Shruti K Gohil’s research while affiliated with University of California, Irvine and other places

Objective Evaluate impact of COVID-19 prevention training with video-based feedback on nursing home (NH) staff safety behaviors. Design Public health intervention Setting & Participants Twelve NHs in Orange County, California, 6/2020-4/2022 Methods NHs received direct-to-staff COVID-19 prevention training and weekly feedback reports with video montages about hand hygiene, mask-wearing, and mask/face-touching. One-hour periods of recorded streaming video from common areas (breakroom, hallway, nursing station, entryway) were sampled randomly across days of the week and nursing shifts for safe behavior. Multivariable models assessed the intervention impact. Results Video auditing encompassed 182,803 staff opportunities for safe behavior. Hand hygiene errors improved from first (67.0%) to last (35.7%) months of the intervention, decreasing 7.6% per month (OR = 0.92, 95% CI = 0.92–0.93, P < 0.001); masking errors improved from first (10.3 %) to last (6.6%) months of the intervention, decreasing 2.3% per month (OR = 0.98, 95% CI = 0.97–0.99, P < 0.001); face/mask touching improved from first (30.0%) to last (10.6%) months of the intervention, decreasing 2.5% per month (OR = 0.98, 95% CI = 0.97–0.98, P < 0.001). Hand hygiene errors were most common in entryways and on weekends, with similar rates across shifts. Masking errors and face/mask touching errors were most common in breakrooms, with the latter occurring most commonly during the day (7A.M.–3P.M.) shift, with similar rates across weekdays/weekends. Error reductions were seen across camera locations, days of the week, and nursing shifts, suggesting a widespread benefit within participating NHs. Conclusion Direct-to-staff training with video-based feedback was temporally associated with improved hand hygiene, masking, and face/mask-touching behaviors among NH staff during the COVID-19 pandemic.

Objectives To evaluate the impact of a mobile-app-based central line-associated bloodstream infection (CLABSI) prevention program in oncology clinic patients with peripherally inserted central catheters (PICCs). Design Pre-post prospective cohort study with baseline (July 2015–December 2016), phase-in (January 2017–April 2017), and intervention (May 2017–November 2018). Generalized linear mixed models compared intervention with baseline frequency of localized inflammation/infection and dressing peeling. Cox proportional hazards models compared days-to-removal of lines with localized inflammation/infection. Chi-square test compared bacteremia rates before and after intervention. Setting Oncology clinic at a large medical center. Patients Oncology clinic adult patients with PICCs. Intervention CLABSI prevention program consisting of an actionable scoring system for identifying insertion site infection/inflammation coupled with a mobile-app enabling photo-assessments and automated physician alerting for remote response. Results We completed 5,343 assessments of 569 PICCs in 401 patients (baseline: 2,924 assessments, 300 PICCs, 216 patients; intervention: 2,419 assessments, 269 PICCs, 185 patients). The intervention was associated with a 92% lower likelihood of having a dressing with peeling (OR 0.08, 95%CI 0.04-0.17, P < 0.001), 53% lower local inflammation/infection (OR 0.47, 95%CI 0.27-0.84, P < 0.011), and 24% (non-significant) lower CLABSI rates ( P = .63). Physician mobile-app alerting and response enabled 80% lower risk of lines remaining in place after inflammation/infection was identified (HR 0.20, 95%CI:0.14-0.30, P < 0.001) and 85% faster removal of infected lines from mean (SD) 11.1 (9.7) to 1.7 (2.4) days. Conclusions A mobile-app-based CLABSI prevention program decreased frequency of inflamed/infected central line insertion sites and increased speed of removal when inflammation/infection was found.

Importance Empiric extended-spectrum antibiotics are routinely prescribed for patients hospitalized with skin and soft tissue infections (SSTIs) despite low likelihoods of infection with multidrug-resistant organisms (MDROs). Objective To evaluate whether computerized provider order entry (CPOE) prompts presenting patient-specific and pathogen-specific MDRO infection risk estimates could reduce empiric extended-spectrum antibiotics for noncritically ill patients admitted with SSTI. Design, Setting, and Participants This cluster randomized clinical trial included 92 hospitals and assessed the effect of an antibiotic stewardship bundle that included CPOE prompts vs routine stewardship on antibiotic selection during the first 3 hospital days (empiric period) in noncritically ill adults hospitalized with SSTI. The trial population included adults 18 years and older treated with empiric antibiotics for SSTI in non–intensive care unit (ICU) settings. Data were collected from January 2019 to December 2023. Interventions CPOE prompts recommending standard-spectrum antibiotics in patients prescribed extended-spectrum antibiotics during the empiric period when absolute risk of MDRO SSTI was estimated to be less than 10%, coupled with feedback and education. Main Outcomes and Measures The primary outcome was empiric extended-spectrum antibiotic days of therapy (summed number of different extended-spectrum antibiotics targeting Pseudomonas and/or MDR gram-negative bacteria received per patient each calendar day). The secondary outcome was antipseudomonal days of therapy. Safety outcomes included days to ICU transfer and hospital length of stay. Outcomes compared differences between baseline and intervention periods across strategies. Results Among 118 562 patients admitted with SSTI at 92 hospitals, 67 033 (56.7%) were male and the mean (SD) age was 58.0 (17.5) years. A total of 57 837 patients were included in the baseline period and 60 725 in the intervention period. Receipt of any empiric extended-spectrum antibiotic during the baseline and intervention periods was 57.0% (16 855 of 29 595) and 56.0% (17 534 of 31 337), respectively, for the routine stewardship group compared with 55.4% (15 650 of 28 242) and 43.0% (12 647 of 29 388), respectively, for the CPOE group. Empiric extended-spectrum days of therapy per 1000 empiric days targeting Pseudomonas and/or MDR gram-negative pathogens was 511.5 during the baseline period and 488.7 during the intervention period in the routine stewardship group and was 496.2 and 359.1, respectively, in the CPOE bundle group (rate ratio, 0.72; 95% CI, 0.67-0.79; P < .001). There was no evidence of inferiority in the CPOE bundle group for mean (SD) hospital length of stay (routine stewardship, 6.5 [3.8] days; CPOE bundle, 6.4 [3.8] days) and days to ICU transfer (routine stewardship, 6.3 [3.2] days; CPOE bundle, 6.3 [3.1] days). Conclusions and Relevance In this randomized clinical trial, CPOE prompts recommending standard-spectrum empiric antibiotics for low-risk patients hospitalized with SSTI coupled with education and feedback significantly reduced use of extended-spectrum antibiotics without increasing admissions to ICUs or hospital length of stay. Trial Registration ClinicalTrials.gov Identifier: NCT05423756

Importance Empiric extended-spectrum antibiotics are routinely prescribed for over a million patients hospitalized annually with abdominal infection despite low likelihoods of infection with multidrug-resistant organisms (MDROs). Objective To evaluate whether computerized provider order entry (CPOE) prompts providing patient- and pathogen-specific MDRO infection risk estimates can reduce empiric extended-spectrum antibiotics for non–critically ill patients admitted with abdominal infection. Design, Setting, and Participants This 92-hospital cluster randomized clinical trial assessed the effect of an antibiotic stewardship bundle with CPOE prompts vs routine stewardship on antibiotic selection during the first 3 hospital days (empiric period) in non–critically ill adults hospitalized with abdominal infection. The trial population included adults (≥18 years) treated with empiric antibiotics for abdominal infection in non–intensive care units (ICUs). The trial periods included a 12-month baseline from January to December 2019 and an intervention period from January to December 2023. Intervention CPOE prompts recommending standard-spectrum antibiotics in patients prescribed extended-spectrum antibiotics during the empiric period if the patient’s estimated absolute risk of MDRO abdominal infection was less than 10%, coupled with feedback and education. Main Outcomes and Measures The primary outcome was empiric extended-spectrum antibiotic days of therapy. Safety outcomes: days to ICU transfer and hospital length of stay. Analyses compared differences between baseline and intervention periods across strategies. Results Among 92 hospitals with 198 480 patients, mean (SD) age was 60 (19) years and 118 723 (59.8%) were female. The trial included 93 476 and 105 004 patients hospitalized with abdominal infection during the baseline and intervention periods, respectively. Receipt of any empiric extended-spectrum antibiotics for the routine care group was 48.2% (22 519 of 46 725) during baseline and 50.5% (27 452 of 54 384) during intervention vs 47.8% (22 367 of 46 751) and 37.6% (19 010 of 50 620) for the CPOE bundle group. The group receiving CPOE prompts had a 35% relative reduction (rate ratio, 0.65; 95% CI, 0.60-0.71; P < .001) in empiric extended-spectrum antibiotic days of therapy vs routine care (raw absolute reduction between baseline and intervention periods was −169 for the CPOE bundle vs −20 for routine care). Hospital length of stay was noninferior to routine care (0.1 days longer during intervention; mean [SD], baseline, 5.4 [3.4] days vs intervention, 5.5 [3.5] days; hazard ratio [HR], 1.02; 90% CI, 0.99-1.06), and mean days to ICU transfer in the CPOE group was indeterminate (both groups 0.2 days longer during intervention; HR, 1.10; 90% CI, 0.99-1.23). Conclusions and Relevance CPOE prompts recommending empiric standard-spectrum antibiotics (coupled with education and feedback) for patients admitted with abdominal infection who have low risk for MDRO infection significantly reduced extended-spectrum antibiotics without increasing ICU transfers or length of stay. Trial Registration ClinicalTrials.gov Identifier: NCT05423743

Background Various underlying medical conditions (UMCs) elevate the risk of influenza-associated hospitalization. We evaluated how these rates changed by type and number of UMCs. Methods Retrospective cohorts were constructed among adult members of two health systems aged ≥18 years with prior healthcare utilization. Across the 2016–17 to 2019–20 seasons, we estimated influenza-associated hospitalization rates by type and number of UMCs. Hospitalizations were defined using discharge diagnoses or laboratory confirmation. We calculated adjusted rate ratios (aRR) using Poisson regression controlling for site, season, and demographic characteristics. We used causal mediation to estimate the effect of UMCs on influenza-associated hospitalization accounting for influenza vaccination status. Results Among 870,888 cohort members, 1,403 were hospitalized with influenza at least once within a season across four seasons. Compared to those without, the aRR for influenza-associated hospitalization was highest for individuals with congestive heart failure (4.2, 95% CI: 3.6–4.9). The aRRs also increased with each additional UMCs compared to those with no UMCs. The effect of UMCs on influenza-associated hospitalizations was higher when not mediated by vaccination status; for those with ≥4 UMCs compared to no UMCs, rates were about 60% higher. Conclusion The burden of baseline medical conditions is associated with higher rates of influenza-associated hospitalization. Among those with varying types and number of UMCs, if vaccination prevalence had been lower than observed, influenza-associated hospitalization rates would have been higher. These findings highlight the importance of preventive medical care and annual influenza vaccination in reducing influenza-associated hospitalizations, particularly for individuals at high-risk.

Each day a venous catheter is retained poses unnecessary safety risks. In a retrospective evaluation of central/peripheral lines in nursing home residents receiving antibiotics, 80% were retained beyond antibiotic treatment end and nearly one third were retained longer than a week. Interventions for timely catheter removal are urgently needed.

Objectives:To evaluate the impact of a mobile-app-based central line-associated bloodstream infection (CLABSI) prevention program in nursing home residents with peripherally inserted central catheters (PICCs). Design:Pre-post prospective cohort study with baseline (September 2015–December 2016), phase-in (January 2017–April 2017), and intervention (May 2017–December 2018). Generalized linear mixed models compared intervention with baseline frequency of localized inflammation/infection, dressing peeling, and infection-related hospitalizations. Cox proportional hazards models compared days-to-removal of lines with localized inflammation/infection. Setting:Six nursing homes in Orange County, California. Patients:Adult nursing home residents with PICCs. Intervention:CLABSI prevention program consisting of an actionable scoring system for identifying insertion site infection/inflammation coupled with a mobile-app enabling photo-assessments and automated physician alerting for remote response. Results:We completed 8,131 assessments of 817 PICCs in 719 residents (baseline: 4,865 assessments, 422 PICCs, 385 residents; intervention: 4,264 assessments, 395 PICCs, 334 residents). The intervention was associated with 57% lower odds of peeling dressings (OR 0.43, 95% CI 0.28–0.64, P < .001), 73% lower local inflammation/infection (OR = 0.27, 95% CI: 0.13–0.56, P < .001), and 41% lower risk of infection-related hospitalizations (OR = 0.59, 95% CI: 0.42–0.83, P = .002). Physician mobile-app alerting and response enabled 62% lower risk of lines remaining in place after inflammation/infection was identified (HR 0.38, CI: 0.24–0.62, P < .001) and 95% faster removal of infected lines from mean (SD) 19 (20) to 1 (2) days. Conclusions:A mobile-app-based CLABSI prevention program decreased the frequency of inflamed/infected central line insertion sites, improved dressing integrity, increased speed of removal when inflammation/infection were found, and reduced infection-related hospitalization risk.

Background Up to 40% of hospitalized patients receive empiric extended-spectrum (ES) antibiotics despite low risk of multidrug-resistant organism (MDRO) infection, increasing the risk for adverse effects and future resistance. We evaluated whether computerized physician order entry (CPOE) prompts providing patient-specific MDRO risk estimates could reduce ES antibiotic use compared to routine stewardship in patients hospitalized with abdominal infections. Methods This 92-hospital cluster-randomized trial compared CPOE prompts providing patient-specific absolute risk estimates for MDRO abdominal infection and recommending standard-spectrum antibiotics for risk < 10% vs. routine stewardship. Trial population: adults treated with antibiotics for abdominal infection in non-ICUs in the first 3 days of admission (empiric period). Prompts were triggered if ES antibiotics were ordered. Trial periods: 12-month Baseline (Jan 2019-Dec 2019); 5-month Phase-in (Aug 2022–Dec 2022); 12-month Intervention (Jan 2023-Dec 2023). Primary outcome: ES antibiotic days of therapy (ES-DOT) per patient per empiric day; secondary outcomes were a) vancomycin and b) anti-pseudomonal DOT per empiric day. Unadjusted, as-randomized analyses used (1) generalized linear mixed effects models to assess differences in ES-DOT rates across intervention and baseline periods between groups clustering by patient, hospital, and period and (2) proportional hazards models to assess safety outcomes: days to ICU transfer and hospital LOS. Results We randomized 92 hospitals in 15 states. Across baseline and intervention periods there were 100,890 and 97,680 non-ICU patients with abdominal infection in the routine and CPOE prompt groups, respectively. The CPOE prompt group had a 35% reduction in ES-DOT compared to routine care (rate ratio 0.65 [95% CI 0.60-0.71], p< 0.001). Vancomycin and anti-pseudomonal DOT were reduced by 20% and 39%, respectively (Table, Figure 1) without significant differences in LOS or ICU transfers. Conclusion INSPIRE CPOE prompts providing patient-specific MDRO risk estimates recommending standard spectrum antibiotics in low risk patients significantly reduced empiric ES prescribing in adults admitted with abdominal infection. Disclosures Ken Kleinman, ScD, Xttrium Laboratories: Conducting studies in which participating hospital patients received contributed antiseptic products outside the submitted work Richard Platt, MD, MSc, GlaxoSmithKline: Contract to academic department|Janssen: Contract to academic department|Pfizer: Contract to academic department Susan Huang, MD, MPH, Xttrium Laboratories: Conducting studies in which participating hospital patients received contributed antiseptic products outside the submitted work

Background Up to 40% of hospitalized patients receive extended-spectrum (ES) antibiotics despite low risk of multidrug-resistant organism (MDRO) infection, increasing the risk for adverse effects and future resistance. We evaluated whether computerized physician order entry (CPOE) prompts providing patient-specific MDRO risk estimates could reduce ES antibiotic use compared to routine stewardship practices in patients hospitalized with skin and soft tissue (SST) infections. Methods This 92-hospital cluster-randomized trial compared CPOE prompts providing patient-specific absolute risk estimates for MDRO SST infection and recommending standard-spectrum antibiotics for risk < 10% vs. routine stewardship. Trial population: adults treated with antibiotics for SST infection in non-ICUs in the first 3 days of admission (empiric period). Prompts were triggered if ES antibiotics were ordered. Trial periods: 12-month Baseline (Jan 2019-Dec 2019); 5-month Phase-in (Aug 2022–Dec 2022); 12-month Intervention (Jan 2023-Dec 2023). Primary outcome: ES antibiotic days of therapy (ES-DOT) per patient per empiric day; secondary outcome was anti-pseudomonal DOT per empiric day. Unadjusted, as-randomized analyses used (1) generalized linear mixed effects models to assess differences in ES-DOT rates across intervention and baseline periods between groups, clustering by patient, hospital, and period and (2) proportional hazards models to assess safety outcomes: days to ICU transfer and hospital LOS. Results We randomized 92 hospitals in 15 states. Across the baseline and intervention periods there were 60,654 and 57,655 non-ICU patients with skin and soft tissue infection in the routine and CPOE prompt groups, respectively. The CPOE prompt group had a 28% reduction in ES-DOT compared to routine care (rate ratio 0.72 [95% CI 0.67-0.79], p< 0.001). Anti-pseudomonal DOT was reduced by 28% (Table, Figure 1) without significant differences in LOS or ICU transfers. Conclusion INSPIRE CPOE prompts providing patient-specific MDRO risk estimates recommending standard spectrum antibiotics in low risk patients significantly reduced empiric ES prescribing in adults admitted with skin and soft tissue infection. Disclosures Ken Kleinman, ScD, Xttrium Laboratories: Conducting studies in which participating hospital patients received contributed antiseptic products outside the submitted work Richard Platt, MD, MSc, GlaxoSmithKline: Contract to academic department|Janssen: Contract to academic department|Pfizer: Contract to academic department Susan Huang, MD, MPH, Xttrium Laboratories: Conducting studies in which participating hospital patients received contributed antiseptic products outside the submitted work