Background: Methicillin-Resistant Staphylococcus aureus (MRSA) is frequently targeted with empiric treatment for pneumonia in the hospital. Obtaining quality lower respiratory tract cultures to promote appropriate de-escalation can be difficult or impractical. Nasal screening for MRSA has a high negative predictive value for MRSA pneumonia and can be an effective tool for early de-escalation. Methods: A pharmacist-driven process for nasopharyngeal MRSA screening of patients prescribed intravenous vancomycin was implemented in October 2018. Vancomycin utilization was extracted from the electronic medical record (EMR) and summarized as days of therapy per 1,000 patient days (DOT/1,000 PD). Vancomycin utilization data for the 6 months following process implementation (November 2018–April 2019) were compared to the same period from the previous year (November 2017–April 2018). Specific patient outcomes data were manually collected for patients prescribed vancomycin for pneumonia during the first 2 months following process implementation (November–December 2018; postintervention group) and comparable months (November–December 2017; preintervention group). Data were analyzed using the 2 test (nominal data) and Mann–Whitney U test (continuous data). Results: Total vancomycin utilization decreased from a monthly average of 114 to 95 DOT/1,000 PD (17% reduction) and from 27 to 14 DOT/1,000 PD for pneumonia (48% reduction). In-patient mortality was unchanged following process implementation at 17.2% versus 17.5% in the pre- and postintervention groups, respectively. Other clinical outcomes were also similar between the pre- and postintervention groups (Table 1). Fewer vancomycin levels were obtained following implementation with 34.4% of patients (0.61 levels per patient) having a level obtained in the preintervention group compared to 21.6% (0.30 levels per patient; P.001) in the postintervention group. Conclusions: Nasopharyngeal MRSA screening of patients prescribed vancomycin for pneumonia is an effective antimicrobial stewardship strategy to reduce unnecessary use of anti-MRSA therapy without negatively impacting clinical outcomes.

Funding: None

Disclosures: None

Background: Hospital-acquired Clostridioides difficile infection (HA-CDI) rates are highly variable over time, posing problems for research assessing interventions that might improve rates. By understanding seasonality in HA-CDI rates and the impacts that other factors such as influenza admissions might have on these rates, we can account for them when establishing the relationship between interventions and infection rates. We assessed whether there were seasonal trends in HA-CDI and whether they could be accounted for by influenza rates. Methods: We assessed HA-CDI rates per 10,000 patient days, and the rate of hospitalized patients with influenza per 1,000 admissions in 4 acute-care facilities (n = 2,490 beds) in Calgary, Alberta, from January 2016 to December 2018. We used 4 statistical approaches in R (version 3.5.1 software): (1) autoregressive integrated moving average (ARIMA) to assess dependencies and trends in each of the monthly HA-CDI and influenza series; (2) cross correlation to assess dependencies between the HA-CDI and influenza series lagged over time; (3) Poisson harmonic regression models (with sine and cosine components) to assess the seasonality of the rates; and (4) Poisson regression to determine whether influenza rates accounted for seasonality in the HA-CDI rates. Results: Conventional ARIMA approaches did not detect seasonality in the HA-CDI rates, but we found strong seasonality in the influenza rates. A cross-correlation analysis revealed evidence of correlation between the series at a lag of zero (R = 0.41; 95% CI, 0.10–0.65) and provided an indication of a seasonal relationship between the series (Fig. 1). Poisson regression suggested that influenza rates predicted CDI rates (P < .01). Using harmonic regression, there was evidence of seasonality in HA-CDI rates (2 [2 df] = 6.62; P < .05) and influenza rates (2 [2 df] = 1,796.6; P < .001). In a Poisson model of HA-CDI rates with both the harmonic components and influenza admission rates, the harmonic components were no longer predictive of HA-CDI rates. Conclusions: Harmonic regression provided a sensitive means of identifying seasonality in HA-CDI rates, but the seasonality effect was accounted for by influenza admission rates. The relationship between HA-CDI and influenza rates is likely mediated by antibiotic prescriptions, which needs to be assessed. To improve precision and reduce bias, research on interventions to reduce HA-CDI rates should assess historic seasonality in HA-CDI rates and should account for influenza admissions.

Funding: None

Disclosures: None

Background: The current NHSN guideline states that positive results from both blood cultures and non–culture-based testing (NCT) methodologies are to be used for central-line–associated bloodstream infection (CLABSI) surveillance determination. A positive NCT result in the absence of blood cultures or negative blood cultures in patients who meet CLABSI criteria is to be reported to NHSN. However, the reporting criteria for NCT changed starting January 1, 2020: If NCT is positive and the blood culture is negative 2 days before or 1 day after, the NCT result is not reported. If the NCT is positive with no blood culture within the 3-day window period, the NCT result is reported in patients who meet CLABSI criteria. We estimated the impact of the new NCT criteria on CLABSI numbers and rates compared to the previous definition. Methods: At our facility, the T2Candida Panel (T2), an NCT, was implemented for clinical use for the detection of early candidemia and invasive candidiasis. The T2 is a rapid molecular test performed directly on blood samples to detect DNA of 5 Candida spp: C. albicans/C. tropicalis, C. glabrata/C. krusei, and C. parapsilosis. In this retrospective study performed at an 877-bed teaching hospital in Detroit, we reviewed the impact of discordant T2 results (positive T2 with negative blood cultures) on CLABSI rates from January 1, 2017, to September 30, 2019, based on the current definition, and we applied the revised criteria to estimate the new CLABSI numbers and rates for the same period. Results: Of 343 positive T2 results, 202 (58.9%) were discordant and qualified for CLABSI determination during the study period. Of these, 109 (54%) met CLABSI criteria based on the current definition and 11 (5%) met CLABSI criteria using the new definition (proportional P < .001), resulting in an 89.9% reduction. The CLABSI rate per 1,000 central-line days, which includes discordant T2 results, based on the current and new NCT criteria, are listed in Table 1. Conclusions: In institutions that utilize NCT such as T2, application of the new 2020 NCT NHSN definition would significantly reduce the CLABSI number and have a significant impact on the CLABSI rates and standardized infection ratios (SIRs).

Funding: None

Disclosures: None

Background: Manual cleaning is the recommended method of environmental disinfection; it plays a key role in the prevention of healthcare-associated infections. Recently, automated no-touch disinfection technologies, such as ultraviolet (UV) light, have been proposed as a supplement to manual cleaning. However, UV light adds time to the cleaning process and may decrease the quality of manual cleaning. We evaluated the impact of adding UV light on the quality of manual cleaning and on room turnover times. Methods: During January–September 2019, we assessed the thoroughness of disinfection cleaning (TDC) of environmental surfaces in rooms identified for discharge. According to hospital policy, contact precautions rooms use UV light after manual cleaning with an EPA-approved sporicidal agent (bleach). Non–contact precautions rooms are disinfected using quaternary ammonium only. Rooms were identified after patient admission, selected randomly, and marked once discharge orders were placed. Fluorescent markers were applied on high-touch surfaces before discharge and were assessed after the cleaning process was completed. TDC scores were defined as the percentage of cleaned surfaces of the total of examined surfaces. UV-light disinfection time is determined automatically based on room size. We compared TDC scores and manual cleaning times between contact precautions rooms and noncontact precautions rooms. We also calculated UV-light cycle durations. Results: We assessed 2,383 surfaces in 24 contact precautions rooms with UV-light disinfection and 201 noncontact precautions rooms without UV-light disinfection. The TDC score was similar in contact precautions rooms (243 of 273 surfaces) and noncontact precautions rooms (1,835 of 2,110 surfaces; 89% vs 87%). The median manual cleaning time for contact precautions rooms was 56 minutes (IQR, 37–79), and for noncontact precautions rooms the median manual cleaning time was 33 minutes (IQR, 22–43). UV-light use added a median of 49 minutes (IQR, 35–67) to the overall cleaning process. The median turnover time for contact precautions rooms was 156 minutes (IQR, 87–216) versus 58 minutes (IQR, 40–86) in noncontact precautions room. Conclusions: In a setting with an objective assessment of environmental cleaning, there was no difference in quality of manual cleaning between contact precautions rooms (UV light) and noncontact precautions rooms (UV light). Adding UV light following manual disinfection increased the overall cleaning time and delayed room availability.

Funding: None

Disclosures: None

Background: After the Middle East respiratory syndrome coronavirus outbreak in Korea in 2015, the government newly established the additional reimbursement for infection prevention to encourage infection control activities in the hospitals. The new policy was announced in December 2015 and was implemented in September 2016. We evaluated how infection control activities improved in hospitals after the change of government policy in Korea. Methods: Three cross-sectional surveys using the WHO Hand Hygiene Self-Assessment Framework (HHSAF) were conducted in 2013, 2015, and 2017. Using multivariable linear regression model including hospital characteristics, we analyzed the changes in total HHSAF scores according to the survey time. Results: In total, 32 hospitals participated in the survey in 2013, 52 in 2015, and 101 in 2017. The number of inpatient beds per infection control professionals decreased from 324 in 2013 to 303 in 2015 and 179 in 2017. Most hospitals were at intermediate or advanced levels of progress (90.6% in 2013, 86.6% in 2015, and 94.1% in 2017). In a multivariable linear regression model, the total HHSAF scores were significantly associated with hospital teaching status (β coefficient of major teaching hospital, 52.6; 95% CI, 8.9–96.4; P = .018), bed size (β coefficient of 100-bed increase, 5.1; 95% CI, 0.3–9.8; P = .038), and survey time (β coefficient of 2017 survey, 45.1; 95% CI, 19.3–70.9; P = .001). Conclusions: After the national policy implementation, the number of infection control professionals increased, and the promotion of hand hygiene activities was strengthened in Korean hospitals.

Funding: None

Disclosures: None

Background: Literature supports appropriate testing as a key factor affecting the hospital-onset (HO) Clostridium difficile infections (CDI) standardized infection ratio (SIR). In 2016, facility A was a significant outlier in HO CDI with an SIR of 2.57. In 2017, facility B had a peak SIR of 1.9. Both SIRs were considerably higher than the Centers for Medicare and Medicaid Services (CMS) national SIR of 0.997. Methods: Hospital-onset CDIF cases from both hospitals were reviewed. Current electronic decision support in the electronic health record (EHR) was evaluated for CDI laboratory orders. Literature was reviewed for best practice of appropriate specimen collection and testing. Interventions were implemented at facility A in November 2016 and facility B in June 2018. Results: In total, 67 HO CDIF cases were reviewed from both facilities (October 2015–September 2016 for facility A and April 2017–June 2018 for facility B), and 46% were due to inappropriate testing. A CDI testing order set with decision support and best practice alerts was implemented based on national best-practice guidelines (Fig. 1). Physician and nurse education were completed on appropriate testing for CDI, including symptoms and timely specimen collection. Real-time review of appropriate testing was validated by the infection prevention team, and outliers were communicated to the ordering provider. After implementation, decreases in HO-CDIF SIRs occurred at both facilities (facility A SIR, 0.36; facility B SIR, 0.56). Both facilities have been able to sustain an SIR below the current CMS national average of 0.784. Conclusions: By implementing a sophisticated order-entry process that includes electronic decision support based on best practices, clinician education, and real-time feedback to providers, patients are appropriately tested for CDI. This intervention has allowed for appropriate classification within the NHSN and has decreased the overall HO-CDIF SIR.

Funding: None

Disclosures: None

Background: Unnecessary and prolonged antibiotic use is an important driver of antimicrobial resistance, increasing patient harm and resource utilization. Antimicrobials prescribed at hospital discharge represent an important opportunity to intervene and optimize therapy. Objective: We describe the implementation of a pharmacist-led multidisciplinary antimicrobial stewardship (AMS) intervention at transition of care (TOC) to improve antibiotic selection and duration. Methods: This intervention an IRB-approved multihospital, quasi-experimental, 3-phase stepped-wedge project in a 5-hospital health system. The setting included a large, urban, academic medical center in Detroit, Michigan, and 4 community hospitals in southeastern Michigan. AMS is provided by a pharmacist and infectious diseases physician at each site. For the AMS TOC intervention, pharmacists implemented 3 strategies: (1) early identification of patients to be discharged on oral antibiotics; (2) collaborative planning and communication regarding guideline-recommended antibiotic selection and duration; and (3) facilitation of discharge antibiotic prescription with appropriate stop date. Process improvements were modified to fit the academic and community hospital practice models. The process was implemented in general and specialty practice wards at each hospital site. Prior to implementation in October 2018, pharmacists were trained on tools to standardize identification, collaboration, and documentation. Pocket cards were used to augment education and electronic medical record (EMR) templates standardized documentation. Physicians and nurses on participating units were educated on the rationale and process. Following initiation, ongoing feedback was provided regularly to pharmacists to discuss challenges and to identify solutions. Process measures included the total number of patients receiving the intervention monthly, as indicated by pharmacist AMS TOC notes placed. Protocol adherence was evaluated in 25 randomly selected patients in each study phase each month. Adherence was defined as a pharmacist preparing discharge prescriptions and a placing note in the EMR. Results: Over the study period, 1,558 patient encounters received AMS TOC facilitation by a pharmacist. Monthly protocol adherence ranged from 29% to 87% (higher in academic institutions than community) (Fig. 1). Months of low protocol adherence were associated with times of reduced staffing and onboarding a large group of new employees or trainees. Additional barriers included discharges over weekends. The most common area needing clarification was how to count days of therapy to determine the appropriate stop date. A guide of how to count days of therapy was created to assist. Conclusions: Pharmacist-led antimicrobial stewardship at discharge is a feasible intervention in both academic and community settings. Identifying potential barriers and assessing strategies with multidisciplinary healthcare teams allows for optimal implementation and intervention rollout.

Funding: This work was completed under CDC contract number 200-2018-02928.

Disclosures: None

Background: Updated IDSA-SHEA guidelines recommend different diagnostic approaches to C. difficile depending on whether There are pre-agreed institutional criteria for patient stool submission. If stool submission criteria are in place, nucleic acid amplification testing (NAAT) alone may be used. If not, a multistep algorithm is suggested, incorporating various combinations of toxin enzyme immunoassay (EIA), glutamate dehydrogenase (GDH), and NAAT, with discordant results adjudicated by NAAT. At our institution, we developed a multistep algorithm leading with NAAT with reflex to EIA for toxin testing if NAAT is positive. This algorithm resulted in a significant proportion of patients with discordant results (NAAT positive and toxin EIA negative) that some experts have categorized as possible carriers or C. difficile colonized. In this study, we describe the impact of a multistep algorithm on hospital-onset, community-onset, and healthcare-facility–associated C. difficile infection (HO-CDI, CO-CDI, and HFA-CDI, respectively) rates and the management of possible carriers. Methods: The study setting was a 399-bed, tertiary-care VA Medical Center in Richmond, Virginia. A retrospective chart review was conducted. The multistep C. difficile testing algorithm was implemented June 4, 2019 (Fig. 1). C. difficile testing results and possible carriers were reviewed for the 5 months before and 4 months after implementation (January 2019 to September 2019). Results: In total, 587 NAATs were performed in the inpatient and outpatient setting (mean, 58.7 per month). Overall, 123 NAATs (21%) were positive: 59 in the preintervention period and 63 in the postintervention period. In the postintervention period, 23 positive NAATs (26%) had a positive toxin EIA. Based on LabID events, the mean rate of HO+CO+HCFA CDI cases per 10,000 bed days of care (BDOC) decreased significantly from 9.49 in the preintervention period to 1.15 in the postintervention period (P = .019) (Fig. 2). Also, 9 of the possible carriers (22%) were treated for CDI based on high clinical suspicion, and 6 of the possible carriers (14%) had a previous history of CDI. Of these, 5 (83%) were treated for CDI. In addition, 1 patient (2%) converted from possible carrier to positive toxin EIA within 14 days. The infectious diseases team was consulted for 11 possible carriers (27%). Conclusions: Implementation of a 2-step C difficile algorithm leading with NAAT was associated with a lower rate of HO+CO+HCFA CDI per 10,000 BDOC. A considerable proportion (22%) of possible carriers were treated for CDI but did not count as LabID events. Only 2% of the possible carriers in our study converted to a positive toxin EIA.

Funding: None

Disclosures: None

Background: Patients with a penicillin/aminopenicillin (PCN) allergy label are more likely to receive non–β-lactam antibiotics and to experience worse clinical outcomes. Given that nurses are often first to interact with patients, we pilot tested a nurse-driven quality improvement initiative to improve PCN allergy documentation and increase β-lactam use. Methods: We conducted a before-and-after study on a labor and delivery unit at The Johns Hopkins Hospital (JHH) from May 2018 to September 2019. Patients aged 18 years with a PCN allergy were included. The intervention included (1) the use of an algorithm developed by the antimicrobial stewardship team to assist nurses in obtaining accurate PCN allergy histories (Fig. 1), (2) identification of a nurse champion to facilitate implementation of the algorithm, and (3) in-person education by a stewardship physician regarding the importance and impact of adequate PCN allergy documentation on clinical outcomes. Readmissions were counted as separate encounters. The primary outcome was improved allergy documentation (either fewer blank documentations, nonspecified rash reactions, drug intolerance documentations (eg, isolated nausea), documentation of signs and symptoms of anaphylaxis not specified as such). The secondary outcome was β-lactam use. Categorical variables were compared using the 2 test and continuous variables were compared with the Student t test. Severe allergic reactions were defined as anaphylaxis, severe skin reactions (eg, Stevens-Johnson syndrome), and organ involvement (eg, hepatitis). Results: Overall, 382 patient admissions were included, 305 in the preintervention (May 2018 to May 2019) and 77 in the postintervention period (June 2019 to September 2019). Mean age and length-of-stay were 30 years and 4 days, respectively, for both periods. The proportion of admitted patients with a PCN allergy label was 8% and 7% for pre- and postintervention periods. Documentation findings in the pre- and postintervention periods respectively were as follows: blank documentation 11% and 12% (P = .89), documentation of specified rashes 0.6% and 1.3% (P = .56), documentation of drug intolerance 11% and 8% (P = .39), documentation of reactions that were indicative of anaphylaxis but not documented specifically as anaphylaxis 8% and 13% (P = .20). Among patients with a documented PCN allergy who received antibiotics, 83 of 177 (47%) and 27 of 43 (63%) received β-lactams (P = .01) in the pre- and postintervention periods, with cefazolin being the antibiotic most commonly used in both periods. Conclusions: Nursing education and an algorithm did not result in significant improvements in PCN allergy documentation in the 3 months after implementation. More data collection is planned to assess the impact of the intervention.

Funding: None

Disclosures: None

Background: Handshake antibiotic stewardship is an effective but resource-intensive strategy for reducing antimicrobial utilization. At larger hospitals, widespread implementation of direct handshake rounds may be constrained by available resources. To optimize resource utilization and mirror handshake antimicrobial stewardship, we designed an indirect feedback model utilizing existing team pharmacy infrastructure. Methods: The antibiotic stewardship program (ASP) utilized the plan-do-study-act (PDSA) improvement methodology to implement an antibiotic stewardship intervention centered on antimicrobial utilization feedback and patient-level recommendations to optimize antimicrobial utilization. The intervention included team-based antimicrobial utilization dashboard development, biweekly antimicrobial utilization data feedback of total antimicrobial utilization and select drug-specific antimicrobial utilization, and twice weekly individualized review by ASP staff of all patients admitted to the 5 hospitalist teams on antimicrobials with recommendations (discontinuation, optimization, etc) relayed electronically to team-based pharmacists. Pharmacists were to communicate recommendations as an indirect surrogate for handshake antibiotic stewardship. As reviewer duties expanded to include a rotation of multiple reviewers, a standard operating procedure was created. A closed-loop communication model was developed to ensure pharmacist feedback receipt and to allow intervention acceptance tracking. During implementation optimization, a team pharmacist-champion was identified and addressed communication lapses. An outcome measure of days of therapy per 1,000 patient days present (DOT/1,000 PD) and balance measure of in-hospital mortality were chosen. Implementation began April 5, 2019, and data were collected through October 31, 2019. Preintervention comparison data spanned December 2017 to April 2019. Results: Overall, 1,119 cases were reviewed by the ASP, of whom 255 (22.8%) received feedback. In total, 236 of 362 recommendations (65.2%) were implemented (Fig. 1). Antimicrobial discontinuation was the most frequent (147 of 362, 40.6%), and most consistently implemented (111 of 147, 75.3%), recommendation. The DOT/1,000 PD before the intervention compared to the same metric after intervention remained unchanged (741.1 vs 725.4; P = .60) as did crude in-hospital mortality (1.8% vs 1.7%; P = .76). Several contributing factors were identified: communication lapses (eg, emails not received by 2 pharmacists), intervention timing (mismatch of recommendation and rounding window), and individual culture (some pharmacists with reduced buy-in selectively relayed recommendations). Conclusion: Although resource efficient, this model of indirect handshake did not significantly impact total antimicrobial utilization. Through serial PDSA cycles, implementation barriers were identified that can be addressed to improve the feedback process. Communication, expectation management, and interpersonal relationship development emerged as critical issues contributing to poor recommendation adherence. Future PDSA cycles will focus on streamlining processes to improve communication among stakeholders.

Funding: None

Disclosures: None

Background: More than 50% of antibiotics used in hospitals are unnecessary or inappropriate. The antimicrobial stewardship programs (ASPs) are coordinated efforts to promote the rational and effective use of antibiotics including appropriate selection, dosage, administration, and duration of therapy. When an ASP integrates infection control strategies, it is possible to decrease the transmission of multidrug-resistant pathogens. Methods: In 2018, 5 Colombian hospitals were selected to implement an ASP. Private and public hospitals from different cities were included in the study, ranging from 200 to 700 beds. Our team, consisting of an infectious disease and hospital epidemiologist, visited each hospital to establish the baseline of their ASP program, to define the ASP outcomes according to each hospital’s needs, and to set goals for ASP outcomes in the following 6–12 months. Follow-up was scheduled every 2 months through Skype video conference. The baseline diagnosis or preintervention evaluation was done using a tool adapted from previous reports (ie, international consensus and The Joint Commission international standards). Documentation related to ASPs, such as microbiological profiles, antimicrobial guidelines (AMG) and indicators for the adherence to them as well as antimicrobial resistance (AMR) prevention through protocols, were written and/or updated. Prevention and infection control requirements and protocols were also updated, and cleaning and antiseptic policies were created. Training in rational use of antibiotic, infection control and prevention, and cleaning and disinfection were carried out with the healthcare workers in each institution. Results: Before the intervention, the development of the ASP according to the tool was 27% (range, 5%–47%). The lowest institutional scores were the item related to ASP feedback and reports (11% on average), followed by education and training (14%), defined ASP responsibilities (23%), ASP function according to priorities (26%), and AMR surveillance (27%). After the intervention, the ASP development increased to 57% (range, 39%–81%) in the hospitals. The highest scores achieved were for education and training (90%), surveillance (75%), and the activities of the infection control committee (70%). The items that made the greatest contribution to ASP development were the individual antibiogram, including the bacteria resistance profile, and the development of the AMG based on the local epidemiology in each hospital. Conclusions: The implementation of an ASP should include training and education as well as defining outcomes according to the hospital’s needs. Once the strategy is implemented, follow-up is key to achieving the goals.

Funding: None

Disclosures: None

Background: Travel screening can facilitate the identification of patients at risk for emerging infectious diseases, such as Middle East respiratory syndrome (MERS). A travel navigator with associated decision support through a best practice advisory (BPA) was implemented in an electronic health record to build upon the CDC identify-isolate-inform framework. Compliance with documentation of travel history, symptom screening when appropriate, and isolation of suspect MERS patients were assessed. Methods: Adult and pediatric emergency department encounters at the Massachusetts General Hospital, a 1,035-bed, tertiary-care, academic health center in Boston, Massachusetts, from August 2018 to October 2019, were included. We categorized an encounter as adherent to initial travel screening if providers answered foreign, domestic, or no travel to the screen. Encounters were defined as nonadherent if they were recorded as unknown or if an answer was not selected. Adherence to completion of data entry for the subgroup of patients with documented foreign travel was further assessed for region- and country-level specification, completion of symptom screen, and response to the MERS BPA (Fig. 1). Results: In total, 127,866 encounters were included, of which 105,593 (83%) were adherent to initial travel screening. Among 4,498 encounters with documented foreign travel, 2,970 (66%) specified the region of travel, and 710 (16%) selected a country of travel from the listing. Moreover, 214 encounters had documented travel to the Middle East. Selection of Middle East or 1 of the 13 countries identified by the CDC as at risk for MERS triggered symptom screening for fever and cough, which was performed in 139 encounters (65%). Of these, 95 encounters documented absence of fever and cough, 15 documented fever and cough, 12 documented a cough alone, and 17 documented a fever alone through reporting or obtaining vitals. The MERS BPA was triggered in 37 encounters; 10 patients were ordered for isolation using the BPA. Of these, 4 patients met CDC criteria for a MERS patient under investigation and were tested; all were negative. Conclusions: Initial screening to document foreign travel is completed at a high rate; however, use of the travel navigator to specify region and country, key components necessary to prompt clinicians for symptom screening, are documented in a minority of encounters. Future interventions are needed to improve region and country capture and appropriate symptom screening, with isolation when appropriate.

Funding: None

Disclosures: None

Background: Antibiotic time outs (ABTOs), formal reassessments of all new antimicrobial regimens by the care team, can optimize antimicrobial regimens, reducing antimicrobial overuse and potentially improving outcomes. Implementation of ABTOs is a substantial challenge. We used quality improvement methods to implement robust, meaningful, team-driven ABTOs in general medicine ward services. Methods: We identified and engaged stakeholders to serve as champions for the quality improvement initiative. On October 1, 2018, 2 internal medicine teaching services (services A and B), began conducting ABTOs on all patients admitted to their services receiving systemic antimicrobials for at least 36 hours. Eligible patients were usually identified by the team pharmacist. ABTOs were completed within 72 hours of antibiotic initiation and were documented in the electronic medical record (EMR) by providers using a template. The process was modified as necessary in response to feedback from frontline clinicians using plan-do-study-act (PDSA) methods. We subsequently spread the project to 2 additional internal medicine services (services C and D); 2 family medicine teams (services E and F); and 1 general pediatric service (service G). The project is ongoing. We collected data for the following metrics: (1) proportion of ABTO-eligible patients with an ABTO; (2) proportion of ABTOs conducted within the recommended time frame; (3) documented plan changes as a result of ABTO (eg, change IV antibiotics to PO); (4) proportion of documented plan changes actually completed within 24 hours. Results: Within 12 weeks, services A and B were successfully completing time outs in >80% of their patients. This target was consistently reached by services C, D, E, F, and G almost immediately following launch on those services. As of June 29, 2019, >80% of eligible patients across all participating services have had a time out conducted for 16 consecutive weeks. ABTOs have resulted in a change in management in 35% of cases, including IV-to-PO change in 19% of cases and discontinuation in 5%. Overall, 77% of time outs occurred during the 36–72-hour window. Ultimately, 95% of documented plan changes were completed within 24 hours. Conclusions: ABTOs are effective but implementation is challenging. We achieved high compliance with ABTOs without using electronic reminders. Our results suggest that ABTOs were impactful in the non–critical-care general medicine setting. Next steps include (1) development of EMR-based tools to facilitate identifying eligible patients and ABTO documentation; (2) continued spread through our health care system; and (3) analysis of ABTO impact using ABTO-unexposed patients as a control group.

Funding: None

Disclosures: None

Background: Bedside nurses have been recognized as potential antibiotic stewards; however, data on effective ways that nurses can contribute to stewardship activities in acute-care hospitals are scarce. Methods: A nurse-driven urine culture intervention to improve urine culture ordering practices was implemented in a medicine and a neurocritical care unit (NCCU) at The Johns Hopkins Hospital. Bedside nurses implemented an algorithm (Fig. 1) developed by the antibiotic stewardship program (ASP) to review the appropriateness of urine culture and to guide discussions with ordering providers regarding unnecessary urine cultures. Nurses received in-person training by an ASP physician champion on how to use the algorithm and education on the definition and indications for evaluation for asymptomatic bacteriuria and urinary tract infections. The ASP physician periodically visited the units to address concerns and questions. In both units, a nurse champion was identified to serve as liaison between the ASP and bedside nurses, and physician support was obtained before the intervention. The pre- and postintervention periods for the medicine unit were September 2017–August 2018 and September 2018–August 2019, respectively. For the NCCU, these periods were September 2018–February 2019 and March 2019–September 2019, respectively. Trends in urine cultures per 100 patient days (PD) were examined with statistical process charts and compared before and after the intervention using a standard incident ratio (IRR) and Poisson regression. Results: In total, 327 urine cultures were collected in the medicine unit and 293 in the NCCU over the study period. Although the intervention led to a significant 34% reduction in the rate of urine cultures on the medicine unit (from 2.3 to 1.5 cultures/100 PD; IRR, 0.66; 95% CI, 0.50–0.87; P < .01), the number of urine cultures remained without a significant change in the NCCU (from 4.5 to 3.7 cultures/100 PD; IRR, 0.89; 95% CI, 0.65–1.22; P = .48) (Fig. 2). Conclusions: Algorithm-based, nurse-driven review of urine culture indications reduced urine cultures on a medicine unit but not in a neurosciences ICU. Success on the medicine unit may have been driven by highly engaged nurse and physician champions and by patients being able to respond questions about symptoms. The following factors might have impacted results on NCCU: presence of conflicting protocols (eg, panculturing patients every 48 hours per a hypothermia protocol), unit tradition (eg, obtaining cultures to assess treatment response), perception of greater risk benefit in NCCU patients, and unit dynamics (open unit with other primary services placing orders for patients). Unit and team dynamics can affect effective implementation of antimicrobial stewardship interventions by nurses.

Funding: None

Disclosures: None

Background:Candida auris is an emerging multidrug-resistant pathogen associated with outbreaks in hospitals and skilled nursing facilities (SNFs). Patients with C. auris can have invasive disease or asymptomatic colonization. Because C. auris can be difficult to treat and eradicate in the environment, the CDC recommends using contact precautions and sporicidal agents during patient care. After C. auris was identified in a patient from an LA County SNF (SNF-X), our institution initiated surveillance screening on high-risk patients. Methods: Nurses identified patients residing at SNF-X on admission and contacted infection prevention. These patients were placed on contact or spore precautions. Bilateral axilla and inguinal folds were swabbed with an Eswab and sent for testing by a clinical laboratory-developed RT PCR assay, which can detect C. auris with high sensitivity and specificity with a rapid turnaround time (4–6 hours). This PCR assay was based on a commercial platform IntegratedCycler (Diasorin) and reagents from the same vendor. Environmental swabs from the index patient’s room were sent for PCR by HardyCHROM Candida agar (Hardy Diagnostics) before and after cleaning with OxyCideTM. PCR-positive samples were set up for culture. Results: In total, 27 patients from SNF-X were screened by PCR. Of these patients, 15 (55%) had a tracheostomy present on admission. Moreover, 26 swabs were negative; 1 was positive in the index patient (cycle threshold [Ct] value, 26). Clinical specimens from the index patient’s blood did not grow C. auris; the tracheostomy sample grew predominantly C. albicans which made identification of C. auris challenging by culture. However, investigational testing of this sample by PCR was positive (Ct value, 31). Environmental swabs collected from the patient room were obtained before and after cleaning (Table 1); all environmental cultures were negative at 5 days. Conclusions: Developing hospital-based, high-risk patient screening for C. auris is feasible and may be useful for controlling the spread of C. auris within the community. Further study is needed to determine the usefulness of PCR for environmental testing to assess the risk of nosocomial transmission of C. auris.

Funding: None

Disclosures: None

Background: In recent years, several rapid molecular diagnostic tests (RMDTs) for infectious diseases diagnostics, such as bloodstream infections (BSIs), have become available for clinical use. The extent to which RMDTs have been adopted and how the results of these tests have been incorporated into clinical care are currently unknown. Methods: We surveyed members of the Society for Healthcare Epidemiology of America Research Network to characterize utilization of RMDT in hospitals and antimicrobial stewardship program (ASP) involvement in result communication and interpretation. The survey was administered using Qualtrics software, and data were analyzed using Stata and Excel software. Results: Overall, 57 responses were received (response rate, 59%), and 72% were from academic hospitals; 50 hospitals (88%) used at least 1 RMDT for BSI (Fig. 1). The factors most commonly reported to have been important in the decision to adopt RMDT were improvements in antimicrobial usage (82%), clinical outcomes (74%), and laboratory efficiency (52%). Among 7 hospitals that did not use RMDT for BSI, the most common reason was cost of new technology. In 50 hospitals with RMDT for BSI, 54% provided written guidelines for optimization or de-escalation of antimicrobials based upon RMDT results. In 40 hospitals (80%), microbiology laboratories directly notified a healthcare worker of the RMDT results: 70% provided results to a physician, nurse practitioner, or physician assistant; 48% to the ASP team; and 33% to a nurse. Furthermore, 11 hospitals (22%) had neither guidelines nor ASP intervention. In addition, 24 hospitals (48%) reported performing postimplementation evaluation of RMDT impact. Reported findings included reduction in time to antibiotic de-escalation (75%), reduction in length of stay (25%), improved laboratory efficiency (20%), and reduction in mortality and overall costs (12%). Among the 47 hospitals with both RMDT and ASP, 79% reported that the ASP team routinely reviewed blood culture RMDT results, and 53.2% used clinical decision support software to do so. Finally, 53 hospitals (93%) used 1 or more RMDT for non–bloodstream infections (Fig. 1). Fewer than half of hospitals provided written guidelines to assist clinicians in interpreting these RMDT results. Conclusions: RMDTs have been widely adopted by participating hospitals and are associated with positive self-reported clinical, logistic, and financial outcomes. However, nearly 1 in 4 hospitals did not have guidelines or ASP interventions to assist clinicians with optimization of antimicrobial prescribing based on RMDT results for BSI. Also, most hospitals did not have guidelines for RMDT results for non-BSI. These findings suggest that opportunities exist to further enhance the potential benefits of RMDT.

Funding: None

Disclosures: None

Background: Surgical site infections (SSIs) are a major healthcare quality issue; they lead to increased morbidity and mortality rates. They also prolong the length of stay and increase the cost to the patient and the healthcare system. Depending on the procedure, the risk of death is 2 to 11 times greater for patients with an SSI than for patients without an SSI. Additionally, the financial burden and patient burden is considerable; it ranks as the most common and costly of hospital-acquired infections (HAIs) and can extend a patient’s length of stay by 11.2 days. The risk of developing an SSI is affected by multiple factors at the patient, operative, and institutional levels. Methods: A Midwestern healthcare system conducted a review of the recommended best-practice guidelines that are currently accepted as the standards of care in US healthcare facilities. A gap analysis instrument for colorectal SSI prevention was drafted and reviewed for content validity and accuracy by field experts. Hospital infection preventionists worked in conjunction with operating room leaders to disseminate the survey to staff. Responses were collected from June 5 to June 30, 2019. Concurrently, the system infection preventionist team developed a standardized SSI dashboard template that could be used at the hospital, regional, and system level to visualize SSI infection counts, standardized infection ratios (SIRs) as well as procedure count data. These dashboard reports are updated and distributed on a monthly basis to each hospital’s campus executive team and other leaders. Federal- and state-required procedures were included and additional procedures were included based on hospital risk. Results: In total, 35 responses were recorded from 8 ministries across the system. Infection preventionists, operating room directors, physicians, nurses, and surgical technologists were represented among the respondents. The following areas were identified areas for improvement: use of chlorhexidine gluconate (CHG) bathing kit, mechanical bowel preparation with preoperative oral antibiotics, hair removal practices, use of fascial wound protector, maintenance of patients’ blood glucose levels, glove and gown changing procedures, and use of antimicrobial-coated sutures. The development and distribution of the SSI dashboard increased awareness and knowledge of SSIs by hospital and system-level leaders. Conclusions: The implementation of both the gap analysis and dashboard reports improved the awareness areas needed for improvement and knowledge of the burden of SSIs. These findings will drive discussions within the hospitals and at the system-level to implement evidence-based practice to improve care and decrease infections as well as guide the development of SSI patient care bundles.

Funding: None

Disclosures: None

Background:Clostridioides difficile infection (CDI) is the most common cause of infectious diarrhea in hospitalized patients. Probiotics have been studied as a measure to prevent CDI. Timely probiotic administration to at-risk patients receiving systemic antimicrobials presents significant challenges. We sought to determine optimal implementation methods to administer probiotics to all adult inpatients aged 55 years receiving a course of systemic antimicrobials across an entire health region. Methods: Using a randomized stepped-wedge design across 4 acute-care hospitals (n = 2,490 beds), the probiotic Bio-K+ was prescribed daily to patients receiving systemic antimicrobials and was continued for 5 days after antimicrobial discontinuation. Focus groups and interviews were conducted to identify barriers, and the implementation strategy was adapted to address the key identified barriers. The implementation strategy included clinical decision support involving a linked flag on antibiotic ordering and a 1-click order entry within the electronic medical record (EMR), provider and patient education (written/videos/in-person), and local site champions. Protocol adherence was measured by tracking the number of patients on therapeutic antimicrobials that received BioK+ based on the bedside nursing EMR medication administration records. Adherence rates were sorted by hospital and unit in 48- and 72-hour intervals with recording of percentile distribution of time (days) to receipt of the first antimicrobial. Results: In total, 340 education sessions with >1,800 key stakeholders occurred before and during implementation across the 4 involved hospitals. The overall adherence of probiotic ordering for wards with antimicrobial orders was 78% and 80% at 48 and 72 hours, respectively over 72 patient months. Individual hospital adherence rates varied between 77% and 80% at 48 hours and between 79% and 83% at 72 hours. Of 246,144 scheduled probiotic orders, 94% were administered at the bedside within a median of 0.61 days (75th percentile, 0.88), 0.47 days (75th percentile, 0.86), 0.71 days (75th percentile, 0.92) and 0.67 days (75th percentile, 0.93), respectively, at the 4 sites after receipt of first antimicrobial. The key themes from the focus groups emphasized the usefulness of the linked flag alert for probiotics on antibiotic ordering, the ease of the EMR 1-click order entry, and the importance of the education sessions. Conclusions: Electronic clinical decision support, education, and local champion support achieved a high implementation rate consistent across all sites. Use of a 1-click order entry in the EMR was considered a key component of the success of the implementation and should be considered for any implementation strategy for a stewardship initiative. Achieving high prescribing adherence allows more precision in evaluating the effectiveness of the probiotic strategy.

Funding: Partnerships for Research and Innovation in the Health System, Alberta Innovates/Health Solutions Funding: Award

Disclosures: None

Background: Mandatory reporting of all healthcare-associated infections (HAIs) leads to substantial surveillance volume for infection prevention and control (IPC) programs. Prior to 2019, 6 infection preventionists were performing system-wide surveillance for all infection types using NHSN definitions at a large quaternary-care center in Pennsylvania. Limited surveillance validation was performed. With the continued expansion of the health system, increased demands for IPC expertise, and a growing team, the need for streamlined surveillance, and a validation program were identified. Methods: A surveillance training program for novice team members was developed and implemented. Infection prevention associates (IPAs), whose primary role was data management, began training. The new program included NHSN training videos, direct observation of surveillance with infection preventionists and practice case studies. Following training, IPAs performed surveillance for experienced infection preventionists covering high-risk inpatient units. To ensure high reliability, surveillance validation was initiated. Each month, ~10% of investigated infections were randomly pulled from the electronic surveillance system and divided among experienced infection preventionists. These validators performed unbiased reviews of the charts based on limited data, including patient demographics and culture results. Validation documentation included noting whether an infection was reportable to NHSN and a rationale. Data on whether or not each patient had a complex medical history and time spent validating each case were collected. Compliance of validator documentation aligning with original documentation was tracked. Discrepancies were discussed as a team and were adjudicated as needed. IPAs tracked hours spent on surveillance to capture effort transitioned from infection preventionists. Results: Between March and July 2019, an average of 223 (range, 178–261) potential infections were reviewed per month. From March through June 2019, 61 infections were selected for validation, with 98% compliance with original documentation. One minor discrepancy was attributed to interpretation of documentation in the medical record. Medical complexity accounted for 78% of reviews and validation time spent averaged 12 minutes per infection (range, 3–28 minutes). Self-reported effort directed from infection preventionists to 2 IPAs for surveillance was ~20 hours per week. An additional IPA was hired to perform surveillance in addition to other job responsibilities. Conclusions: Centralized surveillance programs can promote high reliability and cost-efficient IPC staffing for large healthcare systems, especially those with mandatory reporting requirements or medically complex patient populations. Improving surveillance skills among associate staff can increase experienced infection preventionist bandwidth for project management, staff supervision, and other leadership responsibilities. Lastly, validation programs are crucial to ensuring quality assurance of data reporting to both internal and external stakeholders.

Funding: None

Disclosures: None

Background: Personal protective equipment (PPE) is defined by the Occupational Safety and Health Administration as specialized clothing or equipment worn by an employee for protection against infectious materials. They include gloves, gowns, masks, respirators, googles and face shields. The CDC has issued guidelines on appropriateness of when, what, and how to use PPE. Despite these guidelines, compliance with PPE remains challenging. Methods: We implemented a massive hospital-wide rapid education program on PPE donning and doffing of all employees and staff. This program included an online video, return demonstration and just-in-time training. To develop the program, we recorded PPE training video, reviewed PPE validation checklist, developed new isolation precaution signage with quick response (QR) code to video, developed a nutrition tray removal video and a equipment cleaning video, developed family and visitor guidelines for isolation precautions, and created an audit tool for PPE donning and doffing practices. The program required interdisciplinary collaboration including administration, infection prevention, nursing education, central supply, environmental services, facility maintenance, and security. Results: The first phase of the program was implemented through 30 separate 4-hour PPE skills fair offered over 48 hours. In total, 500 staff members were trained in the first 48 hours; 6 additional 3-hour sessions were provided on site in the following 3 month. Additionally, training was provided in off-site clinics, physician leadership meetings, new-hire orientation for nursing staff, and monthly resident and fellow training through graduate medical education. As needed, training was provided by infection prevention, nursing education, and floor nurses. In total, 5,237 staff members were trained within 3 months after implementation. Actual audit results (50 audits per week) showed improved and sustained compliance to >94%. Conclusions: A massive hospital-wide educational program including online video, return demonstration, and just-in-time training is a feasible and very effective method to improve compliance with PPE donning and doffing. A multidisciplinary team approach, administration support, and continuous education and audits are key factors in successful implementation.

Funding: None

Disclosures: None