Revolutionizing Combat Casualty Care: The Power of Digital Twins in Optimizing Casualty Care Through Passive Data Collection.

The potential impact of large-scale combat operations and multidomain operations against peer adversaries poses significant challenges to the Military Health System including large volumes of critically ill and injured casualties, prolonged care times in austere care contexts, limited movement, contested logistics, and denied communications. These challenges contribute to the probability of higher casualty mortality and risk that casualty care hinders commanders' forward momentum or opportunities for overmatch on the battlefield. Novel technical solutions and associated concepts of operation that fundamentally change the delivery of casualty care are necessary to achieve desired medical outcomes that include maximizing Warfighter battle-readiness, minimizing return-to-duty time, optimizing medical evacuation that clears casualties from the battlefield while minimizing casualty morbidity and mortality, and minimizing resource consumption across the care continuum. These novel solutions promise to "automate" certain aspects of casualty care at the level of the individual caregiver and the system level, to unburden our limited number of providers to do more and make better (data-driven) decisions. In this commentary, we describe concepts of casualty digital twins-virtual representations of a casualty's physical journey through the roles of care-and how they, combined with passive data collection about casualty status, caregiver actions, and real-time resource use, can lead to human-machine teaming and increasing automation of casualty care across the care continuum while maintaining or improving outcomes. Our path to combat casualty care automation starts with mapping and modeling the context of casualty care in realistic environments through passive data collection of large amounts of unstructured data to inform machine learning models. These context-aware models will be matched with patient physiology models to create casualty digital twins that better predict casualty needs and resources required and ultimately inform and accelerate decision-making across the continuum of care. We will draw from the experience of the automotive industry as an exemplar for achieving automation in health care and inculcate automation as a mechanism for optimizing the casualty care survival chain.

Refocusing the Military Health System to Support Role 4 Definitive Care in future large-scale combat operations.

ABSTRACT: The last twenty years of sustained combat operations during the Global War on Terror generated significant advancements in combat casualty care. Improvements in point-of-injury, en route, and forward surgical care appropriately aligned with the survival, evacuation, and return to duty needs of the small-scale unconventional conflict. However, casualty numbers in large-scale combat operations have brought into focus the critical need for modernized casualty receiving and convalescence: Role 4 definitive care (R4DC). Historically, World War II was the most recent conflict in which the United States fought in multiple operational theaters, with hundreds of thousands of combat casualties returned to the continental United States. These numbers necessitated the establishment of a "Zone of the Interior" which integrated military and civilian healthcare networks for definitive treatment and rehabilitation of casualties. Current security threats demand refocusing and bolstering the Military Health System's definitive care capabilities to maximize its force regeneration capacity in a similar fashion. Medical force generation, medical force sustainment and readiness, and integrated casualty care capabilities are three pillars that must be developed for MHS readiness of Role 4 definitive care in future large-scale contingencies against near-peer/peer adversaries.

The influence of anthropogenic regulation and evaporite dissolution on earthquake-triggered ground failure.

Remote sensing observations of Searles Lake following the 2019 moment magnitude 7.1 Ridgecrest, California, earthquake reveal an area where surface ejecta is arranged in a repeating hexagonal pattern that is collocated with a solution-mining operation. By analyzing geologic and geotechnical data, here we show that the hexagonal surface ejecta is likely not a result of liquefaction. Instead, we propose dissolution cavity collapse (DCC) as an alternative driving mechanism. We support this theory with pre-event Interferometric Synthetic Aperture Radar data, which reveals differential subsidence patterns and the creation of subsurface void space. We also find that DCC is likely triggered at a lower shaking threshold than classical liquefaction. This and other unknown mechanisms can masquerade as liquefaction, introducing bias into liquefaction prediction models that rely on liquefaction inventories. This paper also highlights the opportunities and drawbacks of using remote sensing data to disentangle the complex factors that influence earthquake-triggered ground failure.

Disguised Among the Sea: The Implications of Artificial Islands on Casualty Care in the Indo-Pacific.

As reported in the 2022 Biden-Harris National Security Strategy, China is perceived as the primary U.S. competitor with the intent and means to become the world's greatest superpower. China's efforts, which are at odds with America's ambition to maintain its global influence, are complemented by ostensibly harmless "gray zone tactics," defined as coercive geopolitical, economic, military, and cyber activities below the use of kinetic military force. Such tactics may be utilized with seemingly innocuous intentions, but in reality, they can complicate U.S. combat casualty care in the event of an Indo-Pacific conflict. One tactic of particular impact is China's development of artificial islands throughout the South China Sea. By creating these islands, China is expanding its reach beyond its continental borders. These islands, alongside China's well-developed naval and missile capabilities, will cause disruptions to U.S. casualty care staging, medical resupply, and aeromedical evacuations. To mitigate those threats, the USA should implement a robust regional Combatant Command Trauma System, improve global health security cooperation with local partner nations, and implement irregular or guerilla trauma systems that meet medical needs in impromptu, clandestine settings. Operational recommendations based on these efforts could include pre-positioning tactical combat casualty care and damage control resuscitation supplies and developing with nearby host-nation evacuation platforms such as small boat operators. These solutions, among others, require years of training, relationship-building, and capability development to institute successfully. As a result, U.S. Military leaders should act now to incorporate these strategies into their irregular warfare, low-intensity conflict, and large-scale combat operation toolkits.

17†Development of a questionnaire to study fear and anxiety factors affecting patients and their families undergoing strabismus surgery.

Patients and their Families undergoing Strabismus Surgery. The aim of this study was to develop a questionnaire to identify perioperative fear and anxiety factors affecting pediatric strabismus surgery patients.First, we reviewed the literature to determine precipitants of fears and anxieties experienced by pediatric patients. Subsequently, we developed a questionnaire for pediatric patients undergoing strabismus surgery. This was a two part questionnaire, consisting of a 16-piece section for patients and a 22-piece section for parents. Finally, we piloted this questionnaire to validate its clinical use.Common anxiety factors for children include pain, minor clinical procedures requiring needles, separation from parents and engaging with medical professionals. We used this information to develop a two part questionnaire for patients and parents. The questionnaire elicited positive and negative aspects of the patient journey, corroborated fears reported in the literature, and identified anxiety inducing factors specific to strabismus patients.There is a lack of evidence regarding fear and anxiety specific to pediatric ophthalmology surgeries. Strabismus surgery carries unique fear inducing factors. Interventions which may alleviate the stress of pediatric surgery, therefore greatly benefit patient experience and surgical outcomes, and should be considered in the care of pediatric patients. Patient educational material is known to provide a sense of control to patients, helping to alleviate such fear.Evidenced by the literature and the pilot questionnaire, there still exists anxiety inducing factors in pediatric surgery. Investigation into patient fears regarding pediatric strabismus surgery is needed to better understand how clinical staff can support patients perioperatively.

The maintenance of classism in medical education: "time" as a form of social capital in first-generation and low-income medical students.

As first generation (FG)/low income (LI) students enter the elite profession of medicine, schools make presumptions about how FGLI students allocate their time. However, their lives are markedly different compared to their peers. This study argues that while all forms of capital are necessary for success, time as a specific form keeps classism in place. Using constructivist grounded theory techniques, we interviewed 48 FGLI students to understand where, why and how they allocated their time, and the perceived impact it had on them. Using open coding and constant comparison, we developed an understanding of FGLI students' relationship to time and then contextualized it within larger conversations on how time is conceptualized in a capitalist system that demands time efficiency, and the activities where time is needed in medical school. When students discussed time, they invoked the concept of 'time famine;' having too much to do and not enough time. In attempting to meet medicine's expectations, they conceptualized time as something that was 'spent' or 'given/taken' as they traversed different marketplaces, using their time as a form of currency to make up for the social capital expected of them. This study shows that because medical education was designed around the social elite, a strata of individuals who have generational resources, time is a critical aspect separating FGLI students from their peers. This study undergirds the idea that time is a hidden organizational framework that helps to maintain classism, thus positioning FGLI students at a disadvantage.

Reward history modulates visual attention in an avian model.

Attention can be biased towards previously reward-associated stimuli even when they are task-irrelevant and physically non-salient, although studies of reward-modulated attention have been largely limited to primate (including human and nonhuman) models. Birds have been shown to have the capacity to discriminate reward and spatial cues in a manner similar to primates, but whether reward history involuntarily affects their attention in the same way remains unclear. We adapted a spatial cueing paradigm with differential rewards to investigate how reward modulates the allocation of attention in peafowl (Pavo cristatus). The birds were required to locate and peck a target on a computer screen that was preceded by a high-value or low-value color cue that was uninformative with respect to the location of the upcoming target. All birds exhibited a validity effect (performance enhanced on valid compared to invalid cue), and an interaction effect between value and validity was evident at the group level, being particularly pronounced in the birds with the greatest amount of reward training. The time course of reward learning was conspicuously incremental, phenomenologically slower compared to primates. Our findings suggest a similar influence of reward history on attention across phylogeny despite a significant difference in neuroanatomy.

Targeted muscle reinnervation in upper extremity amputation in military hand surgery: A systematic review.

INTRODUCTION: Targeted Muscle Reinnervation (TMR) is a surgical technique utilized to alleviate post-amputation neuroma pain, reduce reliance on narcotic pain medication, and enhance control of prosthetic devices. Motor targets for upper extremity TMR vary depending on injury patterns and amputation levels, with conventional transfer patterns serving as general guides. This study aims to summarize the common patterns of TMR in transradial and transhumeral amputations, focusing on anatomic and surgical considerations. METHODS: A comprehensive systematic review of TMR literature was conducted by two independent physician reviewers (M.H.A. and D.M.G.R.) to identify the prevailing motor targets, while considering injury patterns and amputation levels. INCLUSION CRITERIA: 1) TMR techniques, outcomes, or advancements; 2) Original research, systematic reviews, meta-analyses, or clinical trials; 3) Peer-reviewed journal articles or reputable conference proceedings. EXCLUSION CRITERIA: non-English resources, editorials, opinion pieces, and case reports. The databases utilized include MEDLINE (PubMed), EMBASE (Scopus) and Cochrane CENTRAL, last searched 01APR2023. RESULTS: The reviewed literature revealed multiple motor targets described for upper extremity TMR out of our included 51 studies. However, the selection of motor targets is influenced by the availability of viable options based on injury patterns and amputation levels. Conventional transfer patterns provide useful guidance for determining appropriate motor targets in transradial and transhumeral amputations. DISCUSSION: TMR has played a significant role in military medicine, particularly in addressing the impact of blast-related injuries. The energy associated with such injuries often results in substantial soft tissue defects, higher amputation levels, and increased post-amputation pain. TMR, in conjunction with advancements in prosthetic technology and ongoing military research, offers improved outcomes to help achieve the goals of active-duty service members. The capabilities and applications of TMR continue to expand rapidly due to its high surgical success rate, technological innovations in prosthetic care, and favorable patient outcomes. As technology evolves to include implantable devices, osseointegration techniques, and bidirectional neuroprosthetic devices, the future of amputation surgery and TMR holds immense promise, offering innovative solutions to optimize patient outcomes. It is important to note, this review was limited to the data available in the included resources which was mostly qualitative; thus, it did not involve primary data analysis.

Symbiosis preservation: Putative regulation of fatty acyl-CoA reductase by miR-31a within the symbiont harboring bacteriome through tsetse evolution.

Tsetse flies are the sole vectors of African trypanosomes. In addition to trypanosomes, tsetse harbor obligate Wigglesworthia glossinidia bacteria that are essential to tsetse biology. The absence of Wigglesworthia results in fly sterility, thus offering promise for population control strategies. Here, microRNA (miRNAs) and mRNA expression are characterized and compared between the exclusive Wigglesworthia-containing bacteriome and adjacent aposymbiotic tissue in females of two evolutionarily distant tsetse species (Glossina brevipalpis and G. morsitans). A total of 193 miRNAs were expressed in either species, with 188 of these expressed in both species, 166 of these were novel to Glossinidae, and 41 miRNAs exhibited comparable expression levels between species. Within bacteriomes, 83 homologous mRNAs demonstrated differential expression between G. morsitans aposymbiotic and bacteriome tissues, with 21 of these having conserved interspecific expression. A large proportion of these differentially expressed genes are involved in amino acid metabolism and transport, symbolizing the essential nutritional role of the symbiosis. Further bioinformatic analyses identified a sole conserved miRNA::mRNA interaction (miR-31a::fatty acyl-CoA reductase) within bacteriomes likely catalyzing the reduction of fatty acids to alcohols which comprise components of esters and lipids involved in structural maintenance. The Glossina fatty acyl-CoA reductase gene family is characterized here through phylogenetic analyses to further understand its evolutionary diversification and the functional roles of members. Further research to characterize the nature of the miR-31a::fatty acyl-CoA reductase interaction may find novel contributions to the symbiosis to be exploited for vector control.

Climate-mediated population dynamics of a migratory songbird differ between the trailing edge and range core.

Understanding the demographic drivers of range contractions is important for predicting species' responses to climate change; however, few studies have examined the effects of climate change on survival and recruitment across species' ranges. We show that climate change can drive trailing edge range contractions through the effects on apparent survival, and potentially recruitment, in a migratory songbird. We assessed the demographic drivers of trailing edge range contractions using a long-term demography dataset for the black-throated blue warbler (Setophaga caerulescens) collected across elevational climate gradients at the trailing edge and core of the breeding range. We used a Bayesian hierarchical model to estimate the effect of climate change on apparent survival and recruitment and to forecast population viability at study plots through 2040. The trailing edge population at the low-elevation plot became locally extinct by 2017. The local population at the mid-elevation plot at the trailing edge gradually declined and is predicted to become extirpated by 2040. Population declines were associated with warming temperatures at the mid-elevation plot, although results were more equivocal at the low-elevation plot where we had fewer years of data. Population density was stable or increasing at the range core, although warming temperatures are predicted to cause population declines by 2040 at the low-elevation plot. This result suggests that even populations within the geographic core of the range are vulnerable to climate change. The demographic drivers of local population declines varied between study plots, but warming temperatures were frequently associated with declining rates of population growth and apparent survival. Declining apparent survival in our study system is likely to be associated with increased adult emigration away from poor-quality habitats. Our results suggest that demographic responses to warming temperatures are complex and dependent on local conditions and geographic range position, but spatial variation in population declines is consistent with the climate-mediated range shift hypothesis. Local populations of black-throated blue warblers near the warm-edge range boundary at low latitudes and low elevations are likely to be the most vulnerable to climate change, potentially leading to local extirpation and range contractions.

The in vitro replication phenotype of hepatitis B virus (HBV) splice variant Sp1.

Although not critical for hepatitis B virus (HBV) replication, splicing of HBV pre-genomic RNA generates multiple HBV splice variants, some of which have been shown to impact replication of the genome-length HBV on which they rely for their replication. To date, all replication studies of splice variants have utilised truncated RNA or over-expression constructs, and studies utilising constructs that produce authentic splice derived HBV RNA are lacking. Here we utilise a greater than genome length model to interrogate the complete replication phenotype of HBV splice variant Sp1, and investigate mechanisms by which it negatively impacts genome-length HBV replication.

The Tsetse Metabolic Gambit: Living on Blood by Relying on Symbionts Demands Synchronization.

Tsetse flies have socioeconomic significance as the obligate vector of multiple Trypanosoma parasites, the causative agents of Human and Animal African Trypanosomiases. Like many animals subsisting on a limited diet, microbial symbiosis is key to supplementing nutrient deficiencies necessary for metabolic, reproductive, and immune functions. Extensive studies on the microbiota in parallel to tsetse biology have unraveled the many dependencies partners have for one another. But far less is known mechanistically on how products are swapped between partners and how these metabolic exchanges are regulated, especially to address changing physiological needs. More specifically, how do metabolites contributed by one partner get to the right place at the right time and in the right amounts to the other partner? Epigenetics is the study of molecules and mechanisms that regulate the inheritance, gene activity and expression of traits that are not due to DNA sequence alone. The roles that epigenetics provide as a mechanistic link between host phenotype, metabolism and microbiota (both in composition and activity) is relatively unknown and represents a frontier of exploration. Here, we take a closer look at blood feeding insects with emphasis on the tsetse fly, to specifically propose roles for microRNAs (miRNA) and DNA methylation, in maintaining insect-microbiota functional homeostasis. We provide empirical details to addressing these hypotheses and advancing these studies. Deciphering how microbiota and host activity are harmonized may foster multiple applications toward manipulating host health, including identifying novel targets for innovative vector control strategies to counter insidious pests such as tsetse.

Variation in Trauma Team Response Fees in United States Trauma Centers: An Additional Undisclosed Variable Cost in Trauma Care.

BACKGROUND: The rising costs associated with trauma care in the United States is an important topic in today's healthcare environment. Factors such as innovations in technology, increasing governmental and organizational regulations, and the specialization of care have led to increasing costs to the patient. A component of trauma cost is the one-time trauma team response fee (TTRF). The determination process of the TTRF's dollar amount is elusive as no apparent standardized process exists and the literature is scant regarding this aspect of trauma care. METHODS: A nationwide cross-sectional convenience sample was conducted using SurveyMonkey. Surveys were sent to 525 trauma centers in the continental United States, including Alaska and Hawaii, between October 8, 2019 and March 11, 2020. Additionally, hospital medical directors and trauma medical directors were queried on their knowledge of their facility's TTRF amount. RESULTS: Only 46 out of 525 trauma centers, or 8.8% of those surveyed shared their scheduled fees. Comparisons of TTRFs among different trauma centers, activation levels, and geographical locations were not statistically significant. CONCLUSIONS: Understanding the true costs of trauma care and fees for patients in the United States remains elusive due to inadequate data and low response rates. Trauma centers struggle to maintain financial viability as regulatory agencies and the public push for transparency of TTRFs. Collaboration between trauma centers and regulatory agencies is needed to ensure a balance between providing quality trauma care with justified associated charges and financial sustainability.

Epidemiology of healthcare-associated infection reported from a hospital-wide incidence study: considerations for infection prevention and control planning.

BACKGROUND: The measure of disease frequency most widely used to report healthcare-associated infection (HAI) is the point-prevalence survey. Incidence studies are rarely performed due to time and cost constraints; they show which patients are affected by HAI, when and where, and inform planning and design of infection prevention and control (IPC) measures. AIM: To determine the epidemiology of HAI within a general and a teaching hospital in Scotland. METHODS: A prospective observational incidence study was undertaken for one year from April 2018 using data collected as part of the Evaluation of Cost of Nosocomial Infection (ECONI) study. A novel, robust approach was undertaken, using record linkage to national administrative data to provide full admission and discharge information. Cases were recorded if they met international HAI definitions. FINDINGS: Incidence of HAI for the combined hospitals was 250 HAI cases per 100,000 acute occupied bed-days (AOBD). Highest frequency was in urinary tract (51.2 per 100,000 AOBD), bloodstream (44.7), and lower respiratory tract infection (42.2). The most frequently reported organisms were Escherichia coli, Staphylococcus aureus, and norovirus. Incidence of HAI was higher in older people and emergency cases. There was an increase in the rate of HAI in summer months (pneumonia, respiratory, surgical, and gastrointestinal infection) and in winter months norovirus gastrointestinal infection (P < 0.0001). The highest incidence specialties were intensive care, renal medicine, and cardiothoracic surgery. HAI occurred at a median of 9 days (interquartile range: 4-19) after admission. Incidence data were extrapolated to provide an annual national estimate of HAI in NHS Scotland of 7437 (95% confidence interval: 7021-7849) cases. CONCLUSION: This study provides a unique overview of incidence of HAI and identifies the burden of HAI at the national level for the first time. Understanding the incidence in different clinical settings, at different times, will allow targeting of IPC measures to those patients who would benefit the most.

Impact of healthcare-associated infection on length of stay.

BACKGROUND: Increased length of stay (LOS) for patients is an important measure of the burden of healthcare-associated infection (HAI). AIM: To estimate the excess LOS attributable to HAI. METHODS: This was a one-year prospective incidence study of HAI observed in one teaching hospital and one general hospital in NHS Scotland as part of the Evaluation of Cost of Nosocomial Infection (ECONI) study. All adult inpatients with an overnight stay were included. HAI was diagnosed using European Centres for Disease Prevention and Control definitions. A multi-state model was used to account for the time-varying nature of HAI and the competing risks of death and discharge. FINDINGS: The excess LOS attributable to HAI was 7.8 days (95% confidence interval (CI): 5.7-9.9). Median LOS for HAI patients was 30 days and for non-HAI patients was 3 days. Using a simple comparison of duration of hospital stay for HAI cases and non-cases would overestimate the excess LOS by 3.5 times (27 days compared with 7.8 days). The greatest impact on LOS was due to pneumonia (16.3 days; 95% CI: 7.5-25.2), bloodstream infections (11.4 days; 5.8-17.0) and surgical site infection (SSI) (9.8 days; 4.5-15.0). It is estimated that 58,000 bed-days are occupied due to HAI annually. CONCLUSION: A reduction of 10% in HAI incidence could make 5800 bed-days available. These could be used to treat 1706 elective patients in Scotland annually and help reduce the number of patients awaiting planned treatment. This study has important implications for investment decisions in infection prevention and control interventions locally, nationally, and internationally.

Personalized infection prevention and control: identifying patients at risk of healthcare-associated infection.

BACKGROUND: Few healthcare-associated infection (HAI) studies focus on risk of HAI at the point of admission. Understanding this will enable planning and management of care with infection prevention at the heart of the patient journey from the point of admission. AIM: To determine intrinsic characteristics of patients at hospital admission and extrinsic events, during the two years preceding admission, that increase risk of developing HAI. METHODS: An incidence survey of adults within two hospitals in NHS Scotland was undertaken for one year in 2018/19 as part of the Evaluation of Cost of Nosocomial Infection (ECONI) study. The primary outcome measure was developing any HAI using recognized case definitions. The cohort was derived from routine hospital episode data and linkage to community dispensed prescribing data. FINDINGS: The risk factors present on admission observed as being the most significant for the acquisition of HAI were: being treated in a teaching hospital, increasing age, comorbidities of cancer, cardiovascular disease, chronic renal failure and diabetes; and emergency admission. Relative risk of developing HAI increased with intensive care unit, high-dependency unit, and surgical specialties, and surgery <30 days before admission and a total length of stay of >30 days in the two years to admission. CONCLUSION: Targeting patients at risk of HAI from the point of admission maximizes the potential for prevention, especially when extrinsic risk factors are known and managed. This study proposes a new approach to infection prevention and control (IPC), identifying those patients at greatest risk of developing a particular type of HAI who might be potential candidates for personalized IPC interventions.

Bed-days and costs associated with the inpatient burden of healthcare-associated infection in the UK.

BACKGROUND: Healthcare-associated infection (HAI) is associated with increased morbidity and mortality resulting in excess costs. AIM: To investigate the impact of all types of HAI on the inpatient cost of HAI using different approaches. METHODS: The incidence, types of HAI, and excess length of stay were estimated using data collected as part of the Evaluation of Cost of Nosocomial Infection (ECONI) study. Scottish NHS reference costs were used to estimate unit costs for bed-days. Variable (cash) costs associated with infection prevention and control (IPC) measures and treatment were calculated for each HAI type and overall. The inpatient cost of HAI is presented in terms of bed-days lost, bed-day costs, and cash costs. FINDINGS: In Scotland 58,010 (95% confidence interval: 41,730-74,840) bed-days were estimated to be lost to HAI during 2018/19, costing £46.4 million (19m-129m). The total annual cost in the UK is estimated to be £774 million (328m-2,192m). Bloodstream infection and pneumonia were the most costly HAI types per case. Cash costs are a small proportion of the total cost of HAI, contributing 2.4% of total costs. CONCLUSION: Reliable estimates of the cost burden of HAI management are important for assessing the cost-effectiveness of IPC programmes. This unique study presents robust economic data, demonstrating that HAI remains a burden to the UK NHS and bed-days capture the majority of inpatient costs. These findings can be used to inform the economic evaluation and decision analytic modelling of competing IPC programmes at local and national level.

Evaluating the post-discharge cost of healthcare-associated infection in NHS Scotland.

BACKGROUND: Whereas the cost burden of healthcare-associated infection (HAI) extends beyond the inpatient stay into the post-discharge period, few studies have focused on post-discharge costs. AIM: To investigate the impact of all types of HAI on the magnitude and distribution of post-discharge costs observed in acute and community services for patients who developed HAI during their inpatient stay. METHODS: Using data from the Evaluation of Cost of Nosocomial Infection (ECONI) study and regression methods, this study identifies the marginal effect of HAI on the 90-daypost-discharge resource use and costs. To calculate monetary values, unit costs were applied to estimates of excess resource use per case of HAI. FINDINGS: Post-discharge costs increase inpatient HAI costs by 36%, with an annual national cost of £10,832,437. The total extra cost per patient with HAI was £1,457 (95% confidence interval: 1,004-4,244) in the 90 days post discharge. Patients with HAI had longer LOS if they were readmitted and were prescribed more antibiotics in the community. The results suggest that HAI did not have an impact on the number of readmissions or repeat surgeries within 90 days of discharge. The majority (95%) of the excess costs was on acute care services after readmission. Bloodstream infection, gastrointestinal infection, and pneumonia had the biggest impact on post-discharge cost. CONCLUSION: HAI increases costs and antibiotic consumption in the post-discharge period. Economic evaluations of IPC studies should incorporate post-discharge costs. These findings can be used nationally and internationally to support decision-making on the impact of IPC interventions.