Mercy Health System

Letters11 November 2020Sixty-Day Outcomes Among Patients Hospitalized With COVID-19FREEVineet Chopra, MD, MSc, Scott A. Flanders, MD, Megan O’Malley, PhD, Anurag N. Malani, MD, and Hallie C. Prescott, MD, MScVineet Chopra, MD, MScUniversity of Michigan Health System and The Michigan Hospital Medicine Safety Collaborative, Ann Arbor, MichiganSearch for more papers by this author, Scott A. Flanders, MDUniversity of Michigan Health System and The Michigan Hospital Medicine Safety Collaborative, Ann Arbor, MichiganSearch for more papers by this author, Megan O’Malley, PhDUniversity of Michigan Health System and The Michigan Hospital Medicine Safety Collaborative, Ann Arbor, MichiganSearch for more papers by this author, Anurag N. Malani, MDSt. Joseph Mercy Health System and The Michigan Hospital Medicine Safety Collaborative, Ann Arbor, MichiganSearch for more papers by this author, and Hallie C. Prescott, MD, MScUniversity of Michigan Health System and The Michigan Hospital Medicine Safety Collaborative, Ann Arbor, MichiganSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M20-5661 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Background: Although characteristics and in-hospital outcomes for persons with coronavirus disease 2019 (COVID-19) have been well described, less is known about the longer-term outcomes of hospitalized patients.Objective: To describe 60-day postdischarge clinical, financial, and mental health outcomes of patients with COVID-19.Methods: This observational cohort study looked at patients hospitalized with COVID-19 (discharged between 16 March and 1 July 2020) at 38 hospitals participating in the MI-COVID19 initiative. The aim of MI-COVID19, a Michigan statewide collaboration sponsored by Blue Cross Blue Shield of Michigan (BCBSM) and Blue Care Network, is to improve care for patients hospitalized with COVID-19. Trained quality abstractors (often registered nurses) collect data from patient medical records using structured templates. For hospitals unable to abstract all COVID-19 hospitalizations, a sample is selected for inclusion by using a pseudo-randomization procedure (minute of hospital discharge).At 60 days after discharge, abstractors review the medical record to collect data on clinical events, including readmission (to the index hospital or any hospital viewable in the medical record) and postdischarge death. In addition, for all patients alive and not residing in a health care or correctional facility, abstractors contact patients by telephone to complete a survey about primary care follow-up, ongoing cardiopulmonary symptoms, return to normal activity, financial impact, and emotional and mental health outcomes. At least 3 attempts are made to contact patients. The study was deemed “not regulated” by the University of Michigan institutional review board (HUM 00179611).Findings: Of 1648 patients with COVID-19 admitted to 38 hospitals, 398 (24.2%) died during hospitalization and 1250 (75.8%) survived. Of 1250 patients discharged alive, 975 (78.0%) went home whereas 158 (12.6%) were discharged to a skilled nursing or rehabilitation facility (Table 1). By 60 days after discharge, an additional 84 patients (6.7% of hospital survivors and 10.4% of intensive care unit [ICU]-treated hospital survivors) had died, bringing the overall mortality rate for the cohort to 29.2%, and 63.5% for the 405 patients who received treatment in an ICU. Within 60 days of discharge, 189 patients (15.1% of hospital survivors) were rehospitalized.Table 1. Demographic and Clinical Characteristics of 1250 Survivors of COVID-19 HospitalizationOf patients alive 60 days after discharge, 488 (41.8%) were successfully contacted and completed the 60-day postdischarge telephone survey. Of these, 265 reported seeing a primary care physician within 2 weeks (Table 2). Most follow-up visits (304 of 382) occurred virtually by videoconference (161 of 382) or telephone (143 of 382), whereas 77 occurred in person and 1 was of unknown format.Table 2. 60-Day Outcomes Among 1250 Survivors of COVID-19 Hospitalization, 488 of Whom Completed the Telephone SurveyCardiopulmonary symptoms (such as cough and dyspnea) were reported by 159 patients, including 92 with new or worsening symptoms and 65 with persistent loss of taste or smell. Fifty-eight patients reported new or worsening difficulty completing activities of daily living. Among 195 patients who were employed before hospitalization, 117 had returned to work whereas 78 could not because of ongoing health issues or job loss. Of the 117 patients who returned to work, 30 reported reduced hours or modified duties due to health reasons.Nearly half of all patients (238 of 488) reported being emotionally affected by their health, and 28 sought care for mental health after discharge. Moreover, 179 patients reported at least a mild financial impact from their hospitalization, with 47 reporting use of most or all of their savings and 35 rationing food, heat, housing, or medications due to cost.Discussion: In this multihospital cohort of patients hospitalized with COVID-19 in Michigan, nearly 1 in 3 patients died during hospitalization or within 60 days of discharge. For most patients who survived, ongoing morbidity, including the inability to return to normal activities, physical and emotional symptoms, and financial loss, was common (1). These data confirm that the toll of COVID-19 extends well beyond hospitalization, a finding consistent with long-term sequelae from sepsis (2) and other severe respiratory viral illnesses (3). Although most patients saw a primary care provider after discharge, 1 in 5 had no primary care follow-up visit within 60 days of discharge. Collectively, these findings suggest that better models to support COVID-19 survivors are necessary (4).Our study has limitations. Although postdischarge chart review was completed for all patients, telephone contact occurred in fewer than half. Loss to follow-up may be nonrandom; thus, the proportion of patients who had adverse outcomes may be biased. We therefore report numbers of events, which should be interpreted as the minimum known number of patients with a given outcome. Despite these limitations, our study conveys that adverse events after COVID-19 hospitalization are common. Policies and clinical and research programs targeting these aspects are needed.References1. Carfì A, Bernabei R, Landi F; Gemelli Against COVID-19 Post-Acute Care Study Group. Persistent symptoms in patients after acute COVID-19. JAMA. 2020;324:603-5. [PMID: 32644129] doi:10.1001/jama.2020.12603 CrossrefMedlineGoogle Scholar2. Prescott HC, Angus DC. Enhancing recovery from sepsis: a review. JAMA. 2018;319:62-75. [PMID: 29297082] doi:10.1001/jama.2017.17687 CrossrefMedlineGoogle Scholar3. Ahmed H, Patel K, Greenwood DC, et al. Long-term clinical outcomes in survivors of severe acute respiratory syndrome and Middle East respiratory syndrome coronavirus outbreaks after hospitalisation or ICU admission: a systematic review and meta-analysis. J Rehabil Med. 2020;52:jrm00063. [PMID: 32449782] doi:10.2340/16501977-2694 MedlineGoogle Scholar4. Prescott HC, Girard TD. Recovery from severe COVID-19: leveraging the lessons of survival from sepsis. JAMA. 2020;324:739-40. [PMID: 32777028]doi:10.1001/jama.2020.14103 CrossrefMedlineGoogle Scholar Comments 0 Comments Sign In to Submit A Comment Steve Caritas, Professor Emeritus of Maternal Fetal Medicine, Magee-Women's Hospital, University of School of MedicineUniversity of Pittsburgh School of Medicine16 November 2020 Pennsylvania licensed physician My comment is quite short. After reviewing all charts and grafts for treatment: There is absolutely no documentation of all the various OUTPATIENT treatments available prior to hospitalization that may well have precluded becoming an inpatient. I find this totally unacceptable. Dr Joseph BellIHS23 December 2020 Follow up on comment Thank you Dr Caritas for your comment-- could you share the names of various outpatient medications that may be effective? Author, Article, and Disclosure InformationAuthors: Vineet Chopra, MD, MSc; Scott A. Flanders, MD; Megan O’Malley, PhD; Anurag N. Malani, MD; Hallie C. Prescott, MD, MScAffiliations: University of Michigan Health System and The Michigan Hospital Medicine Safety Collaborative, Ann Arbor, MichiganSt. Joseph Mercy Health System and The Michigan Hospital Medicine Safety Collaborative, Ann Arbor, MichiganAcknowledgment: The authors thank all the BCBSM Collaborative Quality Initiatives that partnered together on data collection and all the hospitals that volunteered to be part of MI-COVID19.Financial Support: From BCBSM and Blue Care Network as part of the BCBSM Value Partnerships program.Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M20-5661.Reproducible Research Statement: Study protocol: Information available at https://mi-hms.org/quality-initiatives/mi-covid19-initiative. Statistical code: Available on request from Dr. O’Malley (e-mail, meganom@med.umich.edu). Data set: Not available.Corresponding Author: Vineet Chopra, MD, MSc, 2800 Plymouth Road, Building 16, #432 W, Ann Arbor, MI 48109; e-mail, vineetc@umich.edu.This article was published at Annals.org on 11 November 2020. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics Cited byPathogenesis of Pulmonary Long COVID-19The effect of COVID-19 on cancer immunotherapy and cancer careLong COVID-19 Syndrome and Sudden Cardiac Death: The Phantom MenaceThe potential clinical impact and cost-effectiveness of the updated COVID-19 mRNA fall 2023 vaccines in the United StatesIntrinsic factors behind long COVID: III. 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Symptoms in Long COVID: Systematic ReviewAssessment of and in Patients Hospitalized for COVID-19 at 6 of in COVID-19 of pain, fatigue, and function between and fatigue syndrome: a survey effects of COVID‐19 in patients hospitalized during the first of the The impact of persistent fatigue on quality of life in a cross‐sectional impact of COVID-19 by life years at national in in of after a new coronavirus infection ICU and Critical Care Analysis of in an International of with a of COVID-19 and and Cognitive Among Patients for Post-COVID An COVID: A for of in and of the post-COVID syndrome and Acute Respiratory Syndrome and Risk for Long COVID Symptoms: impact of COVID-19 pandemic on the quality of life of healthcare and the associated A systematic Care and Post-COVID-19 symptoms and recovery in hospitalized mild and COVID-19 Acute Respiratory Syndrome and features of the post-COVID syndrome for the Pulmonary of After for COVID-19: for a Scoping long-term effects of COVID-19 on pulmonary 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Syndrome Severe Long COVID-19: An of COVID-19 among previously hospitalized patients up to 1 year after a systematic review and for Post-Acute or Cognitive of SARS-CoV-2 A 2 Clinical Study and Quality of at Work in Patients after Management of in COVID-19 Patients Referred to a Cardiac Center after Hospital in COVID-19: and Disease 2019 Pulmonary or of Clinical and Among Patients with Post-Acute COVID-19 Analysis of a Nationwide Survey in of Medicine for COVID-19 Syndrome: A Survey of Medicine COVID-19 survivors from and Syndrome from A for COVID-19 to and following recovery from of in common associated with symptoms: a condition 3 months after hospitalisation with SARS-CoV-2 in a prospective cohort COVID and among adults and older adults in the of for an cohort health for from functional in patients with coronavirus admitted to intensive care and the effect of vs on functional COVID-19 on the of health of COVID-19 A post-vaccination of health of COVID-19 A post-vaccination for 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OBJECTIVES: To evaluate the extent to which intensive care units participating in the initial Keystone ICU project sustained reductions in rates of catheter related bloodstream infections. Design Collaborative cohort study to implement and evaluate interventions to improve patients' safety. SETTING: Intensive care units predominantly in Michigan, USA. INTERVENTION: Conceptual model aimed at improving clinicians' use of five evidence based recommendations to reduce rates of catheter related bloodstream infections rates, with measurement and feedback of infection rates. During the sustainability period, intensive care unit teams were instructed to integrate this intervention into staff orientation, collect monthly data from hospital infection control staff, and report infection rates to appropriate stakeholders. MAIN OUTCOME MEASURES: Quarterly rate of catheter related bloodstream infections per 1000 catheter days during the sustainability period (19-36 months after implementation of the intervention). RESULTS: Ninety (87%) of the original 103 intensive care units participated, reporting 1532 intensive care unit months of data and 300 310 catheter days during the sustainability period. The mean and median rates of catheter related bloodstream infection decreased from 7.7 and 2.7 (interquartile range 0.6-4.8) at baseline to 1.3 and 0 (0-2.4) at 16-18 months and to 1.1 and 0 (0.0-1.2) at 34-36 months post-implementation. Multilevel regression analysis showed that incidence rate ratios decreased from 0.68 (95% confidence interval 0.53 to 0.88) at 0-3 months to 0.38 (0.26 to 0.56) at 16-18 months and 0.34 (0.24-0.48) at 34-36 months post-implementation. During the sustainability period, the mean bloodstream infection rate did not significantly change from the initial 18 month post-implementation period (-1%, 95% confidence interval -9% to 7%). CONCLUSIONS: The reduced rates of catheter related bloodstream infection achieved in the initial 18 month post-implementation period were sustained for an additional 18 months as participating intensive care units integrated the intervention into practice. Broad use of this intervention with achievement of similar results could substantially reduce the morbidity and costs associated with catheter related bloodstream infections.

BACKGROUND: Catheter-associated urinary tract infections (CAUTI) are costly, common and often preventable by reducing unnecessary urinary catheter (UC) use. METHODS: To summarise interventions to reduce UC use and CAUTIs, we updated a prior systematic review (through October 2012), and a meta-analysis regarding interventions prompting UC removal by reminders or stop orders. A narrative review summarises other CAUTI prevention strategies including aseptic insertion, catheter maintenance, antimicrobial UCs, and bladder bundle implementation. RESULTS: 30 studies were identified and summarised with interventions to prompt removal of UCs, with potential for inclusion in the meta-analyses. By meta-analysis (11 studies), the rate of CAUTI (episodes per 1000 catheter-days) was reduced by 53% (rate ratio 0.47; 95% CI 0.30 to 0.64, p<0.001) using a reminder or stop order, with five studies also including interventions to decrease initial UC placement. The pooled (nine studies) standardised mean difference (SMD) in catheterisation duration (days) was -1.06 overall (p=0.065) including a statistically significant decrease in stop-order studies (SMD -0.37; p<0.001) but not in reminder studies (SMD, -1.54; p=0.071). No significant harm from catheter removal strategies is supported. Limited research is available regarding the impact of UC insertion and maintenance technique. A recent randomised controlled trial indicates antimicrobial catheters provide no significant benefit in preventing symptomatic CAUTIs. CONCLUSIONS: UC reminders and stop orders appear to reduce CAUTI rates and should be used to improve patient safety. Several evidence-based guidelines have evaluated CAUTI preventive strategies as well as emerging evidence regarding intervention bundles. Implementation strategies are important because reducing UC use involves changing well-established habits.

xisting American Heart Association cardiopulmonary resuscitation (CPR) guidelines do not address the challenges of providing resuscitation in the setting of the coronavirus disease 2019 (COVID-19) global pandemic, wherein rescuers must continuously balance the immediate needs of the patients with their own safety.To address this gap, the American Heart Association, in collaboration with the American Academy of Pediatrics, American Association for Respiratory Care, American College of Emergency Physicians, The Society of Critical Care Anesthesiologists, and American Society of Anesthesiologists, and with the support of the American Association of Critical Care Nurses and National Association of EMS Physicians, has compiled interim guidance to help rescuers treat individuals with cardiac arrest with suspected or confirmed COVID-19.Over the past 2 decades, there has been a steady improvement in survival after cardiac arrest occurring both inside and outside the hospital. 1That success has relied on initiating proven resuscitation interventions such as high-quality chest compressions and defibrillation within seconds to minutes.The evolving and expanding outbreak of severe acute respiratory syndrome coronavirus 2 infections has created important challenges to such resuscitation efforts and requires potential modifications of established processes and practices.The challenge is to ensure that patients with or without COVID-19 who experience cardiac arrest get the best possible chance of survival without compromising the safety of rescuers, who will be needed to care for future patients.Complicating the emergency response to both out-of-hospital and in-hospital cardiac arrest is that COVID-19 is highly transmissible, particularly during resuscitation, and carries a high morbidity and mortality.3][4] Hypoxemic respiratory failure secondary to acute respiratory distress syndrome, myocardial injury, ventricular arrhythmias, and shock are common among critically ill patients and predispose them to cardiac arrest, [5][6][7][8] as do some of the proposed treatments such as hydroxychloroquine and azithromycin, which can prolong the QT. 9 With infections currently growing exponentially in the United States and internationally, the percentage of patients with cardiac arrests and COVID-19 is likely to increase.Healthcare workers are already the highest-risk profession for contracting the disease. 10This risk is compounded by worldwide shortages of personal protective equipment (PPE).Resuscitations carry added risk to healthcare workers for many reasons.First, the administration of CPR involves performing numerous aerosol-generating procedures, including chest compressions, positive-pressure ventilation, and establishment of an advanced airway.During those procedures, viral particles can remain suspended in the air with a half-life of ≈1 hour and

BACKGROUND: Antibacterials may be initiated out of concern for bacterial coinfection in coronavirus disease 2019 (COVID-19). We determined prevalence and predictors of empiric antibacterial therapy and community-onset bacterial coinfections in hospitalized patients with COVID-19. METHODS: A randomly sampled cohort of 1705 patients hospitalized with COVID-19 in 38 Michigan hospitals between 3/13/2020 and 6/18/2020. Data were collected on early (within 2 days of hospitalization) empiric antibacterial therapy and community-onset bacterial coinfections (positive microbiologic test ≤3 days). Poisson generalized estimating equation models were used to assess predictors. RESULTS: Of 1705 patients with COVID-19, 56.6% were prescribed early empiric antibacterial therapy; 3.5% (59/1705) had a confirmed community-onset bacterial infection. Across hospitals, early empiric antibacterial use varied from 27% to 84%. Patients were more likely to receive early empiric antibacterial therapy if they were older (adjusted rate ratio [ARR]: 1.04 [1.00-1.08] per 10 years); had a lower body mass index (ARR: 0.99 [0.99-1.00] per kg/m2), more severe illness (eg, severe sepsis; ARR: 1.16 [1.07-1.27]), a lobar infiltrate (ARR: 1.21 [1.04-1.42]); or were admitted to a for-profit hospital (ARR: 1.30 [1.15-1.47]). Over time, COVID-19 test turnaround time (returned ≤1 day in March [54.2%, 461/850] vs April [85.2%, 628/737], P < .001) and empiric antibacterial use (ARR: 0.71 [0.63-0.81] April vs March) decreased. CONCLUSIONS: The prevalence of confirmed community-onset bacterial coinfections was low. Despite this, half of patients received early empiric antibacterial therapy. Antibacterial use varied widely by hospital. Reducing COVID-19 test turnaround time and supporting stewardship could improve antibacterial use.

Background: Randomized trials demonstrate no benefit from antibiotic treatment exceeding the shortest effective duration. Objective: To examine predictors and outcomes associated with excess duration of antibiotic treatment. Design: Retrospective cohort study. Setting: 43 hospitals in the Michigan Hospital Medicine Safety Consortium. Patients: 6481 general care medical patients with pneumonia. Measurements: The primary outcome was the rate of excess antibiotic treatment duration (excess days per 30-day period). Excess days were calculated by subtracting each patient's shortest effective (expected) treatment duration (based on time to clinical stability, pathogen, and pneumonia classification [community-acquired vs. health care-associated]) from the actual duration. Negative binomial generalized estimating equations (GEEs) were used to calculate rate ratios to assess predictors of 30-day rates of excess duration. Patient outcomes, assessed at 30 days via the medical record and telephone calls, were evaluated using logit GEEs that adjusted for patient characteristics and probability of treatment. Results: Two thirds (67.8% [4391 of 6481]) of patients received excess antibiotic therapy. Antibiotics prescribed at discharge accounted for 93.2% of excess duration. Patients who had respiratory cultures or nonculture diagnostic testing, had a longer stay, received a high-risk antibiotic in the prior 90 days, had community-acquired pneumonia, or did not have a total antibiotic treatment duration documented at discharge were more likely to receive excess treatment. Excess treatment was not associated with lower rates of any adverse outcomes, including death, readmission, emergency department visit, or Clostridioides difficile infection. Each excess day of treatment was associated with a 5% increase in the odds of antibiotic-associated adverse events reported by patients after discharge. Limitation: Retrospective design; not all patients could be contacted to report 30-day outcomes. Conclusion: Patients hospitalized with pneumonia often receive excess antibiotic therapy. Excess antibiotic treatment was associated with patient-reported adverse events. Future interventions should focus on whether reducing excess treatment and improving documentation at discharge improves outcomes. Primary Funding Source: Blue Cross Blue Shield of Michigan (BCBSM) and Blue Care Network as part of the BCBSM Value Partnerships program.

OBJECTIVE: To evaluate a clinic-based multimedia intervention for diabetes education targeting individuals with low health literacy levels in a diverse population. RESEARCH DESIGN AND METHODS: Five public clinics in Chicago, Illinois, participated in the study with computer kiosks installed in waiting room areas. Two hundred forty-four subjects with diabetes were randomized to receive either supplemental computer multimedia use (intervention) or standard of care only (control). The intervention includes audio/video sequences to communicate information, provide psychological support, and promote diabetes self-management skills without extensive text or complex navigation. HbA(1c) (A1C), BMI, blood pressure, diabetes knowledge, self-efficacy, self-reported medical care, and perceived susceptibility of complications were evaluated at baseline and 1 year. Computer usage patterns and implementation barriers were also examined. RESULTS: Complete 1-year data were available for 183 subjects (75%). Overall, there were no significant differences in change in A1C, weight, blood pressure, knowledge, self-efficacy, or self-reported medical care between intervention and control groups. However, there was an increase in perceived susceptibility to diabetes complications in the intervention group. This effect was greatest among subjects with lower health literacy. Within the intervention group, time spent on the computer was greater for subjects with higher health literacy. CONCLUSIONS: Access to multimedia lessons resulted in an increase in perceived susceptibility to diabetes complications, particularly in subjects with lower health literacy. Despite measures to improve informational access for individuals with lower health literacy, there was relatively less use of the computer among these participants.

Between August 1992 and December 1996, more than 700 unicondylar knee arthroplasty (UKA) procedures were done by the senior author (JA.R.), using well-defined patient selection criteria, which is paramount to the outcome of the procedure. The UKA procedure described is done through a smaller incision than that required for total knee arthroplasty (TKA) (3 inches versus 8 inches), thus minimizing blood loss (less than 200 mL), avoiding normal tissue sacrifice (opposite compartment, patellar bone, and cruciate ligaments), and decreasing morbidity (no patellofemoral disruption). The UKA costs less because it is done as an outpatient procedure in 80% of cases; since postoperative physical therapy is minimal or unnecessary, recovery time is shorter (90% independent function at 2 weeks after operation). Whereas TKA can have universal application, UKA is patient specific and cannot replace TKA in all circumstances. Likewise, the techniques for TKA and UKA are not interchangeable. However, with the use of well-defined patient populations and surgical techniques, the intermediate results of UKA have paralleled reported outcomes of TKA.

OBJECTIVES: To review the scientific literature pertaining to the use of hand-carried and hand-held ultrasound devices in low- and middle-income countries (LMIC), with a focus on clinical applications, geographical areas of use, the impact on patient management and technical features of the devices used. METHODS: The electronic databases PubMed and Google Scholar were searched. No language or date restrictions were applied. Case reports and original research describing the use of hand-carried ultrasound devices in LMIC were included if agreed upon as relevant by two-reviewer consensus based on our predefined research questions. RESULTS: A total of 644 articles were found and screened, and 36 manuscripts were included for final review. Twenty-seven studies were original research articles, and nine were case reports. Several reports describe the successful diagnosis and management of difficult, often life-threatening conditions, using hand-carried and hand-held ultrasound. These portable ultrasound devices have also been studied for cardiac screening exams, as well as a rapid triage tool in rural areas and after natural disaster. Most applications focus on obstetrical and abdominal complaints. Portable ultrasound may have an impact on clinical management in up to 70% of all cases. However, no randomised controlled trials have evaluated the impact of ultrasound-guided diagnosis and treatment in resource-constrained settings. The exclusion of articles published in journals not listed in the large databases may have biased our results. Our findings are limited by the lack of higher quality evidence (e.g. controlled trials). CONCLUSIONS: Hand-carried and hand-held ultrasound is successfully being used to triage, diagnose and treat patients with a variety of complaints in LMIC. However, the quality of the current evidence is low. There is an urgent need to perform larger clinical trials assessing the impact of hand-carried ultrasound in LMIC.

Carvalho, Alexandre MD, MPH1; Alqusairi, Rana MD1; Adams, Anna DO1; Paul, Michelle BS2; Kothari, Neelay MD1,3; Peters, Stevany MD1,4; DeBenedet, Anthony T. MD, MSc1,4 Author Information

Previously published guidelines provide comprehensive recommendations for hand hygiene in healthcare facilities. The intent of this document is to highlight practical recommendations in a concise format, update recommendations with the most current scientific evidence, and elucidate topics that warrant clarification or more robust research. Additionally, this document is designed to assist healthcare facilities in implementing hand hygiene adherence improvement programs, including efforts to optimize hand hygiene product use, monitor and report back hand hygiene adherence data, and promote behavior change. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.

BACKGROUND: The INTRINSIC RV (Inhibition of Unnecessary RV Pacing with AVSH in ICDs) study tested the hypothesis that dual-chamber rate-responsive (DDDR) with atrioventricular search hysteresis (AVSH) 60-130 programming is not inferior to single-chamber (VVI)-40 programming in an implantable cardioverter defibrillator with respect to all-cause mortality and heart failure hospitalizations using an equivalence margin of 5%. METHODS AND RESULTS: At 108 centers, 1530 patients with an implantable cardioverter defibrillator indication received a VITALITY AVT (Guidant Corporation, St. Paul, Minn) implantable cardioverter defibrillator programmed consistently to DDDR AVSH 60-130 for the first week. Of those, 988 patients with <20% right ventricular pacing at 1 week were randomized to DDDR AVSH 60-130 or to VVI-40 programming. Among those randomized, 502 were assigned to DDDR AVSH and 486 to VVI. Groups were similar with regard to coronary disease (68%), gender (21% female), and New York Heart Association functional class >I (79%). A total of 32 patients (6.4%) in the DDDR AVSH arm and 46 patients (9.5%) in the VVI arm died or were hospitalized for heart failure during a mean follow-up of 10.4 months (relative risk=0.67, P=0.072 in favor of DDDR AVSH). DDDR AVSH was not inferior to VVI programming (P<0.001). All-cause mortality was not significantly different between the DDDR AVSH arm (3.6%) and the VVI arm (5.1%; P=0.23). The mean percent right ventricular pacing in the DDDR AVSH arm was 10% (median 4%) versus 3% (median 0%) in the VVI arm. CONCLUSIONS: In the INTRINSIC RV trial, among those randomized, DDDR AVSH was associated with similar outcomes as with VVI backup pacing.

In Brief Objective: To determine the utility of adding oral nonabsorbable antibiotics to the bowel prep prior to elective colon surgery. Summary Background Data: Bowel preparation prior to colectomy remains controversial. We hypothesized that mechanical bowel preparation with oral antibiotics (compared with without) was associated with lower rates of surgical site infection (SSI). Methods: Twenty-four Michigan hospitals participated in the Michigan Surgical Quality Collaborative–Colectomy Best Practices Project. Standard perioperative data, bowel preparation process measures, and Clostridium difficile colitis outcomes were prospectively collected. Among patients receiving mechanical bowel preparation, a logistic regression model generated a propensity score that allowed us to match cases differing only in whether or not they had received oral antibiotics. Results: Overall, 2011 elective colectomies were performed over 16 months. Mechanical bowel prep without oral antibiotics was administered to 49.6% of patients, whereas 36.4% received a mechanical prep and oral antibiotics. Propensity analysis created 370 paired cases (differing only in receiving oral antibiotics). Patients receiving oral antibiotics were less likely to have any SSI (4.5% vs. 11.8%, P = 0.0001), to have an organ space infection (1.8% vs. 4.2%, P = 0.044) and to have a superficial SSI (2.6% vs. 7.6%, P = 0.001). Patients receiving bowel prep with oral antibiotics were also less likely to have a prolonged ileus (3.9% vs. 8.6%, P = 0.011) and had similar rates of C. difficile colitis (1.3% vs. 1.8%, P = 0.58). Conclusions: Most patients in Michigan receive mechanical bowel preparation prior to elective colectomy. Oral antibiotics may reduce the incidence of SSI. Using a statewide surgical quality collaborative, we evaluated the importance of oral antibiotics as part of bowel preparation prior to elective colon surgery. Using propensity matching, we noted significantly lower surgical site infection rates and low Clostridium difficile colitis rates in the group that received oral nonabsorbable antibiotics prior to surgery.

IMPORTANCE: Treatment of asymptomatic bacteriuria (ASB) with antibiotics is a common factor in inappropriate antibiotic use, but risk factors and outcomes associated with treatment of ASB in hospitalized patients are not well defined. OBJECTIVE: To evaluate factors associated with treatment of ASB among hospitalized patients and the possible association between treatment and clinical outcomes. DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort study was conducted from January 1, 2016, through February 1, 2018, at 46 hospitals participating in the Michigan Hospital Medicine Safety Consortium. A total of 2733 hospitalized medical patients with ASB, defined as a positive urine culture without any documented signs or symptoms attributable to urinary tract infection, were included in the analysis. EXPOSURES: One or more antibiotic dose for treatment of ASB. MAIN OUTCOMES AND MEASURES: Estimators of antibiotic treatment of ASB. Secondary outcomes included 30-day mortality, 30-day hospital readmission, 30-day emergency department visit, discharge to post-acute care settings, Clostridioides difficile infection (formerly known as Clostridium difficile) at 30 days, and duration of hospitalization after urine testing. RESULTS: Of 2733 patients with ASB, 2138 were women (78.2%); median age was 77 years (interquartile range [IQR], 66-86 years). A total of 2259 patients (82.7%) were treated with antibiotics for a median of 7 days (IQR, 4-9 days). Factors associated with ASB treatment included older age (odds ratio [OR], 1.10 per 10-year increase; 95% CI, 1.02-1.18), dementia (OR, 1.57; 95% CI, 1.15-2.13), acutely altered mental status (OR, 1.93; 95% CI, 1.23-3.04), urinary incontinence (OR, 1.81; 95% CI, 1.36-2.41), leukocytosis (white blood cell count >10 000/μL) (OR, 1.55; 95% CI, 1.21-2.00), positive urinalysis (presence of leukocyte esterase or nitrite, or >5 white blood cells per high-power field) (OR, 2.83; 95% CI, 2.05-3.93), and urine culture with a bacterial colony count greater than 100 000 colony-forming units per high-power field (OR, 2.30; 95% CI, 1.83-2.91). Treatment of ASB was associated with longer duration of hospitalization after urine testing (4 vs 3 days; relative risk, 1.37; 95% CI, 1.28-1.47). No other differences in secondary outcomes were identified after propensity weighting. CONCLUSIONS AND RELEVANCE: Hospitalized patients with ASB commonly receive inappropriate antibiotic therapy. Antibiotic treatment did not appear to be associated with improved outcomes; rather, treatment may be associated with longer duration of hospitalization after urine testing. To possibly reduce inappropriate antibiotic use, stewardship efforts should focus on improving urine testing practices and management strategies for elderly patients with altered mental status.

Mucous membrane pemphigoid encompasses a group of autoimmune bullous diseases with a similar phenotype characterized by subepithelial blisters, erosions, and scarring of mucous membranes, skin, or both. Although knowledge about autoimmune bullous disease is increasing, there is often a lack of clear definitions of disease, outcome measures, and therapeutic end points. With clearer definitions and outcome measures, it is possible to directly compare the results and data from various studies using meta-analyses. This consensus statement provides accurate and reproducible definitions for disease extent, activity, outcome measures, end points, and therapeutic response for mucous membrane pemphigoid and proposes a disease extent score, the Mucous Membrane Pemphigoid Disease Area Index.

IMPORTANCE: Indwelling devices (eg, urinary catheters and feeding tubes) are often used in nursing homes (NHs). Inadequate care of residents with these devices contributes to high rates of multidrug-resistant organisms (MDROs) and device-related infections in NHs. OBJECTIVE: To test whether a multimodal targeted infection program (TIP) reduces the prevalence of MDROs and incident device-related infections. DESIGN, SETTING, AND PARTICIPANTS: Randomized clinical trial at 12 community-based NHs from May 2010 to April 2013. Participants were high-risk NH residents with urinary catheters, feeding tubes, or both. INTERVENTIONS: Multimodal, including preemptive barrier precautions, active surveillance for MDROs and infections, and NH staff education. MAIN OUTCOMES AND MEASURES: The primary outcome was the prevalence density rate of MDROs, defined as the total number of MDROs isolated per visit averaged over the duration of a resident's participation. Secondary outcomes included new MDRO acquisitions and new clinically defined device-associated infections. Data were analyzed using a mixed-effects multilevel Poisson regression model (primary outcome) and a Cox proportional hazards model (secondary outcome), adjusting for facility-level clustering and resident-level variables. RESULTS: In total, 418 NH residents with indwelling devices were enrolled, with 34,174 device-days and 6557 anatomic sites sampled. Intervention NHs had a decrease in the overall MDRO prevalence density (rate ratio, 0.77; 95% CI, 0.62-0.94). The rate of new methicillin-resistant Staphylococcus aureus acquisitions was lower in the intervention group than in the control group (rate ratio, 0.78; 95% CI, 0.64-0.96). Hazard ratios for the first and all (including recurrent) clinically defined catheter-associated urinary tract infections were 0.54 (95% CI, 0.30-0.97) and 0.69 (95% CI, 0.49-0.99), respectively, in the intervention group and the control group. There were no reductions in new vancomycin-resistant enterococci or resistant gram-negative bacilli acquisitions or in new feeding tube-associated pneumonias or skin and soft-tissue infections. CONCLUSIONS AND RELEVANCE: Our multimodal TIP intervention reduced the overall MDRO prevalence density, new methicillin-resistant S aureus acquisitions, and clinically defined catheter-associated urinary tract infection rates in high-risk NH residents with indwelling devices. Further studies are needed to evaluate the cost-effectiveness of this approach as well as its effects on the reduction of MDRO transmission to other residents, on the environment, and on referring hospitals. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01062841.

BACKGROUND: Traumatic brain injury (TBI) is a major source of death and severe disability worldwide. Raised Intracranial pressure (ICP) is an important predictor of mortality in patients with severe TBI and aggressive treatment of elevated ICP has been shown to reduce mortality and improve outcome. The acute post-injury period in TBI is characterized by several pathophysiologic processes that start in the minutes to hours following injury. All of these processes are temperature-dependent; they are all aggravated by fever and inhibited by hypothermia. METHODS: This study reviewed the current clinical evidence in support of the use of therapeutic hypothermia (TH) for the treatment of intracranial hypertension (ICH) in patients with severe TBI. RESULTS: This study identified a total of 18 studies involving hypothermia for control of ICP; 13 were randomized controlled trials (RCT) and five were observational studies. TH (32-34°C) was effective in controlling ICH in all studies. In the 13 RCT, ICP in the TH group was always significantly lower than ICP in the normothermia group. In the five observational studies, ICP during TH was always significantly lower than prior to inducing TH. CONCLUSIONS: Pending results from large multi-centre studies evaluating the effect of TH on ICH and outcome, TH should be included as a therapeutic option to control ICP in patients with severe TBI.

PURPOSE: To answer the question, "should elderly non-small-cell lung cancer patients be offered elderly-specific trials?" PATIENTS AND METHODS: The North Central Cancer Treatment Group (NCCTG) performed a pooled analysis of elderly patients who participated in elderly-specific trials (required age > or = 65 years) and age-unspecified trials (required age > or = 18 years). Between 1998 and 2000, all NCCTG non-small-cell lung cancer (NSCLC) patients with incurable cancer, age > or = 65 years, and receiving first-line chemotherapy were included. A total of 118 elderly patients participated in elderly-specific trials, and 108, in age-unspecified trials. Demographics and outcomes were compared based on trial type. RESULTS: The median age of elderly patients in elderly-specific trials was greater: median (range): 73 years (65 to 87) and 70 years (65 to 85), respectively (P < .001), as was the percentage older than 80 years: 17% and 3%, respectively (P = .0008). Median survival times were 232 and 302 days, respectively (P = .08). After adjustment for baseline age, Eastern Cooperative Oncology Group performance score, cancer stage, and body mass index, this survival difference was not statistically significant (hazard ratio = 1.25; P = .16). Grade 3 or worse nonhematologic adverse event rates were greater in age-unspecified trials (81% v 57%, respectively; P < .001), as were grade 3 or worse hematologic events (68% v 10%, respectively; P < .001). CONCLUSION: Elderly patients in NSCLC elderly-specific trials suffered lower rates of severe adverse events with no statistically significant differences in survival. It seems that elderly-specific trials are providing quality care and helping to define optimal cancer therapy in the elderly, particularly among the "oldest of the old."

Legislation aimed at controlling antimicrobial-resistant pathogens through the use of active surveillance cultures to screen hospitalized patients has been introduced in at least 2 US states. In response to the proposed legislation, the Society for Healthcare Epidemiology of America (SHEA) and the Association of Professionals in Infection Control and Epidemiology (APIC) have developed this joint position statement. Both organizations are dedicated to combating healthcare-associated infections with a wide array of methods, including the use of active surveillance cultures in appropriate circumstances. This position statement reviews the proposed legislation and the rationale for use of active surveillance cultures, examines the scientific evidence supporting the use of this strategy, and discusses a number of unresolved issues surrounding legislation mandating use of active surveillance cultures. The following 5 consensus points are offered. (1) Although reducing the burden of antimicrobial-resistant pathogens, including methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE), is of preeminent importance, APIC and SHEA do not support legislation to mandate use of active surveillance cultures to screen for MRSA, VRE, or other antimicrobial-resistant pathogens. (2) SHEA and APIC support the continued development, validation, and application of efficacious and cost-effective strategies for the prevention of infections caused by MRSA, VRE, and other antimicrobial-resistant and antimicrobial-susceptible pathogens. (3) APIC and SHEA welcome efforts by healthcare consumers, together with private, local, state, and federal policy makers, to focus attention on and formulate solutions for the growing problem of antimicrobial resistance and healthcare-associated infections. (4) SHEA and APIC support ongoing additional research to determine and optimize the appropriateness, utility, feasibility, and cost-effectiveness of using active surveillance cultures to screen both lower-risk and high-risk populations. (5) APIC and SHEA support stronger collaboration between state and local public health authorities and institutional infection prevention and control experts.

Importance: Peripherally inserted central catheters (PICCs) and midlines are frequently used for short-term venous access; whether one is safer than the other in this setting has not been adequately reported. Objective: To compare outcomes between patients who had a PICC vs midline placed for the indication of difficult vascular access or antibiotic therapy for 30 or fewer days. Design, Setting, and Participants: This cohort study analyzed data from a multihospital registry including patients admitted to a participating site from December 2017 through January 2020 who had a PICC or midline placement for the indications of difficult venous access or intravenous antibiotic therapy prescribed for 30 or fewer days. Data were analyzed from October 2020 to March 2021. Exposures: PICC and midline placement. Main Outcomes and Measures: Major complications, including a composite of symptomatic catheter-associated deep vein thrombosis (DVT), catheter-related bloodstream infection, and catheter occlusion. Logistic regression and Cox proportional hazards regression models (taking into account catheter dwell) were used to estimate risk for major complications, adjusting for patient and device characteristics and the clustered nature of the data. Sensitivity analyses limiting analyses to 10 days of device dwell were performed. Results: Data on 10 863 patients, 5758 with PICCs and 5105 with midlines (median [IQR] age of device recipients, 64.8 [53.4-75.4] years; 5741 [52.8%] were female), were included. After adjusting for patient characteristics, comorbidities, catheter lumens, and dwell time in logit models, patients who received PICCs had a greater risk of developing a major complication compared with those who received midlines (odds ratio, 1.99; 95% CI, 1.61-2.47). Reduction in complications stemmed from lower rates of occlusion (2.1% vs 7.0%; P < .001) and bloodstream infection (0.4% vs 1.6%; P < .001) in midlines vs PICCs; no significant difference in the risk of DVT between PICCs and midlines was observed. In time-to-event models, similar outcomes for bloodstream infection and catheter occlusion were noted; however, the risk of DVT events was lower in patients who received PICCs vs midlines (hazard ratio, 0.53; 95% CI, 0.38-0.74). Results were robust to sensitivity analyses. Conclusions and Relevance: In this cohort study among patients with placement of midline catheters vs PICCs for short-term indications, midlines were associated with a lower risk of bloodstream infection and occlusion compared with PICCs. Whether DVT risk is similar or greater with midlines compared with PICCs for short-term use is unclear. Randomized clinical trials comparing these devices for this indication are needed.