When Infections Are Found: A Qualitative Study Characterizing Best Management Practices for Central Line-Associated Bloodstream Infection and Catheter-Associated Urinary Tract Infection Performance Monitoring and Feedback.

Healthcare-associated infections (HAIs) remain a significant patient safety problem that can lead to illness and death, despite the implementation of clinical bundles to prevent HAIs. Management practices can support HAI prevention, but their role in HAI performance monitoring and feedback is not well understood. To address this knowledge gap, we previously conducted semi-structured interviews with staff at 18 hospitals to examine the role of management practices around the prevention of central line-associated bloodstream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs). Interview transcripts were analyzed to identify themes related to HAI performance monitoring and feedback. The current analysis focuses on 10 higher-performing hospitals that were successful in preventing CLABSIs and CAUTIs. These institutions had robust practices including timely event analysis, leadership engagement, and multidisciplinary participation in HAI reviews. Across these sites, we found common goals including investigating HAIs without blame and identifying opportunities for improvement. Management practices such as timely analysis of HAIs, collaboration between facility leadership and multidisciplinary team members, and a focus on identifying the failure of a procedure or protocol, rather than the failure of staff members, are all approaches that can support infection prevention efforts. These management practices may be especially important as hospitals attempt to address increases in CLABSI and CAUTI rates that may have occurred during the coronavirus pandemic.

Changes in prospectively collected patient-reported outcomes among women with incident endometrial cancer.

PURPOSE: We examined associations between patient and treatment characteristics with longitudinally collected patient-reported outcome (PRO) measures to provide a data-informed description of the experiences of women undergoing treatment for endometrial cancer. METHODS: We administered National Institutes of Health Patient Reported Outcomes Measurement Information System (PROMIS) questionnaires at the preoperative visit and at 6 and 12 months after surgery. Anxiety, depression, fatigue, sleep disturbance, pain, physical function, and ability to participate in social roles were assessed. Analysis of variance (ANOVA) and linear mixed models were used to examine associations between patient characteristics and PRO measures at baseline and through time. RESULTS: Of 187 women enrolled, 174 (93%) and 103 (69%) completed the 6- and 12-month questionnaires, respectively. Anxiety was substantially elevated at baseline (half of one population-level standard deviation) and returned to general population mean levels at 6 and 12 months. Younger age, Medicaid/None/Self-pay insurance, prevalent diabetes, and current smoking were associated with higher symptom burden on multiple PRO measures across the three time points. Women with aggressive histology, higher disease stage, or those with adjuvant treatment had worse fatigue at 6 months, which normalized by 12 months. CONCLUSIONS: We observed a high symptom burden at endometrial cancer diagnosis, with most PRO measures returning to general population means by 1 year. Information on risk factor-PRO associations can be used during the clinical visit to inform supportive service referral. IMPLICATIONS FOR CANCER SURVIVORS: These findings can inform clinicians' discussions with endometrial cancer survivors regarding expected symptom trajectory following diagnosis and treatment.

Describing the monthly variability of hospital-onset Clostridioides difficile during early coronavirus disease 2019 (COVID-19) using electronic health record data.

OBJECTIVE: To assess the relative risk of hospital-onset Clostridioides difficile (HO-CDI) during each month of the early coronavirus disease 2019 (COVID-19) pandemic and to compare it with historical expectation based on patient characteristics. DESIGN: This study used a retrospective cohort design. We collected secondary data from the institution's electronic health record (EHR). SETTING: The Ohio State University Wexner Medical Center, Ohio, a large tertiary healthcare system in the Midwest. PATIENTS OR PARTICIPANTS: All adult patients admitted to the inpatient setting between January 2018 and May 2021 were eligible for the study. Prisoners, children, individuals presenting with Clostridioides difficile on admission, and patients with <4 days of inpatient stay were excluded from the study. RESULTS: After controlling for patient characteristics, the observed numbers of HO-CDI cases were not significantly different than expected. However, during 3 months of the pandemic period, the observed numbers of cases were significantly different from what would be expected based on patient characteristics. Of these 3 months, 2 months had more cases than expected and 1 month had fewer. CONCLUSIONS: Variations in HO-CDI incidence seemed to trend with COVID-19 incidence but were not fully explained by our case mix. Other factors contributing to the variability in HO-CDI incidence beyond listed patient characteristics need to be explored.

Exploring the Incorporation of a Novel Cardiotoxicity Mobile Health App Into Care of Patients With Cancer: Qualitative Study of Patient and Provider Perspectives.

BACKGROUND: Cardiotoxicity is a limitation of several cancer therapies and early recognition improves outcomes. Symptom-tracking mobile health (mHealth) apps are feasible and beneficial, but key elements for mHealth symptom-tracking to indicate early signs of cardiotoxicity are unknown. OBJECTIVE: We explored considerations for the design of, and implementation into a large academic medical center, an mHealth symptom-tracking tool for early recognition of cardiotoxicity in patients with cancer after cancer therapy initiation. METHODS: We conducted semistructured interviews of >50% of the providers (oncologists, cardio-oncologists, and radiation oncologists) who manage cancer treatment-related cardiotoxicity in the participating institution (n=11), and either interviews or co-design or both with 6 patients. Data were coded and analyzed using thematic analysis. RESULTS: Providers indicated that there was no existing process to enable early recognition of cardiotoxicity and felt the app could reduce delays in diagnosis and lead to better patient outcomes. Signs and symptoms providers recommended for tracking included chest pain or tightness, shortness of breath, heart racing or palpitations, syncope, lightheadedness, edema, and excessive fatigue. Implementation barriers included determining who would receive symptom reports, ensuring all members of the patient's care team (eg, oncologist, cardiologist, and primary care) were informed of the symptom reports and could collaborate on care plans, and how to best integrate the app data into the electronic health record. Patients (n=6, 100%) agreed that the app would be useful for enhanced symptom capture and education and indicated willingness to use it. CONCLUSIONS: Providers and patients agree that a patient-facing, cancer treatment-related cardiotoxicity symptom-tracking mHealth app would be beneficial. Additional studies evaluating the role of mHealth as a potential strategy for targeted early cardioprotective therapy initiation are needed.

Emergency department patient and physician survey accuracy compared to chart abstraction in patients with acute respiratory illness.

BACKGROUND: High-quality research studies in older adults are needed. Unfortunately, the accuracy of chart review data in older adult patients has been called into question by previous studies. Little is known on this topic in patients with suspected pneumonia, a disease with 500,000 annual older adult U.S. emergency department (ED) visits that presents a diagnostic challenge to ED physicians. The study objective was to compare direct interview and chart abstraction as data sources. METHODS: We present a preplanned secondary analysis of a prospective, observational cohort of ED patients ≥65 years of age with suspected pneumonia in two Midwest EDs. We describe the agreement between chart review and a criterion standard of prospective direct patient survey (symptoms) or direct physician survey (examination findings). Data were collected by chart review and from the patient and treating physician by survey. RESULTS: The larger study enrolled 135 older adults; 134 with complete symptom data and 129 with complete examination data were included in this analysis. Pneumonia symptoms (confusion, malaise, rapid breathing, any cough, new/worse cough, any sputum production, change to sputum) had agreement between patient/legally authorized representative survey and chart review ranging from 47.8% (malaise) to 80.6% (confusion). All examination findings (rales, rhonchi, wheeze) had percent agreement between physician survey and chart review of ≥80%. However, all kappas except wheezing were less than 0.60, indicating weak agreement. CONCLUSIONS: Both patient symptoms and examination findings demonstrated discrepancies between chart review and direct survey with larger discrepancies in symptoms reported. Researchers should consider these potential discrepancies during study design and data interpretation.

Inventory of Patient-Reported Outcome Measures Used in the Non-Operative Care of Scoliosis: A Scoping Review.

It is unclear which patient-reported outcome measures (PROMs) can assess non-operative care for scoliosis. Most existing tools aim to assess the effects of surgery. This scoping review aimed to inventory the PROMs used to assess non-operative scoliosis treatment by population and languages. We searched Medline (OVID) as per COSMIN guidelines. Studies were included if patients were diagnosed with idiopathic scoliosis or adult degenerative scoliosis and used PROMs. Studies without quantitative data or reporting on fewer than 10 participants were excluded. Nine reviewers extracted the PROMs used, the population(s), language(s), and study setting(s). We screened 3724 titles and abstracts. Of these, the full texts of 900 articles were assessed. Data were extracted from 488 studies, in which 145 PROMs were identified across 22 languages and 5 populations (Adolescent Idiopathic Scoliosis, Adult Degenerative Scoliosis, Adult Idiopathic Scoliosis, Adult Spine Deformity, and an Unclear category). Overall, the most used PROMs were the Oswestry Disability Index (ODI, 37.3%), Scoliosis Research Society-22 (SRS-22, 34.8%), and the Short Form-36 (SF-36, 20.1%), but the frequency varied by population. It is now necessary to determine the PROMs that demonstrate the best measurement properties in the non-operative treatment of scoliosis to include in a core set of outcomes.

Understanding comorbidities and health disparities related to COVID-19: a comprehensive study of 776 936 cases and 1 362 545 controls in the state of Indiana, USA.

Objective: To characterize COVID-19 patients in Indiana, United States, and to evaluate their demographics and comorbidities as risk factors to COVID-19 severity. Materials and Methods: EHR data of 776 936 COVID-19 cases and 1 362 545 controls were collected from the COVID-19 Research Data Commons (CoRDaCo) in Indiana. Data regarding county population and per capita income were obtained from the US Census Bureau. Statistical analysis was conducted to determine the association of demographic and clinical variables with COVID-19 severity. Predictive analysis was conducted to evaluate the predictive power of CoRDaCo EHR data in determining COVID-19 severity. Results: Chronic obstructive pulmonary disease, cardiovascular disease, and type 2 diabetes were found in 3.49%, 2.59%, and 4.76% of the COVID-19 patients, respectively. Such COVID-19 patients have significantly higher ICU admission rates of 10.23%, 14.33%, and 11.11%, respectively, compared to the entire COVID-19 patient population (1.94%). Furthermore, patients with these comorbidities have significantly higher mortality rates compared to the entire COVID-19 patient population. Health disparity analysis suggests potential health disparities among counties in Indiana. Predictive analysis achieved F1-scores of 0.8011 and 0.7072 for classifying COVID-19 cases versus controls and ICU versus non-ICU cases, respectively. Discussion: Black population in Indiana was more adversely affected by COVID-19 than the White population. This is consistent to findings from existing studies. Our findings also indicate other health disparities in terms of demographic and economic factors. Conclusion: This study characterizes the relationship between comorbidities and COVID-19 outcomes with respect to ICU admission across a large COVID-19 patient population in Indiana.

Concerns and frustrations about the public reporting of device-related healthcare-associated infections: Perspectives of hospital leaders and staff.

BACKGROUND: Public reporting of healthcare-associated infections (HAIs) aims to incentivize improvement in infection prevention. The motivation and mechanisms of public reporting have raised concerns about the reliability of this data, but little is known about the specific concerns of hospital leaders and staff. This study sought to better understand perspectives of individuals in these roles regarding the identification and public reporting of HAIs. METHODS: We conducted interviews with 471 participants including hospitals leaders (eg, administrative and clinical leaders) and hospital staff (eg, physicians and nurses) between 2017 and 2019 across 18 US hospitals. A semistructured interview guide was used to explore perspectives about the use of HAI data within the context of management strategies used to support infection prevention. RESULTS: Interviewees described concerns about public reporting of HAI data, including a lack of trust in the data and inadvertent consequences of its public reporting, as well as specific frustrations related to the identification and accountability for publicly-reported HAIs. CONCLUSION: Concerns and frustrations related to public reporting of HAI data highlight the need for improved guidelines, transparency, and incentives. Efforts to build trust in publicly-reported HAI data can help ensure this information is used effectively to improve infection prevention practices.

Review of applied health informatics courses in a multidisciplinary biomedical informatics department.

Introduction: Applied health informatics infrastructure is a requirement for learning health systems and it is imperative that we train a workforce that can support this infrastructure. Our department offers courses in several interdisciplinary programs with topics ranging from bioinformatics to population health informatics. Due to changes in the field and our faculty members, we sought to assess our courses relevant to applied health informatics. Methods: In this paper, we discuss the three-phase evaluation of our program and include the survey we developed to identify the skills and knowledge base of our faculty. Results: We show how this assessment allowed us to identify gaps and develop strategies for program expansion. Conclusions: A focus on workforce development can help to guide and focus curricular review in an interdisciplinary graduate program.

Impact of concomitant fluconazole on direct oral anticoagulant bleeding risk.

STUDY OBJECTIVE: The aim of this study was to evaluate the effect on bleeding risk when fluconazole is administered concomitantly with direct oral anticoagulants (DOACs). DESIGN: This was a retrospective cohort study including hospitalized adult patients prescribed a DOAC with or without fluconazole. SETTING: The Ohio State University Wexner Medical Center, a tertiary care academic medical center with more than 1800 beds. PATIENTS: Hospitalized patients ages 18-89 years who received apixaban or rivaroxaban with or without fluconazole from October 1, 2016, to September 30, 2021, were included. The minimum duration of DOAC or DOAC with fluconazole therapy was 48 h. Patients were excluded if they received fluconazole <400 mg daily or a DOAC at doses outside those recommended for atrial fibrillation or venous thromboembolism treatment or prophylaxis. Patients were matched based on DOAC received. INTERVENTION: Patients who received a DOAC with fluconazole were compared with those receiving a DOAC alone. The primary outcome was a composite of major, clinically relevant nonmajor, and minor bleeding events at 30 days. MEASUREMENTS AND MAIN RESULTS: There were 216 patients included, 108 in the DOAC with fluconazole group and 108 in the DOAC alone group. More patients in the DOAC with fluconazole group experienced bleeding at 30 days compared with the DOAC alone group [35/108 (32%) vs. 21/108 (19%), respectively; p = 0.03]; however, after adjusting for proven confounding variables (hemoglobin and concomitant carvedilol) this was found not to be statistically significant [adjusted odds ratio 1.71, 95% confidence interval 0.85-3.40]. CONCLUSIONS: Patients receiving a DOAC with fluconazole were not at significantly increased risk for bleeding at 30 days compared with those receiving a DOAC alone after controlling for confounding variables. As an increasing number of patients are prescribed DOACs, the results of this study may inform clinical decision-making on the safety of concomitant DOAC and fluconazole use.

Implementing a Novel Interprofessional Clinical Informatics Curriculum.

A novel interprofessional clinical informatics curriculum was developed, piloted, and implemented, using an academic medical record. Targeted learners included undergraduate, graduate, and professional students across five health science colleges. A team of educators and practitioners representing those five health science colleges was formed in 2016, to design, develop, and refine educational modules covering the essentials of clinical informatics. This innovative curriculum consists of 10 online learning modules and 18 unique imbedded exercises that use standardized patient charts and tailored user views. The exercises allow learners to adopt the role of various providers who document in EMRs. Students are exposed to the unique perspectives of an attending physician, nurse, radiological technician, and health information manager, with the goal of developing knowledge and skills necessary for efficient and effective interprofessional communication within the EMR. The campus-wide clinical informatics curriculum is online, flexible, asynchronous, and well-established within each college, allowing faculty to select and schedule content based on discipline-specific learner and course needs. Program modifications over the past 4 years have correlated with a positive impact on the students' experience.

Risk of Cytomegalovirus Infection with Post-Transplantation Cyclophosphamide in Haploidentical and HLA-Matched Unrelated Donor Transplantation.

Post-transplantation cyclophosphamide (PTCy) is effective for graft-versus-host disease (GVHD) prevention but is associated with an increased risk of cytomegalovirus (CMV) infection. The effect of PTCy on CMV infection in matched unrelated donor (MUD) hematopoietic stem cell transplantation (HSCT) is unclear, and whether there is any difference in CMV risk with 1 or 2 doses of PTCy is not well established. This study aimed to compare the incidence of CMV infection and the association between T cell recovery in patients who received PTCy-based GVHD prophylaxis and those who received non-PTCy-based GVHD prophylaxis. We conducted a retrospective study to compare the risk of CMV infection in 3 cohorts: cohort A (n = 94), matched related donor (MRD)/MUD HSCT with calcineurin inhibitor-based GVHD prophylaxis; cohort B (n = 103), MRD/MUD HSCT with 1 dose of PTCy, tacrolimus, and mycophenolate mofetil (MMF); and cohort C (n = 28), haploidentical donor HSCT with 2 doses of PTCy, tacrolimus, and MMF. The day +100 cumulative incidence of CMV infection was 29% for cohort A, 39% for cohort B, and 61% for cohort C (P = .009), with no difference among the cohorts in the duration of viremia (P = .46). CD3+ and CD4+ T cell counts were significantly higher in cohort A at day +30 but not at days +60 and +90. Nonrelapse mortality (NRM) trended higher and relapse was significantly lower with PTCy. There was no difference in survival among the 3 cohorts. There is an increased risk of early CMV infection in patients receiving PTCy irrespective of donor type and number of PTCy doses compared with those not receiving PTCy. Strategies focusing on CMV prevention in PTCy recipients to mitigate the risk of NRM may lead to improved long-term outcomes.

Predictive Models for Very Preterm Birth: Developing a Point-of-Care Tool.

OBJECTIVE: The objective of this study was to create three point-of-care predictive models for very preterm birth using variables available at three different time points: prior to pregnancy, at the end of the first trimester, and mid-pregnancy. STUDY DESIGN: This is a retrospective cohort study of 359,396 Ohio Medicaid mothers from 2008 to 2015. The last baby for each mother was included in the final dataset. Births prior to 22 weeks were excluded. Multivariable logistic regression was used to create three models. These models were validated on a cohort that was set aside and not part of the model development. The main outcome measure was birth prior to 32 weeks. RESULTS: The final dataset contained 359,396 live births with 6,516 (1.81%) very preterm births. All models had excellent calibration. Goodness-of-fit tests suggested strong agreement between the probabilities estimated by the model and the actual outcome experience in the data. The mid-pregnancy model had acceptable discrimination with an area under the receiver operator characteristic curve of approximately 0.75 in both the developmental and validation datasets. CONCLUSION: Using data from a large Ohio Medicaid cohort we developed point-of-care predictive models that could be used before pregnancy, after the first trimester, and in mid-pregnancy to estimate the probability of very preterm birth. Future work is needed to determine how the calculator could be used to target interventions to prevent very preterm birth. KEY POINTS: · We developed predictive models for very preterm birth.. · All models showed excellent calibration.. · The models were integrated into a risk calculator..

Identifying management practices for promoting infection prevention: Perspectives on strategic communication.

BACKGROUND: Engaging leaders to share information about infections and infection prevention across their organizations is known to be important in initiatives designed to reduce healthcare-associated infections (HAIs). Yet the topics and communication strategies used by leaders that focus on HAI prevention are not well understood. This study aimed to identify and describe practices around information sharing used to support HAI prevention. METHODS: We visited 18 U.S. hospitals between 2017 and 2019 and interviewed 188 administrative and clinical leaders to ask about management practices they used to facilitate HAI prevention. Interview transcripts were analyzed to characterize practices involving strategic communications. RESULTS: Sharing information to support infection prevention involved strategic communications around two main topics: (1) facilitators of success and best practices, and (2) barriers to success and lessons learned. In addition, the practice of storytelling reportedly allowed leaders to highlight impact and elicit emotion, provide education, and acknowledge success in infection prevention by providing examples of real events. CONCLUSIONS: Our findings provide insight about how strategic communication of information around HAIs and HAI prevention can be used to support improvement. Organizations and leaders should consider the different opportunities to incorporate the practice of strategic communication, including using storytelling, to advance their infection prevention efforts.

Making the case for workforce diversity in biomedical informatics to help achieve equity-centered care: a look at the AMIA First Look Program.

Developing a diverse informatics workforce broadens the research agenda and ensures the growth of innovative solutions that enable equity-centered care. The American Medical Informatics Association (AMIA) established the AMIA First Look Program in 2017 to address workforce disparities among women, including those from marginalized communities. The program exposes women to informatics, furnishes mentors, and provides career resources. In 4 years, the program has introduced 87 undergraduate women, 41% members of marginalized communities, to informatics. Participants from the 2019 and 2020 cohorts reported interest in pursuing a career in informatics increased from 57% to 86% after participation, and 86% of both years' attendees responded that they would recommend the program to others. A June 2021 LinkedIn profile review found 50% of participants working in computer science or informatics, 4% pursuing informatics graduate degrees, and 32% having completed informatics internships, suggesting AMIA First Look has the potential to increase informatics diversity.

Emergency department disposition of non-neutropenic febrile patients with cancer.

OBJECTIVES: National data reveal that 60% of the 4.5 million annual emergency department (ED) visits by patients with cancer result in admission. Many of these visits are due to a febrile illness. Current literature provides limited guidance on how to treat non-neutropenic febrile ED patients. This study characterizes clinical outcomes of non-neutropenic febrile patients with cancer presenting to an academic, Comprehensive Cancer Center affiliated ED. METHODS: Retrospective chart review of 101 randomly selected adult patients with active cancer presenting with a chief complaint of fever or a documented fever in the ED and an absolute neutrophil count above 1000 between October 2015 and September 2016. Descriptive statistics were calculated. RESULTS: The primary malignancies represented were hematologic (24%), gastrointestinal (13%), head and neck (13%), and genitourinary (8%). Sixty-two percent were on chemotherapy, 15% on radiation therapy, and 12% were on targeted therapy. Severe illness outcomes occurred in 39% and 83% were admitted with a median length of stay of 4 days. Among admitted patients, 24% experienced a length of stay ≤2 days. A return visit to the ED or an in-system hospitalization within 7 days of the index visit occurred in 10% and death occurred within 7 days of the index visit in 4%. CONCLUSION: A majority of patients presenting to the ED with non-neutropenic fever are admitted (83%), of whom nearly a quarter experience a length of stay of ≤2 days with infrequent serious illness outcomes. Future efforts should focus on the development of risk stratification tools in this population to avoid potentially unnecessary hospitalizations.

Management practices for leaders to promote infection prevention: Lessons from a qualitative study.

BACKGROUND: Prevention of healthcare-associated infections (HAIs) is critical to reduce preventable deaths and healthcare costs. Variable success with HAI prevention efforts has suggested that management practices are critical to support clinical infection prevention practices. This study examined hospital leaders' management practices around the prevention of catheter-associated urinary tract infections (CAUTIs) and central line-associated bloodstream infections (CLABSIs) to identify actions that leaders can take to promote HAI prevention efforts. METHODS: We conducted interviews with 420 key informants, including managers and frontline staff, in 18 hospitals across the United States. Interviewees were asked about management practices supporting HAI prevention. We analyzed interview transcripts using rigorous qualitative methods to understand how management practices were operationalized in infection prevention efforts. RESULTS: Across hospitals and interviewees, three management practices were characterized as important facilitators of HAI prevention: (1) engagement of executive leadership; (2) information sharing; and (3) manager coaching. We found that visible executive leadership, efficient communication, and frequent opportunities to provide and promote learning from feedback were perceived to promote and sustain HAI prevention efforts. CONCLUSIONS: Our findings provide insight into management practices for leaders that support successful HAI prevention. In practice, these tactics may need to be adjusted to accommodate the current restrictions caused by the COVID-19 pandemic, in order to maintain HAI prevention efforts as a priority.

Investigating the association of room features with healthcare-facility-onset Clostridioides difficile: An exploratory study.

OBJECTIVE: To investigate hospital room and patient-level risk factors associated with increased risk of healthcare-facility-onset Clostridioides difficile infection (HO-CDI). DESIGN: The study used a retrospective cohort design that included patient data from the institution's electronic health record, existing surveillance data on HO-CDI, and a walk-through survey of hospital rooms to identify potential room-level risk factors. The primary outcome was HO-CDI diagnosis. SETTING: A large academic medical center. PATIENTS AND PARTICIPANTS: All adult patients admitted between January 1, 2015, and December 31, 2016 were eligible for inclusion. Prisoners were excluded. Patients who only stayed in rooms that were not surveyed were excluded. RESULTS: The hospital room survey collected room-level data on 806 rooms. Included in the study were 17,034 patients without HO-CDI and 251 with HO-CDI nested within 535 unique rooms. In this exploratory study, room-level risk factors associated with the outcome in the multivariate model included wear on furniture and flooring and antibiotic use by the prior room occupant. Hand hygiene devices and fixed in-room computers were associated with reduced odds of a HO-CDI. Differences between hospital buildings were also detected. The only individual patient factors that were associated with increased odds of HO-CDI were antibiotic use and comorbidity score. CONCLUSION: Combining a hospital-room walk-through data collection survey, EHR data, and CDI surveillance data, we were able to develop a model to investigate room and patient-level risks for HO-CDI.