Effect of Frequency of Changing Point-of-Use Reminder Signs on Health Care Worker Hand Hygiene Adherence: A Cluster Randomized Clinical Trial.

Importance: Although hand hygiene (HH) is considered the most effective strategy for preventing hospital-acquired infections, HH adherence rates remain poor. Objective: To examine whether the frequency of changing reminder signs affects HH adherence among health care workers. Design, Setting, and Participants: This cluster randomized clinical trial in 9 US Department of Veterans Affairs acute care hospitals randomly assigned 58 inpatient units to 1 of 3 schedules for changing signs designed to promote HH adherence among health care workers: (1) no change; (2) weekly; and (3) monthly. Hand hygiene rates among health care workers were documented at entry and exit to patient rooms during the baseline period from October 1, 2014, to March 31, 2015, of normal signage and throughout the intervention period of June 8, 2015, to December 28, 2015. Data analyses were conducted in April 2018. Interventions: Hospital units were randomly assigned into 3 groups: (1) no sign changes throughout the intervention period, (2) signs changed weekly, and (3) signs changed monthly. Main Outcomes and Measures: Hand hygiene adherence as measured by covert observation. Interrupted time series analysis was used to examine changes in HH adherence from baseline through the intervention period by group. Results: Among 58 inpatient units, 19 units were assigned to the no change group, 19 units were assigned to the weekly change group, and 20 units were assigned to the monthly change group. During the baseline period, 9755 HH opportunities were observed at room entry and 10 095 HH opportunities were observed at room exit. During the intervention period, a total of 15 855 HH opportunities were observed at room entry, and 16 360 HH opportunities were observed at room exit. Overall HH adherence did not change from baseline compared with the intervention period at either room entry (4770 HH events [48.9%] vs 3057 HH events [50.1%]; P = .14) or exit (6439 HH events [63.8%] vs 4087 HH events [65.2%]; P = .06). In units that changed signs weekly, HH adherence declined from baseline at room entry (-1.9% [95% CI, -2.7% to -0.8%] per week; P < .001) and exit (-0.8% [95% CI, -1.5% to 0.1%] per week; P = .02). No significant changes in HH adherence were observed in other groups. Conclusions and Relevance: The frequency of changing reminder signs had no effect on HH rates overall. Units assigned to change signs most frequently demonstrated worsening adherence. Considering the abundance of signs in the acute care environment, the frequency of changing signs did not appear to provide a strong enough cue by itself to promote behavioral change. Trial Registration: ClinicalTrials.gov Identifier: NCT02223455.

Impact of Rural Residence on Kidney Transplant Rates Among Waitlisted Candidates in the VA Transplant Programs.

BACKGROUND: Although proportionally more veterans live in rural areas compared to nonveterans, the impact of rurality status on kidney transplantation (KTP) access among veterans is unknown. Our objective was to study KTP rates among veterans listed for KTP and to compare the impact of rurality status on KTP rates among veterans and nonveterans. METHODS: Retrospective cohort study of adult patients waitlisted per the United Network for Organ Sharing from January 2000 to December 2014. Patient characteristics were compared using Chi-square or t tests, as appropriate, by veteran status and patient rurality. Multivariable competing-risks Cox regression was performed. RESULTS: The study sample included 3281 veterans receiving care in Veteran Health Administration transplant programs and 445 177 nonveterans. Veterans, compared to nonveterans, were older (57 versus 50 y; P < 0.001), more likely to be male (96% versus 60%; P < 0.001) or diabetic at waitlisting (51% versus 41%; P < 0.001), and less likely be an urban resident (79% versus 84%; P < 0.001). Among veterans, dialysis duration prior to registration was longer among urban compared to all other rurality types (810 ± 22.1 d versus 632 to 702 ± 41.6 to 77.6 d; P = 0.02). In multivariate competing risks models, there was no evidence that the hazard of transplant among veterans differs by residential rurality. CONCLUSIONS: Among waitlisted veterans served by Veteran Health Administration transplant programs, residential rurality status does not portend longer waiting time for KTP.

Temporal Stability in Chronic Wound Microbiota Is Associated With Poor Healing.

Microbial burden of chronic wounds is believed to play an important role in impaired healing and the development of infection-related complications. However, clinical cultures have little predictive value of wound outcomes, and culture-independent studies have been limited by cross-sectional design and small cohort size. We systematically evaluated the temporal dynamics of the microbiota colonizing diabetic foot ulcers, a common and costly complication of diabetes, and its association with healing and clinical complications. Dirichlet multinomial mixture modeling, Markov chain analysis, and mixed-effect models were used to investigate shifts in the microbiota over time and their associations with healing. Here we show, to our knowledge, previously unreported temporal dynamics of the chronic wound microbiome. Microbiota community instability was associated with faster healing and improved outcomes. Diabetic foot ulcer microbiota were found to exist in one of four community types that experienced frequent and nonrandom transitions. Transition patterns and frequencies were associated with healing time. Exposure to systemic antibiotics destabilized the wound microbiota, rather than altering overall diversity or relative abundance of specific taxa. This study provides evidence that the dynamic wound microbiome is indicative of clinical outcomes and may be a valuable guide for personalized management and treatment of chronic wounds.

Cultures of diabetic foot ulcers without clinical signs of infection do not predict outcomes.

OBJECTIVE: We examined associations between ulcer bioburden and ulcer outcomes in neuropathic diabetic foot ulcers (DFUs) that lacked clinical signs of infection. RESEARCH DESIGN AND METHODS: Three dimensions of bioburden (i.e., microbial load, microbial diversity, and the presence of likely pathogens) were measured at baseline using swab cultures obtained by Levine's technique. Subjects were assessed every 2 weeks for 26 weeks to determine the rate of healing and development of infection-related complications. Foot ulcers were off-loaded using total-contact casts and routinely debrided. To establish associations between bioburden and rate of healing, Cox proportional hazards and least squares regression were used after adjusting for ulcer depth, surface area, and duration. RESULTS: A total of 77 subjects completed the study. Sixty-five (84.4%) had ulcers that healed during follow-up; weeks-to-closure ranged from 2 to 26 (median 4.0). Mean (± SD) percent reduction in surface area/week was 25.0% (± 23.33). Five (6.5%) of the DFUs developed an infection-related complication. None of the bioburden dimensions (i.e., microbial load, microbial diversity, or presence of likely pathogens) was significantly associated with weeks-to-closure or percent reduction in surface area per week. Weeks-to-closure was best predicted by ulcer duration, depth, and surface area (c-statistic = 0.75). CONCLUSIONS: Culturing DFUs that showed no clinical signs of infection had no predictive value for outcomes of DFUs managed with total-contact casts and routine debridement. These findings support recommendations of the Infectious Disease Society of America that culturing and antibiotics should be avoided in treating DFUs that show no clinical signs of infection.

Feasibility and desirability of web-based mental health screening and individualized education for female OEF/OIF reserve and national guard war veterans.

Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Reserve and National Guard (RNG) service members have an increased risk for postdeployment mental health (MH) and readjustment problems, yet most do not access needed care. It is unknown if RNG servicewomen experiencing postdeployment readjustment symptoms are aware these may signify treatable MH concerns or if this knowledge activates care-seeking. The aims of this proof-of-concept study were to determine the feasibility of web-based MH screening for postdeployment MH symptoms to inform individualized psychoeducation, and to assess user perceptions about the online instrument and process, MH care access, and VA and other MH care. A midwestern sample (N = 131) of recently deployed (past 24 months) OEF/OIF RNG Army and Air Force servicewomen participated. High rates of combat experiences (95%) and military sexual trauma (50%) were reported. Positive screens for key symptoms of MH problems were prevalent. One third (31%) of satisfaction survey completers indicated online information reduced discomfort with seeking MH care; 42% reported they would subsequently seek MH assessment. Participants interviewed by telephone indicated that stigma and limited knowledge about women-specific services were key reasons servicewomen do not use MH care. This study demonstrated web-based screenings with individualized psychoeducation are implementable and favorable to RNG servicewomen.

Sustained blood pressure control following discontinuation of a pharmacist intervention.

Team-based care can improve hypertension control. The purpose of the present study was to evaluate blood pressure (BP) control 18 months following the discontinuation of a physician-pharmacist collaborative intervention. This was a retrospective analysis of patients who had previously participated in a prospective, cluster randomized, controlled clinical trial. Six community-based family medicine offices were randomized to control or intervention groups. Research nurses measured BPs using an automated device during the prospective trial. The research nurses then abstracted data from medical records, including BPs, medications, changes in therapy, and laboratory values for 18 months following the discontinuation of the 6-month prospective trial. The study included 228 patients in the control (n = 146) or intervention (n = 82) groups. The control group contained more patients with diabetes or chronic kidney disease (P < .013), were older (P = .047), and had more coexisting conditions (P < .001) than the intervention group. Systolic BP 9 months following discontinuation of the physician-pharmacist intervention was 137.2 ± 18.2 mm Hg and 129.8 ± 13.3 mm Hg in the control and intervention groups, respectively (P = .0015). BP control was maintained in 61 (41.8%) control patients and 55 (67.1%) intervention patients (P = .0003). At 18 months post-intervention, systolic BP was 138.1 ± 20.4 mm Hg and 130.0 ± 16.0 mm Hg in the control and intervention groups, respectively (P = .023). BP control was maintained in 53 (36.3%) control patients and 55 (67.1%) intervention patients at 18 months post-intervention (P < .0001). A sensitivity analysis was conducted to address the uneven distribution of patients with diabetes or chronic kidney disease, and the differences between groups were still significant. BP control rates remained significantly higher following a physician-pharmacist intervention compared with usual care for 18 months after discontinuation of the intervention. This model has the potential value as a useful long-term strategy to benefit patients with hypertension.

Deterioration of blood pressure control after discontinuation of a physician-pharmacist collaborative intervention.

STUDY OBJECTIVE: To assess blood pressure control after discontinuation of a physician-pharmacist collaborative intervention. DESIGN: Comparative analysis of data of the patients who received the intervention versus a control group from a prospective, cluster-randomized, 9-month efficacy trial and the same patients' data 18 and 27 months after completion of the trial, abstracted from their medical records. SETTING: Five primary care medical offices operated by a university health system. PATIENTS: One hundred four patients with hypertension; 65 were in the intervention group, and 39 were in the control group. MEASUREMENTS AND MAIN RESULTS: In the prospective study, patients were randomized to receive a physician-pharmacist collaborative intervention to improve blood pressure control or to the control group. Systolic and diastolic blood pressures were measured by a research nurse at baseline and at the end of the study (9 mo later). In the current study, data were abstracted for blood pressure and blood pressure control at 18 and 27 months (9 and 18 mo, respectively, after discontinuation of the study). At baseline, mean +/- SD systolic blood pressure was 152.5 +/- 9.5 and 150.1 +/- 9.6 mm Hg in the intervention and control groups, respectively (p=0.22). At 9 months, systolic blood pressure decreased to 124.5 +/- 10.7 and 132.0 +/- 15.1 mm Hg (p=0.0038 between groups), and blood pressure was controlled in 78.5% and 48.7% (p=0.0017) of patients in the intervention and control groups, respectively. By 18 months, systolic blood pressure had deteriorated to 131.0 +/- 12.2 and 143.3 +/- 17.5 mm Hg (p<0.001), and blood pressure control rates decreased to 53.9% and 30.8% (p=0.02). By 27 months, systolic blood pressure was 131.3 +/- 13.0 and 141.2 +/- 15.8 mm Hg (p=0.0008), and blood pressure control was 55.4% and 35.9% (p=0.05). CONCLUSION: A sustained positive effect on blood pressure control was noted up to 18 months after discontinuation of a physician-pharmacist collaborative intervention, when compared with a control group. Blood pressure control did deteriorate at a similar rate in both the intervention and control groups, but the percentage of patients with controlled blood pressure remained significantly higher in the intervention group. These results suggest that continued interventions by pharmacists may be necessary to maintain high rates of blood pressure control, especially in those patients whose blood pressure begins to increase.

Physician and pharmacist collaboration to improve blood pressure control.

BACKGROUND: Studies have demonstrated that blood pressure (BP) control can be improved when clinical pharmacists assist with patient management. The objective of this study was to evaluate if a physician and pharmacist collaborative model in community-based medical offices could improve BP control. METHODS: This was a prospective, cluster randomized, controlled clinical trial with clinics randomized to a control group (n = 3) or to an intervention group (n = 3). The study enrolled 402 patients (mean age, 58.3 years) with uncontrolled hypertension. Clinical pharmacists made drug therapy recommendations to physicians based on national guidelines. Research nurses performed BP measurements and 24-hour BP monitoring. RESULTS: The mean (SD) guideline adherence scores increased from 49.4 (19.3) at baseline to 53.4 (18.1) at 6 months (8.1% increase) in the control group and from 40.4 (22.6) at baseline to 62.8 (13.5) at 6 months (55.4% increase) in the intervention group (P = .09 for adjusted between-group comparison). The mean BP decreased 6.8/4.5 mm Hg in the control group and 20.7/9.7 mm Hg in the intervention group (P < .05 for between-group systolic BP comparison). The adjusted difference in systolic BP was -12.0 (95% confidence interval [CI], -24.0 to 0.0) mm Hg, while the adjusted difference in diastolic BP was -1.8 (95% CI, -11.9 to 8.3) mm Hg. The 24-hour BP levels showed similar effect sizes. Blood pressure was controlled in 29.9% of patients in the control group and in 63.9% of patients in the intervention group (adjusted odds ratio, 3.2; 95% CI, 2.0-5.1; P < .001). CONCLUSIONS: A physician and pharmacist collaborative intervention achieved significantly better mean BP and overall BP control rates compared with a control group. Additional research should be conducted to evaluate efficient strategies to implement team-based chronic disease management. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00201019.

Physician adherence to blood pressure guidelines and its effect on seniors.

STUDY OBJECTIVE: To compare physician adherence to guidelines from the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure for patients younger than 65 years of age with those aged 65 years and older, and to analyze whether factor groupings (subsets of criteria used to determine adherence) were predictive of blood pressure control. DESIGN: Retrospective medical record review. SETTING: Five university-affiliated family medicine and internal medicine outpatient clinics. PATIENTS: One hundred seventy-nine patients (age range 21-85 yrs) with uncontrolled hypertension: 105 patients were younger than 65 years (nonsenior), and 74 patients were 65 years or older (senior). MEASUREMENTS AND MAIN RESULTS: Data abstracted from each patient's medical record were used to evaluate adherence to 17 process-of-care criteria, identified to assess physician adherence to the guidelines. A computer algorithm generated scores for each criterion as well as an overall adherence score. The relationship between the adherence score and blood pressure control was then examined. Separate factor analyses were conducted to ascertain differences in the way that the criteria were grouped. Factor scores were calculated for each patient, and the scores were evaluated in the context of blood pressure control. Guideline adherence scores were significantly higher for nonsenior patients than for senior patients (59.3% vs 56.1%, p=0.024). Blood pressure control rate was also higher, although not significantly, in nonseniors versus seniors (68.6% vs 56.8%, p=0.063). No factors in the senior group were significantly associated with blood pressure control, but one was significantly correlated in the nonsenior group (p<0.0001). It included diuretic therapy, adjusting a drug when a patient's blood pressure was uncontrolled, documentation of uncontrolled blood pressure in the medical record at the visit, documentation of the correct blood pressure goal, documentation of cardiovascular risk factors, and measurement of urine albumin level. CONCLUSION: Overall physician adherence to blood pressure guidelines was significantly higher for the nonsenior group than for the senior group. Similarly, control of blood pressure was better in the nonsenior group. However, no significant relationship between overall adherence scores and blood pressure control was found in either group. In nonseniors, one factor grouping was significantly correlated with blood pressure control. Future studies should evaluate the process-of-care criteria to determine if and how they are related to blood pressure control in senior patients.

Are United States hospitals following national guidelines for the analysis and presentation of cumulative antimicrobial susceptibility data?

The National Committee for Clinical Laboratory Standards recently published guidelines for analysis and presentation of cumulative antimicrobial susceptibility test data (antibiograms). We sought to determine how well US hospitals already adhere to standards for antibiogram compilation, and to examine the relationship between hospital characteristics and guideline adherence. We surveyed laboratory directors at 670 hospitals and examined 3 guideline criteria: compilation of an antibiogram, annual updating, and distribution to infection control staff and medical staff yearly; 494 surveys were returned (74%). Almost all of the hospitals surveyed publish an antibiogram (95%, n = 481); however, only 60% (n = 296) met all three criteria. Hospital laboratories meeting criteria were more likely to serve as referral laboratories (OR = 1.82; 95% CI = 1.26-2.63), perform susceptibility testing on site (OR = 4.47; 95% CI = 1.84-10.84), use confirmatory tests to detect extended-spectrum beta-lactamases (OR = 1.8; 95% CI = 1.2-2.6), and have more laboratory personnel per bed (3.0 vs. 2.0 FTEs/bed, p = 0.0031). Adherence to guidelines for preparation and dissemination of antibiograms could be improved. Institutional commitment to high quality, on-site microbiology laboratory services will improve adherence to these guidelines.

Antimicrobial resistance trends and outbreak frequency in United States hospitals.

We assessed resistance rates and trends for important antimicrobial-resistant pathogens (oxacillin-resistant Staphylococcus aureus [ORSA], vancomycin-resistant Enterococcus species [VRE], ceftazidime-resistant Klebsiella species [K-ESBL], and ciprofloxacin-resistant Escherichia coli [QREC]), the frequency of outbreaks of infection with these resistant pathogens, and the measures taken to control resistance in a stratified national sample of 670 hospitals. Four hundred ninety-four (74%) of 670 surveys were returned. Resistance rates were highest for ORSA (36%), followed by VRE (10%), QREC (6%), and K-ESBL (5%). Two-thirds of hospitals reported increasing ORSA rates, whereas only 4% reported decreasing rates, and 24% reported ORSA outbreaks within the previous year. Most hospitals (87%) reported having implemented measures to rapidly detect resistance, but only approximately 50% reported having provided appropriate resources for antimicrobial resistance prevention (53%) or having implemented antimicrobial use guidelines (60%). The most common resistant pathogen in US hospitals is ORSA, which accounts for many recognized outbreaks and is increasing in frequency in most facilities. Current practices to prevent and control antimicrobial resistance are inadequate.