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A 2014 study assessed infection prevention (IP) practices in Thai hospitals for catheter-associated urinary tract infection (CAUTI), central line-associated bloodstream infection (CLABSI), and ventilator-associated pneumonia (VAP). This study compares current IP practices to results obtained in 2014.Between February 1, 2021 and August 31, 2021, we resurveyed Thai hospitals regarding practices to prevent CAUTI, CLABSI, and VAP. We also assessed COVID-19 impact and healthcare worker burnout and coping strategies. We distributed 100 surveys to a convenience sample of infection preventionists.Response rate: 100%. One-third (31%) of hospitals reported excellent leadership support for infection control (ie, responses of "good" or "excellent" to one survey question). Some prevention practices increased between 2014 vs 2021 (CAUTI: catheter reminder/stop-order/nurse-initiated discontinuation [50.0% vs 70.0%, P.001]; condom catheters [36.3% vs 51.0%, P = .01]; ultrasound bladder scanner [4.7% vs 12.0%, P = .03]; CLABSI: chlorhexidine gluconate insertion site antisepsis [73.6% vs 85.0%, P = .03]; maximum sterile barrier precautions [63.2% vs 80.0%, P = .003]; VAP: selective digestive tract decontamination [26.9% vs 40.0%, P = .02]). Antimicrobial catheter use decreased since 2014 (10.4% vs 3.0%, P.001). Many other practices remain suboptimal. COVID-19 challenges: staff shortages (71%), financial hardships (67%). Only 46% of infection preventionists felt safe working during COVID-19.More national strategic support is needed for IP programs to prevent CAUTI, CLABSI, VAP and healthcare worker well-being in Thailand during the COVID-19 pandemic.

Background Oral case presentations – structured verbal reports of clinical cases – are fundamental to patient care and learner education. Despite their continued importance in a modernized medical landscape, their structure has remained largely unchanged since the 1960s, based on the traditional Subjective, Objective, Assessment, Plan (SOAP) format developed for medical records. We developed a problem-based alternative known as Events, Assessment, Plan (EAP) to understand the perceived efficacy of EAP compared to SOAP among learners. Methods We surveyed (Qualtrics, via email) all third- and fourth-year medical students and internal medicine residents at a large, academic, tertiary care hospital and associated Veterans Affairs medical center. The primary outcome was trainee preference in oral case presentation format. The secondary outcome was comparing EAP and SOAP on 10 functionality domains assessed via a 5-point Likert scale. We used descriptive statistics (proportion and mean) to describe the results. Results The response rate was 21% (118/563). Of the 59 respondents with exposure to both the EAP and SOAP formats, 69% (n = 41) preferred the EAP format as compared to 19% (n = 11) who preferred SOAP (p Conclusions Our findings suggest that trainees prefer the EAP format over SOAP and that EAP may facilitate clearer and more efficient communication on rounds, which in turn may enhance patient care and learner education. A broader, multi-center study of the EAP oral case presentation will help to better understand preferences, outcomes, and barriers to implementation.

While Severe Acute Respiratory Syndrome Coronavirus-2 vaccine breakthrough infections are expected, reporting on breakthrough infections requiring hospitalization remains limited. This observational case series report reviewed 10 individuals hospitalized with vaccine breakthrough infections to identify patient risk factors and serologic responses upon admission.Electronic medical records of BNT162b2 (Pfizer-BioNTech) or mRNA-1732 (Moderna) vaccinated patients admitted to Veterans Affairs Ann Arbor Healthcare System with newly diagnosed Coronavirus Infectious Disease 2019 (COVID-19) between March 15, 2021 and April 15, 2021 were reviewed. Patient variables, COVID-19 lab testing including anti-S IgM, anti-N IgG antibodies, and hospital course were recorded. Based on lab testing, infections were defined as acute infection or resolving/resolved infection.Of the 10 patients admitted with breakthrough infections, all were70 years of age with multiple comorbidities. Mean time between second vaccine dose and COVID-19 diagnosis was 49 days. In the 7 individuals with acute infection, none had observed serologic response to mRNA vaccination, 5 developed severe disease, and 1 died. Three individuals had anti-N IgG antibodies and a high polymerase chain reaction cycle threshold value, suggesting resolving/resolved infection.Given the variability of vaccine breakthrough infections requiring hospitalization, serologic testing may impart clarity on timing of infection and disease prognosis. Individuals at risk of diminished response to vaccines and severe COVID-19 may also benefit from selective serologic testing after vaccination to guide risk mitigation strategies in a post-pandemic environment.

Background “Sacred moments” are brief periods of time in which people experience a deep interconnectedness that may possess spiritual qualities and emotions. This concept has been shown to have a positive impact on individuals’ overall well-being and stress in mental health settings. The concept of sacred moments has not been studied in acute care hospital settings. Objective To better understand the occurrence of sacred moments among hospitalized patients and their healthcare workers. Design An exploratory qualitative study that included in-depth interviews with patients and healthcare workers at two academic medical centers in the Midwestern United States. Participants Hospital healthcare workers (e.g., physicians, nurses, ancillary staff) and discharged patients with a recent hospital stay. Approach Semi-structured telephone interviews were conducted with 30 participants between August 2020 and April 2021. Interviews were recorded and transcribed before conducting thematic analysis. Key Results Both healthcare workers and patients reported having experienced at least one sacred moment. Interview findings were organized into three main domains including (1) several common elements described by participants as marking these moments; (2) benefits experienced by both patients and healthcare workers; and (3) suggestions for fostering sacred moments within the hospital setting. Conclusions Among our participants, sacred moments were extremely common with the vast majority reporting to have experienced at least one in their lifetime. These moments were described as profound and important and shared many common elements. Our findings can be used to help recognize, understand, and promote sacred moments between hospitalized patients and healthcare workers.

Background Healthcare-associated infection (HAI) is a common and largely preventable cause of morbidity and mortality. The COVID-19 pandemic has presented unprecedented challenges to health systems. We conducted a national survey to ascertain hospital characteristics and the use of HAI prevention measures in Israel. Methods We e-mailed surveys to infection prevention and control (IPC) leads of acute care hospitals in Israel. The survey included questions about the use of practices to prevent catheter-associated urinary tract infection (CAUTI), central line-associated bloodstream infection (CLABSI), ventilator-associated pneumonia (VAP), and Clostridioides difficile infection (CDI). The survey also assessed COVID-19 impact and healthcare worker well-being. Results IPC leads from 15 of 24 invited hospitals (63%) completed the survey. Only one-third of respondents reported strong support for IPC from hospital leadership. Although several prevention practices were used by all hospitals (e.g., maximum sterile barrier precautions for CLABSI and real-time assessment of environmental cleaning for CDI), use of other practices was suboptimal—particularly for CAUTI and VAP. COVID-19 had a profound impact on Israeli hospitals, with all hospitals reporting opening of new units to care for COVID patients and most reporting moderate to extreme financial hardship. All hospitals reported highly successful plans to vaccinate all staff and felt confident that the vaccine is safe and effective. Conclusion We provide a status report of the IPC characteristics and practices Israeli hospitals are currently using to prevent HAIs during the COVID-19 era. While many globally accepted IPC practices are widely implemented, opportunities to increase the use of certain IPC practices in Israeli hospitals exist.

Background As the COVID-19 pandemic evolves, it is critical to understand characteristics that have allowed US healthcare systems, including the Veterans Affairs (VA) and non-federal hospitals, to mount an effective response in the setting of limited resources and unpredictable clinical demands generated by this system shock. Objective To compare the impact of and response to resource shortages to both VA and non-federal healthcare systems during the COVID-19 pandemic. Design Cross-sectional national survey administered April 2021 through May 2022. Participants Lead infection preventionists from VA and non-federal hospitals across the US. Main Measures Surveys collected hospital demographic factors along with 11 questions aimed at assessing the effectiveness of the hospital’s COVID response. Key Results The response rate was 56% (71/127) from VA and 47% (415/881) from non-federal hospitals. Compared to VA hospitals, non-federal hospitals had a larger average number of acute care (214 vs. 103 beds, ppp=.03) and more frequently opened new units to care specifically for COVID patients (71% vs. 49%, pp=.001) and financial hardships stemming from the pandemic (58% vs. 7%, p Conclusions In our survey-based national study, lead infection preventionists noted several distinct advantages in VA versus non-federal hospitals in their ability to expand bed capacity, retain staff, mitigate supply shortages, and avoid financial hardship. While these benefits appear to be inherent to the VA’s structure, non-federal hospitals can adapt their infrastructure to better weather future system shocks.

Purpose Leadership development may be a key strategy to enhance job satisfaction, reduce burnout and improve patient safety in health-care systems. This study aims to assess feasibility of a leadership development series in an effort to invigorate a collaborative culture, create peer networks and elevate autonomy in daily work. Design/methodology/approach The authors implemented a collectivistic leadership development series titled Fueling Leadership in Yourself. The series was designed for all types of health-care workers in the medicine service at a tertiary referral center for veterans. Two series of leadership development sessions with varied experiential learning methods were facilitated by content experts. Subjects focused on leadership approaches and attributes applicable to all roles within a health-care system. The authors collected participant perceptions using pre- and post-series surveys. Primary outcomes were understanding and applicability of leadership concepts, employee engagement in leadership, satisfaction with training and work environment and qualitative reflections. Findings A total of 26 respondents (of 38 participants) from 8 departments and several role types increased their knowledge of leadership techniques, were highly satisfied with and would recommend the series and found leadership principles applicable to their daily work. Participants continued to use skills years after the series. Practical implications Short, intermittent, collectivistic leadership development sessions appear effective in expanding knowledge, satisfaction and skills used in daily practice for a diverse group of health-care workers. Originality/value Novel programmatic aspects included inviting all types of health-care workers, practicing universally applicable content and using a variety of active, experiential learning methods.

BackgroundThe Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) provides evidence-based criteria for peripherally inserted central catheter (PICC) use. Whether implementing MAGIC improves PICC appropriateness and reduces complications is unknown.MethodsA quasiexperimental study design to implement MAGIC in 52 Michigan hospitals was used. Data were collected from medical records by trained abstractors. Hospital performance on three appropriateness criteria was measured: short-term PICC use (≤5 days), use of multilumen PICCs and PICC placement in patients with chronic kidney disease. PICC appropriateness and device complications preintervention (January 2013 to December 2016) versus postintervention (January 2017 to January 2020) were compared. Change-point analysis was used to evaluate the effect of the intervention on device appropriateness. Logistic regression and Poisson models were fit to assess the association between appropriateness and complications (composite of catheter occlusion, venous thromboembolism (VTE) and central line-associated bloodstream infection (CLABSI)).ResultsAmong 38 592 PICCs, median catheter dwell ranged from 8 to 56 days. During the preintervention period, the mean frequency of appropriate PICC use was 31.9% and the mean frequency of complications was 14.7%. Following the intervention, PICC appropriateness increased to 49.0% (absolute difference 17.1%, pConclusionsImplementation of MAGIC in Michigan hospitals was associated with improved PICC appropriateness and fewer complications. These findings have important quality, safety and policy implications for hospitals, patients and payors.

Hunting for a Diagnosis A 47-year-old man in Michigan presented to the ED with a 1-day history of presyncope, swelling of the eyelids, and diffuse pruritic rash. He reported a 3-week history of pos...

This SHEA white paper identifies knowledge gaps and challenges in healthcare epidemiology research related to coronavirus disease 2019 (COVID-19) with a focus on core principles of healthcare epidemiology. These gaps, revealed during the worst phases of the COVID-19 pandemic, are described in 10 sections: epidemiology, outbreak investigation, surveillance, isolation precaution practices, personal protective equipment (PPE), environmental contamination and disinfection, drug and supply shortages, antimicrobial stewardship, healthcare personnel (HCP) occupational safety, and return to work policies. Each section highlights three critical healthcare epidemiology research questions with detailed description provided in supplementary materials. This research agenda calls for translational studies from laboratory-based basic science research to well-designed, large-scale studies and health outcomes research. Research gaps and challenges related to nursing homes and social disparities are included. Collaborations across various disciplines, expertise and across diverse geographic locations will be critical.

Objective:To assess the extent to which evidence-based practices are regularly used in acute care hospitals in different countries.Design:Cross-sectional survey study. Participants and setting: Infection preventionists in acute care hospitals in the United States (US), the Netherlands, Switzerland, and Japan.Methods:Data collected from hospital surveys distributed between 2015 and 2017 were evaluated to determine the use of practices to prevent catheter-associated urinary tract infection (CAUTI), central-line–associated bloodstream infection (CLABSI), ventilator-associated pneumonia (VAP), and Clostridioides difficile infection (CDI). Descriptive statistics were used to examine hospital characteristics and the percentage of hospitals reporting regular use of each infection prevention practice.Results:Survey response rates were 59% in the United States, 65% in the Netherlands, 77% in Switzerland, and 65% in Japan. Several recommended practices were used in the majority of hospitals: aseptic catheter insertion and maintenance (CAUTI), maximum sterile barrier precautions (CLABSI), semirecumbent patient positioning (VAP), and contact precautions and routine daily cleaning (CDI). Other prevention practices for CAUTI and VAP were used less frequently, particularly in Swiss and Japanese hospitals. Established surveillance systems were also lacking in Dutch, Swiss and Japanese hospitals.Conclusions:Most hospitals in the United States, the Netherlands, Switzerland, and Japan have adopted certain infection prevention practices. Clear opportunities for reducing HAI risk in hospitals exist across all 4 countries surveyed.

Burnout in medicine is a substantial problem with adverse consequences for both physicians and the patients who they treat. In our efforts to combat burnout, we must consider every tool at our disposal, since a complex problem requires a multifaceted approach. Recognizing that many physicians derive meaning from spirituality and religion, attempts to improve physician and trainee wellness should acknowledge the importance of religion and spirituality for self-care more than has heretofore been the case.

BACKGROUND: Women in medicine experience discrimination, hostility, and unconscious bias frequently and with deleterious effects. While these gender-based challenges are well described, strategies to navigate and respond to them are less understood. OBJECTIVE: To explore the lived experiences of female teaching attending physicians emphasizing strategies they use to mitigate gender-based challenges in clinical environments. DESIGN: Multisite exploratory, qualitative study. SETTING: Inpatient general medicine teaching rounds in six geographically diverse US academic hospitals between April and August 2018. PARTICIPANTS: With use of a modified snowball sampling approach, female attendings and their learners were identified; six female attendings and their current (n = 24) and former (n = 17) learners agreed to participate. MEASUREMENTS: Perceptions of gender-based challenges in clinical teaching environments and strategies with which to respond to these challenges were evaluated through semistructured in-depth interviews, focus group discussions, and direct observations of rounds. Observations were documented using handwritten field notes. Interviews and focus groups were audio recorded and transcribed. All transcripts and field note data were analyzed using a content analysis approach. MAIN OUTCOMES: Attending experience levels ranged from 8 to 20 years (mean, 15.3 years). Attendings were diverse in terms of race/ethnicity. Strategic approaches to gender-based challenges clustered around three themes: female attendings (1) actively position themselves as physician team leaders, (2) consciously work to manage gender-based stereotypes and perceptions, and (3) intentionally identify and embrace their unique qualities. CONCLUSION: Female attendings manage their roles as women in medicine through specific strategies to both navigate complex gender dynamics and role model approaches for learners. Journal of Hospital Medicine 2020;15:XXX-XXX. © 2020 Society of Hospital Medicine

BACKGROUND: Hand hygiene is key to preventing healthcare-associated infection and the spread of respiratory viruses like the novel coronavirus that causes COVID-19. Unfortunately, hand hygiene adherence of healthcare workers (HCWs) in Japan is suboptimal according to previous studies. OBJECTIVES: Our objectives were to evaluate hand hygiene adherence among physicians and nurses before touching hospitalized patients and to evaluate changes in hand hygiene adherence after a multimodal intervention was implemented. DESIGN, SETTING, AND PARTICIPANTS: We conducted a pre- and postintervention study with HCWs at four tertiary hospitals in Niigata, Japan. Hand hygiene observations were conducted from June to August 2018 (preintervention) and February to March 2019 (postintervention). INTERVENTION: The multimodal hand hygiene intervention recommended by the World Health Organization was tailored to each hospital and implemented from September 2018 to February 2019. MAIN OUTCOMES AND MEASURES: We observed hand hygiene adherence before touching patients in each hospital and compared rates before and after intervention. Intervention components were also evaluated. RESULTS: There were 2,018 patient observations preintervention and 1,630 postintervention. Overall, hand hygiene adherence improved from 453 of 2,018 preintervention observations (22.4%) to 548 of 1,630 postintervention observations (33.6%; P < .001). Rates improved more among nurses (13.9 percentage points) than among doctors (5.7 percentage points). Improvement varied among the hospitals: Hospital B (18.4 percentage points) was highest, followed by Hospitals D (11.4 percentage points), C (11.3 percentage points), and Hospital A (6.5 percentage points). CONCLUSIONS: A multimodal intervention improved hand hygiene adherence rates in physicians and nurses in Niigata, Japan; however, further improvement is necessary. Given the current suboptimal hand hygiene adherence rates in Japanese hospitals, the spread of COVID-19 within the hospital setting is a concern.

Background Psychological safety is a critical factor in team learning that positively impacts patient safety. We sought to examine the influence of psychological safety on using recommended health care–associated infection (HAI) prevention practices within US hospitals. Methods We mailed surveys to infection preventionists in a random sample of nearly 900 US acute care hospitals in 2017. Our survey asked about hospital and infection control program characteristics, organizational factors, and the use of practices to prevent common HAIs. Hospitals that scored 4 or 5 (5-point Likert scale) on 7 psychological safety questions were classified as high psychological safety. Using sample weights, we conducted multivariable regression to determine associations between psychological safety and the use of select HAI prevention practices. Results Survey response rate was 59%. High psychological safety was reported in approximately 38% of responding hospitals, and was associated with increased odds of regularly using urinary catheter reminders or stop-orders and/or nurse-initiated urinary catheter discontinuation (odds ratio, 2.37; P = .002) for catheter-associated urinary tract infection prevention, and regularly using sedation vacation (odds ratio, 1.93; P = .04) for ventilator-associated pneumonia prevention. Conclusions We provide a snapshot of psychological safety in US hospitals and how this characteristic influences the use of select HAI prevention practices. A culture of psychological safety should be considered an integral part of HAI prevention efforts.

Background Indwelling urinary catheters are commonly used in hospitalized patients, which can lead to the development of urinary catheter complications, including catheter-associated urinary tract infection (CAUTI). Limited reports on the appropriateness of urinary catheter use exist in Japan. This study investigated the prevalence and appropriateness of indwelling urinary catheters, and the incidence of CAUTI in non-intensive care unit (non-ICU) wards in Japanese hospitals. Methods This prospective observational study was conducted in 7 non-ICU wards from 6 hospitals in Japan from October 2017 to June 2018. At each hospital the study teams evaluated urinary catheter prevalence through in-person bedside evaluation for at least 5 days of each week for 3 months. Catheter associated urinary tract infection (CAUTI) incidence and appropriateness of catheter use was collected via chart review. Results We assessed 710 catheter-days over 5528 patient-days. The mean prevalence of indwelling urinary catheter use in participating wards was 13% (range: 5% to 19%), while the mean incidence of CAUTI was 9.86 per 1000 catheter-days (range: 0 to 33.90). Approximately 66% of the urinary catheter days assessed had an appropriate indication for use (range: 17% to 81%). A physician's order for catheter placement was present in only 10% of catheterized patients. Conclusion This multicenter study provides epidemiological information about the appropriate use of urinary catheters in Japanese non-ICU wards. A multimodal intervention may help improve the appropriate use of urinary catheters.

ObjectiveThe patient–physician relationship impacts patients’ experiences and health outcomes. Physician attire is a form of nonverbal communication that influences this relationship. Prior studies examining attire preferences suffered from heterogeneous measurement and limited context. We thus performed a multicentre, cross-sectional study using a standardised survey instrument to compare patient preferences for physician dress in international settings.Setting20 hospitals and healthcare practices in Italy, Japan, Switzerland and the USA.ParticipantsConvenience sample of 9171 adult patients receiving care in academic hospitals, general medicine clinics, specialty clinics and ophthalmology practices.Primary and secondary outcome measuresThe survey was randomised and included photographs of a male or female physician dressed in assorted forms of attire. The primary outcome measure was attire preference, comprised of composite ratings across five domains: how knowledgeable, trustworthy, caring and approachable the physician appeared, and how comfortable the respondent felt. Secondary outcome measures included variation in preferences by country, physician type and respondent characteristics.ResultsThe highest rated forms of attire differed by country, although each most preferred attire with white coat. Low ratings were conferred on attire extremes (casual and business suit). Preferences were more uniform for certain physician types. For example, among all respondents, scrubs garnered the highest rating for emergency department physicians (44.2%) and surgeons (42.4%). However, attire preferences diverged for primary care and hospital physicians. All types of formal attire were more strongly preferred in the USA than elsewhere. Respondent age influenced preferences in Japan and the USA only.ConclusionsPatients across a myriad of geographies, settings and demographics harbour specific preferences for physician attire. Some preferences are nearly universal, whereas others vary substantially. As a one-size-fits-all dress policy is unlikely to reflect patient desires and expectations, a tailored approach should be sought that attempts to match attire to clinical context.

Thirty Rules for Healthcare Leaders is the essential guide for everyone in healthcare, from those just starting their careers to those who are established leaders. The authors have been in leadership roles within healthcare systems for several years, and have carefully studied healthcare leadership during site visits to hospitals around the world. The book presents practical and timely advice packaged in pithy “pearls” that can be used by time-pressured professionals. Original artwork makes each rule memorable. Meant to be read in one sitting, or one at a time, Thirty Rules for Healthcare Leaders speaks to a broad range of healthcare professionals, regardless of title or experience. If you work in healthcare, this is your new must-read book.

Objective: Clostridioides difficile infection (CDI) can be prevented through infection prevention practices and antibiotic stewardship. Diagnostic stewardship (ie, strategies to improve use of microbiological testing) can also improve antibiotic use. However, little is known about the use of such practices in US hospitals, especially after multidisciplinary stewardship programs became a requirement for US hospital accreditation in 2017. Thus, we surveyed US hospitals to assess antibiotic stewardship program composition, practices related to CDI, and diagnostic stewardship. Methods: Surveys were mailed to infection preventionists at 900 randomly sampled US hospitals between May and October 2017. Hospitals were surveyed on antibiotic stewardship programs; CDI prevention, treatment, and testing practices; and diagnostic stewardship strategies. Responses were compared by hospital bed size using weighted logistic regression. Results: Overall, 528 surveys were completed (59% response rate). Almost all (95%) responding hospitals had an antibiotic stewardship program. Smaller hospitals were less likely to have stewardship team members with infectious diseases (ID) training, and only 41% of hospitals met The Joint Commission accreditation standards for multidisciplinary teams. Guideline-recommended CDI prevention practices were common. Smaller hospitals were less likely to use high-tech disinfection devices, fecal microbiota transplantation, or diagnostic stewardship strategies. Conclusions: Following changes in accreditation standards, nearly all US hospitals now have an antibiotic stewardship program. However, many hospitals, especially smaller hospitals, appear to struggle with access to ID expertise and with deploying diagnostic stewardship strategies. CDI prevention could be enhanced through diagnostic stewardship and by emphasizing the role of non–ID-trained pharmacists and clinicians in antibiotic stewardship.

A “Fluid” Diagnosis A 61-year-old woman hospitalized in Michigan for treatment of newly diagnosed acute myeloid leukemia had a fever on hospital day 10. She had no localizing symptoms.

We assessed the long-term sustainability of a quality improvement intervention to reduce urethral catheter use at a Veterans Affairs (VA) hospital. During the 8 years after the initial intervention, point-prevalence surveillance showed that urethral catheter use continued to decrease (OR, 0.91; 95% CI, 0.86–0.97; P = .003) and that appropriateness of catheter use remained unchanged.

[Graphic][1] ### Biography Professor Sanjay Saint, MD, MPH, FRCP, is the Chief of Medicine at the VA Ann Arbor and the George Dock Professor of Medicine at the University of Michigan. He has authored over 375 peer-reviewed papers, and serves on the editorial board of several peer-reviewed journals including NEJM Catalys t and BMJ Quality & Safety . He is a Special Correspondent to the New England Journal of Medicine, and is an elected member of the American Society for Clinical Investigation (ASCI), and the Association of American Physicians (AAP). He has coauthored three books published by Oxford University Press: ‘Preventing Hospital Infections: Real-World Problems, Realistic Solutions’, ‘Teaching Inpatient Medicine: What Every Physician Needs to Know’ and ‘The Saint-Chopra Guide to Inpatient Medicine (4th Edition)’. In 2019 he received Mastership in the American College of Physicians (MACP). In 2017 he was awarded the Health System Impact Award from the Department of Veterans Affairs, and the Distinguished Mentor Award from the University of Michigan. In 2016 he received the Mark Wolcott Award from the Department of Veterans Affairs as the National VA Physician of the Year and was named an honorary Fellow of the Royal College of Physicians (FRCP). The key leadership messages are mostly the same whether or not a pandemic is occurring. However, during a pandemic, adhering to several of the following becomes even more crucial since time seems compressed during urgencies. My key leadership messages are: [1]: /embed/inline-graphic-1.gif

We conducted a prospective observational study of indications for use and patient experiences with midline catheters (n = 50) compared to peripherally inserted central catheters (n = 63). The primary indication for patients with midline catheters was difficult venous access. Patients with midline catheters reported fewer complications than patients with peripherally inserted central catheters.

A national survey conducted in 2012 revealed that the rates of regular use of many evidence-based practices to prevent device-associated infections were low in Japanese hospitals. We conducted a second survey 4 years later to evaluate changes in infection prevention practices.Between July 2016 and January 2017, the instrument used in a survey of Japanese hospitals in 2012 was sent to 1,456 Japanese hospitals. The survey assessed general hospital and infection prevention program characteristics and use of practices specific to preventing catheter-associated urinary tract infection (CAUTI), central line-associated bloodstream infection (CLABSI), and ventilator-associated pneumonia (VAP). Independent sample chi-square tests were used to compare prevention practice rates between the first and second surveys.A total of 685/971 (71%) and 940/1,456 (65%) hospitals responded to the first and second surveys, respectively. For CAUTI, only use of bladder ultrasound scanners (11.1%-18.1%; P.001) increased. For CLABSI, use of chlorhexidine gluconate for insertion site antisepsis (18.5%-41.1%; P.001), antimicrobial dressing with chlorhexidine (3.4%-7.1%; P = .001), and central line insertion bundle (22.9%-33.0%; P.001) increased. For VAP, use of semirecumbent positioning of patients (65.0%-72.3%; P = .002), sedation vacation (31.5%-41.6%; P.001), oscillating/kinetic beds (4.7%-8.6%; P = .002), and a collective VAP prevention bundle (24.8%-34.8%; P.001) increased. Fewer than 50% of Japanese hospitals reported conducting CAUTI and VAP surveillance.Collaborative approaches and stronger incentives promoting infection prevention efforts may be warranted to further increase use of most evidence-based practices to reduce common health care-associated infections in Japan.

The technical advances described in this chapter could markedly aid the struggle to prevent healthcare-associated infection. They range from nanomedicine to oral doses of probiotics and IBM’s Watson computer as diagnostician. The adaptive possibilities include further empowerment of the patient on the one hand and new approaches to bring hard-pressed clinicians emotional relief and improve their interactions with patients on the other hand. Studies have shown that large numbers of physicians have suffered burnout. Many doctors and nurses are not fully attentive in their encounters with patients. Growing numbers of clinicians have begun practicing mindfulness, and a model designed to show how a mindful focus can help clinicians in implementing infection prevention initiatives is presented.

After the formal initiative is finished, the project team continues working to secure and perpetuate the progress made in reducing Foley usage and institutionalizing the bladder bundle checklist. Members put into effect plans formulated during the initiative’s early days. The evaluation of catheter use and of infection rates goes on, though the data collection intervals are farther apart. Successes are promoted throughout the hospital, a reminder that the initiative continues. A major mission is to identify backsliders and realign them. Because of the possibility that champions will leave the hospital or be reassigned, current champions are urged to develop their replacements. The team makes sure that the orientation process for new arrivals to the hospital includes prevention information related to catheter-associated urinary tract infection and the hospital’s protocols concerning Foley insertion and removal.

The adaptive approach used in the previous chapters to prevent catheter-associated urinary tract infection (CAUTI) is applied to an initiative to prevent Clostridioides difficile (formerly Clostridium difficile) infection. These two initiatives differ regarding their scope, the members of their teams, and the elements of their bundles. For preventing C. difficile, for example, the most important bundle item is antimicrobial stewardship since the use of broad-spectrum antibiotics vastly increases a person’s risk of becoming infected. Infectious diseases physicians or clinical pharmacists are to examine the circumstances of antimicrobial prescriptions they have filled to see whether they meet infection prevention standards; if not, the prescribing physician will receive prompt feedback. Differences aside, the basic elements of the CAUTI framework apply, from the C-suite’s decision to go ahead with the initiative to the tactics used to sell the C. difficile bundle to the hospital staff.

A hospital-wide intervention is rolled out. There are changes in the team leadership and many operational adjustments: supplies ordered, procedures redesigned, nursing assignments altered. Three major types of troublemakers are described: the active resisters, the organizational constipators, and the time-servers. Motivations range from opposition to any kind of change to a personal animus toward the project champions to a determination to do as little extra work as possible. Requests by patients and their families may be used to try to get around bladder bundle items or a member of the project team may approach nurses with a patronizing attitude. The team cheers short-term progress to encourage staff compliance, solicits concrete criticism as a path to improvement, and adjusts the implementation process to allow for special circumstances. Efforts to use the electronic medical record to game the system must be squelched. Unfortunately, these challenges are all too common when implementing an infection prevention initiative—but there are solutions.

This book provides a detailed, step-by-step description of a model quality improvement intervention for hospitals, pinpointing the obstacles and showing how to surmount them. This second edition has been carefully updated, with new material describing some technical aspects of infection prevention, new tools for use by front-line providers, and results of recent large collaborative infection prevention studies. In easy-to-read, user-friendly language, it explains why clinicians neglect or actively oppose quality changes—from physicians who distrust change, to nurses who want to protect their turf, to infection preventionists who avoid the wards. The book also sheds light on how and why hospitals embark on quality improvements, the role of the hospital’s leadership cadre, the selection and training of the project team, and how to sustain quality gains long term. The intervention framework described in the book focuses on the prevention of hospital-associated infections—in particular, catheter-associated urinary tract infection (CAUTI)—but it is directly applicable to a variety of other hospital issues, such as falls, pressure sores, and Clostridioides difficile infection (CDI). In fact, the book includes a chapter applying this framework to a CDI prevention initiative. In addition, for hospitals having trouble with staff adherence to a quality initiative, we provide three infection-specific questionnaires (for CAUTI, CLABSI, and CDI) to help pinpoint individual problems, and provide a link to a website offering advice tailored to their specific circumstances.

Prevention of central line–associated bloodstream infection (CLABSI), while initially making great strides in 2003, has declined as use of peripherally inserted central catheters (PICCs) has grown tremendously over the past two decades. The convenience of a PICC has led to sicker patients being treated outside the intensive care unit, and there has been little recognition of a trade-off between benefits and risks after PICC placement. For these reasons, CLABSI prevention has become more challenging. This chapter describes the contents of an infection prevention bundle for CLABSI. In the case of CLABSI, the intervention outlines appropriate and inappropriate uses of central lines. Several new tools are discussed, which help doctors and nurses think through which device is most appropriate for any given patient.

What motivates a hospital administration to take on an infection prevention initiative? It may simply reflect a hospital’s culture of excellence, a commitment to patient safety, though that may be combined with a determination to keep up with competing institutions or to avoid federal financial penalties. Quality initiatives can drain staff time and energy but save substantial dollars in the long run. Once the decision to proceed with the catheter-associated urinary tract infection initiative is made, hospital leaders start a team-building process, choosing an executive sponsor with experience on the wards, the project’s main venue. The sponsor in turn selects a project manager, who will find physician and nurse champions to carry the goals and content of the initiative to the staff. The initiative calls for the adoption of a bundle of evidence-based behaviors—in this case, to reduce the unnecessary use of indwelling urinary catheters known as Foleys.

The recruitment of a nurse champion and a physician champion is described in detail. At in-person meetings and via online presentations, team members familiarize themselves with current catheter practices and absorb the new protocols. They decide which medical floor unit will be the first target and pilot project for the initiative. Their criteria: a unit with a track record for cooperating with interventions and that also has a sizable number of Foleys and catheter-associated urinary tract infection cases. The project manager, champions, and other team members work out implementation details—promoting the project’s goals throughout the hospital, coordinating with other ongoing quality initiatives in the hospital, and identifying those people who will need special convincing. The changes will drive staff from their comfort zones, add to their workload, and challenge traditional relationships between nurses and doctors.

Leadership in a hospital setting differs substantially from that in a for-profit corporation, regarding both mission and practice; that is evident during a quality improvement initiative. Top administrative and clinical leaders need to continually communicate the value and scientific validity of the project to staff members by all available means—including personal cheerleading. Project managers and team champions have to energize the staff with their own enthusiasm for the initiative, capitalizing on the trust and respect they have earned. What is called for is transformational leadership and substantial emotional intelligence. Leaders on all levels need to devote themselves to helping colleagues become exemplary followers. The major characteristics of the leaders of successful infection prevention projects are described.

When hospitals join in a collaborative infection prevention project, they agree to work within the requirements and discipline of the sponsors. That includes providing baseline and monthly infection rate data to the collaborative leaders and committing some staff members to intense weekly phone talks with the collaborative experts and other coaching sessions. Ideally, a community emerges, both online and in-person. The community members exchange experiences and ideas related to the initiative, socialize, and establish a behavioral norm within each hospital that can help convince resisters, particularly physicians, to change their ways. To make up for the limited attention paid to the problems individual hospitals may encounter, some collaboratives provide a troubleshooting group of expert advisors. The collaborative approach has strong support from federal and state agencies, but some studies have questioned its effectiveness.

Healthcare-associated infection takes a heavy toll on patients, and negatively affects hospitals themselves, both financially and psychologically. Proven technical approaches to prevent infection have often faltered because of the failure of hospital staff to adopt them. This book focuses on these adaptive problems, particularly as experienced during efforts to combat catheter-associated urinary tract infection (CAUTI), central line–associated bloodstream infection (CLABSI), and Clostridioides difficile infection (CDI). It provides a step-by-step description of a model quality improvement intervention, explaining why clinicians neglect or actively oppose such initiatives and how to change their minds. The focus is on preventing CAUTI, which has proven far more resistant to quality improvement efforts than CLABSI. The CAUTI intervention framework is also broadly applicable to a variety of other hospital issues, including preventing falls and CDI. The solutions presented grow out of the extensive research by the clinical authors and their colleagues at the University of Michigan and VA Ann Arbor Healthcare System.

Infection prevention programs were slow to develop—they were a rarity as recently as the 1950s—but they have become a staple of modern-day hospitals. Great strides have been made in identifying clinician activities that can control or prevent various healthcare-associated infections. This chapter describes the contents of an infection prevention bundle for catheter-associated urinary tract infection (CAUTI). In the case of CAUTI, the so-called bladder bundle sets forth appropriate and inappropriate use of indwelling catheters. A nursing checklist, on paper or as a template in the electronic medical record, is used to track patients’ daily urinary catheter status. Doctors and nurses are asked to rethink when a Foley is called for, what alternatives should be considered, what catheter equipment should be used, and how long the Foley should remain in place.

Background Previous studies have shown that patients have specific expectations regarding physician dress. Japan has a cultural background that is in many ways distinct from western countries. Thus, physician attire may have a different impact in Japan. Methods We conducted a multicenter, cross-sectional study to examine patients' preferences for and perceptions of physician attire in Japan. The questionnaire was developed using photographs of either a male or female physician dressed in seven different forms of attire, and it was randomly distributed to inpatients and outpatients. Respondents were asked to rate the provider pictured; they were also asked to provide preferences for different forms of attire in varied clinical settings. Preference was evaluated for five domains (knowledgeable, trustworthy, caring, approachable, and comfortable). We also assessed variation in preferences for attire by respondent characteristics. Results A total of 1,233 (61%) patients indicated that physician dress was important, and 950 (47%) patients agreed that it influenced their satisfaction with care. Compared with all forms, casual attire with a white coat was the most preferred dress. Older patients more often preferred formal attire with a white coat in primary care and hospital settings. In addition, physician attire had a greater impact on older respondents' satisfaction and experience. Conclusion The majority of Japanese patients indicated that physician attire is important and influenced their satisfaction with care. Geography, settings of care, and patient age appear to play a role in patient preferences.

Health care-associated infection (HAI) is associated with substantial harm. To reduce HAI, the largest integrated health care system in the United States-the Veterans Health Administration-was an early adopter of infection prevention policies and initiatives. Whether these efforts translated into increased use of practices to prevent HAI in Veterans Affairs (VA) hospitals is unknown.To evaluate changes over time in infection prevention practices and the perception of the importance of infection prevention to hospital leadership.For this survey study, every 4 years between 2005 and 2017, infection preventionists were surveyed at all VA hospitals on use of practices associated with common HAIs, including central line-associated bloodstream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), ventilator-associated pneumonia (VAP), and (beginning in 2013) Clostridioides difficile infection. Data analysis was performed from February 1, 2019, to July 1, 2019.Reported regular use of key infection prevention practices and perceived importance of infection prevention to hospital leadership.Between 2005 and 2017, 320 total surveys were completed with response rates ranging from 59% (73 of 124) in 2017 to 80% (95 of 119) in 2005. Use of 12 different infection prevention practices increased. Since 2013, 92% (69 of 75) to 100% of VA hospitals reported regular use of key infection prevention practices for C difficile infection and CLABSI. In contrast, adoption of many practices to prevent CAUTI, although increasing, have lagged. Despite reported increases in the use of some practices for VAP such as semirecumbent positioning (89% [79 of 89] in 2005 vs 97% [61 of 63] in 2017, P = .007 for trend) and subglottic secretion drainage (23% [19 of 84] in 2005 vs 65% [40 of 62] in 2017, P .001), use of other key practices such as daily interruptions of sedation (85% [55 of 65] in 2009 vs 87% [54 of 62] in 2017, P = .66) and early mobilization (81% [52 of 64] in 2013 vs 82% [51 of 62] in 2017, P = .88) has not increased. Antibiotic stewardship programs are now reported in nearly every VA hospital (97% [71 of 73]); however, some hospitals report practices for microbiologic testing for HAIs (eg, 22% [16 of 72] report routine urine culture testing in 2017) that could also contribute to antibiotic overuse.From 2005 to 2017, reported use of 12 different infection prevention practices increased in VA hospitals. Areas for continued improvement of infection prevention practices appear to include CAUTI, certain VAP practices, and diagnostic stewardship for HAI. The reported adoption of many infection prevention practices in VA hospitals was higher than in non-VA hospitals. As hospitals continue to merge and health systems become increasingly integrated, these successes could help inform patient safety broadly.

Objectives Little is known about how physician diagnostic thinking unfolds over time when evaluating patients. We designed a case-based simulation to understand how physicians reason, create differential diagnoses, and employ strategies to achieve a correct diagnosis. Methods Between June 2017 and August 2018, hospital medicine physicians at two academic medical centers were presented a standardized case of a patient presenting with chest pain who was ultimately diagnosed with herpes zoster using an interview format. Case information was presented in predetermined aliquots where participants were then asked to think-aloud, describing their thoughts and differential diagnoses given the data available. At the conclusion of the interview, participants were asked questions about their diagnostic process. Interviews were recorded, transcribed, and content analysis was conducted to identify key themes related to the diagnostic thinking process. Results Sixteen hospital medicine physicians (nine men, seven women) participated in interviews and four obtained the correct final diagnosis (one man, three women). Participants had an average of nine years of experience. Overall, substantial heterogeneity in both the differential diagnoses and clinical reasoning among participants was observed. Those achieving the correct diagnosis utilized systems-based or anatomic approaches when forming their initial differential diagnoses, rather than focusing on life-threatening diagnoses alone. Evidence of cognitive bias was common; those with the correct diagnosis more often applied debiasing strategies than those with the incorrect final diagnosis. Conclusions Heterogeneity in diagnostic evaluation appears to be common and may indicate faulty data processing. Structured approaches and debiasing strategies appear helpful in promoting diagnostic accuracy.

Objective To examine the extent to which acute care hospitals in the Netherlands have adopted recommended practices to prevent catheter-associated urinary tract infection (CAUTI), central line-associated bloodstream infection (CLABSI), ventilator-associated pneumonia (VAP), and Clostridioides difficile infection (CDI). Methods Between 18 July 2017 and 31 October 2017, we surveyed the infection prevention teams of all acute care hospitals in the Netherlands. The survey instrument was based on the ‘Translating Healthcare-Associated Infection Prevention Research into Practice’ (TRIP) questionnaire and adapted to the Dutch context. Descriptive statistics were used to examine the reported regular use of CAUTI, CLABSI, VAP, and CDI prevention practices as well as the hospital characteristics. Results Out of 72 eligible hospitals, 47 (65.3%) responded. Surveillance systems for monitoring CAUTI, CLABSI, VAP, and CDI were present in 17.8, 95.4, 26.2, and 77.3% of hospitals, respectively. Antimicrobial stewardship programs have been established in 91.5% of participating hospitals. For CAUTI, the majority of hospitals regularly used aseptic technique during catheter insertion (95%) and portable bladder ultrasound scanners (86.1%). Intermittent catheterization and catheter stop-orders were regularly used by 65.8 and 62.2% of hospitals. For CLABSI, all hospitals regularly used maximum sterile barrier precautions and chlorhexidine gluconate for insertion site antisepsis. Avoidance of the femoral site for central line insertions was regularly used by 65.9% of hospitals. Urinary catheters and central-lines impregnated with antibiotics or antiseptics were rarely used (≤ 5%). Selective decontamination strategies for preventing VAP were used in 84% of hospitals. With the exception of disposable thermometers (31.8%), all prevention practices to prevent CDI were regularly used by more than 80% of hospitals. Conclusions Most Dutch hospitals report regular use of recommended practices for preventing CLABSI and CDI. Several specific practices to prevent CAUTI and VAP were less frequently used, however, providing an opportunity for improvement.

Clostridioides difficile infection (CDI) can be prevented through infection prevention practices and antibiotic stewardship. Diagnostic stewardship (ie, strategies to improve use of microbiological testing) can also improve antibiotic use. However, little is known about the use of such practices in US hospitals, especially after multidisciplinary stewardship programs became a requirement for US hospital accreditation in 2017. Thus, we surveyed US hospitals to assess antibiotic stewardship program composition, practices related to CDI, and diagnostic stewardship.Surveys were mailed to infection preventionists at 900 randomly sampled US hospitals between May and October 2017. Hospitals were surveyed on antibiotic stewardship programs; CDI prevention, treatment, and testing practices; and diagnostic stewardship strategies. Responses were compared by hospital bed size using weighted logistic regression.Overall, 528 surveys were completed (59% response rate). Almost all (95%) responding hospitals had an antibiotic stewardship program. Smaller hospitals were less likely to have stewardship team members with infectious diseases (ID) training, and only 41% of hospitals met The Joint Commission accreditation standards for multidisciplinary teams. Guideline-recommended CDI prevention practices were common. Smaller hospitals were less likely to use high-tech disinfection devices, fecal microbiota transplantation, or diagnostic stewardship strategies.Following changes in accreditation standards, nearly all US hospitals now have an antibiotic stewardship program. However, many hospitals, especially smaller hospitals, appear to struggle with access to ID expertise and with deploying diagnostic stewardship strategies. CDI prevention could be enhanced through diagnostic stewardship and by emphasizing the role of non-ID-trained pharmacists and clinicians in antibiotic stewardship.

BackgroundIndwelling urinary catheters are commonly used for patients undergoing general and orthopaedic surgery. Despite infectious and non-infectious harms of urinary catheters, there is limited guidance available to surgery teams regarding appropriate perioperative catheter use.ObjectiveUsing the RAND Corporation/University of California Los Angeles (RAND/UCLA) Appropriateness Method, we assessed the appropriateness of indwelling urinary catheter placement and different timings of catheter removal for routine general and orthopaedic surgery procedures.MethodsTwo multidisciplinary panels consisting of 13 and 11 members (physicians and nurses) for general and orthopaedic surgery, respectively, reviewed the available literature regarding the impact of different perioperative catheter use strategies. Using a standardised, multiround rating process, the panels independently rated clinical scenarios (91 general surgery, 36 orthopaedic surgery) for urinary catheter placement and postoperative duration of use as appropriate (ie, benefits outweigh risks), inappropriate or of uncertain appropriateness.ResultsAppropriateness of catheter use varied by procedure, accounting for procedure-specific risks as well as expected procedure time and intravenous fluids. Procedural appropriateness ratings for catheters were summarised for clinical use into three groups: (1) can perform surgery without catheter; (2) use intraoperatively only, ideally remove before leaving the operating room; and (3) use intraoperatively and keep catheter until postoperative days 1–4. Specific recommendations were provided by procedure, with postoperative day 1 being appropriate for catheter removal for first voiding trial for many procedures.ConclusionWe defined the appropriateness of indwelling urinary catheter use during and after common general and orthopaedic surgical procedures. These ratings may help reduce catheter-associated complications for patients undergoing these procedures.

OBJECTIVECollaborative programs have helped reduce catheter-associated urinary tract infection (CAUTI) rates in community-based nursing homes. We assessed whether collaborative participation produced similar benefits among Veterans Health Administration (VHA) nursing homes, which are part of an integrated system.SETTINGThis study included 63 VHA nursing homes enrolled in the “AHRQ Safety Program for Long-Term Care,” which focused on practices to reduce CAUTI.METHODSChanges in CAUTI rates, catheter utilization, and urine culture orders were assessed from June 2015 through May 2016. Multilevel mixed-effects negative binomial regression was used to derive incidence rate ratios (IRRs) representing changes over the 12-month program period.RESULTSThere was no significant change in CAUTI among VHA sites, with a CAUTI rate of 2.26 per 1,000 catheter days at month 1 and a rate of 3.19 at month 12 (incidence rate ratio [IRR], 0.99; 95% confidence interval [CI], 0.67–1.44). Results were similar for catheter utilization rates, which were 11.02% at month 1 and 11.30% at month 12 (IRR, 1.02; 95% CI, 0.95–1.09). The numbers of urine cultures per 1,000 residents were 5.27 in month 1 and 5.31 in month 12 (IRR, 0.93; 95% CI, 0.82–1.05).CONCLUSIONSNo changes in CAUTI rates, catheter use, or urine culture orders were found during the program period. One potential reason was the relatively low baseline CAUTI rate, as compared with a cohort of community-based nursing homes. This low baseline rate is likely related to the VHA’s prior CAUTI prevention efforts. While broad-scale collaborative approaches may be effective in some settings, targeting higher-prevalence safety issues may be warranted at sites already engaged in extensive infection prevention efforts.Infect Control Hosp Epidemiol 2018;820–825