Universal Protection: Operationalizing Infection Prevention Guidance in the COVID-19 Era.

INTRODUCTION: The COVID-19 pandemic has required facilities to quickly respond to a myriad of infection prevention recommendations, as well as design their own protocols. The varied and changing guidance has been difficult for staff to absorb and has presented challenges for managing compliance. APPROACH: HCA Healthcare recognized the need for a coordinated approach to managing infection prevention guidance during the COVID-19 pandemic and a mechanism for monitoring compliance and responding to implementation challenges remotely. This innovation consisted of a bundle of infection prevention guidance referred to as the Universal Protection Framework that collated existing recommendations into an easy-to-understand structure with four domains: core infection prevention practices, access control, distancing, and patient flow. This was supported by education and clear communication. A remote monitoring program that incorporated a combination of report review and virtual observation via videoconferencing using an on-site leader as a navigator for the discussion assessed 46 survey domains for compliance. RESULTS: This framework was implemented in a large health care system, and to date compliance has been monitored at 15 facilities. Overall, compliance was high (average, 90%). High compliance was seen with oversight and distribution of personal protective equipment, cohorting of COVID-19 patients, facility access controls, and employee exposure monitoring. Challenges were identified in compliance with social distancing and universal masking. CONCLUSION: Complex infection prevention expectations for COVID-19 can be communicated and implemented by bundling into a simple framework. This innovation also demonstrated that compliance can be measured remotely, which may be useful even after the pandemic challenges have passed.

Analysis of antibiotic use in a large network of emergency departments.

PURPOSE: To assess antibiotic selection, administration, and prescribing practices in emergency departments across a large hospital system using evidence-based practices and susceptibility patterns. METHODS: This retrospective data review was conducted using health system-level electronic data compiled from 145 emergency departments (EDs) across the United States. Data were examined for national generalizability, most common diagnoses of infectious origin seen in nonadmitted patients in the ED, most commonly administered antibiotics in the ED, and geographically defined areas' unique patterns of antibiotic resistance and susceptibility. RESULTS: More than 627,000 unique patient encounters and 780,000 antibiotic administrations were assessed for trends in patient demographics, antibiotics administered for a diagnosis of infectious origin, and corresponding susceptibility patterns. Results indicated that practices in the EDs of this health system aligned with evidence-based practices for streptococcal pharyngitis, otitis media, cellulitis, and uncomplicated urinary tract infections. CONCLUSION: These results provide a representative sample of the current state of practices within many EDs across the United States for nonadmitted patients. A similar data reconstruction can be completed by other health systems to assess their prescribing practices in the ED to improve and elevate care for patients visiting the emergency room and treated as outpatients.

Retrospective evaluation of the impact of functional immunotoxicity testing on pesticide hazard identification and risk assessment.

Conduct of a T-cell-dependent antibody response (TDAR) assay in rodents according to Environmental Protection Agency (EPA) Test Guideline OPPTS 870.7800 is now required for chemical pesticide active ingredients registered in the United States. To assess potential regulatory impact, a retrospective analysis was developed using TDAR tests conducted on 78 pesticide chemicals from 46 separate chemical classes. The objective of the retrospective analysis was to examine the frequency of positive responses and determine the potential for the TDAR to yield lower endpoints than those utilized to calculate reference doses (RfDs). A reduction in the TDAR response was observed at only the high-dose level in five studies, while it was unaltered in the remaining studies. Importantly, for all 78 pesticide chemicals, the TDAR no-observed-adverse-effect levels (TDAR NOAELs) were greater than the NOAELS currently in use as risk assessment endpoints. The TDAR NOAELs were higher than the current EPA-selected endpoints for the chronic RfD, short-term, intermediate and long-term exposure scenarios by 3-27,000, 3-1,688, 3-1,688 and 4.9-1,688 times, respectively. Based on this analysis, conduct of the TDAR assay had minimal impact on hazard identification and did not impact human health risk assessments for the pesticides included in this evaluation. These data strongly support employment of alternative approaches including initial weight-of-evidence analysis for immunotoxic potential prior to conducting functional immunotoxicity testing for pesticide active ingredients.