Background: Outpatient Parenteral Antimicrobial Therapy (OPAT) moves specialized, technically demanding care from hospitals to homes, where patients and caregivers take on tasks performed traditionally by trained nurses. However, infection prevention research rarely examines the home environment where OPAT administration and intravenous (IV) line management increasingly occur. Standard quantitative and qualitative approaches (e.g., surveys, interviews) may miss subtle medication administration deviations, environmental constraints, and other challenges that influence IV catheter- and medication-related risks. Video Reflexive Ethnography (VRE) and Photo Elicitation Interviews (PEI) offer a way to observe medication administration processes directly and to incorporate patient and caregiver perspectives to improve infection prevention education and practices. Methods: Using a VRE approach, we videorecorded discharge teaching and in-home OPAT routines, then conducted reflexive sessions in which patients and caregivers reviewed their own discharge teaching videos and discussed aspects of the process they found helpful, unclear, or challenging within their home environments. PEI added a participant-driven perspective by inviting patients and caregivers to photograph features of their home care setup that facilitated or hindered antibiotic administration and IV handling. Figure 1 demonstrates the steps in data collection. The Systems Engineering Initiative for Patient Safety Results: Observations of four patients, both in hospital and at home, revealed that visual methods captured behavioral details (e.g., using teeth to open syringe packaging) not typically discussed in interviews. Reflexive sessions and photo elicitation interviews highlighted uncertainties (e.g., doubts about correct processes), challenges with medication or IV-line maintenance (e.g., difficulty with IV clamps), and practical strategies for managing complex care tasks at home (e.g., hanging IV bag from wall hook rather than IV pole). These methods provided deeper insights into patients' experiences with care. Conclusions: This study demonstrates how VRE and PEI used together can strengthen infection prevention research. Both methodologies in concert provide new insight into how real-world patient and caregiver behaviors, constraints, and teaching gaps shape IV-line care, medication administration, and overall safety outside the hospital. By providing a clearer view of OPAT-related care as it occurs in home settings, this work shows promise for informing future refinement of education and IV medication administration guidance. This work is especially relevant given the growing complexity of infection-related care, including care delivered outside the hospital setting, requiring new approaches to understand and support patient safety.

Background:Hospital-onset urinary tract infections (HOUTIs), including catheter-associated (CAUTI) and non-catheter-associated UTI (non-CAUTI), remain a significant source of morbidity and healthcare burden. While CAUTI prevention strategies are well established, non-CAUTIs lack standardized definitions, surveillance protocols, and targeted interventions. To address this gap, consensus recommendations identifying prevention strategies for HOUTIs in adult patients were developed. Methods:A panel of 17 experts in infectious diseases, infection prevention and control, healthcare epidemiology and quality improvement, clinical microbiology, urology, urogynecology, and nursing, participated in a modified Delphi process. An online anonymized survey based on a systematic literature review was completed, before meeting to determine consensus on HOUTI prevention strategies. A further anonymous online survey was shared to finalize recommendations. Thresholds of ≥15/17 panel members in agreement (≥88%) for strong consensus and ≥13/17 (≥76%) for moderate consensus were prospectively set for all statements. Results:Strong consensus was reached on 37 statements spanning surveillance, intervention selection, strategies and maintenance, related care interventions, specimens and cultures, provider training, and outcome assessment. Key topics-particularly those focused on non-CAUTI HOUTI prevention-were identified as important priorities requiring further exploration and research. Conclusions:These recommendations offer the foundation for a structured, scalable framework to reduce the burden of all HOUTIs, while also defining future research priorities. By harmonizing established CAUTI best practices with existing literature, and bridging current evidence gaps for non-CAUTI prevention and management with expert consensus, these recommendations provide a road map for improved prevention strategies for all HOUTIs.

When chronic kidney disease (CKD) progresses to end-stage kidney disease (ESKD), many patients receive in-center hemodialysis. Although lifesaving, hemodialysis is associated with intradialytic hypotension (IDH), a common complication that can cause distressing symptoms and lead to organ and tissue damage. Peer mentoring and patient activation have supported self-management in other chronic illnesses, but their use to improve hemodialysis session stability has not been well studied. The Dialysafe Study combined patient education and peer mentoring to promote health behaviors supporting hemodialysis session stability. We aimed to describe intervention recruitment, engagement, completion, and attrition; assess participants’ health goals and self-reported behavior changes; and evaluate satisfaction and recommendations for improvement. Ten Dialysafe hemodialysis centers were assigned to patient activation, and all eligible English-speaking patients were invited. The intervention included 5 tablet-based educational modules and 5 corresponding videoconference peer mentoring sessions. Analyses integrated electronic health record demographic and clinical data, intervention-platform usage data, postintervention surveys, and qualitative notes from clinic Operations Committee meetings. A weighted engagement score ranging from 0-50 summarized completion of mentoring sessions, goal-setting, videos, quizzes, and patient stories, with greater weight assigned to the more interactive mentoring and goal-setting elements. Descriptive statistics, t-tests, chi-square tests and regression models assessed recruitment, completion (defined as completing all 5 mentoring sessions), and engagement. Qualitative data were inductively coded in NVivo and integrated with quantitative findings via joint displays. Approximately one-quarter (155/639, 24.3%) of eligible patients were recruited to the intervention. Recruitment was more likely among younger, college-educated patients and those with sleep disorders. Of recruited patients, 46.5% (72/155) met with a peer mentor at least once. The average engagement score was 18.37 out of 50 possible points. Overall engagement was higher among men, Black patients, patients newer to dialysis, and those with more comorbidities. Attrition was concentrated before mentoring sessions began, and younger age and more comorbidities predicted completion. Communication with the care team was the most frequently patient-selected behavior change goal and the most frequently identified behavior change. Both mentees and mentors identified peer mentoring sessions as the most valuable part of the intervention, and both were highly satisfied with the intervention activities. Participants in the patient activation intervention were a self-selecting group who likely were already more engaged in their care than others in their clinics. However, that “communication with care team” was the most frequently selected health behavior goal and health behavior change demonstrates the importance and challenge of patient-clinician communication, even among highly activated patients. Mentees and mentors described the mentoring relationship as a highlight of the intervention. Digital patient activation interventions using peer mentoring may promote personal connection and improvements in communication with healthcare providers among the dialysis patient population, though reach is limited. ClinicalTrials.gov NCT03171545 RR2-10.2196/46187

INTRODUCTION:Central nervous system (CNS) -active polypharmacy, defined as concurrent use of antidepressants, antipsychotics, anti-seizure medications, benzodiazepines, nonbenzodiazepine benzodiazepine receptor agonists, opioids, or skeletal muscle relaxants for ≥ 31 consecutive days, poses significant risks patients with dementia. METHODS:Among community-dwelling patients in Medicare plans aged ≥ 65 with dementia and Medicare Part D coverage in 2021, we determined the rate of CNS-active polypharmacy initiation as well as medication and prescribing clinician characteristics. RESULTS:Among beneficiaries with dementia (n = 1,214,928, mean age 81.6 years), 7.8% (n = 94,190) experienced incident polypharmacy. Antidepressants were the most frequent class (92.3%), and quetiapine (30.9%), gabapentin (29.0%), and trazodone (28.3%) the top individual medications. At the time of initiation, 43.8% of patients were prescribed all CNS-active medications by a single clinician; primary care clinicians accounted for most polypharmacy prescriptions. DISCUSSION:Interventions to address polypharmacy should focus on development of guidelines targeting individual prescribers to help clarify appropriate use of CNS-active medications.

BACKGROUND:Overdiagnosis of urinary tract infections (UTIs) and unnecessary antibiotics are common. This is particularly true in older adult populations such as veterans. Diagnostic stewardship can decrease overdiagnosis and overtreatment, but optimal implementation of such interventions has not been fully studied. METHODS:This was a multicenter hybrid type 2 effectiveness-implementation study of UTI diagnostic stewardship interventions at 3 participating Veterans Administration hospitals. Each hospital implemented 1 intervention at either the ordering, processing (conditional reflex urine culturing), or reporting stage. The primary outcome was inpatient UTI antibiotic days of therapy (DOTs) per admission evaluated using generalized estimating equations. Secondary outcomes included rates of urine cultures ordered and performed and a safety measure of secondary bacteremia from a uropathogen. RESULTS:A total of 37 085 hospital admissions occurred in the preintervention phase and 17 221 in the postintervention phase. Of these, 6914 (12.7%) included UTI antibiotics. Hospital 3, which implemented conditional reflex urine culturing, had a 39.5% reduction in UTI DOT (95% confidence interval, 13.9-57.5) in the year following the intervention. Additionally, hospital 3 noted fewer urine cultures ordered (22.8% immediate and 35.7% slope reduction) and performed (38.9% immediate and 38.8% slope reduction). No change in UTI DOT was observed for ordering or results reporting interventions at other hospitals. There was no difference in the safety measure of uropathogen bacteremia. CONCLUSIONS:Conditional reflex urine culturing had a large decrease on UTI antibiotic DOTs and urine cultures performed. Health systems or medical centers starting urine culture diagnostic stewardship should implement conditional reflex urine culturing first. Article Summary: A multicenter pragmatic pre-/poststudy in Veterans Administration hospitals found that conditional reflex urine culturing significantly reduced urinary tract infection antibiotic use and urine cultures without increasing bacteremia, highlighting its potential as a high-value diagnostic stewardship intervention among older hospitalized adults.

Background: Outpatient parenteral antimicrobial therapy (OPAT) is a common approach to treating complex infections, offering benefits of higher patient satisfaction, reduced risk of hospital-acquired infections, and lower healthcare costs. However, limited information exists regarding how OPAT is delivered across U.S. healthcare systems. We sought to understand OPAT practices and identify facilitators and barriers to OPAT delivery at Veterans Affairs (VA) medical centers (VAMCs), which constitute the largest integrated healthcare system in the U.S. Methods: We conducted a national survey of VAMCs between January-April 2025. OPAT providers were invited via email to complete an online Qualtrics survey. Topics included care delivery, patient monitoring, and perceived challenges to safe, effective OPAT care. Data were summarized using descriptive statistics. Results: Of 139 surveys, 106 (76.3%) were completed and analyzed. Most VAMCs offered OPAT (78/106; 73.6%). Among those, 60/78 (76.9%) designated OPAT providers to monitor and manage care, often Infectious Disease (ID) physicians (54/60; 90.0%) and ID pharmacists (44/60; 73.3%). Dedicated time for OPAT care activities varied by site and role. Guidelines for OPAT care were reported at 45/78 (57.7%) VAMCs, typically outlining eligibility criteria as well as protocols for patient monitoring and follow-up. Generally, VAMCs required ID consultation prior to discharge and discharged 1-10 patients on OPAT per month, most of whom were followed by ID providers. OPAT-related outcomes were measured by about half of VAMCs (40/78; 52.6%); adverse events were most frequently measured. OPAT delivery extended beyond VAMCs through referrals to outside healthcare systems and collaboration with contract infusion pharmacies and home health agencies (Table 1). Respondents noted challenges to providing safe OPAT care, including dedicated time, communication with organizations outside the VA, and timeliness of labs (Figure 1). Conclusions: While individual VAMCs varied in delivery practices, key elements across programs included designated providers and defined OPAT care components. Challenges were driven by fragmented care, which hindered communication and coordination. Expanding VAMC capacity to provide OPAT and monitor patients may streamline communication, delivery, and continuity. A process map for referrals outside the VA may help designate roles and responsibilities for monitoring and providing OPAT care.

Abstract Background Infections with Clostridioides difficile are associated with prolonged hospital stays, higher costs, and significant morbidity. Artificial intelligence (AI) tools can accurately predict which hospitalized patients are most likely to acquire C. difficile infection (CDI). However, to date, such tools have not been used in clinical practice. We investigated how AI tools for CDI risk stratification could be integrated into clinical workflows to promote targeted infection prevention efforts. Details of the infection prevention bundle (a) Screenshot of the BPA for enhanced handwashing precautions. This BPA instructs the receiving provider to place an order for putting up the “Enhanced Handwashing Precautions” sign, depicted in Figure 2. (b) Screenshot of the BPA for antimicrobial stewardship. This BPA is educational and provides a list of recommendations for reducing risk of CDI, including discontinuing unnecessary acid suppressants, minimizing unnecessary antibiotics, consulting the beta-lactam allergy evaluation service, and encouraging patient to eat yogurt if appropriate. Methods A previously validated AI model for predicting CDI risk from routinely collected data in electronic health records was used to generate daily risk scores for adult inpatients presenting to Michigan Medicine between January 1, 2023 and December 31, 2023. These scores were used to focus infection prevention efforts on high-risk patients in 10 selected hospital units with the greatest concentration of CDI cases. The infection prevention bundle, aimed at reducing both susceptibility and exposure, included provider-facing best practice alerts (BPAs) for enhanced handwashing precautions and antimicrobial stewardship (Figure 1). Using retrospective data, we determined a risk threshold that targets 5 alerts/unit/week on average. Clinical staff on selected units were educated about the AI tool by the study team. Picture of the “Enhanced Handwashing Precautions” sign This sign is placed on the door of the rooms for high-risk patients in selected hospital units and instructs all persons to wash their hands with soap and water upon room entry. Results During the study, 12,983 hospitalizations corresponding to 10,815 patients were assessed daily by the model, totaling 109,068 CDI risk scores. Among this population, 2,151 (16.6%) high-risk hospitalizations exceeded the risk threshold and triggered BPAs (an average of 4.1 alerts/unit/week). Among the high-risk population, 1,647 (76.6%) and 117 (5.4%) hospitalizations received an order for enhanced handwashing precautions and an order for a β-lactam allergy evaluation consultation, respectively. Field observations and interviews with clinical staff revealed challenges associated with behavior changes such as compliance with handwashing using soap and water to remove spores. Conclusion AI tools can be integrated into clinical workflows to promote targeted infection prevention efforts. However, continuous monitoring of how such tools interact with existing workflows and education on novel infection prevention strategies are key to success. Disclosures Krishna Rao, MD, MS, Merck and Company, Inc.: Grant/Research Support|Rebiotix Inc.: Advisor/Consultant|Seres Therapeutics: Advisor/Consultant|Summit pharmaceuticals: Advisor/Consultant

Background: Variability in outpatient parenteral antimicrobial therapy (OPAT) management and challenges to providing recommended OPAT care can compromise patient safety and care quality. Little is known about how OPAT is currently delivered by healthcare systems across the United States (US), including within the Veteran’s Health Administration (VHA). We sought to understand and compare OPAT delivery at selected Veterans Affairs medical centers. Method: Using a qualitative methodology, we conducted semi-structured interviews with key informants involved in OPAT delivery at 6 VHA medical centers with different complexity levels in the Midwestern US. Facility complexity is determined by patient volume and complexity level along with the amount of teaching and research conducted at the facility. Interviews occurred between February and December 2024 with healthcare personnel (n=30), including primary care and infectious diseases physicians, pharmacists, nursing staff, care coordinators, and vascular access providers. Data collection focused on better understanding OPAT processes within key domains of decision-making, patient education, care coordination, and post-discharge management. We used rapid analysis and a summary matrix to compare practices across sites within each domain. Result: Our findings highlight significant variability among VHA medical centers that provide OPAT to Veteran patients. Three of the 6 medical centers had dedicated OPAT programs as evidenced by a multidisciplinary team with clearly delineated roles and responsibilities, and processes that may help mitigate adverse outcomes and improve communication between providers at all OPAT care points. These processes map to the key elements outlined in the Infectious Diseases Society of America (IDSA) practice guidelines for OPAT programs, and include determination of appropriate therapy, patient education, lab monitoring, and discontinuation of treatment. (Figure 1) Conversely, at the three VHA sites without evidence of a multidisciplinary OPAT team or program, most participants described poor communication and coordination, lack of support, and uncertainty among providers about who is responsible for OPAT care. This confusion extends to follow-up and discontinuation of treatment. OPAT key elements were lacking or poorly defined. A process map helps visualize the contrasts in care between sites with and without defined OPAT programs. (Figure 1) Conclusion: Despite its centralized healthcare system, VHA medical centers demonstrate highly variable processes with respect to OPAT care. In the absence of a clear OPAT policy or program, uncertainty among providers about roles and responsibilities may be greater. The presence of a dedicated multidisciplinary OPAT team may help improve communication and care coordination, thereby minimizing quality and safety concerns.

Importance:Increasingly, artificial intelligence (AI) is being used to develop models that can identify patients at high risk for adverse outcomes. However, the clinical impact of these models remains largely unrealized. Objective:To evaluate the association of an AI-guided infection prevention bundle with Clostridioides difficile infection (CDI) incidence in a hospital setting. Design, Setting, and Participants:This prospective, single-center quality improvement study evaluated adult inpatient hospitalizations before (September 1, 2021, to August 31, 2022) and after (January 1, 2023, to December 31, 2023) AI implementation. Data analysis was performed from January to August 2024. Intervention:A previously validated institution-specific AI model for CDI risk prediction was integrated into clinical workflows at the study site. The model was used to guide infection prevention practices for reducing pathogen exposure through enhanced hand hygiene and reducing host susceptibility through antimicrobial stewardship. Main Outcomes and Measures:The primary outcome was CDI incidence rate. Secondary outcomes included antimicrobial use and qualitative assessments of bundle implementation. Results:Pre-AI and post-AI samples included 39 046 (21 645 [55.4%] female; median [IQR] age, 58 [36-70] years) and 40 515 (22 575 [55.7%] female; median [IQR] age, 58 [37-70] years) hospitalizations, respectively. After adjusting for differences in clinical characteristics, there was no significant reduction in CDI incidence (pre-AI period: 5.76 per 10 000 patient-days vs post-AI period: 5.65 per 10 000 patient-days; absolute difference, -0.11; 95% CI, -1.43 to 1.18; P = .85). Relative reductions greater than 10% in normalized antimicrobial days were seen for piperacillin-tazobactam (-9.64; 95% CI, -12.93 to -6.28; P < .001) and clindamycin (-1.04; 95% CI, -1.60 to -0.47; P = .03), especially for high-risk patients alerted by AI (relative reduction for piperacillin-tazobactam, 16.8%; 95% CI, 8.0%-24.6%). On the basis of qualitative assessments via semistructured interviews and field observations, the study found that health care staff's experiences with AI-guided workflows varied. In particular, the enhanced hand hygiene protocols were met with poor adherence, whereas pharmacists consistently engaged with the alerts. Conclusions and Relevance:In this quality improvement study, the implementation of an AI-guided infection prevention bundle was not associated with a significant reduction in the already low CDI incidence rate at the study site, but it was associated with reduced CDI-associated antimicrobial use. The results highlight the potential of AI in supporting antimicrobial stewardship. Barriers to implementation, including infrastructure, staff knowledge, and workflow integration, need to be addressed in future applications.

Home-based care for patients diagnosed in emergency departments (EDs) with low-risk pulmonary embolism (PE) is an evidence-based, guideline-recommended practice that is not widely adopted in the US. Few studies demonstrate how this care pathway can be implemented effectively or test whether implementation strategies can address known barriers. Further, prior studies have lacked diversity in population and health system type and did not integrate theory-informed implementation frameworks. Although essential for establishing the evidence base for safe home management of low-risk acute PE, these studies have thus fallen short of guiding broad dissemination and equitable implementation. To bridge this gap, we are conducting a pragmatic multi-site implementation trial, guided by implementation science theory and frameworks, across twelve diverse hospital settings to assess the effectiveness of new care pathways for patients with low-risk PE presenting to EDs. The study uses a cluster-randomized stepped wedge trial design to investigate a set of implementation strategies to support establishing low-risk PE pathways in 12 EDs. Clusters of three hospitals were randomly assigned to one of four start dates, staggered over a 12-month period. During an initial three-month pre-implementation period, we will work with site champions to identify key site personnel and understand site barriers and facilitators. We will then tailor the care pathway to local needs and capabilities. During the six-month active implementation period, we will provide coaching to help sites implement a multi-component intervention informed by behavioral economics intended to address multi-level (site, provider, patient) barriers and integrate the new care pathway for discharging low-risk PE patients. Sites are then followed for a minimum of 12 months post-implementation. Our primary aim is to assess the change in discharge rates of patients with acute PE pre- and post-implementation. Secondary and exploratory aims will assess change in patient safety outcomes along with other key implementation outcomes guided by the RE-AIM framework. This study expands upon prior effectiveness research to tailor, implement, and robustly evaluate a multi-component implementation intervention for diverse health systems aiming to increase guideline-based outpatient management of low-risk PE. Broad-scale implementation in the US could avert up to 100,000 hospitalizations annually. Clinicaltrials.gov (NCT06312332), registered on March 13, 2024.

BACKGROUND:Family caregiver psychological distress during an older adult's critical care hospitalization can compromise their well-being and ability to function in a supportive role for patient recovery. Understanding factors influencing family caregiver distress and well-being during this period is crucial for developing approaches to support caregiver health. We sought to better understand and compare caregiver and care team member perspectives about factors and strategies that affect psychological distress and well-being among family caregivers during a critical care hospitalization. METHODS:Using a qualitative design, we conducted a directed content analysis of semi-structured interview data collected from 20 family caregivers of Veterans in critical care and 12 care team members at a US Veterans Affairs medical and surgical intensive care unit between October 2020 and July 2021. We examined factors related to caregiver psychological distress or well-being. The Consolidated Criteria for Reporting Qualitative Research guidelines were followed. RESULTS:Factors identified as related to caregiver psychological distress by caregivers and care team members included unfamiliarity with the health system, care team, and treatment processes; uncertainties about the illness and patient appearance; and responsibilities associated with the caregiver role. Factors related to caregiver well-being included proactive and personal communication, and a comfortable and respectful environment. Within these factors, however, there were differences in focus between caregivers and care teams. Caregivers focused on unfamiliar treatment processes, with unmet expectations around predictable communication. Few care team members indicated awareness of this concern. Other family, home, or caregiving responsibilities were described by caregivers as contributing to distress but were not mentioned by care team members. Caregivers discussed proactive communication by the care team that occurred either in-person or over the phone as emotionally supportive. Care team members emphasized in-person communication and videoconference options as beneficial and comforting to caregivers during visitor restrictions. The impact of a comfortable and respectful environment was recognized as promoting caregiver well-being by primarily non-clinical care team members. CONCLUSIONS:We found parallels between the factors identified by caregivers and care teams related to caregiver psychological distress and well-being, yet often with differences in focus. These findings provide essential information for addressing factors contributing to distress and developing practices that support caregiver well-being.

Importance:Nursing homes deliver rehabilitative and long-term care for people with serious medical illnesses, functional impairment, and/or cognitive impairment. The population of nursing home residents with serious mental illness (ie, bipolar disorder, schizophrenia, other psychotic disorders) has grown substantially. Other than prisons and jails, nursing homes are the largest institutional care setting for adults (aged ≥18 years) with serious mental illness. Nursing home residents with serious mental illness become long-term residents despite less functional impairment, which may be a function of difficulty discharging these individuals to the community. Objective:To examine barriers associated with discharging nursing home residents with serious mental illness back to the community from the perspective of frontline staff and administrative leaders. Design, Setting, and Participants:This qualitative study included semistructured interviews conducted by phone and videoconferencing with staff members at nursing homes across the US between August 29, 2024, and January 9, 2025. Nursing homes that deliver care to patients with serious mental illness were identified using LTCFocus. Main Outcomes and Measures:Themes and subthemes that represented barriers to discharge were analyzed from interview notes and transcripts using a rapid qualitative analysis approach. Results:Interviews were conducted with 15 staff members (mean [SD] age, 44.7 [12.6] years; 13 women [86.7%]) from 8 nursing homes. Staff roles included social services directors (8 participants [53.3%]), social workers or related roles (3 participants [20.0%]), and administrators or other roles (eg, executive director, memory care coordinator, behavioral unit manager of a lock unit) (4 participants [26.7%]). Participants identified multiple barriers to discharge at individual (eg, behavioral issues, medication compliance, withholding information, refusal to leave, comorbidities), relational (eg, lack of family support, strain on professional relationships), and structural (eg, limitations of insurance coverage, barriers to facility admissions, lack of substance and psychiatric treatment, waiting lists, transportation) levels, which together limited pathways to community discharge for residents with serious mental illness. Conclusions and Relevance:This qualitative study found that multiple intersecting barriers are associated with discharging nursing home residents with serious mental illness back to the community, which may lead to clinically inappropriate long-term stays for those who could theoretically have been in a lower level of care setting. These findings suggest that enabling successful discharge to the community for nursing home residents with serious mental illness may require collaborative strategies that address individual, relational, and structural factors.

Transitions from one EHR to another can be enormously disruptive to care. Nurses are the largest group of EHR users, but nurse experiences with EHR transitions have not been well documented. We sought to understand nurse experiences with an EHR transition at the US Department of Veterans Affairs. We used a mixed methods design, combining a cumulative 26 longitudinal interviews with 317 survey free-text responses and quantitative measures from a repeated cross-sectional survey, all from nurses at one of the first facilities to transition from the Department of Veterans Affairs' homegrown EHR to a commercial system. We conducted inductive/deductive content analysis of qualitative data and paired qualitative findings with descriptive statistics of survey questions. Analyses yielded insights about three key aspects of the transition: (1) EHR functionality: diverse perceived causes of challenges using the new EHR; (2) transition process: barriers and facilitators of nurses' EHR training and technical support; and (3) outcomes: nurse-perceived impacts on safety, quality, nurse satisfaction, and efficiency. Alongside improvements to EHR functionality, findings underscore the need for organizationally informed training and careful alignment between the new EHR and the organization's nursing practices—all of which have been undertaken by Department of Veterans Affairs nurses informed by this and other studies.

BACKGROUND:Nursing home (NH) residents are susceptible to healthcare-associated infections (HAIs). Alignment among NHs, hospitals, and health departments is critical for effective implementation of infection prevention efforts. We tested a collaborative model that engaged hospitals and NHs to reduce infections among NH residents. METHODS:We recruited 92 NHs and 15 hospitals over four 12-month cohorts (2018-2022). The intervention focused on HAI prevention; practices to reduce infection transmission; and effective communication among hospitals, NHs, and state health departments. NHs submitted data on urinary tract infection, catheter-associated urinary tract infection, Clostridioides difficile infection, methicillin-resistant Staphylococcus aureus infection, catheter use, and urine cultures. Changes in outcomes before and during the coronavirus disease 2019 (COVID-19) pandemic were assessed using multilevel negative binomial regression. RESULTS:A total of 63 NHs (68%) partnered with 18 hospitals and submitted 2 or more months of outcome data. Forty NHs participated before COVID-19 (contributing to 1 364 492 resident-days, 56 258 device-days), and 23 NHs participated during COVID-19 (566 142 resident-days, 29 568 device-days). While reductions in the incidence of urine cultures (incidence rate ratio [IRR], 0.37; P < .001) and total composite infections (IRR, 0.68; P = .03) were observed before COVID-19, these reductions were not sustained during the pandemic. CONCLUSIONS:Prior to COVID-19 pandemic, collaboration between NHs and referring regional hospitals with engagement from state health departments led to reductions in NH urine cultures and total infections. Although the pandemic significantly impacted our study, we demonstrate the importance of regional networks in promoting infection prevention in NHs.

Objectives To examine whether nursing facility proportion of residents with serious mental illness (SMI) is associated with nursing staff turnover. Design Cross-sectional analysis of employee-level payroll data from the Centers for Medicare and Medicaid Services, examining facility-level annual staff turnover and the proportion of residents with SMI derived using the Minimum Data Set 3.0, adjusting for other facility, resident, and county characteristics. Setting and Participants US nursing homes in 2022 (N = 14,124). Methods Linear mixed models with states as random intercepts. Dependent variables were annual turnover for nursing aides, licensed practical nurses, registered nurses, and nurse administrators. The primary exposure variable was the proportion of residents with SMI, categorized into 4 groups. Control variables included facility and resident characteristics, and employee hours per resident day. Results The interquartile range for the percent of residents with SMI is 5.0% to 15.1%. Average annual turnover exceeded 50% for all staff types; registered nurses and nurse administrators had the highest turnover (54.1%; 95% CI, 53.7%-54.5% and 95% CI, 53.6%-54.6%, respectively). High SMI serving nursing homes generally had higher unadjusted turnover than low SMI serving facilities. Adjusting for covariates, however, there was no consistent relationship between SMI proportion and turnover within or between staffing roles. For example, relative to SMI quartile 1, turnover was higher for licensed practical nurses in quartile 2 (50.2%; 95% CI, 48.8%-51.6% vs 49.0%; 95% CI, 47.5%-50.5%; P = .03), for registered nurses in quartile 4 (53.9%; 95% CI, 52.3%-55.5% vs 51.6%; 95% CI, 50.2%-53.1%; P < .01), and for nurse administrators in quartile 3 (53.1%; 95% CI, 51.4%-54.9% vs 51.3%; 95% CI, 49.6%-53.1%; P = .02). Conclusion and Implications Nursing home staff turnover rates were high across staff types with no meaningful relationship or consistent trends between the proportion of residents with SMI and staff turnover. Nursing homes might focus on other factors when developing strategies to reduce turnover, rather than those specific to residents with SMI.

Interviews with 22 home-based primary care (HBPC) clinicians revealed that infectious disease physicians and clinical pharmacists facilitate infection management and antibiotic selection, respectively, and that local initiatives within programs support antibiotic prescribing decisions. Interventions that facilitate specialist engagement and tailored approaches that address the unique challenges of HBPC are needed.

Central sensitization (CS) is a neural mechanism associated with the development and perpetuation of chronic pain. The purpose of this study was to examine the severity and prevalence of central sensitization and examine its relationships with demographics and pain indicators among veterans with chronic pain. This study used a cross-sectional design. Data for the Central Sensitization Inventory Part A (CSI-A), Pain Catastrophizing Scale, and Brief Pain Inventory-Short Form were manually extracted from paper forms and hospital electronic health records. Descriptive statistics, Kendall Tau correlation coefficient, and independent samples t test were used for data analysis. The sample consisted of 184 veterans, predominantly men (87%) with a mean age of 60 years. The mean CSI-A score was 45.06 ± 17.06 and 62.5% of veterans (n = 115) were identified as having CS (CSI-A ≥ 40), with 23.9% (n = 44) identified as having severe CS (CSI-A = 50-59). A significant but weak negative correlation was obtained between CSI-A score and age (τb = -0.121, P = .016) and a significant positive weak to moderate correlation was obtained between CSI-A score and severity of pain (τb = 0.209, P < .001), pain interference (τb = 0.333, P < .001), and pain catastrophizing (τb = 0.385, P < .001). Women veterans had a significantly higher mean CSI-A score compared to men (55.38 ± 13.23 vs 43.51 ± 17.06, tdf = 182 = 3.260, P = .001). These findings highlight the high prevalence of CS among veterans with chronic pain, particularly in women, emphasizing the need to assess CS to improve chronic pain management in this population.

Nursing home (NH) residents in the United States routinely attend interactive visits for services such as therapy or dialysis, creating opportunities for pathogen transmission. A paucity of studies exist which delineate spread of pathogens beyond residents' in-room environment. In this prospective cohort study, we recruited 197 newly-admitted residents across three Veterans Affairs NHs to characterize multidrug-resistant organism (MDRO) prevalence, acquisition, and transmission. Participant hands, nares, groin, and seven environmental surfaces were swabbed during 758 regularly scheduled in-room visits; participant hands, healthcare personnel hands, and equipment were swabbed during 345 unscheduled interactive visits. We demonstrate that baseline MDRO colonization and new acquisition is common, and one in six interactive visits result in MDRO transmission. Whole genome sequencing on a subset of participants enabled us to identify sources of transmission where it was unknown using microbiologic methods alone. Our results illustrate MDRO transmission pathways and highlight the need for innovative, multidisciplinary interventions.