Assessing the Impact of 2-Step Clostridioides difficile Testing at the Healthcare Facility Level.

BACKGROUND: Two-step testing for Clostridioides difficile infection (CDI) aims to improve diagnostic specificity but may also influence reported epidemiology and patterns of treatment. Some providers fear that 2-step testing may result in adverse outcomes if C. difficile is underdiagnosed. METHODS: Our primary objective was to assess the impact of 2-step testing on reported incidence of hospital-onset CDI (HO-CDI). As secondary objectives, we assessed the impact of 2-step testing on C. difficile-specific antibiotic use and colectomy rates as proxies for harm from underdiagnosis or delayed treatment. This longitudinal cohort study included 2 657 324 patient-days across 8 regional hospitals from July 2017 through March 2022. Impact of 2-step testing was assessed by time series analysis with generalized estimating equation regression models. RESULTS: Two-step testing was associated with a level decrease in HO-CDI incidence (incidence rate ratio, 0.53 [95% confidence interval {CI}, .48-.60]; P < .001), a similar level decrease in utilization rates for oral vancomycin and fidaxomicin (utilization rate ratio, 0.63 [95% CI, .58-.70]; P < .001), and no significant level (rate ratio, 1.16 [95% CI, .93-1.43]; P = .18) or trend (rate ratio, 0.85 [95% CI, .52-1.39]; P = .51) change in emergent colectomy rates. CONCLUSIONS: Two-step testing is associated with decreased reported incidence of HO-CDI, likely by improving diagnostic specificity. The parallel decrease in C. difficile-specific antibiotic use offers indirect reassurance against underdiagnosis of C. difficile infections still requiring treatment by clinician assessment. Similarly, the absence of any significant change in colectomy rates offers indirect reassurance against any rise in fulminant C. difficile requiring surgical management.

CDC's Hospital-Onset Clostridioides difficile Prevention Framework in a Regional Hospital Network.

Importance: Despite modest reductions in the incidence of hospital-onset Clostridioides difficile infection (HO-CDI), CDI remains a leading cause of health care-associated infection. As no single intervention has proven highly effective on its own, a multifaceted approach to controlling HO-CDI is needed. Objective: To assess the effectiveness of the Centers for Disease Control and Prevention's Strategies to Prevent Clostridioides difficile Infection in Acute Care Facilities Framework (hereafter, the Framework) in reducing HO-CDI incidence. Design, Setting, and Participants: This quality improvement study was performed within the Duke Infection Control Outreach Network from July 1, 2019, through March 31, 2022. In all, 20 hospitals in the network participated in an implementation study of the Framework recommendations, and 26 hospitals did not participate and served as controls. The Framework has 39 discrete intervention categories organized into 5 focal areas for CDI prevention: (1) isolation and contact precautions, (2) CDI confirmation, (3) environmental cleaning, (4) infrastructure development, and (5) antimicrobial stewardship engagement. Exposures: Monthly teleconferences supporting Framework implementation for the participating hospitals. Main Outcomes and Measures: Primary outcomes were HO-CDI incidence trends at participating hospitals compared with controls and postintervention HO-CDI incidence at intervention sites compared with rates during the 24 months before the intervention. Results: The study sample included a total of 2184 HO-CDI cases and 7 269 429 patient-days. In the intervention cohort of 20 participating hospitals, there were 1403 HO-CDI cases and 3 513 755 patient-days, with a median (IQR) HO-CDI incidence of 2.8 (2.0-4.3) cases per 10 000 patient-days. The first analysis included an additional 3 755 674 patient-days and 781 HO-CDI cases among the 26 controls, with a median (IQR) HO-CDI incidence of 1.1 (0.7-2.7) case per 10 000 patient-days. The second analysis included an additional 2 538 874 patient-days and 1751 HO-CDI cases, with a median (IQR) HO-CDI incidence of 5.9 (2.7-8.9) cases per 10 000 patient-days, from participating hospitals 24 months before the intervention. In the first analysis, intervention sites had a steeper decline in HO-CDI incidence over time relative to controls (yearly incidence rate ratio [IRR], 0.79 [95% CI, 0.67-0.94]; P = .01), but the decline was not temporally associated with study participation. In the second analysis, HO-CDI incidence was declining in participating hospitals before the intervention, and the rate of decline did not change during the intervention. The degree to which hospitals implemented the Framework was associated with steeper declines in HO-CDI incidence (yearly IRR, 0.95 [95% CI, 0.90-0.99]; P = .03). Conclusions and Relevance: In this quality improvement study of a regional hospital network, implementation of the Framework was not temporally associated with declining HO-CDI incidence. Further study of the effectiveness of multimodal prevention measures for controlling HO-CDI is warranted.

Burnout and staff turnover among certified nursing assistants working in acute care hospitals during the COVID-19 pandemic.

INTRODUCTION: Healthcare worker burnout is a growing problem in the United States which affects healthcare workers themselves, as well as the healthcare system as a whole. The goal of this qualitative assessment was to understand factors that may lead to healthcare worker burnout and turnover through focus groups with Certified Nursing Assistants who worked in acute care hospitals during the COVID-19 pandemic. METHODS: Eight focus group discussions lasting approximately 30 minutes each were held remotely from October 2022-January 2023 with current and former Certified Nursing Assistants who worked during the COVID-19 pandemic in acute care hospitals. Participants were recruited through various sources such as social media and outreach through professional organizations. The focus groups utilized open-ended prompts including topics such as challenges experienced during the pandemic, what could have improved their experiences working during the pandemic, and motivations for continuing or leaving their career in healthcare. The focus groups were coded using an immersion-crystallization technique and summarized using NVivo and Microsoft Excel. Participant demographic information was summarized overall and by current work status. RESULTS: The focus groups included 58 Certified Nursing Assistants; 33 (57%) were current Certified Nursing Assistants and 25 (43%) were Certified Nursing Assistants who no longer work in healthcare. Throughout the focus groups, five convergent themes emerged, including staffing challenges, respect and recognition for Certified Nursing Assistants, the physical and mental toll of the job, facility leadership support, and pay and incentives. CONCLUSIONS: Focus group discussions with Certified Nursing Assistants identified factors at individual and organizational levels that might contribute to burnout and staff turnover in healthcare settings. Suggestions from participants on improving their experiences included ensuring staff know they are valued, being included in conversations with leadership, and improving access to mental health resources.

Making a C-DIFFerence: Implementation of a prevention collaborative to reduce hospital-onset Clostridioides difficile infection rates.

Objective: To assist hospitals in reducing Clostridioides difficile infections (CDI), the Centers for Disease Control and Prevention (CDC) implemented a collaborative using the CDC CDI prevention strategies and the Targeted Assessment for Prevention (TAP) Strategy as foundational frameworks. Setting: Acute-care hospitals. Methods: We invited 400 hospitals with the highest cumulative attributable differences (CADs) to the 12-month collaborative, with monthly webinars, coaching calls, and deployment of the CDC CDI TAP facility assessments. Infection prevention barriers, gaps identified, and interventions implemented were qualitatively coded by categorizing them to respective CDI prevention strategies. Standardized infection ratios (SIRs) were reviewed to measure outcomes. Results: Overall, 76 hospitals participated, most often reporting CDI testing as their greatest barrier to achieving reduction (61%). In total, 5,673 TAP assessments were collected across 46 (61%) hospitals. Most hospitals (98%) identified at least 1 gap related to testing and at least 1 gap related to infrastructure to support prevention. Among 14 follow-up hospitals, 64% implemented interventions related to infrastructure to support prevention (eg, establishing champions, reviewing individual CDIs) and 86% implemented testing interventions (eg, 2-step testing, testing algorithms). The SIR decrease between the pre-collaborative and post-collaborative periods was significant among participants (16.7%; P < .001) but less than that among nonparticipants (25.1%; P < .001). Conclusions: This article describes gaps identified and interventions implemented during a comprehensive CDI prevention collaborative in targeted hospitals, highlighting potential future areas of focus for CDI prevention efforts as well as reported challenges and barriers to prevention of one of the most common healthcare-associated infections affecting hospitals and patients nationwide.

Chemically recyclable thermoplastics from reversible-deactivation polymerization of cyclic acetals.

Identifying plastics capable of chemical recycling to monomer (CRM) is the foremost challenge in creating a sustainable circular plastic economy. Polyacetals are promising candidates for CRM but lack useful tensile strengths owing to the low molecular weights produced using current uncontrolled cationic ring-opening polymerization (CROP) methods. Here, we present reversible-deactivation CROP of cyclic acetals using a commercial halomethyl ether initiator and an indium(III) bromide catalyst. Using this method, we synthesize poly(1,3-dioxolane) (PDXL), which demonstrates tensile strength comparable to some commodity polyolefins. Depolymerization of PDXL using strong acid catalysts returns monomer in near-quantitative yield and even proceeds from a commodity plastic waste mixture. Our efficient polymerization method affords a tough thermoplastic that can undergo selective depolymerization to monomer.

Unnecessary antibiotic prescribing in pediatric ambulatory care visits for bronchitis and bronchiolitis in the United States, 2006-2015.

Antibiotics are not indicated for the treatment of bronchitis and bronchiolitis. Using a nationally representative database from 2006-2015, we found that antibiotics were prescribed in 58% of outpatient visits for bronchitis and bronchiolitis in children, serving as a possible baseline for the expanded HEDIS 2020 measure regarding antibiotic prescribing for bronchitis.

A qualitative assessment of factors affecting nursing home caregiving staff experiences during the COVID-19 pandemic.

BACKGROUND: A large portion of COVID-19 cases and deaths in the United States have occurred in nursing homes; however, current literature including the frontline perspective of staff working in nursing homes is limited. The objective of this qualitative assessment was to better understand what individual and facility level factors may have contributed to the impact of COVID-19 on Certified Nursing Assistants (CNAs) and Environmental Services (EVS) staff working in nursing homes. METHODS: Based on a simple random sample from the National Healthcare Safety Network (NHSN), 7,520 facilities were emailed invitations requesting one CNA and/or one EVS staff member for participation in a voluntary focus group over Zoom. Facility characteristics were obtained via NHSN and publicly available sources; participant demographics were collected via SurveyMonkey during registration and polling during focus groups. Qualitative information was coded using NVIVO and Excel. RESULTS: Throughout April 2021, 23 focus groups including 110 participants from 84 facilities were conducted homogenous by participant role. Staffing problems were a recurring theme reported. Participants often cited the toll the pandemic took on their emotional well-being, describing increased stress, responsibilities, and time needed to complete their jobs. The lack of consistent and systematic guidance resulting in frequently changing infection prevention protocols was also reported across focus groups. CONCLUSIONS: Addressing concerns of low wages and lack of financial incentives may have the potential to attract and retain employees to help alleviate nursing home staff shortages. Additionally, access to mental health resources could help nursing home staff cope with the emotional burden of the COVID-19 pandemic. These frontline staff members provided invaluable insight and should be included in improvement efforts to support nursing homes recovering from the impact of COVID-19 as well as future pandemic planning.

Gaps in infection prevention practices for catheter-associated urinary tract infections and central line-associated bloodstream infections as identified by the Targeted Assessment for Prevention Strategy.

BACKGROUND: Catheter-associated urinary tract infections (CAUTI) and central line-associated bloodstream infections (CLABSI) represent a substantial portion of health care-associated infections (HAIs) reported in the United States. The Targeted Assessment for Prevention Strategy is a quality improvement framework to reduce health care-associated infections. Data from the Targeted Assessment for Prevention Facility Assessments were used to determine common infection prevention gaps for CAUTI and CLABSI. METHODS: Data from 2,044 CAUTI and 1,680 CLABSI assessments were included in the analysis. Items were defined as potential gaps if ≥33% respondents answered Unknown, ≥33% No, or ≥50% No or Unknown or Never, Rarely, Sometimes, or Unknown to questions pertaining to those areas. Review of response frequencies and stratification by respondent role were performed to highlight opportunities for improvement. RESULTS: Across CAUTI and CLABSI assessments, lack of physician champions (<35% Yes) and nurse champions (<55% Yes), along with lack of awareness of competency assessments, audits, and feedback were reported. Lack of practices to facilitate timely removal of urinary catheters were identified for CAUTI and issues with select device insertion practices, such as maintaining aseptic technique, were perceived as areas for improvement for CLABSI. CONCLUSIONS: These data suggest common gaps in critical components of infection prevention and control programs. The identification of these gaps has the potential to inform targeted CAUTI and CLABSI prevention efforts.

Association of Patient-Reported Difficulty with Adherence with Achievement of Clinical Targets Among Hemodialysis Patients.

BACKGROUND: Non-adherence to dialysis recommendations is common and associated with poor outcomes. We used data from a cohort of in-center hemodialysis patients to determine whether patients' reported difficulties with adherence were associated with achievement of clinical targets for treatment recommendations. PATIENTS AND METHODS: We included 799 in-center patients receiving hemodialysis from February 2010 to October 2016 at Emory Dialysis (Atlanta, GA, USA). Patient-reported difficulty with adherence (yes vs no) across multiple domains (coming to dialysis, completing dialysis sessions, fluid restrictions, diet restrictions, taking medications) was obtained from baseline social worker assessments. Achievement of clinical targets for coming to dialysis (missing ≥3 expected sessions), completing dialysis sessions (shortening >3 sessions by ≥15 min), fluid restrictions (mean interdialytic weight gain ≥3 kg), diet restrictions (mean potassium ≥5.0 mEq/L, mean phosphate >5.5 mg/dL), and taking medications (mean phosphate >5.5 mg/dL) was estimated over the following 12 weeks, using electronic medical record data. Crude agreement was assessed, and multivariable logistic regression was used to estimate the associations between these measures. RESULTS: Agreement between reported difficulty in adherence and failure to achieve clinical targets was generally poor across all domains (percent agreement: 52.9-65.3%). After adjustment, patients reporting difficulty with fluid restrictions were 62% more likely to have mean interdialytic weight gain ≥3 kg than those not reporting difficulty (OR: 1.62, 95% CI: 1.08, 2.43). Patients reporting difficulty with coming to dialysis were 41% more likely to miss ≥3 expected dialysis sessions over 12 weeks (OR: 1.41, 95% CI: 0.96, 2.07); however, this association was not statistically significant. There were no significant associations between reported difficulty and failure to achieve clinical targets in other categories. CONCLUSION: While reported difficulty with only fluid restrictions and coming to dialysis were associated with failure to achieve clinical targets in our study, the general lack of agreement between reported difficulty with adherence and failure to achieve clinical targets highlights a gap that could be explored to develop and target educational interventions aimed at increasing adherence among dialysis patients.

Miscible Polyether/Poly(ether-acetal) Electrolyte Blends.

This study shows that it is possible to obtain homogeneous mixtures of two chemically distinct polymers with a lithium salt for electrolytic applications. This approach is motivated by the success of using mixtures of organic solvents in modern lithium-ion batteries. The properties of mixtures of a polyether, poly(ethylene oxide) (PEO), a poly(ether-acetal), poly(1,3,6-trioxocane) (P(2EO-MO)), and lithium bis(trifluoromethanesulfonyl)imide (LiTFSI) salt were studied by small-angle neutron scattering (SANS) and electrochemical characterization in symmetric cells. The SANS data are used to determine the miscibility window and quantify the effect of added salt on the thermodynamic interactions between the polymers. In the absence of salt, PEO/P(2EO-MO) blends are homogeneous and characterized by attractive interactions, i.e., a negative Flory-Huggins interaction parameter, χ. The addition of small amounts of salt results in a positive effective Flory-Huggins interaction parameter, χ eff, and macrophase separation. Surprisingly, miscible blends and negative χ eff parameters are obtained when the salt concentration is increased beyond a critical value. The electrochemical properties of PEO/P(2EO-MO)/LiTFSI blends at a given salt concentration were close to those obtained in PEO/LiTFSI electrolytes at the same salt concentration. This suggests that in the presence of PEO the electrochemical properties exhibited by P(2EO-MO) chains are similar to those of PEO chains. This work opens the door to a new direction for creating new and improved polymer electrolytes either by combining existing polymers and salt or by synthesizing new polymers with the specific aim of including them in miscible polymer blend electrolytes.

Rapidly Reprocessable Cross-Linked Polyhydroxyurethanes Based on Disulfide Exchange.

Polymer networks that are cross-linked by dynamic covalent bonds often sacrifice the robust mechanical properties of traditional thermosets in exchange for rapid and efficient reprocessability. Polyurethanes are attractive materials for reprocessable cross-linked polymers because of their excellent mechanical properties, widespread use, and ease of synthesis, but their syntheses typically rely on harmful isocyanate precursors. Polyhydroxyurethanes (PHUs), derived from amines and cyclic carbonates, are promising alternatives to traditional polyurethanes. PHU networks are reprocessable via transcarbamoylation reactions even in the absence of external catalysts, but this process occurs over hours at temperatures above 150 °C. We have dramatically shortened the reprocessing times of PHU networks by incorporating dynamic disulfide bonds. Using cystamine as a comonomer gives materials with similar thermal stability and mechanical properties to other rigid cross-linked PHUs. Despite their excellent mechanical properties, these materials show rapid stress relaxation and have characteristic relaxation times as low as 30 s at 150 °C. This property enables reprocessing with quantitative recovery of cross-link density as measured by DMTA after only 30 min of elevated-temperature compression molding. Disulfide incorporation is a promising approach to obtain reprocessable, cross-linked PHU resins that are not derived from isocyanates.