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Hersh AL, Stenehjem EA, Fino N, Spivak ES. Impact of COVID-19 on urgent care diagnoses and the new AXR metric. Antimicrob Steward Healthc Epidemiol 2024; 4:e49. [PMID: 38655021 PMCID: PMC11036422 DOI: 10.1017/ash.2024.62] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 03/20/2024] [Accepted: 03/25/2024] [Indexed: 04/26/2024]
Abstract
We examined the antibiotic prescribing rate for respiratory diagnoses (AXR) before and after onset of the COVID-19 pandemic in urgent care clinics. At the onset, AXR declined substantially due to changes in case mix. Using AXR as a stewardship metric requires monitoring of changes in case mix.
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Affiliation(s)
- Adam L. Hersh
- Department of Pediatrics, Division of Infectious Diseases, University of Utah, Salt Lake City, UT, USA
| | - Edward A. Stenehjem
- Department of Medicine, Division of Infectious Diseases, University of Colorado School of Medicine, Aurora, CO, USA
| | - Nora Fino
- Urgent Care, University of Utah, Salt Lake City, UT, USA
| | - Emily S. Spivak
- Department of Internal Medicine, Division of Epidemiology, University of Utah, Salt Lake City, UT, USA
- Department of Internal Medicine, Division of Infectious Diseases, University of Utah, Salt Lake City, UT, USA
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2
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Seibert AM, Hersh AL, Patel PK, Hicks LA, Fino N, Stanfield V, Stenehjem EA. Impact of an antibiotic stewardship initiative on urgent-care respiratory prescribing across patient race, ethnicity, and language. Infect Control Hosp Epidemiol 2024; 45:530-533. [PMID: 38073559 PMCID: PMC11003825 DOI: 10.1017/ice.2023.258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 10/15/2023] [Accepted: 10/24/2023] [Indexed: 04/10/2024]
Abstract
We conducted a post hoc analysis of an antibiotic stewardship intervention implemented across our health system's urgent-care network to determine whether there was a differential impact among patient groups. Respiratory urgent-care antibiotic prescribing decreased for all racial, ethnic, and preferred language groups, but disparities in antibiotic prescribing persisted.
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Affiliation(s)
- Allan M. Seibert
- Division of Infectious Diseases, Intermountain Health, Salt Lake City, Utah
| | - Adam L. Hersh
- Division of Infectious Diseases, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Payal K. Patel
- Division of Infectious Diseases, Intermountain Health, Salt Lake City, Utah
| | - Lauri A. Hicks
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Nora Fino
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Valoree Stanfield
- Office of Patient Experience, Intermountain Health, Salt Lake City, Utah
| | - Edward A. Stenehjem
- Division of Infectious Diseases, University of Colorado School of Medicine, Aurora, Colorado
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3
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Hart JH, Sakata T, Eve JR, Butler AM, Wallin A, Carman C, Atwood B, Srivastava R, Jones BE, Stenehjem EA, Dean NC. Diagnosis and Treatment of Pneumonia in Urgent Care Clinics: Opportunities for Improving Care. Open Forum Infect Dis 2024; 11:ofae096. [PMID: 38456194 PMCID: PMC10919392 DOI: 10.1093/ofid/ofae096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 02/19/2024] [Indexed: 03/09/2024] Open
Abstract
Background Community-acquired pneumonia is a well-studied condition; yet, in the urgent care setting, patient characteristics and adherence to guideline-recommended care are poorly described. Within Intermountain Health, a nonprofit integrated US health care system based in Utah, more patients present to urgent care clinics (UCCs) than emergency departments (EDs) for pneumonia care. Methods We performed a retrospective cohort study 1 January 2019 through 31 December 2020 in 28 UCCs within Utah. We extracted electronic health record data for patients aged ≥12 years with ICD-10 pneumonia diagnoses entered by the bedside clinician, excluding patients with preceding pneumonia within 30 days or missing vital signs. We compared UCC patients with radiographic pneumonia (n = 4689), without radiographic pneumonia (n = 1053), without chest imaging (n = 1472), and matched controls with acute cough/bronchitis (n = 15 972). Additional outcomes were 30-day mortality and the proportion of patients with ED visits or hospital admission within 7 days after the index encounter. Results UCC patients diagnosed with pneumonia and possible/likely radiographic pneumonia by radiologist report had a mean age of 40 years and 52% were female. Almost all patients with pneumonia (93%) were treated with antibiotics, including those without radiographic confirmation. Hospital admissions and ED visits within 7 days were more common in patients with radiographic pneumonia vs patients with "unlikely" radiographs (6% vs 2% and 10% vs 6%, respectively). Observed 30-day all-cause mortality was low (0.26%). Patients diagnosed without chest imaging presented similarly to matched patients with cough/acute bronchitis. Most patients admitted to the hospital the same day after the UCC visit (84%) had an interim ED encounter. Pneumonia severity scores (pneumonia severity index, electronic CURB-65, and shock index) overestimated patient need for hospitalization. Conclusions Most UCC patients with pneumonia were successfully treated as outpatients. Opportunities to improve care include clinical decision support for diagnosing pneumonia with radiographic confirmation and development of pneumonia severity scores tailored to the UCC.
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Affiliation(s)
- James H Hart
- Intermountain Healthcare, Intermountain Instacare, Salt Lake City, Utah, USA
| | - Theadora Sakata
- Intermountain Healthcare, Intermountain Instacare, Salt Lake City, Utah, USA
- Healthcare Delivery Institute, Intermountain Health, Murray, Utah, USA
| | - Jacqueline R Eve
- Enterprise Analytics, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Allison M Butler
- Office of Research, Intermountain Medical Center, Murray, Utah, USA
| | - Anthony Wallin
- Intermountain Healthcare, Intermountain Instacare, Salt Lake City, Utah, USA
| | - Chad Carman
- Intermountain Healthcare, Intermountain Instacare, Salt Lake City, Utah, USA
| | - Brenda Atwood
- Intermountain Healthcare, Intermountain Instacare, Salt Lake City, Utah, USA
| | - Rajendu Srivastava
- Healthcare Delivery Institute, Intermountain Health, Murray, Utah, USA
- Division of Pediatric Hospital Medicine, Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Barbara E Jones
- Division of Respiratory, Critical Care and Occupational Pulmonary Medicine, School of Medicine, University of Utah, Salt Lake City, Utah, USA
- Veterans Administration Salt Lake City Health Care System, Salt Lake City, Utah, USA
| | - Edward A Stenehjem
- Division of Infectious Disease, School of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Nathan C Dean
- Division of Respiratory, Critical Care and Occupational Pulmonary Medicine, School of Medicine, University of Utah, Salt Lake City, Utah, USA
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, Utah, USA
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4
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O'Toole R, Martinez KA, Rothberg MB, Diiorio G, Stenehjem EA, Ward KE, LaPlante KL. Antibiotics on Demand: Advances in Asynchronous Telemedicine Call for Increased Antibiotic Surveillance. Clin Infect Dis 2024; 78:308-311. [PMID: 37642218 DOI: 10.1093/cid/ciad472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Indexed: 08/31/2023] Open
Abstract
The rapid growth of telehealth services has brought about direct-to-consumer telemedicine platforms, enabling patients to request antibiotics online without a virtual or face-to-face consultation. While telemedicine aims to enhance accessibility, this trend raises significant concerns regarding appropriate antimicrobial use and patient safety. In this viewpoint, we share our first-hand experience with 2 direct-to-consumer platforms, where we intentionally sought inappropriate antibiotic prescriptions for nonspecific symptoms strongly indicative of a viral upper respiratory infection. Despite the lack of clear necessity, requested antibiotic prescriptions were readily transmitted to our local pharmacy following a simple monetary transaction. The effortless acquisition of patient-selected antibiotics online, devoid of personal interactions or consultations, underscores the urgent imperative for intensified antimicrobial stewardship initiatives led by state and national public health organizations in telehealth settings. By augmenting oversight and regulation, we can ensure the responsible and judicious use of antibiotics, safeguard patient well-being, and preserve the efficacy of these vital medications.
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Affiliation(s)
- Rebecca O'Toole
- College of Pharmacy, University of Rhode Island, Kingston, Rhode Island, USA
| | | | | | - Gillian Diiorio
- College of Pharmacy, University of Rhode Island, Kingston, Rhode Island, USA
| | - Edward A Stenehjem
- Division of Infectious Diseases, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Kristina E Ward
- College of Pharmacy, University of Rhode Island, Kingston, Rhode Island, USA
| | - Kerry L LaPlante
- College of Pharmacy, University of Rhode Island, Kingston, Rhode Island, USA
- Division of Infectious Diseases, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
- School of Public Health, Brown University, Providence, Rhode Island, USA
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5
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Tjilos M, Drainoni ML, Burrowes SAB, Butler JM, Damschroder LJ, Bidwell Goetz M, Madaras-Kelly K, Reardon CM, Samore MH, Shen J, Stenehjem EA, Zhang Y, Barlam TF. A qualitative evaluation of frontline clinician perspectives toward antibiotic stewardship programs. Infect Control Hosp Epidemiol 2023; 44:1995-2001. [PMID: 36987859 PMCID: PMC10755145 DOI: 10.1017/ice.2023.35] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 02/02/2023] [Accepted: 02/04/2023] [Indexed: 03/30/2023]
Abstract
OBJECTIVE To examine the perspectives of caregivers that are not part of the antibiotic stewardship program (ASP) leadership team (eg, physicians, nurses, and clinical pharmacists), but who interact with ASPs in their role as frontline healthcare workers. DESIGN Qualitative semistructured interviews. SETTING The study was conducted in 2 large national healthcare systems including 7 hospitals in the Veterans' Health Administration and 4 hospitals in Intermountain Healthcare. PARTICIPANTS We interviewed 157 participants. The current analysis includes 123 nonsteward clinicians: 47 physicians, 26 pharmacists, 29 nurses, and 21 hospital leaders. METHODS Interviewers utilized a semistructured interview guide based on the Consolidated Framework for Implementation Research (CFIR), which was tailored to the participant's role in the hospital as it related to ASPs. Qualitative analysis was conducted using a codebook based on the CFIR. RESULTS We identified 4 primary perspectives regarding ASPs. (1) Non-ASP pharmacists considered antibiotic stewardship activities to be a high priority despite the added burden to work duties: (2) Nurses acknowledged limited understanding of ASP activities or involvement with these programs; (3) Physicians criticized ASPs for their restrictions on clinical autonomy and questioned the ability of antibiotic stewards to make recommendations without the full clinical picture; And (4) hospital leaders expressed support for ASPs and recognized the unique challenges faced by non-ASP clinical staff. CONCLUSION Further understanding these differing perspectives of ASP implementation will inform possible ways to improve ASP implementation across clinical roles.
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Affiliation(s)
- Maria Tjilos
- Department of Community Health Sciences, School of Public Health, Boston University, BostonMassachusetts
| | - Mari-Lynn Drainoni
- Section of Infectious Diseases, Department of Medicine, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
- Department of Health Law, Policy and Management, School of Public Health, Boston University, Boston, Massachusetts
- Evans Center for Implementation and Improvement Sciences, Department of Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
| | - Shana A. B. Burrowes
- Section of Infectious Diseases, Department of Medicine, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
| | - Jorie M. Butler
- Division of Geriatrics, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
- Geriatric Education and Clinical Center and IDEAS Center of Innovation, Veterans’ Affairs (VA) Salt Lake City Health Care System, Salt Lake City, Utah
| | - Laura J. Damschroder
- VA Center for Clinical Management Research, Department of Veterans’ Affairs, Ann Arbor, Michigan
| | - Matthew Bidwell Goetz
- VA Greater Los Angeles Healthcare System, Los Angeles, California
- David Geffen School of Medicine, UCLA, Los Angeles, California
| | - Karl Madaras-Kelly
- Boise VA Medical Center, Boise, Idaho
- College of Pharmacy, Idaho State University, MeridianIdaho
| | - Caitlin M. Reardon
- VA Center for Clinical Management Research, Department of Veterans’ Affairs, Ann Arbor, Michigan
| | - Matthew H. Samore
- IDEAS Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, Utah
- Divison of Epidemiology, Department of Internal Medicine, School of Medicine, University of Utah, Salt Lake City, Utah
| | - Jincheng Shen
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah
| | - Edward A. Stenehjem
- Division of Infectious Diseases and Epidemiology, Intermountain Healthcare, Salt Lake City, Utah
| | - Yue Zhang
- Divison of Epidemiology, Department of Internal Medicine, School of Medicine, University of Utah, Salt Lake City, Utah
| | - Tamar F. Barlam
- Section of Infectious Diseases, Department of Medicine, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
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Rodzik RH, Buckel WR, Hersh AL, Hicks LA, Neuhauser MM, Stenehjem EA, Hyun DY, Zetts RM. Leveraging Health Systems to Expand and Enhance Antibiotic Stewardship in Outpatient Settings. Jt Comm J Qual Patient Saf 2023:S1553-7250(23)00249-0. [PMID: 37968193 DOI: 10.1016/j.jcjq.2023.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 10/13/2023] [Accepted: 10/16/2023] [Indexed: 11/17/2023]
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7
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Hooper GA, Stenehjem EA, Bledsoe JR, Brown SM, Peltan ID. Reply to Adelman et al. Clin Infect Dis 2023; 77:328-329. [PMID: 37092703 PMCID: PMC10371310 DOI: 10.1093/cid/ciad244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 04/11/2023] [Accepted: 04/19/2023] [Indexed: 04/25/2023] Open
Affiliation(s)
- Gabriel A Hooper
- University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Edward A Stenehjem
- Division of Infectious Diseases and Epidemiology, Department of Medicine, Intermountain Medical Center, Salt Lake City, Utah, USA
| | - Joseph R Bledsoe
- Department of Emergency Medicine, Intermountain Medical Center, Murray, Utah, USA
- Department of Emergency Medicine, Stanford University, Palo Alto, California, USA
| | - Samuel M Brown
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, Utah, USA
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Ithan D Peltan
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, Utah, USA
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
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8
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Hooper GA, Klippel CJ, McLean SR, Stenehjem EA, Webb BJ, Murnin ER, Hough CL, Bledsoe JR, Brown SM, Peltan ID. Concordance Between Initial Presumptive and Final Adjudicated Diagnoses of Infection Among Patients Meeting Sepsis-3 Criteria in the Emergency Department. Clin Infect Dis 2023; 76:2047-2055. [PMID: 36806551 PMCID: PMC10273369 DOI: 10.1093/cid/ciad101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 01/21/2023] [Accepted: 02/16/2023] [Indexed: 02/21/2023] Open
Abstract
BACKGROUND Guidelines emphasize rapid antibiotic treatment for sepsis, but infection presence is often uncertain at initial presentation. We investigated the incidence and drivers of false-positive presumptive infection diagnosis among emergency department (ED) patients meeting Sepsis-3 criteria. METHODS For a retrospective cohort of patients hospitalized after meeting Sepsis-3 criteria (acute organ failure and suspected infection including blood cultures drawn and intravenous antimicrobials administered) in 1 of 4 EDs from 2013 to 2017, trained reviewers first identified the ED-diagnosed source of infection and adjudicated the presence and source of infection on final assessment. Reviewers subsequently adjudicated final infection probability for a randomly selected 10% subset of subjects. Risk factors for false-positive infection diagnosis and its association with 30-day mortality were evaluated using multivariable regression. RESULTS Of 8267 patients meeting Sepsis-3 criteria in the ED, 699 (8.5%) did not have an infection on final adjudication and 1488 (18.0%) patients with confirmed infections had a different source of infection diagnosed in the ED versus final adjudication (ie, initial/final source diagnosis discordance). Among the subset of patients whose final infection probability was adjudicated (n = 812), 79 (9.7%) had only "possible" infection and 77 (9.5%) were not infected. Factors associated with false-positive infection diagnosis included hypothermia, altered mental status, comorbidity burden, and an "unknown infection source" diagnosis in the ED (odds ratio: 6.39; 95% confidence interval: 5.14-7.94). False-positive infection diagnosis was not associated with 30-day mortality. CONCLUSIONS In this large multihospital study, <20% of ED patients meeting Sepsis-3 criteria had no infection or only possible infection on retrospective adjudication.
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Affiliation(s)
- Gabriel A Hooper
- University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Carolyn J Klippel
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, Utah, USA
| | - Sierra R McLean
- University of Utah School of Medicine, Salt Lake City, Utah, USA
- Department of Physical Medicine and Rehabilitation, University of North Carolina Health, Chapel Hill, North Carolina, USA
| | - Edward A Stenehjem
- Division of Infectious Diseases and Epidemiology, Department of Medicine, Intermountain Medical Center, Salt Lake City, Utah, USA
| | - Brandon J Webb
- Department of Medicine, University of Wisconsin School of Medicine, Madison, Wisconsin, USA
| | - Emily R Murnin
- University of Utah School of Medicine, Salt Lake City, Utah, USA
- Department of Medicine, University of Wisconsin School of Medicine, Madison, Wisconsin, USA
| | - Catherine L Hough
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Oregon Health and Sciences University, Portland, Oregon, USA
| | - Joseph R Bledsoe
- Department of Emergency Medicine, Intermountain Medical Center, Murray, Utah, USA
- Department of Emergency Medicine, Stanford University, Palo Alto, California, USA
| | - Samuel M Brown
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, Utah, USA
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Ithan D Peltan
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, Utah, USA
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
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9
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May SS, Veillette JJ, Webb BJ, Stenehjem EA, Throneberry SK, Gelman S, Pirozzi M, Stanfield V, Dustin Waters C, Grisel NA, Vento TJ. Effect of tele-COVID rounds and a tele-stewardship intervention on antibiotic use in COVID-19 patients admitted to 17 small community hospitals. J Hosp Med 2023. [PMID: 37127939 DOI: 10.1002/jhm.13118] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 04/12/2023] [Accepted: 04/17/2023] [Indexed: 05/03/2023]
Abstract
Antibiotic stewardship interventions are urgently needed to reduce antibiotic overuse in hospitalized COVID-19 patients, particularly in small community hospitals (SCHs), who often lack access to infectious diseases (ID) and stewardship resources. We implemented multidisciplinary tele-COVID rounds plus tele-antibiotic stewardship surveillance in 17 SCHs to standardize COVID management and evaluate concurrent antibiotics for discontinuation. Antibiotic use was compared in the 4 months preintervention versus 10 months postintervention. Interrupted time-series analysis demonstrated an immediate decrease in antibiotic use by 339 days of therapy/1000 COVID-19 patient days (p < .001), and an estimated 5258 antibiotic days avoided during the postintervention period. Thirty-day mortality was not significantly different, and a significant reduction in transfers was observed following the intervention (23.3% vs. 7.8%, p < .001). A novel tele-ID and tele-stewardship intervention significantly decreased antibiotic use and transfers among COVID-19 patients at 17 SCHs, demonstrating that telehealth is a feasible way to provide ID expertise in community and rural settings.
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Affiliation(s)
- Stephanie Shealy May
- Infectious Diseases Telehealth Services, Intermountain Healthcare, Murray, Utah, USA
- Department of Pharmacy, Intermountain Medical Center, Murray, Utah, USA
| | - John J Veillette
- Infectious Diseases Telehealth Services, Intermountain Healthcare, Murray, Utah, USA
- Department of Pharmacy, Intermountain Medical Center, Murray, Utah, USA
| | - Brandon J Webb
- Infectious Diseases Telehealth Services, Intermountain Healthcare, Murray, Utah, USA
| | - Edward A Stenehjem
- Division of Infectious Diseases and Clinical Epidemiology, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Steven K Throneberry
- Infectious Diseases Telehealth Services, Intermountain Healthcare, Murray, Utah, USA
- Division of Infectious Diseases and Clinical Epidemiology, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Stephanie Gelman
- Infectious Diseases Telehealth Services, Intermountain Healthcare, Murray, Utah, USA
- Division of Infectious Diseases and Clinical Epidemiology, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Michael Pirozzi
- Department of Hospital Medicine, Intermountain Medical Center, Murray, Utah, USA
| | | | - C Dustin Waters
- Department of Pharmacy, McKay-Dee Hospital, Ogden, Utah, USA
| | - Nancy A Grisel
- Enterprise Analytics, Intermountain Healthcare, Murray, Utah, USA
| | - Todd J Vento
- Infectious Diseases Telehealth Services, Intermountain Healthcare, Murray, Utah, USA
- Division of Infectious Diseases and Clinical Epidemiology, Intermountain Healthcare, Salt Lake City, Utah, USA
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10
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Seibert AM, Stanfield VK, Fino N, Gwiazdon M, Hersh A, Stenehjem EA. 1739. An Exploratory Analysis to Examine Urgent Care Antibiotic Prescribing Inequities in a Vertically Integrated Healthcare System. Open Forum Infect Dis 2022. [DOI: 10.1093/ofid/ofac492.1369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Abstract
Background
Previous studies have shown antibiotic prescribing differences based on patient demographics which may represent inequitable care. Our objective was to perform an exploratory analysis of antibiotic prescribing rates for respiratory conditions to better understand possible inequities and identify disparities in our health system.
Methods
This was a retrospective cohort study of urgent care encounters for respiratory conditions in the Intermountain Healthcare (IH) network from July 1st 2018 – June 30th 2019. Individual respiratory encounters were identified using a validated methodology based on ICD10 codes. Overall antibiotic prescribing rates and rates for Tier 1 (antibiotics indicated), 2 (sometimes indicated), and 3 (not indicated, eg bronchitis) conditions were assessed. Prescribing rates for categories in which inequities might exist, including age, weight, patient race/ethnicity, preferred language, provider type, and provider/patient gender combinations, were examined. We considered an absolute percentage difference between groups within a category of ≥5.0% to represent a potential disparity.
Results
93,588 (48.5%) of 193,107 respiratory urgent care encounters were associated with an antibiotic prescription. Overall antibiotic prescribing rates (Results Image 1) were higher in white compared to non-white patients (49.0% vs 38.2%) and in those reporting non-Hispanic ethnicity compared to Hispanics (49.1% vs 43.2%). Patients over 18 years-old were prescribed antibiotics more frequently than younger patients. Among Tier 3 encounters male providers prescribed antibiotics more frequently for male patients than female providers did for female patients (20.8% vs 15.6). Overweight and obese patients with Tier 3 diagnoses received antibiotic prescriptions more frequently than non-obese patients (22.8% vs 15.3%). Minimal differences between patients who preferred English and those who preferred non-English languages were observed. Results Image 1 - Table 1
Overall antibiotic prescribing rates and antibiotic prescribing rates for Tier 3 conditions for urgent care respiratory condition encounters July 1st, 2018 – June 30th, 2019*¥. *Tier 3 codes are those where antibiotics are not indicated (eg bronchitis). ¥Absolute differences of ≥5.0% between groups within each category are indicated in bold.
Conclusion
Antibiotic prescribing rates for respiratory conditions in urgent care encounters in our system differed based on race, ethnicity, age, obesity, and gender. These differences may represent biases contributing to inequities in care and may serve as potential targets for improved stewardship efforts.
Disclosures
All Authors: No reported disclosures.
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Affiliation(s)
| | | | - Nora Fino
- University of Utah , Salt Lake City, Utah
| | | | - Adam Hersh
- University of Utah , Salt Lake City, Utah
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11
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Gwiazdon M, Matheu MM, Seibert AM, Stanfield VK, Kumar N, Stenehjem EA. 2219. Syphilis Diagnosis and Treatment Practices in the Ambulatory Setting of a Large Vertically Integrated Healthcare Organization: An Opportunity for Infectious Diseases Physician Engagement. Open Forum Infect Dis 2022. [DOI: 10.1093/ofid/ofac492.1838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Abstract
Background
Sexually transmitted infections (STIs) continue to increase in the United States. Syphilis management may challenge busy outpatient clinicians and diagnostic delays have been described. To better understand syphilis treatment practices and identify targets for improvement in our organization, we characterized outpatient encounters associated with a positive syphilis test.
Methods
Intermountain Healthcare (IH) is an integrated healthcare system with 23 emergency departments (ED), 34 urgent care (UC), and >100 primary care (PC) clinics. Protocols favor treponemal testing as the initial screening test. All positive treponemal tests associated with a positive non-treponemal test in the ambulatory setting were routed to an electronic inbox within the electronic health record (EHR) and reviewed by a team of Infectious Disease (ID) clinicians from May 1st 2021 – January 31st, 2022. Positive results originating from ID or HIV-trained primary care clinicians were excluded. Each encounter was assessed for staging and treatment plans based on CDC guidelines as well as HIV pre-exposure prophylaxis (PrEP) and HIV treatment eligibility.
Results
119 encounters were reviewed. Patients 30-44 years old were most likely to have a positive test (50, 42.0%). PC (63, 52.9%) and UC (24, 20.2%) accounted for the most positive tests. 102 (85.7%) positive tests were from white patients, consistent with racial demographics of Utah. Only 40 (33.6%) encounters could be clinically staged after chart review by an ID clinician. Of these, 17 (42.5%) were determined to be staged and treated inappropriately by the treating provider. 54 (45.4%) encounters could not be staged and required further testing or more clinical history to determine the significance of positive test. 18 (15.1%) patients could possibly have benefitted from PrEP evaluation and one new HIV diagnosis was referred to ID clinic.
Conclusion
Our exploratory analysis revealed many syphilis cases unable to be staged on chart review and opportunities to improve care. Strategies such as prospective audit and feedback or eConsults may be insufficient and clinical evaluation may be necessary to stage syphilis infection. Syphilis care improvements in our system may be a future target for ID physician engagement and novel stewardship strategies.
Disclosures
All Authors: No reported disclosures.
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12
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Hersh A, Stenehjem EA, Samore MH, Wood T, Spivak ES, Ricker H, Mueller H. 1799. Impact of COVID 19 on urgent care diagnoses and stewardship metrics. Open Forum Infect Dis 2022. [DOI: 10.1093/ofid/ofac492.1429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Abstract
Background
The percentage of all respiratory diagnoses prescribed an antibiotic is an outpatient stewardship metric and was introduced as a HEDIS measure in 2022. Given a stable case mix, this metric is not affected by differences in coding practices between clinicians or health systems since all respiratory diagnoses are considered together. The onset of the COVID-19 pandemic introduced a high number of viral illness episodes where antibiotics are not recommended. The impact of this shift in case mix on respiratory diagnosis coding and prescribing metrics has not been explored.
Methods
We examined antibiotic prescribing rates for respiratory diagnoses in a network of urgent care clinics affiliated with the University of Utah during two periods. Pre-Pandemic was Mar 2019-Feb 2020 and Pandemic was Mar 2020-Mar 2022. Respiratory diagnoses were identified using ICD10 codes and further stratified into 3 Tiers (Tier 1: antibiotics indicated; Tier 2: antibiotics sometimes indicated; Tier 3: antibiotics not indicated). We examined trends in antibiotic prescribing across these periods including the percentage of all respiratory visits prescribed antibiotics and by Tier and the distribution of diagnoses by Tier. No formalized stewardship interventions were introduced during these periods.
Results
There were 146,897 urgent care visits during the study period (47,423 Pre Pandemic and 99,474 Pandemic). The respiratory prescribing rate declined from 42.3% Pre Pandemic to 26.2% during the Pandemic (Figure). The distribution of respiratory diagnoses by Tier and prescribing within Tier are shown in the Table. Tier 3 diagnoses increased from 48% to 67%, while Tier 2 diagnoses declined from 47% to 31%. Antibiotic prescribing declined for both Tier 2 and Tier 3 diagnoses. 15,429 (23%) of Tier 3 diagnoses during the Pandemic were coded as COVID-19. 50% of the reduction in prescribing is attributable to changes in Tiers alone. FigureTable
Conclusion
The COVID 19 pandemic was associated with a reduction in the percentage of respiratory diagnoses prescribed antibiotics. Half was due to an increase in Tier 3 encounters although declines in prescribing occurred with Tiers in addition. Using this metric for benchmarking requires accounting for the impact of case mix differences over time or between systems and clinicians.
Disclosures
All Authors: No reported disclosures.
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Affiliation(s)
- Adam Hersh
- University of Utah , Salt Lake City, Utah
| | | | | | | | - Emily S Spivak
- University of Utah School of Medicine , Salt Lake City, Utah
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Seibert AM, Matheu MM, Stanfield VK, Gwiazdon M, Kumar N, Brunisholz KD, Willis P, Wallin A, Stenehjem EA. 2212. Improving Sexually Transmitted Infection Co-testing in a Large Urgent Care Network. Open Forum Infect Dis 2022. [PMCID: PMC9752697 DOI: 10.1093/ofid/ofac492.1831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background Sexually transmitted infections (STIs) remain a serious public health concern. The state of Utah has the lowest percentage of adults 18-64 years-old ever tested for HIV (26.5%) and the lowest percentage tested for HIV in the previous 12 months (6.5%). Increasing HIV testing in Utah is of the utmost importance. Delayed diagnoses and missed testing opportunities for HIV and other STIs exist. Encounters for evaluation of possible gonorrhea (GC) or chlamydia (CT) infection is a critical opportunity to co-test for HIV and syphilis. With continued growth, urgent care (UC) sites are well-positioned to increase STI diagnosis and treatment. We aimed to develop a multi-faceted quality improvement (QI) bundle to increase STI testing in our UC centers. Methods Intermountain Healthcare (IH) is a vertically integrated healthcare network predominantly in Utah and operates a network of 35 UC clinics across the state. In 2020, qualitative interviews to evaluate barriers to STI testing were performed with UC clinicians. Based on these interviews a QI initiative was designed and implemented throughout 2021. The bundle included clinician education, electronic health record (EHR) improvements, and automatic referral for patients with a new diagnosis of HIV to an Infectious Diseases (ID) physician (Methods Image 1). We compared co-testing rates before (July 2018 – December 2020) and after the intervention began (March 2021 – April 2022).
Methods Table 1 ![]() The quality improvement (QI) initiative began in 2021 and consisted of multiple components as detailed below. Results 13,715 and 5,628 UC encounters were associated with GC/CT testing during the pre-intervention and intervention periods, respectively. HIV co-testing was performed in 2,784 (20.3%) GC/CT testing encounters in the pre-intervention period and in 1,674 (29.7%) encounters during the intervention, a relative increase of 37.6%. HIV/syphilis co-testing was performed in 2,304 (16.8%) GC/CT testing encounters and 1,225 (21.8%) encounters during the pre-intervention and intervention phases, respectively. From January 1 2022 – April 1 2022 3 new outpatient HIV diagnoses were identified. The average time from diagnosis to contact with an ID provider was 30.0 hours. Results Image 1
![]() Co-testing rates for GC/CT UC encounters are presented for HIV (blue), syphilis (green), and HIV/syphilis (orange). Testing reagent quality issues in early 2022 lead to an abrupt decline in syphilis co-testing and once these issues were resolved co-testing trends returned to similar rates prior to the reagent quality issue and testing limitation. Conclusion Multi-modal QI initiatives may increase STI testing rates within UC centers of integrated healthcare systems. Further study is needed to optimize STI screening, diagnosis, and care in UC centers. Disclosures Kimberly D. Brunisholz, PhD, MST, Johnson and Johnson: Advisor/Consultant.
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Veillette JJ, May SS, Gabrellas AD, Gelman SS, Albritton J, Lyons MD, Stenehjem EA, Webb BJ, Dalto JD, Throneberry SK, Stanfield V, Grisel NA, Vento TJ. A Fully Integrated Infectious Diseases and Antimicrobial Stewardship Telehealth Service Improves Staphylococcus aureus Bacteremia Bundle Adherence and Outcomes in 16 Small Community Hospitals. Open Forum Infect Dis 2022; 9:ofac549. [PMID: 36381624 PMCID: PMC9645643 DOI: 10.1093/ofid/ofac549] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 10/12/2022] [Indexed: 02/03/2024] Open
Abstract
Background Infectious diseases (ID) and antimicrobial stewardship (AS) improve Staphylococcus aureus bacteremia (SAB) outcomes. However, many small community hospitals (SCHs) lack on-site access to these services, and it is not known if ID telehealth (IDt) offers the same benefit for SAB. We evaluated the impact of an integrated IDt service on SAB outcomes in 16 SCHs. Methods An IDt service offering IDt physician consultation plus IDt pharmacist surveillance was implemented in October 2016. Patients treated for SAB in 16 SCHs between January 2009 and August 2019 were identified for review. We compared SAB bundle adherence and outcomes between patients with and without an IDt consult (IDt group and control group, respectively). Results A total of 423 patients met inclusion criteria: 157 in the IDt group and 266 in the control group. Baseline characteristics were similar between groups. Among patients completing their admission at an SCH, IDt consultation increased SAB bundle adherence (79% vs 23%; odds ratio [OR], 16.9; 95% CI, 9.2-31.0). Thirty-day mortality and 90-day SAB recurrence favored the IDt group, but the differences were not statistically significant (5% vs 9%; P = .2; and 2% vs 6%; P = .09; respectively). IDt consultation significantly decreased 30-day SAB-related readmissions (9% vs 17%; P = .045) and increased length of stay (median [IQR], 5 [5-8] days vs 5 [3-7] days; P = .04). In a subgroup of SAB patients with a controllable source, IDt appeared to have a mortality benefit (2% vs 9%; OR, 0.12; 95% CI, 0.01-0.98). Conclusions An integrated ID/AS telehealth service improved SAB management and outcomes at 16 SCHs. These findings provide important insights for other IDt programs.
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Affiliation(s)
- John J Veillette
- Infectious Diseases TeleHealth Service, Intermountain Medical Center, Murray, Utah, USA
- Department of Pharmacy, Intermountain Medical Center, Murray, Utah, USA
| | - Stephanie S May
- Infectious Diseases TeleHealth Service, Intermountain Medical Center, Murray, Utah, USA
- Department of Pharmacy, Intermountain Medical Center, Murray, Utah, USA
| | - Alithea D Gabrellas
- Division of Infectious Diseases, University of Utah, Salt Lake City, Utah, USA
| | - Stephanie S Gelman
- Infectious Diseases TeleHealth Service, Intermountain Medical Center, Murray, Utah, USA
- Division of Clinical Epidemiology and Infectious Diseases, Intermountain Medical Center, Murray, Utah, USA
| | - Jordan Albritton
- TeleHealth Services, Intermountain Healthcare, Midvale, Utah, USA
- RTI International, Durham, North Carolina, USA
| | - Michael D Lyons
- TeleHealth Services, Intermountain Healthcare, Midvale, Utah, USA
| | - Edward A Stenehjem
- Division of Clinical Epidemiology and Infectious Diseases, Intermountain Medical Center, Murray, Utah, USA
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Brandon J Webb
- Division of Clinical Epidemiology and Infectious Diseases, Intermountain Medical Center, Murray, Utah, USA
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Joseph D Dalto
- TeleHealth Services, Intermountain Healthcare, Midvale, Utah, USA
| | - S Kyle Throneberry
- Infectious Diseases TeleHealth Service, Intermountain Medical Center, Murray, Utah, USA
- Division of Clinical Epidemiology and Infectious Diseases, Intermountain Medical Center, Murray, Utah, USA
| | - Valoree Stanfield
- Division of Clinical Epidemiology and Infectious Diseases, Intermountain Medical Center, Murray, Utah, USA
| | - Nancy A Grisel
- Division of Clinical Epidemiology and Infectious Diseases, Intermountain Medical Center, Murray, Utah, USA
| | - Todd J Vento
- Infectious Diseases TeleHealth Service, Intermountain Medical Center, Murray, Utah, USA
- Division of Clinical Epidemiology and Infectious Diseases, Intermountain Medical Center, Murray, Utah, USA
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15
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Buckel WR, Stenehjem EA, Hersh AL, Hyun DY, Zetts RM. Harnessing the Power of Health Systems and Networks for Antimicrobial Stewardship. Clin Infect Dis 2022; 75:2038-2044. [PMID: 35758333 PMCID: PMC9710658 DOI: 10.1093/cid/ciac515] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Indexed: 01/17/2023] Open
Abstract
Twenty of 21 health systems and network-based antimicrobial stewardship programs (ASPs) who were invited participated in a questionnaire, a webinar, and focus groups to understand implementation strategies for system-wide antimicrobial stewardship. Four centralized ASPs structures emerged. Of participating organizations, 3 (15%) confirmed classification as collaborative, 3 (15%) as centrally coordinated, 3 (15%) as in between or in transition between centrally coordinated and centrally led, 8 (40%) as centrally led, 2 (10%) as collaborative, consultative network. One (5%) organization considered themselves to be a hybrid. System-level stewardship responsibilities varied across sites and generally fell into 6 major categories: building and leading a stewardship community, strategic planning and goal setting, development of validated data streams, leveraging tools and technology for stewardship interventions, provision of subject-matter expertise, and communication/education. Centralized ASPs included in this study most commonly took a centrally led approach and engaged in activities tailored to system-wide goals.
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Affiliation(s)
- Whitney R Buckel
- Pharmacy Services, Intermountain Healthcare , Taylorsville, Utah , USA
| | - Edward A Stenehjem
- Division of Clinical Epidemiology and Infectious Diseases, Intermountain Healthcare , Salt Lake City, Utah , USA
| | - Adam L Hersh
- Division of Pediatric Infectious Diseases, University of Utah School of Medicine , Salt Lake City, Utah , USA
| | - David Y Hyun
- The Pew Charitable Trusts , Washington, District of Columbia , USA
| | - Rachel M Zetts
- The Pew Charitable Trusts , Washington, District of Columbia , USA
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16
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Knowlton KU, Knight S, Muhlestein JB, Le VT, Horne BD, May HT, Stenehjem EA, Anderson JL. A small but significantly greater incidence of inflammatory heart disease identified after vaccination for SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2). Open Forum Infect Dis 2021; 9:ofab663. [PMID: 35141346 PMCID: PMC8755376 DOI: 10.1093/ofid/ofab663] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 12/29/2021] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
SARS-CoV-2 vaccines are being administered on an unprecedented scale. Assessing the risks of side effects is needed to aid clinicians in early detection and treatment. This study examined the risk of inflammatory heart disease, including pericarditis and myocarditis, following SARS-CoV-2 vaccination.
Methods
Intermountain Healthcare patients with inflammatory heart disease from December 15, 2020, to June 15, 2021, and with or without preceding SARS-CoV-2 vaccinations were studied. Relative rates of inflammatory heart disease were examined for vaccinated patients compared to unvaccinated patients.
Results
Of 67 identified inflammatory heart disease patients, 21 (31.3%) had a SARS-Cov-2 vaccination within the previous 60 days. Overall, 914,611 Intermountain Healthcare patients received a SARS-CoV-2 vaccine, resulting in an inflammatory heart disease rate of 2.30 per 100,000 vaccinated patients. The relative risk of inflammatory heart disease for the vaccinated patients compared to the unvaccinated patients was 2.05 times higher rate within the 30-day window (p=0.01) and had a trend toward increase in the 60-day window (relative rate=1.63; p=0.07). All vaccinated patients with inflammatory heart disease were treated successfully with one death related to a pre-existing condition.
Conclusions
Though rare, the rate of inflammatory heart disease was greater in a SARS-CoV-2 vaccinated population than the unvaccinated population. This risk is eclipsed by the risk of contracting COVID-19 and its associated, commonly severe outcomes. Nevertheless, clinicians and patients should be informed of this risk to facilitate earlier recognition and treatment.
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Affiliation(s)
- Kirk U Knowlton
- Intermountain Medical Center, Salt Lake City, Utah, USA
- University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Stacey Knight
- Intermountain Medical Center, Salt Lake City, Utah, USA
- University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Joseph B Muhlestein
- Intermountain Medical Center, Salt Lake City, Utah, USA
- University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Viet T Le
- Intermountain Medical Center, Salt Lake City, Utah, USA
- Rocky Mountain University of Health Professions Physician Assistant Program, Provo, Utah, USA
| | - Benjamin D Horne
- Intermountain Medical Center, Salt Lake City, Utah, USA
- Stanford University School of Medicine, Stanford, CA, USA
| | - Heidi T May
- Intermountain Medical Center, Salt Lake City, Utah, USA
| | | | - Jeffrey L Anderson
- Intermountain Medical Center, Salt Lake City, Utah, USA
- University of Utah School of Medicine, Salt Lake City, Utah, USA
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17
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Veillette JJ, Shealy SC, Gelman S, Stenehjem EA, Throneberry SK, Pirozzi M, Webb BJ, Waters D, Stanfield VK, Grisel NA, Vento TJ. 138. Tele-COVID Rounds and Tele-Stewardship Surveillance Reduces Antibiotic Use in COVID-19 Patients Admitted to 17 Small Community Hospitals. Open Forum Infect Dis 2021. [PMCID: PMC8643768 DOI: 10.1093/ofid/ofab466.138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Early bacterial co-infection is rare in hospitalized COVID-19 patients, yet antibiotics are commonly prescribed. Antibiotic stewardship (AS) intervention is needed, especially in small community hospitals (SCHs), which often lack access to AS expertise. Methods We implemented daily remote multidisciplinary tele-COVID rounds (synchronous case review between SCH providers and ID clinicians) and tele-stewardship surveillance (ID pharmacist review of COVID patients on antibiotics) on 6/24/2020 in 17 SCHs. We retrospectively included adult symptomatic COVID-19 admissions between 3/2020 and 4/2021. The primary outcome was early use of antibiotics for pneumonia (started within 48 hours of admission); mean monthly days of therapy per 1,000 patient days (DOT) were compared pre- (3/2020-6/2020) and post-intervention (7/2020-4/2021). Secondary outcomes were early use of antibiotics for any indication, estimated days of antibiotics avoided (comparing pre- and post-intervention DOT), and in-hospital mortality. Analyses were conducted using a two-tailed unpaired t-test (antibiotic use) or Fisher’s exact test (mortality). Results Of the 1,976 patients included (124 pre- vs. 1852 post-intervention), 55.4% were male and 85.5% were white. Patients in the pre-intervention group were more likely to require hospital transfer [21.8% vs 8.8% (p< 0.001)] and ICU admission [18.5% vs. 9.7% (p=0.003)]. We observed a significant decrease in mean use of early antibiotics for pneumonia [656.9 vs. 240.1 DOT (p< 0.001)], including among non-ICU patients only [603.6 vs 240.2 DOT (p< 0.001)]. Early antibiotic use for any indication also decreased [686.2 vs. 359.3 DOT (p< 0.001)]. An estimated 3,697 days of unnecessary antibiotics for pneumonia were avoided in the 10-months post-intervention [370 days per month (95% CI 304 – 435)]. Unadjusted in-hospital mortality was not different pre- vs post-intervention (0.8% vs. 2.0%, p=0.511), but was higher among those prescribed early antibiotics (4.4% vs 0.5%, p< 0.001). ![]()
Conclusion A significant, sustained reduction in antibiotic use among COVID-19 patients at 17 SCHs was observed after implementation of tele-COVID rounds and tele-stewardship surveillance without an observed difference in mortality. Disclosures All Authors: No reported disclosures
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Affiliation(s)
| | | | | | | | | | | | | | - Dustin Waters
- McKay-Dee Hospital - Intermountain Healthcare, West Haven, Utah
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18
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Zhang Y, Shen J, Willson TM, Stenehjem EA, Barlam TF, Drainoni ML, Childs E, Butler JM, Goetz MB, Goetz MB, Madaras-Kelly K, Caitlin M. R, Samore MH. 145. Comparing Antibiotic Use Across Inpatient Facilities with Different Antibiotic Stewardship Typologies using Machine Learning and Joint Modeling Approach. Open Forum Infect Dis 2021. [PMCID: PMC8643779 DOI: 10.1093/ofid/ofab466.347] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Hospital antibiotic stewardship programs (ASP) aim to promote the appropriate use of antimicrobials (including antibiotics) and play a critical role in controlling antibiotic costs and antibiotic-resistant bacterial infection risk, and improving patient outcomes. However, unlike other health care quality improvement intervention programs, the ASP implementation strategies vary among healthcare facilities, and little is known about whether different types of ASP implementation will lead to the shifting of antibiotic drug use from one class to another.
Methods
We proposed an analytical framework using unsupervised machine learning and joint model approach to 1) develop a typology of ASP strategies in facilities from the Veterans Health Administration, America’s largest integrated health care system; and 2) simultaneously evaluate the impacts of different ASP types on the annual antibiotic use rates across multiple drug classes. The unsupervised machine learning method was used to leverage the structural components in the surveys conducted by the Veteran Affair (VA) Healthcare Analysis and Information group and the Consolidated Framework for Implementation Research experts from Boston University, and reveal the underlying ASP patterns in the VA facilities in 2016.
Results
We identified 4 groups in the VA facilities in terms of enthusiasm and implementation level of antibiotic control in our ASP typology. We found the facilities with high implementation level and high enthusiasm in ASP and those with high implementation level but low enthusiasm had statistically significant 30% (p-value=0.002) and 22% (p-value=0.031) lower antibiotic use rates in broad-spectrum agents used for community infections, respectively than those with low implementation level and low enthusiasm. However, the facilities with high implementation and high enthusiasm also marginally increased antibiotic use rates in beta-lactam antibiotics (p-value=0.096).
Conclusion
The developed analytical framework in the study provided an approach to the granular assessment of the impact of the healthcare intervention programs and might be informative for future health service policy development.
Disclosures
Matthew B. Goetz, MD, Nothing to disclose
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Affiliation(s)
- Yue Zhang
- University of Utah, Salt Lake City, UT
| | | | | | | | | | | | | | | | - Matthew B Goetz
- VA Greater Los Angeles Healthcare System and David Geffen School of Medicine at UCLA, VA-CDC Practice-Based Research Network, Los Angeles, California
| | - Matthew B Goetz
- VA Greater Los Angeles Healthcare System and David Geffen School of Medicine at UCLA, VA-CDC Practice-Based Research Network, Los Angeles, California
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Casper AC, Stenehjem EA, Gill DM, Evans JD. Streptococcus Intermedius: A Mimicker of Brain Metastases and A Potential Pitfall for Radiation Oncologists. Adv Radiat Oncol 2021; 6:100689. [PMID: 34409201 PMCID: PMC8361051 DOI: 10.1016/j.adro.2021.100689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 03/04/2021] [Accepted: 03/08/2021] [Indexed: 11/29/2022] Open
Affiliation(s)
- Anthony C Casper
- Department of Radiation Oncology, Intermountain Healthcare, Ogden, Utah.,Rocky Vista University College of Osteopathic Medicine, Ivins, Utah
| | - Edward A Stenehjem
- Department of Medicine, Division of Epidemiology and Infectious Diseases, Intermountain Healthcare, Salt Lake City, Utah
| | - David M Gill
- Department of Medical Oncology, Intermountain Healthcare, Salt Lake City, Utah
| | - Jaden D Evans
- Department of Radiation Oncology, Intermountain Healthcare, Ogden, Utah
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Vento TJ, Veillette JJ, Gelman SS, Adams A, Jones P, Repko K, Stenehjem EA. Implementation of an Infectious Diseases Telehealth Consultation and Antibiotic Stewardship Program for 16 Small Community Hospitals. Open Forum Infect Dis 2021; 8:ofab168. [PMID: 34141816 PMCID: PMC8205263 DOI: 10.1093/ofid/ofab168] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 04/01/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Telehealth improves access to infectious diseases (ID) and antibiotic stewardship (AS) services in small community hospitals (SCHs), but the optimal model has not been defined. We describe implementation and impact of an integrated ID telehealth (IDt) service for 16 SCHs in the Intermountain Healthcare system. METHODS The Intermountain IDt service included a 24-hour advice line, eConsults, telemedicine consultations (TCs), daily AS surveillance, long-term AS program (ASP) support by an IDt pharmacist, and a monthly telementoring webinar. We evaluated program measures from November 2016 through April 2018. RESULTS A total of 2487 IDt physician interactions with SCHs were recorded: 859 phone calls (35% of interactions), 761 eConsults (30%), and 867 TCs (35%). Of 1628 eConsults and TCs, 1400 (86%) were SCH provider requests, while 228 (14%) were IDt pharmacist generated. Six SCHs accounted for >95% of interactions. Median consultation times for each initial telehealth interaction type were 5 (interquartile range [IQR], 5-10) minutes for phone calls, 20 (IQR, 15-25) minutes for eConsults, and 50 (IQR, 35-60) minutes for TCs. Thirty-two percent of consults led to in-person ID clinic follow-up. Bacteremia was the most common reason for consultation (764/2487 [31%]) and Staphylococcus aureus the most common organism identified. ASPs were established at 16 facilities. Daily AS surveillance led to 2229 SCH pharmacist and 1305 IDt pharmacist recommendations. Eight projects were completed with IDt pharmacist support, leading to significant reductions in meropenem, vancomycin, and fluoroquinolone use. CONCLUSIONS An integrated IDt model led to collaborative ID/ASP interventions and improvements in antibiotic use at 16 SCHs. These findings provide insight into clinical and logistical considerations for IDt program implementation.
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Affiliation(s)
- Todd J Vento
- Division of Infectious Diseases and Clinical Epidemiology, Intermountain Medical Center, Murray, Utah, USA
- Division of Infectious Diseases, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Intermountain Healthcare TeleHealth Services, Murray, Utah, USA
| | - John J Veillette
- Intermountain Healthcare TeleHealth Services, Murray, Utah, USA
- Department of Pharmacy, Intermountain Medical Center, Murray, Utah, USA
| | - Stephanie S Gelman
- Division of Infectious Diseases and Clinical Epidemiology, Intermountain Medical Center, Murray, Utah, USA
- Division of Infectious Diseases, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Intermountain Healthcare TeleHealth Services, Murray, Utah, USA
| | - Angie Adams
- Division of Infectious Diseases and Clinical Epidemiology, Intermountain Medical Center, Murray, Utah, USA
| | - Peter Jones
- Division of Infectious Diseases and Clinical Epidemiology, Intermountain Medical Center, Murray, Utah, USA
| | - Katherine Repko
- Intermountain Healthcare TeleHealth Services, Murray, Utah, USA
| | - Edward A Stenehjem
- Division of Infectious Diseases and Clinical Epidemiology, Intermountain Medical Center, Murray, Utah, USA
- Office of Patient Experience, Intermountain Healthcare, Salt Lake City, Utah, USA
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21
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Buckel WR, Olson J, Hersh A, Matheu M, Stenehjem EA. 2059. Antimicrobial Stewardship of Community Parenteral Antimicrobial Therapy: A Health System Approach. Open Forum Infect Dis 2019. [PMCID: PMC6808935 DOI: 10.1093/ofid/ofz360.1739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Community parenteral antimicrobial therapy (CoPAT) allows patients to receive intravenous (IV) antimicrobials outside the hospital; however, inappropriate use occurs and can lead to adverse outcomes. In addition, these patients are at high risk of readmission. Our objective was to assess the quality of CoPAT in a large healthcare system in order to guide implementation of an intervention requiring mandatory review by antimicrobial stewardship.
Methods
We identified patients with orders for IV antimicrobials at discharge between January 1 and December 10, 2018. Patients were excluded if transferred to an acute care facility, left against medical advice, or died. 250 patients were selected using a random number generator and reviewed consecutively until 100 confirmed CoPAT encounters were identified. Each encounter was evaluated for evidence of ID consultation, opportunities for stewardship interventions in seven categories (See Table 1), and adverse events such as emergency room (ER) visits and readmissions.
Results
The query identified 4,642 potential CoPAT discharges from 22 hospitals (see Table 2). 117 encounters were reviewed to reach 100 true CoPAT discharges (85% query accuracy). Of these, 55 (55%) received a formal ID consult, 6 (6%) had an ID pharmacist or ID physician curbside, and 5 (5%) had an ID clinic follow-up appointment scheduled without formal ID consult. Opportunity for stewardship intervention was found in 50 (50%) patients (see Table 1). There were 31 (31%) patients who were seen in the ER (n = 21) and/or re-admitted (n = 19) to the hospital during or shortly after completion of CoPAT, of which 25 (81%) were potentially related to CoPAT, including abnormal laboratory findings, PICC-line complications, and signs or symptoms of infection.
Conclusion
CoPAT patients are complex with high healthcare utilization. Mandatory ID review of patients receiving CoPAT has the potential to impact 2,000 lives annually in a large health system.
Disclosures
All authors: No reported disclosures.
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Affiliation(s)
| | - Jared Olson
- School of Medicine, University of Utah, Salt Lake City, Utah
| | - Adam Hersh
- University of Utah, Salt Lake City, Utah
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22
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Gabrellas AD, Veillette JJ, Webb BJ, Stenehjem EA, Grisel NA, Vento TJ. 889. Impact of an Infectious Disease Telehealth (IDt) Service on S. aureus Bacteremia (SAB) Outcomes in 15 Small Community Hospitals. Open Forum Infect Dis 2019. [PMCID: PMC6808898 DOI: 10.1093/ofid/ofz359.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background Infectious diseases (ID) consultation improves SAB readmission rates, compliance with care bundles and mortality. Small community hospitals (SCHs) (which comprise 70% of US hospitals) often lack access to on-site ID physicians. IDt is one way to overcome this barrier, but it is unknown if IDt provides similar clinical benefits to traditional ID consultation. Our study aims to evaluate the impact of IDt on patient outcomes at 15 SCHs (bed range: 16–146) within the Intermountain Healthcare system in Utah. Methods Baseline demographics, Charlson Comorbidity Index (CCI), hospital length of stay (LOS), and mortality (in-hospital, 30- and 90-day) were collected using an electronic health record database and health department vital records on all patients with a positive S. aureus blood culture from January 1, 2009 through December 31, 2018. Data from January 2014 through Sep 2016 were excluded to avoid potential influence of a concurrent antimicrobial stewardship study. Starting in October 2016 an IDt program (staffed by an ID physician and pharmacist) provided consultation for SCH providers and patients using electronic consultation and encrypted two-way audiovisual communication.Statistical analyses were performed using Fisher’s exact test or χ 2 test for categorical variables and Mann–Whitney U test for nonparametric continuous data. Results In total, 625 patients with SAB were identified: 127 (20%) received IDt and 498 (80%) did not (non-IDt). The two groups (IDt vs. non-IDt) were similar in median age (66 vs. 62 years; P = 0.76), percent male (62% vs. 58%; P = 0.35), and median baseline CCI (4 vs. 4; P = 0.54). There were no statistically significant differences in median LOS (5 vs. 5 days; P = 0.93) or in-hospital mortality (2% in both groups). The IDt group had a lower 30-day (9% vs. 15%; P = 0.049) and 90-day mortality (13% vs. 21%; P = 0.034). Conclusion IDt consultation was associated with a decrease in 30- and 90-day mortality for SCH SAB cases. Early transfer of critically ill patients might have affected LOS and in-hospital mortality. Post-discharge care factors might also contribute to 30- and 90-day mortality. While more work is needed to identify other factors associated with the effect of IDt on SAB, these data support the use of IDt to increase access to care and improve SAB outcomes in SCHs. Disclosures All Authors: No reported Disclosures.
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Vento TJ, Gelman SS, Veillette JJ, Adams MA, Repko KA, Jones PS, Webb BJ, Dascomb KK, Lopansri BK, Stenehjem EA. Implementation of a Centralized Infectious Diseases Telehealth (IDt) Service for 16 Small Community Hospitals. Open Forum Infect Dis 2017. [DOI: 10.1093/ofid/ofx163.778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
The majority of U.S. small community hospitals (SCHs) lack access to infectious diseases (ID) subspecialists. Telehealth can extend ID expertise to such facilities. We describe lessons learned from implementing a new IDt program for 16 SCHs in the Intermountain Healthcare system in Utah and Idaho.
Methods
From October 1, 2016 to April 30, 2017, we implemented an IDt service comprised of: a 24-hour ID physician advice line; an inpatient ID consult service that provided chart review and documentation (e-consults) and daytime telemedicine consultation (TC) using encrypted, HIPAA-compliant, synchronous, 2-way audio-video connection; and an ID pharmacist-led antibiotic stewardship program. The IDt service included a medical director, operations officer, ID pharmacist, analyst, and rotating ID physicians, and was implemented in a step-wise manner at 16 SCHs. IDt requests were received through a dedicated phone line with duplicate transcription to a monitored email inbox or generated from daily antibiotic stewardship rounds.
Results
The physician advice line was operational for all 16 SCHs on October 1, 2016. 312 advice-only calls were fielded (92 per 1000 hospital-days covered) through April 30, 2017. Common infections requiring phone advice included: bloodstream (16%), genitourinary (13%), and musculoskeletal (12%). E-consult and TC services were operational at 11 SCHs by April 30, 2017 (hospital-days covered: 1074). The IDt service completed 104 eConsults, 163 TCs, and 1198 stewardship reviews. Mean time [minutes (range)] spent per case was 16 (5–30) for eConsults and 55 (30–120) for TCs [on-camera time: 25 (12–46)]. Common infections requiring e-consult or TC were: bloodstream (45%), musculoskeletal (16%), and skin/soft tissue (11%). 22 patients (14%) seen by TC were surveyed: 100% felt the service improved their care and was necessary at their SCH. 97% of surveyed SCH staff felt the IDt service improved patient care and 90% felt it was a necessary service (32% response from 98 providers, nurses, pharmacists).
Conclusion
A new IDt service was well utilized and received by SCH staff and patients, with bloodstream infections being the most common reason for consultation. Future steps include evaluation of the IDt effect on clinical outcomes, financial metrics, and staff education on common ID conditions.
Disclosures
All authors: No reported disclosures.
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Affiliation(s)
- Todd J Vento
- Clinical Epidemiology/Infectious Diseases, Intermountain Medical Center, Murray, Utah
| | | | | | | | | | - Peter S Jones
- Clinical Epidemiology and Infectious Diseases, Intermountain Medical Center, Murray, Utah
| | - Brandon J Webb
- Intermountain Medical Center and LDS Hospital, Murray, Utah
| | - Kristin K Dascomb
- Clinical Epidemiology and Infectious Diseases, Intermountain Medical Center, Murray, Utah
| | - Bert K Lopansri
- Clinical Epidemiology and Infectious Diseases, Intermountain Medical Center, Murray, Utah
| | - Edward A Stenehjem
- Division of Infectious Disease, Intermountain Medical Center, Murray, Utah
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Thomason J, Rentsch C, Stenehjem EA, Hidron AI, Rimland D. Association between vitamin D deficiency and methicillin-resistant Staphylococcus aureus infection. Infection 2015; 43:715-22. [DOI: 10.1007/s15010-015-0815-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2014] [Accepted: 06/20/2015] [Indexed: 01/18/2023]
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Tenna A, Stenehjem EA, Margoles L, Kacha E, Blumberg HM, Kempker RR. Infection control knowledge, attitudes, and practices among healthcare workers in Addis Ababa, Ethiopia. Infect Control Hosp Epidemiol 2013; 34:1289-96. [PMID: 24225614 PMCID: PMC3995333 DOI: 10.1086/673979] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To better understand hospital infection control practices in Ethiopia. DESIGN A cross-sectional evaluation of healthcare worker (HCW) knowledge, attitudes, and practices about hand hygiene and tuberculosis (TB) infection control measures. METHODS An anonymous 76-item questionnaire was administered to HCWs at 2 university hospitals in Addis Ababa, Ethiopia. Knowledge items were scored as correct/incorrect. Attitude and practice items were assessed using a Likert scale. RESULTS In total, 261 surveys were completed by physicians (51%) and nurses (49%). Fifty-one percent of respondents were male; mean age was 30 years. While hand hygiene knowledge was fair, self-reported practice was suboptimal. Physicians reported performing hand hygiene 7% and 48% before and after patient contact, respectively. Barriers for performing hand hygiene included lack of hand hygiene agents (77%), sinks (30%), and proper training (50%) as well as irritation and dryness (67%) caused by hand sanitizer made in accordance with the World Health Organization formulation. TB infection control knowledge was excellent (more than 90% correct). Most HCWs felt that they were at high risk for occupational acquisition of TB (71%) and that proper TB infection control can prevent nosocomial transmission (92%). Only 12% of HCWs regularly wore a mask when caring for TB patients. Only 8% of HCWs reported that masks were regularly available, and 76% cited a lack of infrastructure to isolate suspected/known TB patients. CONCLUSIONS Training HCWs about the importance and proper practice of hand hygiene along with improving hand sanitizer options may improve patient safety. Additionally, enhanced infrastructure is needed to improve TB infection control practices and allay HCW concerns about acquiring TB in the hospital.
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Affiliation(s)
- Admasu Tenna
- Division of Infectious Diseases, Department of Internal Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Edward A. Stenehjem
- Department of Clinical Epidemiology and Infectious Diseases, Intermountain Medical Center, Salt Lake City, UT, USA
| | - Lindsay Margoles
- Division of Infectious Diseases Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Ermias Kacha
- Division of Infectious Diseases, Department of Internal Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Henry M. Blumberg
- Division of Infectious Diseases Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
- Departments of Epidemiology and Global Health, Emory Rollins School of Public Health, Atlanta, GA, USA
| | - Russell R. Kempker
- Division of Infectious Diseases Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
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