The state of infection prevention and control at home health agencies in the United States prior to COVID-19: A cross-sectional study.

BACKGROUND: Home health care is a rapidly growing healthcare sector worldwide. Home health professionals face unique challenges related to preventing and controlling infections, which are likely to amplify during an infectious disease outbreak (e.g. SARS-CoV-2). Little is known about the current state of infection prevention and control-related policies and outbreak preparedness at U.S. home health agencies. OBJECTIVES: In this study, we conducted a national survey to assess infection prevention and control-related policies, infrastructure, and procedures prior to the SARS-CoV-2 pandemic. DESIGN: Cross-sectional study. SETTING/PARTICIPANTS: Using a stratified random sample of 1506 U.S. home health agencies, we conducted a 61-item survey (paper and online) from November 9, 2018 to December 31, 2019. METHODS: Survey data were linked to publicly-available data on the quality of patient care, patient satisfaction, and other agency characteristics. Probability weights were developed to account for sample design and nonresponse; Pearson's χ2, Fisher's exact, t-tests or linear regression were used to compare the universe of agencies/respondents and urban/rural agencies. RESULTS: 35.6% of agencies responded (n = 536). Most home health personnel in charge of infection prevention and control have other responsibilities; one-third have no formal infection prevention and control training. Rural agencies are more likely to not have anyone in charge of infection prevention and control compared to those in urban areas. About 22% of agencies implement recommended guidelines when administering antibiotics. Less than a third (26.4%) report that their staff vaccination rates were higher than 95% during the last flu season. Only 48.1% of agencies accept patients requiring ventilation, and of those, 40.9% located in rural areas do not have specific infection prevention and control policies for ventilated patients, compared to 20.8% in urban areas (p < 0.001). Only 39.7% of agencies provide N95 respirators to their clinical staff; rural agencies are significantly more likely to provide those supplies than urban agencies (50.7% vs. 37.7%, p = 0.004). Lastly, agencies report their greatest challenges with infection prevention and control are collecting/reporting infection data and adherence to/monitoring of nursing bag technique. CONCLUSIONS: Prior to the SARS-CoV-2 pandemic, we found that infection prevention and control was suboptimal among U.S. home health care agencies. Consequently, most agencies have limited capacity to respond to infectious disease outbreaks. Staff and personal protective equipment shortages remain major concerns, and agencies will need to quickly adjust their existing infection prevention and control policies and potentially create new ones. In the long-term, agencies also need to improve influenza vaccination coverage among their staff. Tweetable abstract: Infection prevention and control infrastructure, policies and procedures and outbreak preparedness at U.S. home health agencies was found to be suboptimal in nationally-representative survey conducted just prior to the COVID-19 pandemic.

The Role of Regional and State Initiatives in Nursing Home Advance Care Planning Policies.

OBJECTIVE: Antibiotic use at the end of life (EoL) may introduce physiological as well as psychological stress and be incongruent with patients' goals of care. Advance care planning (ACP) related to antibiotic use at the EoL helps improve goal-concordant care. Many nursing home (NH) residents are seriously ill. Therefore, we aimed to examine whether state and regional ACP initiatives play a role in the presence of "do not administer antibiotics" orders for NH residents at the EoL. METHODS: We surveyed a random, representative national sample of 810 U.S. NHs (weighted n = 13,983). The NH survey included items on "do not administer antibiotics" orders in place and participation in infection prevention collaboratives. The survey was linked to state Physician Orders for Life-Sustaining Treatment (POLST) adoption status and resident, facility, and county characteristics data. We conducted multivariable regression models with state fixed effects, stratified by state POLST designation. RESULTS: NHs in mature POLST states reported higher rates of "do not administer antibiotics" orders compared to developing POLST states (10.1% vs. 4.6%, respectively, p = 0.004). In mature POLST states, participation in regional collaboratives and smaller NH facilities (<100 beds) were associated with having "do not administer antibiotics" orders for seriously ill residents (ß = 0.11, p = 0.006 and ß = 0.12, p = 0.003, respectively). DISCUSSION: NHs in states with mature POLST adoption that participated in infection control collaboratives were more likely to have "do not administer antibiotics" orders. State ACP initiatives combined with regional antibiotic stewardship initiatives may improve inappropriate antibiotic use at the EoL for NH residents.

COVID-19 Preparedness in US Home Health Care Agencies.

OBJECTIVES: In the United States, home health agencies (HHAs) provide essential services for patients recovering from post-acute care and older adults who are aging in place. During the COVID-19 pandemic, HHAs may face additional challenges caring for these vulnerable patients. Our objective was to explore COVID-19 preparedness of US HHAs and compare results by urban/rural location. DESIGN: Cross-sectional study. SETTING/PARTICIPANTS: Using a stratified random sample of 978 HHAs, we conducted a 22-item online survey from April 10 to 17, 2020. METHODS: Summary statistics were computed; open-ended narrative responses were synthesized using qualitative methods. RESULTS: Similar to national data, most responding HHAs (n = 121, 12% response rate) were for-profit and located in the South. Most HHAs had infectious disease outbreaks included in their emergency preparedness plan (76%), a staff member in charge of outbreak/disaster preparedness (84%), and had provided their staff with COVID-19 education and training (97%). More urban HHAs had cared for confirmed and recovered COVID-19 patients than rural HHAs, but urban HHAs had less capacity to test for COVID-19 than rural HHAs (9% vs 21%). Most (69%) experienced patient census declines and had a current and/or anticipated supply shortage. Rural agencies were affected less than urban agencies. HHAs have already rationed (69%) or implemented extended use (55%) or limited reuse (61%) of personal protective equipment (PPE). Many HHAs reported accessing supplemental PPE from state/local resources, donations, and do-it-yourself efforts; more rural HHAs had accessed these additional resources compared with urban HHAs. CONCLUSIONS/IMPLICATIONS: This survey reveals challenges that HHAs are having in responding to the COVID-19 pandemic, particularly among urban agencies. Of greatest concern are the declines in patient census, which drastically affect agency revenue, and the shortages of PPE and disinfectants. Without proper protection, HHA clinicians are at risk of self-exposure and viral transmission to patients and vulnerable family members.

Exploring Practices of Bedside Shift Report and Hourly Rounding. Is There an Impact on Patient Falls?

OBJECTIVE: To describe the relationship of inpatient falls to bedside shift report (BSR) and hourly rounding (HR). BACKGROUND: Falls are a major healthcare concern. Although measures such as BSR and HR are reported to reduce falls, studies are often based on self-reported data related to nurse compliance with protocols for HR and bedside report. METHODS: Observational data were collected on nursing tasks, including BSR and HR. RESULTS: Nine thousand six hundred ninety-three observations were recorded on 11 units at 4 hospitals over 281 shifts. Falls were associated with shift and day of the week but not BSR, HR, or the frequency of encounters with the patient. The regression model included frequency with patient, shift, day of week, and HR. CONCLUSIONS: Increased nurse frequency with patient may signal increased fall risks. Bedside shift report and HR may require robust and sustained interventions to provide lasting effects.

Self-reported National Healthcare Safety Network knowledge and enrollment: A national survey of nursing homes.

Predictors of nursing home staff knowledge of the National Healthcare Safety Network (NHSN) and facility enrollment were explored in a national survey. Facility participation in Quality Innovation Network-Quality Improvement Organization initiatives was positively associated with both knowledge and enrollment. In addition, engaging clinical personnel in decision making on NHSN enrollment was positively associated with staff knowledge of NHSN.

Characteristics of nursing homes with comprehensive antibiotic stewardship programs: Results of a national survey.

BACKGROUND: Antibiotic stewardship in nursing homes (NHs) is a high priority owing to intense antibiotic use and increased risk of adverse events. Updated Centers for Medicare and Medicaid Services regulations required NHs to establish antibiotic stewardship programs (ASPs). This study describes the current state of NH ASPs. METHODS: A nationally representative survey of NHs was conducted in 2018. ASP comprehensiveness, infection preventionist (IP) training, participation in Quality Innovation Network-Quality Improvement Organization (QIN-QIO) activities, and facility and staff characteristics were analyzed using weighted descriptive statistics and multinomial regression models. RESULTS: Of 861 NHs, 33.2% (6-7) had "comprehensive" ASP policies, 41.1% (4-5) had "moderately comprehensive" ASP policies, and 25.6% (≤ 3) had "not comprehensive" ASP policies. Data collection on antibiotic use was most reported (91.4%), and restricting use of specific antibiotics was least reported (19.0%). Comprehensive ASPs were associated with QIN-QIO involvement; moderate and comprehensive ASPs were associated with IP training and high occupancy. DISCUSSION: Immediately following Centers for Medicare and Medicaid Services regulation changes, a majority of NHs had moderately comprehensive or comprehensive ASPs. Rates for each policy and infection control-trained IPs increased from previous studies. CONCLUSIONS: NH ASPs are becoming more comprehensive. Infection control training and partnerships with QIN-QIOs can support NHs to increase ASP comprehensiveness.

Research Priorities of Clinical Nurses and Midwives in the Eastern Mediterranean Region: a Mixed Methods Study.

Effective use of resources in healthcare research is essential in meeting the United Nation's Sustainable Development Goal (SDG) 3 to achieve universal health coverage, increase retention of healthcare workers, and strengthen the capacity of all countries to reduce risk and manage global health risks; the World Health Organization (WHO) also identifies nursing research as an important piece of the framework for improving global healthcare. Determining research priorities to reduce redundancy and ensure a solid evidence base for practice is especially critical in resource-limited countries or those facing healthcare crises such as those in the Middle East. To identify regional research priorities for nursing, focus group discussions composed of hospital-based nurses were conducted in Egypt, Oman, and Saudi Arabia. Forty-eight percent of research priorities were nearly the same as those identified as critical by regional nursing leadership in a previous study, demonstrating consistency between clinician- and administrator-identified research priorities, and suggesting healthcare administrators are well attuned to the research needs of clinicians. Both groups identified critical gaps in population and community health research. Across countries, research priorities identified were related to nursing workforce, health systems research, and quality of care, representing critical issues needing investigation to build a solid evidence base for nursing practice.

Lemon-shaped halo archaeal virus His1 with uniform tail but variable capsid structure.

Lemon-shaped viruses are common in nature but so far have been observed to infect only archaea. Due to their unusual shape, the structures of these viruses are challenging to study and therefore poorly characterized. Here, we have studied haloarchaeal virus His1 using cryo-electron tomography as well as biochemical dissociation. The virions have different sizes, but prove to be extremely stable under various biochemical treatments. Subtomogram averaging of the computationally extracted virions resolved a tail-like structure with a central tail hub density and six tail spikes. Inside the tail there are two cavities and a plug density that separates the tail hub from the interior genome. His1 most likely uses the tail spikes to anchor to host cells and the tail hub to eject the genome, analogous to classic tailed bacteriophages. Upon biochemical treatment that releases the genome, the lemon-shaped virion transforms into an empty tube. Such a dramatic transformation demonstrates that the capsid proteins are capable of undergoing substantial quaternary structural changes, which may occur at different stages of the virus life cycle.

Filamentous, mixed micelles of triblock copolymers enhance tumor localization of indocyanine green in a murine xenograft model.

Polymeric micelles formed by the self-assembly of amphiphilic block copolymers can be used to encapsulate hydrophobic drugs for tumor-delivery applications. Filamentous carriers with high aspect ratios offer potential advantages over spherical carriers, including prolonged circulation times. In this work, mixed micelles composed of poly(ethylene oxide)-poly[(R)-3-hydroxybutyrate]-poly(ethylene oxide) (PEO-PHB-PEO) and Pluronic F-127 (PF-127) were used to encapsulate a near-infrared fluorophore. The micelle formulations were assessed for tumor accumulation after tail vein injection to xenograft tumor-bearing mice by noninvasive optical imaging. The mixed micelle formulation that facilitated the highest tumor accumulation was shown by cryo-electron microscopy to be filamentous in structure compared to spherical structures of pure PF-127 micelles. In addition, increased dye loading efficiency and dye stability were attained in this mixed micelle formulation compared to pure PEO-PHB-PEO micelles. Therefore, the optimized PEO-PHB-PEO/PF-127 mixed micelle formulation offers advantages for cancer delivery over micelles formed from the individual copolymer components.

Structure of Trypanosoma brucei flagellum accounts for its bihelical motion.

Trypanosoma brucei is a parasitic protozoan that causes African sleeping sickness. It contains a flagellum required for locomotion and viability. In addition to a microtubular axoneme, the flagellum contains a crystalline paraflagellar rod (PFR) and connecting proteins. We show here, by cryoelectron tomography, the structure of the flagellum in three bending states. The PFR lattice in straight flagella repeats every 56 nm along the length of the axoneme, matching the spacing of the connecting proteins. During flagellar bending, the PFR crystallographic unit cell lengths remain constant while the interaxial angles vary, similar to a jackscrew. The axoneme drives the expansion and compression of the PFR lattice. We propose that the PFR modifies the in-plane axoneme motion to produce the characteristic trypanosome bihelical motility as captured by high-speed light microscope videography.

Effect of the peptide secondary structure on the peptide amphiphile supramolecular structure and interactions.

Bottom-up fabrication of self-assembled nanomaterials requires control over forces and interactions between building blocks. We report here on the formation and architecture of supramolecular structures constructed from two different peptide amphiphiles. Inclusion of four alanines between a 16-mer peptide and a 16 carbon long aliphatic tail resulted in a secondary structure shift of the peptide headgroups from α helices to ß sheets. A concomitant shift in self-assembled morphology from nanoribbons to core-shell worm-like micelles was observed by cryogenic transmission electron microscopy (cryo-TEM) and atomic force microscopy (AFM). In the presence of divalent magnesium ions, these a priori formed supramolecular structures interacted in distinct manners, highlighting the importance of peptide amphiphile design in self-assembly.

Mechanism of folding chamber closure in a group II chaperonin.

Group II chaperonins are essential mediators of cellular protein folding in eukaryotes and archaea. These oligomeric protein machines, approximately 1 megadalton, consist of two back-to-back rings encompassing a central cavity that accommodates polypeptide substrates. Chaperonin-mediated protein folding is critically dependent on the closure of a built-in lid, which is triggered by ATP hydrolysis. The structural rearrangements and molecular events leading to lid closure are still unknown. Here we report four single particle cryo-electron microscopy (cryo-EM) structures of Mm-cpn, an archaeal group II chaperonin, in the nucleotide-free (open) and nucleotide-induced (closed) states. The 4.3 A resolution of the closed conformation allowed building of the first ever atomic model directly from the single particle cryo-EM density map, in which we were able to visualize the nucleotide and more than 70% of the side chains. The model of the open conformation was obtained by using the deformable elastic network modelling with the 8 A resolution open-state cryo-EM density restraints. Together, the open and closed structures show how local conformational changes triggered by ATP hydrolysis lead to an alteration of intersubunit contacts within and across the rings, ultimately causing a rocking motion that closes the ring. Our analyses show that there is an intricate and unforeseen set of interactions controlling allosteric communication and inter-ring signalling, driving the conformational cycle of group II chaperonins. Beyond this, we anticipate that our methodology of combining single particle cryo-EM and computational modelling will become a powerful tool in the determination of atomic details involved in the dynamic processes of macromolecular machines in solution.