Purpose: Wastewater surveillance effectively monitors pathogens. This pilot study evaluated the feasibility and utility of hospital-level wastewater surveillance by integrating wastewater and electronic health record (EHR) data. Analyses focused on hospital-acquired infections (HAI) and temporal lags between wastewater and clinical detection. Methods: From August to December 2024, wastewater autosamplers operated across five hospital pavilions at Yale New Haven Hospital, collecting samples every five minutes during a 24-hour period three times per week. Samples were analyzed by dPCR for SARS-CoV-2, Influenza (A/B), and additional pathogens. Deidentified EHR data included admissions, diagnoses, and laboratory data. The primary focus was lab-confirmed HAI SARS-CoV-2 and Influenza. HAI was defined as infections diagnosed during hospitalization without evidence at admission. Clinical and wastewater data were used to calculate the proportion of positive samples, and correlation was assessed using Spearman’s rank correlation coefficient (rho). Correlations were evaluated for lagged associations across 1–3-week lags. A sensitivity analysis was conducted by including all SARS-CoV-2 encounters. Results: Among 33,579 patient encounters, 62 SARS-CoV-2 and 74 Influenza HAI encounters were identified. This corresponded to 97 and 148 tests for SARS-CoV-2 and Influenza, respectively. Of 187 wastewater samples collected 60 (31.1%) and 1 (0.5%) were positive for SARS-CoV-2 and Influenza respectively. Due to only a single detection of Influenza in the wastewater, correlation analysis was limited to SARS-CoV-2. A correlation test of the data found no statistically significant correlation between wastewater and clinical data when aligned temporally (rho: -0.21, p: 0.51). Lagged correlations between wastewater and clinical SARS-CoV-2 positivity were evaluated across 1–3-week temporal lags. These lagged correlations were not statistically significant, but rho increased in magnitude from a 1-week lag (rho: -0.04, p: 0.89) to a 3-weeks lag (rho: 0.46, p:0.21). The sensitivity analysis found no statistically significant correlation between wastewater and clinical positivity. Conclusions: Hospital-level wastewater surveillance shows potential as an early indicator of HAI SARS-CoV-2 infections, with exploratory trends suggesting a ~3-week lead time results in stronger associations between clinical and wastewater data. Although limited by small HAI sample sizes and a short wastewater sampling period, these findings support further evaluation in larger cohorts and highlights pathogen-specific limitations as observed for Influenza. Follow-up studies should employ longer wastewater sampling windows and further refine methods to account for community-associated SARS-CoV-2 contributions to hospital wastewater, an area of active investigation by our group.

Antimicrobial resistant pathogens and associated infections represent major public health threats affecting healthcare facilities, with sink drain biofilms serving as reservoirs for many of these bacteria. Despite attempts at sink drain biofilm disinfection and removal, drain biofilms inevitably regrow, and disinfection may shape the returning microbial communities and their resistance profiles. We applied culture-based and metagenomic approaches to study these drain disinfection effects on microbial community abundance, taxonomy, and antimicrobial resistance in operational hospital sinks. Drain biofilms regrew to baseline densities in approximately four days. Regrown biofilms contained more viable carbapenem-resistant bacteria and were dominated by Pseudomonadota, including Cupriavidus and Pseudomonas. Long-read sequencing revealed an increase in multidrug efflux pump genes after disinfection, which confer broad resistance to antibiotics and disinfectants. This work provides mechanistic insights into how disinfection influences sink drain biofilm ecology and the enrichment of antimicrobial resistance, with implications for infection prevention strategies in healthcare environments.

Purpose: Wastewater surveillance effectively monitors pathogens. This pilot study evaluated the feasibility and utility of hospital-level wastewater surveillance by integrating wastewater and electronic health record (EHR) data. Analyses focused on hospital-acquired infections (HAI) and temporal lags between wastewater and clinical detection. Methods: From August to December 2024, wastewater autosamplers operated across five hospital pavilions at Yale New Haven Hospital, collecting samples every five minutes during a 24-hour period three times per week. Samples were analyzed by dPCR for SARS-CoV-2, Influenza (A/B), and additional pathogens. Deidentified EHR data included admissions, diagnoses, and laboratory data. The primary focus was lab-confirmed HAI SARS-CoV-2 and Influenza. HAI was defined as infections diagnosed during hospitalization without evidence at admission. Clinical and wastewater data were used to calculate the proportion of positive samples, and correlation was assessed using Spearman’s rank correlation coefficient (rho). Correlations were evaluated for lagged associations across 1–3-week lags. A sensitivity analysis was conducted by including all SARS-CoV-2 encounters. Results: Among 33,579 patient encounters, 62 SARS-CoV-2 and 74 Influenza HAI encounters were identified. This corresponded to 97 and 148 tests for SARS-CoV-2 and Influenza, respectively. Of 187 wastewater samples collected 60 (31.1%) and 1 (0.5%) were positive for SARS-CoV-2 and Influenza respectively. Due to only a single detection of Influenza in the wastewater, correlation analysis was limited to SARS-CoV-2. A correlation test of the data found no statistically significant correlation between wastewater and clinical data when aligned temporally (rho: -0.21, p: 0.51). Lagged correlations between wastewater and clinical SARS-CoV-2 positivity were evaluated across 1–3-week temporal lags. These lagged correlations were not statistically significant, but rho increased in magnitude from a 1-week lag (rho: -0.04, p: 0.89) to a 3-weeks lag (rho: 0.46, p:0.21). The sensitivity analysis found no statistically significant correlation between wastewater and clinical positivity. Conclusions: Hospital-level wastewater surveillance shows potential as an early indicator of HAI SARS-CoV-2 infections, with exploratory trends suggesting a ~3-week lead time results in stronger associations between clinical and wastewater data. Although limited by small HAI sample sizes and a short wastewater sampling period, these findings support further evaluation in larger cohorts and highlights pathogen-specific limitations as observed for Influenza. Follow-up studies should employ longer wastewater sampling windows and further refine methods to account for community-associated SARS-CoV-2 contributions to hospital wastewater, an area of active investigation by our group.

Wastewater surveillance (WS) has been widely adopted as a cost-effective and population-representative infectious disease monitoring tool and is increasingly being applied to bacterial and antimicrobial resistance gene (ARG) targets. However, some of these targets may persist in pipe biofilms and detach into wastewater, complicating accurate WS interpretation. To investigate biofilm contributions to wastewater pathogen and ARG signals, paired sink-drain biofilm, branch-drain-plumbing biofilm (sewer biofilm), and wastewater were collected from five hospital sites over a four-month period and analyzed using 16S rRNA gene amplicon sequencing and probe-capture metagenomics. Overall, sewer biofilm bacterial communities were as diverse as wastewater. Across sites, a mean of 9% (0.9 to 23.3%) of wastewater bacterial communities could be attributed to sewer biofilm communities. Many clinically relevant pathogens were consistently detected both in sewer biofilm and wastewater, including environmentally persistent and/or biofilm-associated taxa (e.g., Pseudomonas aeruginosa, Klebsiella pneumoniae). While many ARGs overlapped between wastewater and biofilms (e.g., tetA, sul1, blaCTX-M, vanA), others were significantly enriched in sewer biofilms (e.g., qacL, van-operon and OXA genes). Together, these findings confirm that wastewater pathogen and resistome profiles integrate inputs from both human shedding and pipe-resident communities and therefore need to be considered when selecting WS targets and interpreting signal. ### Competing Interest Statement The authors have declared no competing interest. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present study are available upon reasonable request to the authors

Objectives: Multiple barriers exist for COVID-19 vaccination in high-risk individuals especially adults over the age of 65. Each healthcare visit represents a critical opportunity for vaccination, yet many patients who do seek vaccination receive their vaccines in locations other than their routine health care providers and healthcare sites often lack the capacity for vaccine administration. Here-in we conducted a needs assessment to identify hospital system specific barriers and facilitators to COVID-19 vaccine access in individuals 65 and older in 2024. Methods: We conducted six semi-structured interviews (June-July 2024) with seven healthcare leaders in Yale New Haven Enterprise. We transcribed and analyzed interviews to develop a larger-scale survey targeting healthcare professionals including vaccine leadership of individual clinics across the healthcare systems. The survey was distributed to 42 healthcare leaders (physicians, administrators, and practice supervisors) across 52 ambulatory locations. Results: The survey received twenty responses (47% response rate). Four primary challenges to COVID-19 vaccination among older adults were identified: (1) Patient Hesitancy, driven by misinformation about vaccine contents, concerns about side effects, polarized attitudes, and waning interest in booster doses; (2) Challenges Related to Staff, including distrust in vaccine motives, mandates, and efficacy, as well as a shortage of personnel available to administer vaccinations; (3) Operational and Logistical Barriers, including complex vaccine schedules, vaccine storage, and reliance on retail pharmacies, which led to lower vaccination rates at primary care sites; and (4) Policy and Financial Constraints, such as insufficient financial incentives for on-site vaccinations, Medicare coverage limitations, and high administrative costs. The main proposed actions to address vaccination hesitancy and challenges include enhancing education sessions for patients and staffs, modifying streamlining administration by simplifying the workflows including on-site vaccination process for employees, and centralizing vaccine delivery in primary care or hubs, improving accessibility via routine (home) visits and flexible hours, and partnering with pharmacy department to ensure greater access to vaccination. Conclusion: Through semi-structured interviews and surveys, we identified targets for future quality improvement efforts. Multiple overlapping barriers to COVID-19 vaccination in older adults exist within one U.S. based health care system. Some of these barriers, such as improving vaccine administration workflows or enhancing patient education, can be more readily addressed, while others involve larger structural issues that would require larger societal change. We are seeking a subspecialty clinic partnership to pilot an implementation project, using high-impact intervention tailored to clinic needs and iterative Plan-Do-Study-Act (PDSA) cycles to refine and optimize outcomes.

The use of extended reality (XR) for education of healthcare personnel (HCP) is increasing. XR equipment is reusable and often shared between HCP in clinical areas; however, it may not include manufacturer's instructions for use (MIFU) in healthcare settings. Considerations for the selection of equipment and development of cleaning and disinfection protocols are described.

Background: Virtual reality (VR) headsets are increasingly used in health care settings for a variety of clinical indications, yet processes to ensure safe use between patients are not well-established. Centers vary in how these processes are performed. Most use disinfection wipes that require manual contact with VR devices for a specified dwell time to allow for sufficient pathogen killing, which may introduce manual error and device degradation over time. Ultraviolet-C light (UV-C) devices offer a no-touch, low-cost, and passive method to achieve pathogen killing without the harms of chemical contact-based disinfectants. The use of UV-C for disinfection has been studied for some medical devices but its efficacy for microbe killing on VR headsets is not well-established. Objective: This study aims to determine the bactericidal efficacy of UV-C on VR headsets through quantifying UV-C irradiance and bacterial killing of 3 commercially available UV-C devices. Methods: Three commercially available, low-cost UV-C devices were tested for UV-C energy output at multiple positions, angles, and times across the devices' zone of disinfection. The top and lens of a VR headset, the Meta Oculus Quest 2, were artificially inoculated with high quantities of 3 different strains of bacteria (Staphylococcus aureus, Pseudomonas aeruginosa, and Staphylococcus epidermidis) and subjected to UV-C light according to each device's manufacturer's instructions for use. The primary outcome was the amount of bacterial killing after exposure to UV-C light. Results: All 3 UV-C devices produced a UV-C dose that ranged from 3.57 to 195.37 mJ/cm2, depending on proximity, angle, irradiance, and time the sensor received. At least 3-log10 killing of all 3 strains of bacteria was achieved for each of the tested UV-C devices; however, there was variability by organism with respect to UV-C device and VR headset location within the device, notably with the proximity of the bacteria to the bulb. S aureus and P aeruginosa were more readily killed than S epidermidis, with increased bacterial killing occurring with increased UV-C exposure doses. There was no experiment in which all bacteria were killed. Conclusions: UV-C dosage increased with exposure irradiance, time, proximity, and angle to the bulb for all 3 UV-C devices. Bacterial killing on the top and lens of a VR headset occurred in all 3 UV-C devices when run according to their manufacturer's instructions for use, although full bacterial killing did not occur in any experiment. UV-C may be an effective method for microbial killing on VR equipment with low-level contamination.

Health care–associated infections (HAIs) are a pervasive problem, and although decreased rates of HAIs have been clearly achieved during the past decades, most recent estimates by the Centers for Disease Control and Prevention show the prevalence of HAIs in U.S. hospitals to be about 3%.1 Many HAIs are preventable events and pose undue burdens on both patients and health care facilities. Hospitals' infection prevention teams are responsible for working to prevent HAIs, which includes identifying and managing outbreaks. Although there is no consensus on how to define an outbreak, outbreaks of infectious diseases are most efficiently controlled when they are identified early, so rapid identification is a key strategy.

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Healthcare-associated infections (HAIs) are common and expensive complications that can occur during inpatient hospital stays. Hand hygiene (HH)—which includes hand washing with soap and water and hand rubbing with alcohol-based hand sanitizer—is the primary tool used by healthcare personnel (HCP) to prevent HAIs. Consequently, the World Health Organization (WHO) proposed guidelines for effective HH in healthcare settings. However, consistent performance of HH by HCP is still lacking. HH in healthcare requires both compliance with indications for HH and quality of HH. Integrative approaches in human factors engineering (HFE) and infection prevention can be used to promote sustainable techniques that can be implemented by HCP to improve the quality of HH techniques. This research proposes a three-phase integrative approach that uses HFE-based methods to identify why HH is often insufficiently executed by HCP in hospital settings and ultimately to help guide HCP to improve HH quality. We performed i) a tabular task analysis (TTA), constructed by HFE personnel and infection prevention specialists, ii) card sorting with infection prevention subject matter experts to prioritize HH steps and analyzed with criticality analysis and subsequent modifications to the TTA, and iii) TTA validation and verification with subject matter experts. Finally, we conducted qualitative interviews with members of hospital leadership and determined that it is feasible to implement the use of TTAs in hospital settings. This research provides enhanced HH guidance using an integrative HFE-based approach and is directed to increase the quality of HH performed by HCP, thereby reducing HAI rates and improving patient safety. Furthermore, these results can be used to support the effective implementation of the WHO's HH guidance. Our findings elucidate some of the challenges to patient safety regarding HH and clarify best practices for HH in hospital settings.

We report a cluster of 9 isolates of Parengyodontium album recovered from 4 patients who had surgical tissue specimens processed after dilution with a multiuse diluent saline solution. P album was also identified from a nonclinical sample on agar prepared with the same lot number of saline solution. Our epidemiological investigation revealed this to represent a pseudo-outbreak related to contaminated saline used to process specimens in the microbiology laboratory.

COVID-19 vaccine uptake in healthcare personnel (HCP) is poor. A cross-sectional survey study of behavioral health HCP was performed. Commonly identified reasons for vaccination were protecting others and oneself. Reasons against were a lack of perceived protection, dosing intervals, and side effects. Assessing vaccination attitudes can assist in uptake strategy.

Abstract Objective: Optimizing needleless connector hub disinfection practice is a key strategy in central-line–associated bloodstream infection (CLABSI) prevention. In this mixed-methods evaluation, 3 products with varying scrub times were tested for experimental disinfection followed by a qualitative nursing assessment of each. Methods: Needleless connectors were inoculated with varying concentrations of Staphylococcus epidermidis, Pseudomonas aeruginosa, and Staphylococcus aureus followed by disinfection with a 70% isopropyl alcohol (IPA) wipe (a 15-second scrub time and a 15-second dry time), a 70% IPA cap (a 10-second scrub time and a 5-second dry time), or a 3.15% chlorhexidine gluconate with 70% IPA (CHG/IPA) wipe (a 5-second scrub time and a 5-second dry time). Cultures of needleless connectors were obtained after disinfection to quantify bacterial reduction. This was followed by surveying a convenience sample of nursing staff with intensive care unit assignments at an academic tertiary hospital on use of each product. Results: All products reduced overall bacterial burden when compared to sterile water controls, however the IPA and CHG/IPA wipes were superior to the IPA caps when product efficacy was compared. Nursing staff noted improved compliance with CHG/IPA wipes compared with the IPA wipes and the IPA caps, with many preferring the lesser scrub and dry times required for disinfection. Conclusion: Achieving adequate bacterial disinfection of needleless connectors while maximizing healthcare staff compliance with scrub and dry times may be best achieved with a combination CHG/IPA wipe.

Abstract Background Deep sternal wound infections (DSWI) are a serious complication of cardiac thoracic surgeries and are associated with a significantly higher mortality risk. Our center experienced increased surgical site infection (SSI) rates prompting an epidemiologic evaluation. Methods A retrospective cohort review of 10 cardiac surgery patients with DWSI from 2020-2021 were reviewed. An SSI bundle to decrease DSWI was implemented using a standardized pos-operative wound dressing (prior to this, dressing selection was per the cardiac thoracic surgeon's discretion), glucose optimization in collaboration with our endocrinology team, and chlorhexidine bathing practices. Results Starting in September 2020 Yale New Haven Hospital observed a statistically significant increase in DSWI (0.51), which was a 285% increase in DSWI. Of the 10 out of 15 patients with DSWI who underwent review, the majority were inpatient prior to surgery with a mean length of stay of 5 days before undergoing surgery. Following selective implementation of the SSI bundle to urgent cases who were inpatient at the time of surgery, the DSWI rate decreased from 1.97 in 2021 to 1.13 in 2022, which reflected a 43% clinical decrease with 0 DSWI reported. Conclusion Implementation of an inpatient pre-operative, SSI bundle, including standardization of post-operative sternal wound dressings, resulted in a significant decrease in DSWI that has persisted post-intervention. Disclosures All Authors: No reported disclosures

Abstract Background Patients receiving extracorporeal membrane oxygenation (ECMO) are at high risk for bacteremia which can cause substantial morbidity and mortality. We sought to evaluate risk factors for bacteremia in patients receiving ECMO during the COVID-19 pandemic to better characterize those most at risk and areas for prevention. Methods A retrospective case control study evaluating patients receiving ECMO support at Yale New Haven Hospital from April 2020 – September 2021 was performed. Cases of patients who developed bacteremia were matched 1:2 to control patients on ECMO who had blood cultures drawn but who did not develop bacteremia. There were no set criteria for drawing the blood cultures; when to draw blood cultures were per provider’s discretion. Only the first set of blood cultures drawn were analyzed. Results 60 patients received ECMO support and had blood cultures drawn, 20 (33.3%) with bacteremia matched to 40 (66.7%) without bacteremia. Independent risk factors for bacteremia included being diagnosed with COVID-19 (70.0% vs 40.0%, p = 0.028), days on ECMO until culture (13.4 vs 6.2 days, p = 0.005), days on mechanical ventilation until culture (17.5 vs 7.7 days, p = 0.002), corticosteroid use (75.0% vs 40.0%, p = 0.011), ECMO type (80.0% veno-venous [VV] and 20.0% veno-arterial vs 37.5% veno-venous and 62.5% veno-arterial, p = 0.002), proning (60.0% vs 22.5%, p = 0.004), and preceding antibiotic days during the admission (16.1 days vs 9.3 days, p = 0.025). There was no difference in any evaluated infectious metric (white blood cell count, daily maximum temperature, procalcitonin, CRP, d-dimer, ferritin, fibrinogen, LDH) on the day of blood culture in those with compared to those without bacteremia. Conclusion Patients receiving ECMO support who developed bacteremia were more likely to be on VV-ECMO, proned, receive corticosteroids, and be on mechanical ventilation for longer periods of time, all factors associated with severe COVID-19. Additional risk factors included more days on ECMO and prior antibiotic use. No laboratory metric was predictive of bacteremia, highlighting the challenges in accurately predicting bacteremia in the ECMO patient population. Disclosures All Authors: No reported disclosures