUCTION: In 2005 the American Thoracic Society and Infectious Diseases Society of America (ATS/IDSA) published guidelines for managing hospital-acquired pneumonia (HAP), ventilator-associated pneumonia (VAP), and healthcare-associated pneumonia (HCAP). Although recommendations were evidence based, collective guidelines had not been validated in clinical practice and did not provide specific tools for local implementation. We initiated a performance improvement project designated Improving Medicine Through Pathway Assessment of Critical Therapy in Hospital-Acquired Pneumonia (IMPACT-HAP) at four academic centers in the United States. Our objectives were to develop and implement the project, and to assess compliance with quality indicators in adults admitted to intensive care units (ICUs) with HAP, VAP, or HCAP. METHODS: The project was conducted in three phases over 18 consecutive months beginning 1 February 2006: 1) a three-month planning period for literature review to create the consensus pathway for managing nosocomial pneumonia in these ICUs, a data collection form, quality performance indicators, and internet-based repository; 2) a six-month implementation period for customizing ATS/IDSA guidelines into center-specific guidelines via educational forums; and 3) a nine-month post-implementation period for continuing education and data collection. Data from the first two phases were combined (pre-implementation period) and compared with data from the post-implementation period. RESULTS: We developed a consensus pathway based on ATS/IDSA guidelines and customized it at the local level to accommodate formulary and microbiologic considerations. We implemented multimodal educational activities to teach ICU staff about the guidelines and continued education throughout post-implementation. We registered 432 patients (pre- vs post-implementation, 274 vs 158). Diagnostic criteria for nosocomial pneumonia were more likely to be met during post-implementation (247/257 (96.1%) vs 150/151 (99.3%); P = 0.06). Similarly, empiric antibiotics were more likely to be compliant with ATS/IDSA guidelines during post-implementation (79/257 (30.7%) vs 66/151 (43.7%); P = 0.01), an effect that was sustained over quarterly intervals (P = 0.0008). Between-period differences in compliance with obtaining cultures and use of de-escalation were not statistically significant. CONCLUSIONS: Developing a multi-center performance improvement project to operationalize ATS/IDSA guidelines for HAP, VAP, and HCAP is feasible with local consensus pathway directives for implementation and with quality indicators for monitoring compliance with guidelines.

Establishing a hospital program to improve antimicrobial use, control bacterial resistance and contain healthcare costs: the University of Louisville experience.

Antimicrobials have been used in excess for decades. As a result, antimicrobial resistance and cost have increased. In response to this growing national problem, hospital antimicrobial teams were recom-mended in 1988, but few institutions have invested in comprehensive, interdisciplinary programs. The division of infectious diseases at the University of Louisville School of Medicine was a leader in 1990 by establishing an antimicrobial team at the University of Louisville Hospital and Veterans Affairs Hospital. This manuscript reviews the activities of the antimicrobial teams to create antimicrobial guidelines, evaluate antimicrobial use, and provide feedback to physicians. It also summarizes the successful impact the teams have had on optimizing antimicrobial use in the hospital by improving compliance with the guidelines, controlling resistant organisms, and preventing escalation of antimicrobial cost over the years.

Improving antimicrobial use in the hospital setting by providing usage feedback to prescribing physicians.

OBJECTIVE: To determine whether feedback on antimicrobial use improves physician compliance with local hospital guidelines on antimicrobial prescribing. DESIGN: In this time series analysis, in which a historical control period was compared with an intervention period, all orders for antimicrobials (except those for surgical prophylaxis) placed from November 1, 2002, through April 30, 2004, were prospectively evaluated by an antimicrobial management team (AMT) for compliance with local hospital guidelines. During the control period, orders were evaluated to determine compliance with hospital guidelines before and after recommendations by the AMT were provided to physicians. Feedback was given for the second 9-month period in the form of a weekly report to prescribing physicians, a monthly hospital newsletter, and a quarterly report to various hospital committees. During the intervention period, orders were evaluated to determine compliance with hospital guidelines before and after recommendations by the AMT were provided to physicians. SETTING: The Veterans Affairs Medical Center, a 110-bed facility, in Louisville, Kentucky. PARTICIPANTS: Internal medicine physicians and general surgeons. RESULTS: A total of 2,807 antimicrobial courses were evaluated. Compliance with hospital guidelines before AMT recommendations was 70% during the control period and 74% during the intervention period (P=.02). Compliance after AMT recommendations was 90% during the control period and 93% during the intervention period (P< or =.01). CONCLUSION: The use of feedback had a significantly favorable impact on physician compliance with the hospital's guidelines on antimicrobial prescribing. Use of feedback should be added to the list of interventions that promote appropriate antimicrobial use in the hospital setting.

Improving antimicrobial use: longitudinal assessment of an antimicrobial team including a clinical pharmacist.

BACKGROUND: Inappropriate antimicrobial utilization in hospitalized patients has been associated with adverse effects, emergence of resistant bacteria, and increased health care cost. Participation of clinical pharmacists, working as an integral part of a hospital antimicrobial management team (AMT), has been shown to improve antimicrobial use; however, the long-term impact of such a team on antimicrobial use is unclear. OBJECTIVE: Our primary objective was to evaluate whether the number of recommendations to improve antimicrobial use made by a hospital AMT decreased over time. Our secondary objective was to identify and evaluate the acceptance of AMT recommendations with respect to the clinical service, site of infection, and category of suboptimal use. METHODS: We retrospectively reviewed antimicrobial utilization data collected by the team for the 3-year period from July 1996 to June 1999 at the Veterans Affairs Medical Center in Louisville, Kentucky. The total number of antimicrobial treatment episodes and the number of recommendations were grouped into periods of 6 months each during the 3 years. The type of recommendation, type of infection, and clinical service (medicine versus surgery) were reviewed for the entire 3-year period. RESULTS: The number of antimicrobial treatment episodes for each of the 6-month consecutive periods was 404, 526, 406, 549, 507, and 612. The proportion of episodes requiring team recommendations was constant over the 5 consecutive periods: 39%, 37%, 36%, 36%, 35%, and 37%. (P = 0.8). Acceptance rates of AMT recommendations by the internal medicine and general surgery services remained stable over the length of the study, 84% and 69%, respectively. The distribution of patients treated by the site of infection also remained stable over the study period. CONCLUSION: Our results demonstrate that despite the long-term presence of an AMT, the proportion of antimicrobial episodes requiring intervention and the percentage of accepted recommendations remained constant over a 3-year period. Having new resident physicians in teaching hospitals or staff turnover in managed care organizations may necessitate the continued presence of an active AMT.