American Hospital Association

Infants with past NICU admission have a significantly higher risk of developing neurodevelopmental disorders. Studies have demonstrated an iatrogenic effect of the NICU environment on neurodevelopmental outcomes, even while accounting for physical factors. It is, therefore, critical that an infant's LOS is driven by physical needs versus sociodemographic barriers. We leveraged electronic health records and a backward selection regression model to explore physical and sociodemographic predictors of infant LOS. Our results demonstrated that physical predictors (birthweight and ventilator use) accounted for the majority of variance in our model but that a sociodemographic predictor, mean visits per day, was also significant. Infants who were visited more frequently experienced a shorter LOS, possibly due to increased parental involvement resulting in more individualized care and directly impacting infant stability and morbidity. By supporting visitation, we can reduce the costs of lengthy NICU hospitalizations while improving infant and parent health and well-being.

Hospital equity officers have become critical leaders in the effort to address the determinants of health care disparities, including structural racism. In this mixed-methods study, we surveyed a national sample of equity officers and interviewed a subset of respondents to provide additional perspective. About one-half of survey respondents reported at least some obstacles to achieving their health equity objectives, including racist beliefs among people working in their hospitals and health care systems, policies that perpetuate racism, and a lack of staff diversity. To address these challenges, some hospitals are collecting information about instances of racism, reviewing clinical algorithms for evidence of bias, or forming community partnerships. However, in interviews, equity officers pointed out that racism is a public health issue that cannot be adequately addressed solely within the health care system. Given the relative newness of most hospital equity officer positions, our research may be viewed as an early glimpse into the challenges and opportunities of this evolving work.

Disaster preparedness for a burn mass casualty incident (BMCI) must consider the needs of the first responders and community hospitals, who may be the first to receive those patients. Developing a more comprehensive statewide burn disaster program includes meeting with regional healthcare coalitions (HCCs) to identify gaps in care. Quarterly HCC meetings, which link local hospitals, emergency medical services (EMS) agencies, and other interested parties, are held around the state. We rely on the HCC's regional meetings to serve as a platform for conducting focus group research to identify gaps specific to a BMCI and to inform strategy development. One of the deficiencies identified, particularly in rural areas that infrequently manage burn injuries, was a lack of burn-specific wound care dressings that could support the initial response. Relying on this process, a consensus was created for equipment types and quantities, including a kit for storage. Furthermore, maintenance, supply replacement, and scene delivery processes were developed for these kits that could augment a BMCI response. The feedback from the focus groups reminded us that many systems report having infrequent opportunities to provide care for patients with burn injuries. Additionally, several types of burn-specific dressings are expensive. With the infrequent occurrence, EMS agencies and rural hospitals reported that it was doubtful their agency/hospital would have more than a minimal stock of burn injury supplies. Therefore, developing supply caches that can be quickly mobilized and deployed to the impacted area was one of the deficiencies we identified and addressed through this process.

Background: Ohio First Steps for Healthy Babies (First Steps) is a free, voluntary statewide designation program coadministered by the Ohio Department of Health and the Ohio Hospital Association that promotes breastfeeding-supportive maternity practices aligned with the Baby-Friendly Hospital Initiative (BFHI).Materials and Methods: We examined Ohio birthing hospitals’ participation in First Steps, and changes in breastfeed-ing rates at hospital discharge, over the first 12 quarters of the program (July 15, 2015, to July 14, 2018) for all 110 licensed Ohio birthing hospitals. The 81 (73.6%) that achieved at least 1 step over the study period (designated as First Steps hospitals) were compared to the 29 non-First Steps hospitals, and the 17 that began participation at First Steps startup (July 15, 2015) were identified for additional analysis. Changes in breastfeeding rates were examined using a mixed effects multivariate regression model.Results: Breastfeeding increased significantly over the program period from 73.8% to 76.7% (mean 0.19% per quarter, p = .0002), but without a significant difference in breastfeeding rates between First Steps and non-First Steps hospitals. However, in a pre- and post-program analysis for the 17 hospitals that began participation at First Steps startup (excluding an additional 6 hospitals with BFHI designation), number of quarters in the program, number of steps completed, and number of births in 2015 were significantly associated with breastfeeding rates. Hospitals that completed at least 2 steps every 5 quarters in the First Steps program increased breastfeeding when compared to those not participating in the program.Conclusion: These encouraging results provide a formal evaluation of a best practices BFHI-modelled statewide program.

Children's access to dental general anesthesia (DGA) is limited, with highly variable wait times. Access factors occur at the levels of facility, dental provider, and anesthesia provider. It is unknown if these factors also influence utilization of dental surgery. We characterized patterns in DGA utilization by system, provider, population, and individual disease levels to explain variation. We conducted a cross-sectional analysis of Medicaid-enrolled children (≤9 y) who received DGA in Massachusetts, Maryland, Texas, Connecticut, Washington, Illinois, and Florida from 2011 to 2012. DGA events were characterized by the place of service, measures of disease burden, average reimbursements for dental provider and anesthesia provider, and average total expenditures. A total of 10,149,793 children met study eligibility criteria. States with similar patterns of caries-related visits, such as Illinois (16% of Medicaid enrollees had a caries-related claim) and Washington (22%), had different DGA rates (1% and 17%, respectively). Reimbursement rates for dental providers, DGA services, and nonhospital places of services did not consistently align in states with higher DGA rates. Surgical extraction rates, as a proxy for the most severe disease, exceeded 75% in Maryland, which had the lowest DGA rate (0.3%). Variation in DGA rates across states was not explained by reimbursements rates (provider, DGA services, place of service) or population or individual level of caries burden. Efforts to evaluate and alter utilization of DGA should consider factors such as dental and anesthesia provider capacity, health facility capacity (hospital vs. ambulatory surgery center vs. office), and population- and individual-level disease burden. Our negative findings suggest the presence of other social determinants of oral health that influence utilization of services (e.g., race/ethnicity, language preference, immigration status, policy and budget goals), which should be explored. Our findings also raise the specter that variation in surgical rates may represent instances of unmet needs or overtreatment. The results of this study can be used by clinicians and policy makers as they address policy and clinical interventions to influence children with severe caries. Interventions to change utilization of surgical services on a population level may need to include state-specific factors that extend beyond reimbursement, disease burden, anesthesia provider type, or facility type.

Every day in the United States, health professionals confront the effects of firearm injury. In emergency rooms, trauma centers, ambulatory offices, and acute care and rehabilitation facilities, health professionals and the health systems they work within attempt to heal the wounds that firearms can inflict on individuals and their families. Thus, hospitals and health systems are in a position to grasp the scope of the issue and find opportunities to prevent firearm injury and death. In 2016 and 2017, the physicians and nurses at Kaiser Permanente treated more than 3,400 gunshot victims. These patients—from a single health system among the hundreds that operate across the United States—are a sobering reminder of the toll of firearm injury. Firearm injury—including other-directed, self-directed, and unintentional injury and death—is a broad-based public health issue. In 2016, more than 38,000 people were killed by firearms.1 In the same year, half of those who died by suicide used a firearm, and three quarters of homicides involved a firearm.1 Firearm death is the third leading cause of death for children under age 17 in the United States. A social network analysis by Kalesan and colleagues2 showed that almost everyone in the United States, at some point, will know someone injured or killed by a firearm. The nature of the injury varies—homicide is the more likely cause of a firearm death in an urban area, whereas suicide is more likely in a rural area—but every community in every geographic region and every socioeconomic stratum is … Address correspondence to: Questions or comments should be directed to Melissa French at mfrench{at}nas.edu.

Catheter-associated urinary tract infection (UTI) in nursing home residents is a common cause of sepsis, hospital admission, and antimicrobial use leading to colonization with multidrug-resistant organisms. To develop, implement, and evaluate an intervention to reduce catheter-associated UTI. A large-scale prospective implementation project was conducted in community-based nursing homes participating in the Agency for Healthcare Research and Quality Safety Program for Long-Term Care. Nursing homes across 48 states, Washington DC, and Puerto Rico participated. Implementation of the project was conducted between March 1, 2014, and August 31, 2016. The project was implemented over 12-month cohorts and included a technical bundle: catheter removal, aseptic insertion, using regular assessments, training for catheter care, and incontinence care planning, as well as a socioadaptive bundle emphasizing leadership, resident and family engagement, and effective communication. Urinary catheter use and catheter-associated UTI rates using National Healthcare Safety Network definitions were collected. Facility-level urine culture order rates were also obtained. Random-effects negative binomial regression models were used to examine changes in catheter-associated UTI, catheter utilization, and urine cultures and adjusted for covariates including ownership, bed size, provision of subacute care, 5-star rating, presence of an infection control committee, and an infection preventionist. In 4 cohorts over 30 months, 568 community-based nursing homes were recruited; 404 met inclusion criteria for analysis. The unadjusted catheter-associated UTI rates decreased from 6.78 to 2.63 infections per 1000 catheter-days. With use of the regression model and adjustment for facility characteristics, the rates decreased from 6.42 to 3.33 (incidence rate ratio [IRR], 0.46; 95% CI, 0.36-0.58; P < .001). Catheter utilization was 4.5% at baseline and 4.9% at the end of the project. Catheter utilization remained unchanged (4.50 at baseline, 4.45 at conclusion of project; IRR, 0.95; 95% CI, 0.88-1.03; P = .26) in adjusted analyses. The number of urine cultures ordered for all residents decreased from 3.49 per 1000 resident-days to 3.08 per 1000 resident-days. Similarly, after adjustment, the rates were shown to decrease from 3.52 to 3.09 (IRR, 0.85; 95% CI, 0.77-0.94; P = .001). In a large-scale, national implementation project involving community-based nursing homes, combined technical and socioadaptive catheter-associated UTI prevention interventions successfully reduced the incidence of catheter-associated UTIs.

OBJECTIVE The impact of healthcare system integration on infection prevention programs is unknown. Using catheter-associated urinary tract infection (CAUTI) prevention as an example, we hypothesize that US Department of Veterans Affairs (VA) nursing homes have a more robust infection prevention infrastructure due to integration and centralization compared with non-VA nursing homes. SETTING VA and non-VA nursing homes participating in the AHRQ Safety Program for Long-Term Care collaborative. METHODS Nursing homes provided baseline information about their infection prevention programs to assess strengths and gaps related to CAUTI prevention via a needs assessment questionnaire. RESULTS A total of 353 of 494 nursing homes from 41 states (71%; 47 VA and 306 non-VA facilities) responded. VA nursing homes reported more hours per week devoted to infection prevention-related activities (31 vs 12 hours; P<.001) and were more likely to have committees that reviewed healthcare-associated infections. Compared with non-VA facilities, a higher percentage of VA nursing homes reported tracking CAUTI rates (94% vs 66%; P<.001), sharing CAUTI data with leadership (94% vs 70%; P=.014) and with nursing personnel (85% vs 56%, P=.003). However, fewer VA nursing homes reported having policies for appropriate catheter use (64% vs 81%; P=.004) and catheter insertion (83% vs 94%; P=.004). CONCLUSIONS Among nursing homes participating in an AHRQ-funded collaborative, VA and non-VA nursing homes differed in their approach to CAUTI prevention. Best practices from both settings should be applied universally to create an optimal infection prevention program within emerging integrated healthcare systems. Infect Control Hosp Epidemiol 2017;38:287-293.