Candida auris outbreak at a tertiary care hospital during the COVID-19 pandemic.

BACKGROUND: Candida auris (C auris) is a fungal pathogen that has the potential for environmental persistence leading to outbreaks in health care settings. There has been a worldwide surge in C auris outbreaks during the COVID-19 pandemic. In this report, we describe an outbreak of C auris, its control, patient outcomes, and lessons learned. METHODS: The outbreak occurred in a 600-bed adult academic tertiary care hospital. Contact tracing was initiated immediately after identification of the index case and surveillance testing for C auris was obtained from patients who were exposed to the index case. Infection prevention measures were closely followed. RESULTS: A total of 560 cultures were performed on 453 unique patients between August 2021 and December 2021. Of those, 31 cultures (5.5%) were positive for C auris; 27 (87.1%) were colonized with C auris, while 4 patients developed a clinical infection (12.9%). The secondary attack rate was 6.8% (31/453). The 30-day all-cause mortality rate for all patients who tested positive for C auris was 9.7%. DISCUSSION: C auris can cause protracted outbreaks that result in colonization and invasive infections. Multidisciplinary work to improve adherence to infection prevention measures as well as targeted admission screening are essential to limit outbreaks.

A Unique Use of Regional Information Exchange by a Statewide Health System Serving Refugees: "Operation Allies Welcome".

BACKGROUND: In September 2021, a military camp in the United States was identified for an initial relocation of over 6,600 Afghanistan refugees. This case report describes a novel use of existing health information exchange to expedite and provide health care for a large refugee population throughout the state during the duration of their entry into the United States. METHODS: Medical teams of the health systems and military camp partnered to provide a scalable, reliable mechanism for clinical data exchange leveraging an existing regional health information exchange. Exchanges were evaluated for clinical type, originating source, and closed loop communication with the refugee camp and personnel military camp. RESULTS: Approximately 50% of the camp residents were under the age of 18 years. Over 20 weeks, approximately 4.51% of the refugee camp residents were cared for in participating health systems. A total of 2,699 clinical data messages were exchanged, 62% of which were clinical documents. CONCLUSION: All health systems participating in care were offered support to utilize the tool and process set up using the regional health information exchange. The process and guiding principles may be applied to other refugee health care efforts to provide efficient, scalable, and reliable means of clinical data exchange to health care providers in similar situations.

Mitigation of COVID-19 at the 2021 National Collegiate Athletic Association Men's Basketball Tournament.

BACKGROUND: Data are lacking regarding the risk of viral SARS-CoV-2 transmission during a large indoor sporting event involving fans utilizing a controlled environment. We sought to describe case characteristics, mitigation protocols used, variants detected, and secondary infections detected during the 2021 National Collegiate Athletic Association (NCAA) Men's Basketball Tournament involving collegiate athletes from across the U.S. METHODS: This retrospective cohort study used data collected from March 16 to April 3, 2021, as part of a closed environment which required daily reverse transcription-polymerase chain reaction (RT-PCR) testing, social distancing, universal masking, and limited contact between tiers of participants. Nearly 3000 players, staff, and vendors participated in indoor, unmasked activities that involved direct exposure between cases and noninfected individuals. The main outcome of interest was transmission of SARS-CoV-2 virus, as measured by the number of new infections and variant(s) detected among positive cases. Secondary infections were identified through contact tracing by public health officials. RESULTS: Out of 2660 participants, 15 individuals (0.56%) screened positive for SARS-CoV-2. Four cases involved players or officials, and all cases were detected before any individual played in or officiated a game. Secondary transmissions all occurred outside the controlled environment. Among those disqualified from the tournament (4 cases; 26.7%), all individuals tested positive for the Iota variant (B.1.526). All other cases involved the Alpha variant (B.1.1.7). Nearly all teams (N = 58; 85.3%) reported that some individuals had received at least one dose of a vaccine. Overall, 17.9% of participants either had at least one dose of the vaccine or possessed documented infection within 90 days of the tournament. CONCLUSION: In this retrospective cohort study of the 2021 NCAA Men's Basketball Tournament closed environment, only a few cases were detected, and they were discovered in advance of potential exposure. These findings support the U.S. Centers for Disease Control and Prevention (CDC) guidelines for large indoor sporting events during the COVID-19 pandemic.

Association Between Hospital-Acquired Harm Outcomes and Membership in a National Patient Safety Collaborative.

Importance: Hospital engagement networks supported by the US Centers for Medicare & Medicaid Services Partnership for Patients program have reported significant reductions in hospital-acquired harm, but methodological limitations and lack of peer review have led to persistent questions about the effectiveness of this approach. Objective: To evaluate associations between membership in Children's Hospitals' Solutions for Patient Safety (SPS), a federally funded hospital engagement network, and hospital-acquired harm using standardized definitions and secular trend adjustment. Design, Setting, and Participants: This prospective hospital cohort study included 99 children's hospitals. Using interrupted time series analyses with staggered intervention introduction, immediate and postimplementation changes in hospital-acquired harm rates were analyzed, with adjustment for preexisting secular trends. Outcomes were further evaluated by early-adopting (n = 73) and late-adopting (n = 26) cohorts. Exposures: Hospitals implemented harm prevention bundles, reported outcomes and bundle compliance using standard definitions to the network monthly, participated in learning events, and implemented a broad safety culture program. Hospitals received regular reports on their comparative performance. Main Outcomes and Measures: Outcomes for 8 hospital-acquired conditions were evaluated over 1 year before and 3 years after intervention. Results: In total, 99 hospitals met the inclusion criteria and were included in the analysis. A total of 73 were considered part of the early-adopting cohort (joined between 2012-2013) and 26 were considered part of the late-adopting cohort (joined between 2014-2016). A total of 42 hospitals were freestanding children's hospitals, and 57 were children's hospitals within hospital or health systems. The implementation of SPS was associated with an improvement in hospital-acquired condition rates in 3 of the 8 conditions after accounting for secular trends. Membership in the SPS was associated with an immediate reduction in central catheter-associated bloodstream infections (coefficient = -0.152; 95% CI, -0.213 to -0.019) and falls of moderate or greater severity (coefficient = -0.331; 95% CI, -0.594 to -0.069). The implementation of the SPS was associated with a reduction in the monthly rate of adverse drug events (coefficient = -0.021; 95% CI, -0.034 to -0.008) in the post-SPS period. The study team observed larger decreases for the early-adopting cohort compared with the late-adopting cohort. Conclusions and Relevance: Through the application of rigorous methods (standard definitions and longitudinal time series analysis with adjustment for secular trends), this study provides a more thorough analysis of the association between the Partnership for Patients hospital engagement network model and reductions in hospital-acquired conditions. These findings strengthen previous claims of an association between this model and improvement. However, inconsistent observations across hospital-acquired conditions when adjusted for secular trends suggests that some caution regarding attributing all effects observed to this model is warranted.

Experiences of Informatics Health Care Workers Redeployed to Provide Telehealth in a Coronavirus Disease-Screening Hub.

Introduction: Coronavirus disease 2019 (COVID-19) resulted in many health care workers across the country being redeployed to different clinical roles. This study aimed to evaluate the unique experience of team members in our health system from clinical informatics who were redeployed to provide emergency telehealth care in a clinical role. Methods: Clinical informatics team members were redeployed during the first month of the pandemic onset in March 2020 to a clinic providing virtual screening for COVID-19. Participants completed an anonymous survey after 90 days. Results: During the study period, 76 clinical informatics team members provided telehealth and 85.3% of those eligible responded to the survey. Respondents felt prepared with clinical protocols and technical tools. The most common stressors were rapidly changing clinical protocols. Participants enjoyed the chance to work with patients and aiding during a pandemic. Conclusions: Clinical informatics team members redeployed to a virtual care screening hub endorsed positive experiences and the majority said that they would provide virtual care again. This experience gave important insights on how informatics skills can aid in a rapid coordinated telehealth response.

Improving Follow-Up of Tests Pending at Discharge.

BACKGROUND AND OBJECTIVES: Follow-up on results of inpatient tests pending at discharge (TPAD) must occur to ensure patient safety and high-quality care continue after discharge. We identified a need to improve follow-up of TPAD and began a quality improvement initiative with an aim of reducing the rate of missed follow-up of TPAD to ≤20% within 12 months. METHODS: The team used the Plan-Do-Study-Act method of quality improvement and implemented a process using reminder messages in the electronic health record. We collected data via retrospective chart review for the 6 months before the intervention and monthly thereafter. The primary outcome measure was the percentage of patients with missed follow-up of TPAD, defined as no documented follow-up within 72 hours of a result being available. The use of a reminder message was monitored as a process measure. RESULTS: We reviewed charts of 764 discharged patients, and 216 (28%) were noted to have TPAD. At baseline, the average percentage of patients with missed follow-up was 80%. The use of reminder messages was quickly adopted. The average percentage of patients with missed follow-up of TPAD after beginning the quality improvement interventions was 35%. CONCLUSIONS: We had significant improvement in follow-up after our interventions. Additional work is needed to ensure continued and sustained improvement, focused on reducing variability in performance between providers and investing in technology to allow for automation of the follow-up process.

The Indiana Learning Health System Initiative: Early experience developing a collaborative, regional learning health system.

INTRODUCTION: Learning health systems (LHSs) are usually created and maintained by single institutions or healthcare systems. The Indiana Learning Health System Initiative (ILHSI) is a new multi-institutional, collaborative regional LHS initiative led by the Regenstrief Institute (RI) and developed in partnership with five additional organizations: two Indiana-based health systems, two schools at Indiana University, and our state-wide health information exchange. We report our experiences and lessons learned during the initial 2-year phase of developing and implementing the ILHSI. METHODS: The initial goals of the ILHSI were to instantiate the concept, establish partnerships, and perform LHS pilot projects to inform expansion. We established shared governance and technical capabilities, conducted a literature review-based and regional environmental scan, and convened key stakeholders to iteratively identify focus areas, and select and implement six initial joint projects. RESULTS: The ILHSI successfully collaborated with its partner organizations to establish a foundational governance structure, set goals and strategies, and prioritize projects and training activities. We developed and deployed strategies to effectively use health system and regional HIE infrastructure and minimize information silos, a frequent challenge for multi-organizational LHSs. Successful projects were diverse and included deploying a Fast Healthcare Interoperability Standards (FHIR)-based tool across emergency departments state-wide, analyzing free-text elements of cross-hospital surveys, and developing models to provide clinical decision support based on clinical and social determinants of health. We also experienced organizational challenges, including changes in key leadership personnel and varying levels of engagement with health system partners, which impacted initial ILHSI efforts and structures. Reflecting on these early experiences, we identified lessons learned and next steps. CONCLUSIONS: Multi-organizational LHSs can be challenging to develop but present the opportunity to leverage learning across multiple organizations and systems to benefit the general population. Attention to governance decisions, shared goal setting and monitoring, and careful selection of projects are important for early success.

Enhancing Safe Sleep Counseling by Pediatricians through a Quality Improvement Learning Collaborative.

BACKGROUND: Approximately, 3,500 infants die annually from sleep-related infant deaths in the United States. We sought to improve pediatricians' counseling on safe sleep from birth through 6 months of age through a virtual quality improvement learning collaborative (QILC). Our aim was appropriate screening, counseling, and documentation of safe sleep advice in 75% of eligible patient encounters after the QILC. METHODS: We formed a 9-month QILC for inpatient and outpatient pediatricians. Pediatricians collected data on safe sleep documentation in a newborn discharge or well-child visit note. Data were submitted at baseline and in 9 subsequent phases. Participants met monthly via a webinar, which included a QI presentation, data review, and facilitated discussion among participants. Practices were contacted 12 months after the conclusion of the QILC to assess sustainment. RESULTS: Thirty-four pediatricians from 4 inpatient and 9 outpatient practices participated in the QILC. At baseline, documentation of safe sleep practices varied greatly (0%-98%). However, by the end of the QILC, all participating practices were documenting safe sleep guidance in over 75% of patient encounters. Aggregate practice data show a significant, sustained improvement. The 12-month follow-up data were submitted from 62% of practices, with sustainment of improvement in 75% of practices. CONCLUSION: A facilitated, virtual QILC is an effective methodology to improve safe sleep counseling among a diverse group of pediatric practices. It is one step in improving consistent messaging around safe sleep by healthcare providers as pediatricians work to decrease sleep-related infant deaths.

Seroprevalence of severe acute respiratory coronavirus virus 2 (SARS-CoV-2) antibodies among healthcare workers with differing levels of coronavirus disease 2019 (COVID-19) patient exposure.

Healthcare employees were tested for antibodies against severe acute respiratory coronavirus virus 2 (SARS-CoV-2). Among 734 employees, the prevalence of SARS-CoV-2 antibodies was 1.6%. Employees with heavy coronavirus disease 2019 (COVID-19) exposure had similar antibody prevalence as those with limited or no exposure. Guidelines for PPE use seem effective for preventing COVID-19 infection in healthcare workers.

Quality Improvement Learning Collaborative Improves Timely Newborn Follow-Up Appointments.

BACKGROUND: American Academy of Pediatrics guidelines indicate that newborns should follow up with their primary care providers within three days of discharge from the newborn nursery. Many barriers exist to achieving timely follow-up, with potential implications on a newborn's health. The goal of this project was to improve rates of timely newborn follow-up through a nine-month quality improvement learning collaborative (QILC). Timely newborn follow-up was defined as an appointment scheduled within three days of newborn discharge. METHODS: Both inpatient hospitalist and outpatient pediatric practices were eligible to participate. Inpatient and outpatient practices aimed to have 75% of newborns scheduled appropriately by six months into the project. In addition, outpatient practices aimed to have 60% of newborns seen appropriately by their provider. All practices aimed to have their progress sustained at conclusion of the QILC. Practices submitted data at baseline and nine subsequent phases. Monthly webinars featured a quality improvement didactic, data review, and discussion of practices' changes, successes, and challenges. RESULTS: Eleven practices and 24 physicians participated in the QILC. Aggregate data from the practices showed continual improvement in all measured newborn scheduling metrics throughout the nine-month learning collaborative, with sustainment of progress over the last three months of the QILC. CONCLUSION: A QILC is successful for increasing timely newborn follow-up for both the newborn hospitalist and outpatient pediatrician. Pediatric providers can learn from others' strategies and successes to incorporate meaningful changes in their practice.

Before the Flood: Impact of Coordination of Care and Direct Admissions on Emergency Department Volumes.

BACKGROUND: Transfers of pediatric patients occur to access specialty and subspecialty care, but incur risk, and consume resources. Direct admissions to medical and surgical wards may improve patient experience and mitigate resource utilization. OBJECTIVE: We sought to identify common elements for direct admissions, as well as the pattern of disposition for patients referred to our emergency department (ED). DESIGN: A retrospective qualitative analysis of patients transferred to our pediatric hospital for 12 months was performed. Different physician groups were evaluated for use of direct admissions or evaluation in the ED. Patients referred to the ED were additionally tracked to evaluate their eventual disposition. RESULTS: A total of 3982 transfers occurred during the 12-month analysis period. Of those, 3463 resulted in admission, accounting for 32.55% of all admissions. Transfers accepted by nonsurgical services accounted for 82% of the transfers, whereas 18% were facilitated by one of the surgical services. Direct admissions accounted for 1707 (44.8%) of all referrals and were used more often by nonsurgical services. Of patients referred to the ED (2101 or 55.2% of all referrals), most patients were admitted and 343 (16% of those referred to the ED) were discharged home. CONCLUSIONS: The direct admission process helped avoid ED assessments for some patients; however, some patients referred to the ED were able to be evaluated, treated, and discharged. Consistent triage of the patients being transferred as direct admissions may improve ED throughput and potentially improve the patient's experience, reduce redundant services, and expedite care.

Multifaceted quality improvement initiative to decrease pediatric asthma readmissions.

BACKGROUND: Asthma is the most common chronic disease of childhood and a leading cause of hospitalization in children. A primary goal of asthma control is prevention of hospitalizations. A hospital admission is the single strongest predictor of future hospital admissions for asthma. The 30-day asthma readmission rate at our institution was significantly higher than that of other hospitals in the Children's Hospital Association. As a result, a multifaceted quality improvement project was undertaken with the goal of reducing the 30-day inpatient asthma readmission rate by 50% within two years. METHODS: Analysis of our institution's readmission patterns, value stream mapping of asthma admission, discharge, and follow-up processes, literature review, and examination of comparable successful programs around the United States were all utilized to identify potential targets for intervention. Interventions were implemented in a stepwise manner, and included increasing inhaler availability after discharge, modifying asthma education strategies, and providing in-home post-discharge follow-up. The primary outcome was a running 12-month average 30-day inpatient readmission rate. Secondary outcomes included process measures for individual interventions. RESULTS: From a peak of 7.98% in January 2013, a steady decline to 1.65% was observed by July 2014, which represented a 79.3% reduction in 30-day readmissions. CONCLUSION: A significant decrease in hospital readmissions for pediatric asthma is possible, through comprehensive, multidisciplinary quality improvement that spans the continuum of care.

A Step Toward High Reliability: Implementation of a Daily Safety Brief in a Children's Hospital.

OBJECTIVES: Health care is a high-risk industry. To improve communication about daily events and begin the journey toward a high reliability organization, the Riley Hospital for Children at Indiana University Health implemented a daily safety brief. METHODS: Various departments in our children's hospital were asked to participate in a daily safety brief, reporting daily events and unexpected outcomes within their scope of responsibility. Participants were surveyed before and after implementation of the safety brief about communication and awareness of events in the hospital. The length of the brief and percentage of departments reporting unexpected outcomes were measured. RESULTS: The analysis of the presurvey and the postsurvey showed a statistically significant improvement in the questions related to the awareness of daily events as well as communication and relationships between departments. The monthly mean length of time for the brief was 15 minutes or less. Unexpected outcomes were reported by 50% of the departments for 8 months. CONCLUSIONS: A daily safety brief can be successfully implemented in a children's hospital. Communication between departments and awareness of daily events were improved. Implementation of a daily safety brief is a step toward becoming a high reliability organization.

A Quality Improvement Collaborative to Improve the Discharge Process for Hospitalized Children.

OBJECTIVE: To assess the impact of a quality improvement collaborative on quality and efficiency of pediatric discharges. METHODS: This was a multicenter quality improvement collaborative including 11 tertiary-care freestanding children's hospitals in the United States, conducted between November 1, 2011 and October 31, 2012. Sites selected interventions from a change package developed by an expert panel. Multiple plan-do-study-act cycles were conducted on patient populations selected by each site. Data on discharge-related care failures, family readiness for discharge, and 72-hour and 30-day readmissions were reported monthly by each site. Surveys of each site were also conducted to evaluate the use of various change strategies. RESULTS: Most sites addressed discharge planning, quality of discharge instructions, and providing postdischarge support by phone. There was a significant decrease in discharge-related care failures, from 34% in the first project quarter to 21% at the end of the collaborative (P < .05). There was also a significant improvement in family perception of readiness for discharge, from 85% of families reporting the highest rating to 91% (P < .05). There was no improvement in unplanned 72-hour (0.7% vs 1.1%, P = .29) and slight worsening of the 30-day readmission rate (4.5% vs 6.3%, P = .05). CONCLUSIONS: Institutions that participated in the collaborative had lower rates of discharge-related care failures and improved family readiness for discharge. There was no significant improvement in unplanned readmissions. More studies are needed to evaluate which interventions are most effective and to assess feasibility in non-children's hospital settings.

Development and Implementation Results of a Venous Thromboembolism Prophylaxis Guideline in a Tertiary Care Pediatric Hospital.

OBJECTIVES: Incidence of pediatric venous thromboembolism (VTE) is increasing due to increased survival of children with chronic diseases and use of interventions (eg, central venous lines), with VTE risk. Our objective was to create VTE prophylaxis guidelines with targeted identification of children at high risk to support appropriate mechanical and pharmacologic prophylaxis and integrate into the electronic medical record (EMR) as a hospital-wide quality improvement project. METHODS: Patients aged 12 to 17 years were included. We evaluated institutional data regarding VTE incidence and risk factors. We evaluated literature for populations at high risk for VTE. Guidelines were formulated, and an EMR tool to assess risk and support the guidelines was created and implemented. RESULTS: The EMR tool was used to screen 48% of qualified admissions for the first month and 81% in the final study month. On average, 69.1% of qualified admissions were screened monthly during the first 18 months of the program. No adverse events were reported due to pharmacologic prophylaxis. CONCLUSIONS: Many risk factors are common between children and adults and certain pediatric populations warrant prophylactic consideration. Pediatric VTE prophylaxis guidelines can be successfully implemented into the EMR to identify high-risk populations. Future studies should assess the long-term impact of implementation.

Summary of STARNet: Seamless Transitions and (Re)admissions Network.

The Seamless Transitions and (Re)admissions Network (STARNet) met in December 2012 to synthesize ongoing hospital-to-home transition work, discuss goals, and develop a plan to centralize transition information in the future. STARNet participants consisted of experts in the field of pediatric hospital medicine quality improvement and research, and included physicians and key stakeholders from hospital groups, private payers, as well as representatives from current transition collaboratives. In this report, we (1) review the current knowledge regarding hospital-to-home transitions; (2) outline the challenges of measuring and reducing readmissions; and (3) highlight research gaps and list potential measures for transition quality. STARNet met with the support of the American Academy of Pediatrics' Quality Improvement Innovation Networks and the Section on Hospital Medicine.

Family-centered rounding: can it impact the time of discharge and time of completion of studies at an academic children's hospital?

BACKGROUND AND OBJECTIVE: Family-centered rounds (FCR) involve multidisciplinary rounds at the patient bedside with an emphasis on physicians partnering with patients and families in the clinical decision-making for the patient. Although the purpose of FCR is to provide patient-centered care, an unanticipated benefit of FCR may be to improve time to discharge. The objective of this study was to determine the impact of FCR on time to discharge for pediatric patients in an academic medical center. METHODS: We retrospectively compared the timing of patient discharges from July 2007 to June 2008 (before FCR) versus those from July 2008 to May 2009 (after FCR) on the pediatric hospital medicine service. We further compared time from order entry to study completion on a subset of patients receiving head MRIs and EEGs, studies that typically occurred on the day of discharge. RESULTS: In our center, before FCR, 40% of patients were discharged before 3:00 pm (n = 912). After FCR, 47% of children were discharged before 3:00 pm (n = 911) (P = .0036). Time from order entry to study completion for MRIs and EEGs decreased from 2.15 hours before FCR (n = 225) to 1.73 hours after FCR (n = 206) (P = .001). CONCLUSIONS: FCR provided a modest improvement in the timeliness of the discharge process at our institution.