ABSTRACT
Background. Inequities in healthcare among racial and ethnic minorities are globally recognized. The focus has centered on access to healthcare, equitable treatment, and optimizing outcomes. However, there has been relatively little investigation into potential racial and ethnic disparities in HAI. Methods. We performed a retrospective cohort analysis of select HAI prospectively-collected by a network of community hospitals in the southeastern US, including central line-associated bloodstream infection (CLABSI), catheterassociated urinary tract infection (CAUTI), and laboratory-identified Clostridioides difficile infection (CDI). Outcomes were stratified by race/ethnicity as captured in the electronic medical record. We defined the pre-pandemic period from 1/1/2019 to 2/29/2020 and the pandemic period from 3/1/2020 to 6/30/2021. Outcomes were reported by race/ethnicity as a proportion of the total events. Relative rates were compared using Poisson regression. Results. Overall, relatively few facilities consistently collect race/ethnicity information in surveillance databases within this hospital network (< 40%). Among 21 reporting hospitals, a greater proportion of CLABSI occurred in Black patients relative toWhite patients in both study periods (pre-pandemic, 49% vs 38%;during pandemic, 47% vs 31%;respectively, Figure 1a), while a higher proportion of CAUTI and CDI occurred in White patients (Figures 1b-c). Black patients had a 30% higher likelihood of CLABSI than White patients in the pre-COVID period (RR, 1.30;95% CI, 0.83-2.05), which was not statistically significant (Table 1). However, this risk significantly increased to 51% after the start of the pandemic (RR, 1.51;95% CI, 1.02-2.24). Similar trends were not observed in other HAI (Tables 2-3). Conclusion. We found differences in HAI rates by race/ethnicity in a network of community hospitals. Black patients had higher likelihood of CLABSI, and this likelihood increased during the pandemic. Patient safety events, including HAI, may differ across racial and ethnic groups and negatively impact health outcomes. (Figure Presented).
ABSTRACT
Background. Hospital-onset bloodstream infection (HOBSI) incidence has been proposed as a complementary quality metric to central line-associated bloodstream infection (CLABSI) surveillance. Several recent studies have detailed increases in median HOBSI and CLABSI rates during the COVID-19 pandemic. We sought to understand trends in HOBSI and CLABSI rates at a single health system in the context of COVID-19. Methods. We conducted a retrospective analysis of HOBSIs and CLABSIs at a three-hospital health system from 2017 to 2021 (Figure 1). We compared counts, denominators, and demographic data for HOBSIs and CLABSIs between the prepandemic (1/1/2017-3/30/2020) and pandemic period (4/1/2020-12/31/2021) (Table 1). We applied Poisson or negative binomial regression models to estimate the monthly change in incidence of HO-BSI and CLABSI rates over the study period. Figure 1: Definitions applied for hospital-onset bloodstream infections (HO-BSIs) and central line-associated bloodstream infections (CLABSIs). Potentially contaminated blood cultures were identified by microbiology laboratory technicians as any set of blood culture in which a single bottle was positive for organisms typically considered as skin contaminants. Uncertain cases undergo secondary review by senior lab technicians. Table 1: Count, denominator, and device utilization ratio data for hospital-onset bloodstream infections (HO-BSIs) and central line-associated bloodstream infections (CLABSIs) Note that central line utilization increased upon regression analysis (p<0.001). Results. The median monthly HOBSI rate per 1,000 patient days increased from 1.0 in the pre-pandemic to 1.3 (p< 0.01) in the pandemic period, whereas the median monthly CLABSI rate per central line days was stable (1.01 to 0.88;p=0.1;Table 2). Our regression analysis found that monthly rates of HO-BSIs increased throughout the study, but the increase was not associated with the onset of the COVID-19 pandemic based on comparisons of model fit (Figure 2;Table 3). Despite an increase in central line utilization, regression modelling found no changes in monthly CLABSIs rates with respect to time and the COVID-19 pandemic. Incidence of HOBSIs and CLABSIs by common nosocomial organisms generally increased over this time period, though time to infection onset remained unchanged in our studied population (Table 2). Conclusion. HOBSIs rates did not correlate with CLABSI incidence across a three-hospital health system from 2017 and 2021, as rates of HOBSI increased but CLABSI rates remained flat. Our observed increase in HOBSI rates did not correlate with the onset of the COVID-19 pandemic, and caution should be used in modeling the effects of COVID-19 without time-trended analysis. Further evaluation is needed to understand the etiology, epidemiology, and preventability of HO-BSI.
ABSTRACT
Background. The shift to more transmissible but less virulent strains of SARS-CoV-2 has altered the risk calculation for infection. Particularly among young adults, the economic burden of lost work due to isolation exceeds the economic burden of morbidity due to infection. Testing strategies must adapt to these changing circumstances. Methods. We modeled six testing strategies to estimate total societal costs for symptomatic people 18-49 years old: isolation of all individuals with no testing, rapid antigen test (RAg), RAg followed by a second RAg 48h later if first negative, RAg followed by a polymerase chain reaction (PCR) if negative, RAg followed by a PCR if positive, and PCR alone. We calculated costs for hypothetical cohorts of 100 symptomatic healthcare workers tested with each strategy;we included testing costs, lost wages, and hospitalization costs for the index, secondary, and tertiary cases. Key assumptions were 5% prevalence of infection, sensitivity of first/second RAg 40/80% with 97% specificity, PCR sensitivity/specificity 95/99%, all individuals isolate at symptom onset, are tested the same day, and isolate for 5 days if positive. RAg results were available the same day, PCR results were available the next day (Figure 1). One-way sensitivity analyses were performed for RAg sensitivity (20-80%) and positivity rate (1-80%). Results. The least expensive strategy was RAg alone (Figure 2). This was primarily driven by its low sensitivity, which reduced lost wages at the expense of missing cases. At a threshold for RAg sensitivity lower than 29%, PCR testing alone became the cheapest strategy. When the positivity rate was > 6% confirming a negative RAg with a PCR became the cheapest strategy, closely followed by PCR alone. At a positivity rate of > 29%, isolation without testing was cheapest followed by confirming a negative RAg with a PCR and by the serial RAg test strategies (Figure 3). Conclusion. In relatively young, healthy populations, a single rapid test was the least expensive strategy when the positivity rate was < 6%, testing that included PCR became cheapest at intermediate positivity, and empiric isolation was cheapest at positivity > 29%. Calibrating SARS-CoV-2 test strategies based on epidemiology may save societal costs.
ABSTRACT
The American reaction to the COVID-19 pandemic is polarized, with conservatives often less willing to engage in risk-mitigation strategies such as mask-wearing and vaccination. COVID-19 narratives are also polarized, as some conservative elites focus on the economy over public health. In this registered report, we test whether combining economic and public health messages can persuade individuals to increase support for COVID-19 risk mitigation. We present preliminary evidence that the combination of messages is complementary, rather than competing or polarizing. When given a message emphasizing COVID-19's negative health and economic effects in a pilot study, conservatives increased their support for a broad range of risk-mitigation strategies, while liberals maintained high levels of support. A preregistered larger-n follow-up study, however, failed to replicate this effect. While complementary frames may be a promising way to persuade voters on some issues, they may also struggle to overcome high levels of existing polarization.
ABSTRACT
Background. Children infected with SARS-CoV-2 often have mild or no symptoms, making symptom screening an ineffective tool for determining isolation precautions. As an infection control measure, universal pre-procedural and admission SARS-CoV-2 testing for pediatric patients was implemented in April and August 2020, respectively. Limited data exist on the utility screening programs in the pediatric population. Methods. We performed a retrospective cohort study of pediatric patients (birth to 18 years) admitted to a tertiary care academic medical center from April 2020 to May 2021 that had one or more SARS-CoV-2 point-of-care or polymerase chain reaction tests performed. We describe demographic data, positivity rates and repeat testing trends observed in our cohort. Results. A total of 2,579 SARS-CoV-2 tests were performed among 1,027 pediatric inpatients. Of these, 51 tests (2%) from 45 patients (4.3%) resulted positive. Community infection rates ranged from 4.5-60 cases/100,000 persons/day during the study period. Hispanic patients comprised 16% of the total children tested, but were disproportionately overrepresented (40%) among those testing positive (Figure1). Of 654 children with repeated tests, 7 (0.1%) converted to positive from a prior negative result. Median days between repeat tests was 12 (IQR 6-45), not necessarily performed during the same hospital stay. Five of these 7 patients had tests repeated < 3 days from a negative result, of which only 2 had no history of recent infection by testing performed at an outside facility. Pre-procedural tests accounted for 35% of repeat testing, of which 0.9% were positive. Repeated tests were most frequently ordered for patients in hematology/ oncology (35%) and solid organ transplant/surgical (33%) wards, each with < 3% positive conversion rate. Notably, no hematopoietic stem cell transplant patients tested positive for SARS-CoV-2 during the study period. Conclusion. The positivity rate of universal pre-procedural and admission SARSCoV-2 testing in pediatric patients was low in our inpatient cohort. Tests repeated < 3 days from a negative result were especially low yield, suggesting limited utility of this practice. Diagnostic testing stewardship in certain populations may be useful, especially as community infection rates decline.
ABSTRACT
Background. The correlation between SARS-CoV-2 RNA and infectious viral contamination of the hospital environment is poorly understood. Methods. housed in a dedicated COVID-19 unit at an academic medical center. Environmental samples were taken within 24 hours of the first positive SARS-CoV-2 test (day 1) and again on days 3, 6, 10 and 14. Patients were excluded if samples were not obtained on days 1 and 3. Surface samples were obtained with flocked swabs pre-moistened with viral transport media from seven locations inside (bedrail, sink, medical prep area, room computer, exit door handle) and outside the room (nursing station computer). RNA extractions and RT-PCR were completed on all samples. RT-PCR positive samples were used to inoculate Vero E6 cells for 7 days and monitored for cytopathic effect (CPE). If CPE was observed, RT-PCR was used to confirm the presence of SARS-CoV-2. Results. We enrolled 14 patients (Table 1, Patient Characteristics) between October 2020 and May 2021. A total of 243 individual samples were obtained - 97 on day 1, 98 on day 3, 34 on day 6, and 14 on day 10. Overall, 18 (7.4%) samples were positive via RT-PCR - 9 from bedrails (12.9%), 4 from sinks (11.4%), 4 from room computers (11.4%) and 1 from the exit door handle (2.9%). Notably, all medical prep and nursing station computer samples were negative (Figure 1). Of the 18 positive samples, 5 were from day 1, 10 on day 3, 1 on day 6 and 2 on day 10. Only one sample, obtained from the bedrails of a symptomatic patient with diarrhea and a fever on day 3, was culture-positive (Figure 2). Conclusion. Overall, the amount of environmental contamination of viable SARS-CoV-2 virus in rooms housing COVID-19 infected patients was low. As expected, more samples were considered contaminated via RT-PCR compared to cell culture, supporting the conclusion that the discovery of genetic material in the environment is not an indicator of contamination with live infectious virus. More studies including RT-PCR and viral cell culture assays are needed to determine the significance of discovering SARS-CoV-2 RNA versus infectious virus in the clinical environment.
ABSTRACT
Background. The COVID-19 pandemic significantly impacted hospitalizations and healthcare utilization. Diversion of infection prevention resources toward COVID-19 mitigation limited routine infection prevention activities such as rounding, observations, and education in all areas, including the peri-operative space. There were also changes in surgical care delivery. The impact of the COVID-19 pandemic on SSI rates has not been well described, especially in community hospitals. Methods. We performed a retrospective cohort study analyzing prospectively collected data on SSIs from 45 community hospitals in the southeastern United States from 1/2018 to 12/2020. We included the 14 most commonly performed operative procedure categories, as defined by the National Healthcare Safety Network. Coronary bypass grafting was included a priori due to its clinical significance. Only facilities enrolled in the network for the full three-year period were included. We defined the pre-pandemic time period from 1/1/18 to 2/29/20 and the pandemic period from 3/1/20 to 12/31/20. We compared monthly and quarterly median procedure totals and SSI prevalence rates (PR) between the pre-pandemic and pandemic periods using Poisson regression. Results. Pre-pandemic median monthly procedure volume was 384 (IQR 192-999) and the pre-pandemic SSI PR per 100 cases was 0.98 (IQR 0.90-1.04). There was a transient decline in surgical cases beginning in March 2020, reaching a nadir of 185 cases in April, followed by a return to pre-pandemic volume by June (figure 1). Overall and procedure-specific SSI PRs were not significantly different in the COVID-19 period relative to the pre-pandemic period (total PR per 100 cases 0.96 and 0.97, respectively, figure 2). However, when stratified by quarter and year, there was a trend toward increased SSI PR in the second quarter of 2020 with a PRR of 1.15 (95% CI 0.96-1.39, table 1). Conclusion. The decline in surgical procedures early in the pandemic was shortlived in our community hospital network. Although there was no overall change in the SSI PR during the study period, there was a trend toward increased SSIs in the early phase of the pandemic (figure 3). This trend could be related to deferred elective cases or to a shift in infection prevention efforts to outbreak management.
ABSTRACT
This commentary addresses key differences between remote and on-site experiential education, including necessary resources and rotation structure. Health care education during the COVID-19 pandemic was primarily delivered electronically. Student-based resources such as computers/laptops, stable internet connections, and privacy (physical space and electronic security) became essential for student learning, testing, and provision of patient care. When student resources were limited, educational programs had to adapt to help students in need. Preceptors were required to restructure experiential rotations to provide learning experiences while keeping up with increased clinical-related workloads. Students had increased projects and papers and decreased face-to-face time with patients and professionals. Many community pharmacies were able to educate students on-site, whereas ambulatory care–based sites generally pivoted to telehealth-based interactions. Although telehealth appeared useful, rollout was difficult because of differences in technology, accessibility, and capability. Inpatient-based training proved most difficult and often had to be halted for patient and student safety. Many schools also used unique non–patient care electives to fill experiential gaps and keep students on target for graduation. Delivery of experiential education had a different set of challenges from didactic education. Creative examples to address these challenges included roving tablets with Zoom sessions during rounds, artificial or de-identified cases, and hybrid clinical/dispensing rotations, though most experiences were canceled or restricted by exclusion of patients with COVID-19 patients. Overall, pharmacy education continued. However, many of the methods for training with partly or entirely remote approaches were novel and may become integrated into the “new normal.” The face of the world has changed, and pharmacy education must change with it.
ABSTRACT
This commentary addresses key differences between remote and on-site experiential education, including necessary resources and rotation structure. Health care education during the COVID-19 pandemic was primarily delivered electronically. Student-based resources such as computers/laptops, stable internet connections, and privacy (physical space and electronic security) became essential for student learning, testing, and provision of patient care. When student resources were limited, educational programs had to adapt to help students in need. Preceptors were required to restructure experiential rotations to provide learning experiences while keeping up with increased clinical-related workloads. Students had increased projects and papers and decreased face-to-face time with patients and professionals. Many community pharmacies were able to educate students on-site, whereas ambulatory care-based sites generally pivoted to telehealth-based interactions. Although telehealth appeared useful, rollout was difficult because of differences in technology, accessibility, and capability. Inpatient-based training proved most difficult and often had to be halted for patient and student safety. Many schools also used unique non-patient care electives to fill experiential gaps and keep students on target for graduation. Delivery of experiential education had a different set of challenges from didactic education. Creative examples to address these challenges included roving tablets with Zoom sessions during rounds, artificial or de-identified cases, and hybrid clinical/dispensing rotations, though most experiences were canceled or restricted by exclusion of patients with COVID-19 patients. Overall, pharmacy education continued. However, many of the methods for training with partly or entirely remote approaches were novel and may become integrated into the "new normal." The face of the world has changed, and pharmacy education must change with it.
ABSTRACT
Objectives: Integrating mental health screening and treatment into cystic fibrosis (CF) centres has led to numerous successes: increased awareness, reduced stigma and greater access to mental health care (Quittner et al., 2020). Given that anxiety and depression screening are now part of routine care, the major aim was to identify the most important, future research priorities in mental health. Method: A 22-item online survey was sent out July 2020 to people with CF (pwCF), caregivers, and US providers in the CF community, who were given 3 weeks to respond. Questions focused on: ranking topics by importance and impact, identifying gaps in our understanding of mental health issues, and priorities and needs during COVID-19. Results: Response time was 7–11 minutes, with 693 community respondents (half pwCF, majority ages 26–45 years) and 352 CF clinicians (mainly social workers, center directors). Substantial agreement was found between community respondents and providers on the top 5 priorities:1) anxiety, 2) depression, 3) effects of psychological symptoms on physical health, 4) risk factors for anxiety/depression, and 5) effects on family functioning and parenting. Although ranked highly, differences emerged for substance misuse and disordered eating, with higher rankings endorsed by providers than community respondents. Priorities for improving outcomes were also similar: 1) greater access to mental health providers and 2) improving mental health interventions. Conclusion: A large-scale survey of CF community members and providers revealed clear consensus on the top research priorities. In addition to increased understanding of anxiety and depression (e.g., risk factors, long-term effects), new topics emerged, including substance misuse, disordered eating, and interactions between medications and mental health (e.g., modulators). Acknowledgement: Cystic Fibrosis Foundation