Precision healthcare is an emerging field of science that utilizes an individual’s health information, context, and genetics to provide more personalized diagnostics and treatments. In this manuscript, we leverage that concept and present a group of machine learning models for precision gaming. These predictive models guide adolescents through best practices related to their health. The use case deployed is for girls in India through a mobile application released in three different Indian states. To evaluate the usability of the models, experiments are designed and data (demographic, behavioral, and health-related) are collected. The experimental results are presented and discussed.

We evaluated whether universal chlorhexidine bathing (decolonization) with or without COVID-19 intensive training impacted COVID-19 rates in 63 nursing homes (NHs) during the 2020–2021 Fall/Winter surge. Decolonization was associated with a 43% lesser rise in staff case-rates (P < .001) and a 52% lesser rise in resident case-rates (P < .001) versus control.

Background: Traditional hospital outbreak-detection methods are typically limited to select multidrug-resistant pathogens in a single unit, which can miss transmission of many medically important healthcare-transmissible pathogens. Whole-genome sequencing (WGS) enables comprehensive genomic resolution for accurate identification of clonal transmission. Previously, lack of scalability limited the use of WGS for hospital surveillance. Methods: We conducted prospective surveillance of select bacteria from all inpatient clinical cultures plus all bacteria from clinical cultures from ICUs and oncology units at the University of California Irvine (UCI) Clinical Microbiology Laboratory from September 2021 to February 2022. Due to pandemic stressors, this pilot test was a prelude to a real-time demonstration project. Its goal was to demonstrate the efficiency and scalability of the WGS platform when receiving samples monthly and analyzing results quarterly without the intent for real-time response. Bacterial isolates slated for discard were collected weekly and sent monthly to Day Zero Diagnostics for sequencing. In total, 1,036 samples from 926 patients were analyzed for genomic relatedness, a scalable and automated analysis pipeline already in use for rapid (days) characterization of genomic-relatedness in small and large sets of isolates. Mapping and SNP calling was performed against high-quality, best-match reference genomes. Sets of samples with pairwise distance of 2 persons with genomically related isolates and were denoted as “clusters.” Separately, we also investigated within-patient diversity by quantifying the genomic relatedness of isolates collected from individual patients. Results: Isolates represented 28 distinct species. We identified 10 Escherichia coli clusters (range, 2–4 patients; median, 2 patients), 2 Klebsiella pneumoniae clusters (range, 2–4 patients), and 1 Enterococcus faecium cluster (3 patients). All but 1 involved genomically matched isolates from multiple hospital locations. There were 4 Escherichia coli ST131 clusters spanning 4 months, including 1 with 4 patients across 3 different hospital locations. At a species level, there were distinct differences between the observed SNP distances between samples isolated from the same versus different patients (Fig. 1). All identified clusters had not been flagged by routine outbreak detection methods used by the UCI infection prevention program. Conclusions: Comprehensive WGS-based surveillance of hospital clinical isolates identified multiple potential transmission events between patients not in the same unit at the time cultures were taken. Combining WGS detection and real-time epidemiologic investigation may identify new avenues of transmission risk and could provide early warnings of clonal transmission to prevent larger outbreaks. High-volume surveillance of hospital isolates can also provide species- and context-specific clonality.

Financial support: This study was funded by Day Zero Diagnostics.

Disclosures: None

Background: Existing training for resident bathing in nursing homes (NHs) is brief and limited, likely because bathing is assumed to be intuitive. However, residents have complex skin issues, devices, dressings, and limited ability for self-care. We sought to assess bathing quality and to identify barriers to proper bathing techniques. Methods: We conducted a prospective observational study of bathing in 8 NHs in Orange County, California, involving a convenience sample of observed bed baths and showers conducted for quality improvement. NH staff were told that observation was occurring, and no feedback was given during or after bathing. Survey elements included cleansing of 6 specific body sites and adherence to bathing procedures (11 for bed baths and 17 for showers). Surveys also included queries to staff to further assess knowledge and perceived barriers. Observed lapses were documented, along with observer-determined reasons for noncompliance (ie, training issue, time pressure, facility issue (insufficient water temperature), resident refusal/behavior). Frequency of noncompliance with each element was tabulated for bed-baths and showers separately. Reasons for failure were displayed graphically. Results: In total, 50 bed baths (NH range, 5–8) and 50 showers (NH range, 4–7) were observed across 8 NHs. Lapses in bathing quality and process were extremely common for both bed baths and showers (Fig.). Inadequate body cleansing occurred for all observed body sites (88%–100% failure for bed baths, 58%–100% failure for showers). Most body areas were either skipped or sprayed with water without soaping. Procedural failures were high for both bed baths and showers (insufficient lather: 100% for bed bath and 40% for shower) lack of firm massage for cleaning (94% for bed bath and 90% for shower), failure to change wipes or cloths when dirty (100% for bed bath and 96% for shower), failure to follow clean-to-dirty sequence (100% for bed bath and 96% shower). In addition, failing to wrap or unwrap devices (73%) and failing to towel dry (94%) were common after showering. Reasons for failure were largely based on training or facility shortcomings (eg, insufficient hot water, inflexible showerhead attachment). Also, 86% of residents complained of being cold. Timing constraints and resident combativeness or refusal were rare. Staff-to-staff bathing advice most commonly involved competing for the “better shower” and “bathing early to get hot water.” Conclusions: Knowing how to appropriately bathe NH residents is not intuitive, and current training is brief and insufficient for high-quality resident care. Unacceptably high failures in proper bathing techniques in NHs necessitate re-evaluation of formal training and standardized practices to better cleanse residents. Moreover, common failures in facility processes for ensuring adequate water temperature and showerhead mobility for bathing or showering should be addressed.

Disclosures: None

Background: Recognizing problematic central-line insertion sites is an important activity for CNAs, LVNs, and RNs in nursing homes (NHs). Although CNAs are not responsible for assessing central lines, they are often the first line of defense for noticing and relaying problems with a line because of the greater amount of time they spend with residents. We sought to assess how well CNAs, LVNs, and RNs could identify problematic insertion sites in NHs. Methods: We conducted a prospective observational study of central-line care in 8 NHs in Orange County, California. A convenience sample of central lines with a range of problematic elements was selected for quality improvement purposes. Research staff used standardized observation forms to evaluate presence of redness, cloudy drainage, and dressing integrity and change date. NH CNAs, LVNs, and RNs were asked to directly observe devices and to comment on problems or concerns. Participants were also asked open-ended questions about elements for a “picture-perfect line” and standard frequency of line checks and dressing changes. Failures to recognize existing problematic elements were tabulated for CNAs and LVNs or RNs separately. Results: In total, 50 CNAs (nursing home range, 3–6) and 50 LVNs and RNs (NH range, 4–6) directly observed lines with 131 problematic elements, including redness (N = 36), cloudy drainage (N = 30), peeling dressings (N = 29), and inappropriately dated dressing (N = 36). Failure to identify problematic elements involved redness [CNAs (50%) and LVNs or RNs (53%)], cloudy drainage [CNAs (40%) and LVNs or RNs (39%)], peeling dressings [CNAs (100%) and LVNs or RNs (87%)], and inappropriately dated dressing [CNAs (71%) and LVNs or RNs (68%)]. For both CNAs and LVNs and RNs, recognition of redness and cloudy drainage improved with severity. Failure to recognize minimal erythema [CNAs (83%) and LVNs or RNs (58%)] was higher than substantial erythema [CNAs (54%) and LVNs or RNs (50%)]. Similarly, failure to recognize minimal cloudy drainage [(CNAs (67%) and LVNs or RNs (50%)] was higher than substantial cloudy drainage [CNAs (42%) and LVNs or RNs (36%)]. Overall, identification of problematic elements did not vary by whether the staff member was assigned to care for that resident. Descriptions of “picture-perfect lines” were uniformly poor, with respondents not knowing what elements to mention. Conclusions: Failure to recognize redness, cloudy drainage, peeling dressings, and lapses in dressing change dates was common for CNAs and LVNs and RNs in nursing homes. This lack of recognition could prevent proper response to early and late signs of localized infection at central-line sites. Dedicated training regarding key elements of a “picture-perfect line” is needed, including changing the threshold for concern for both small and large amounts of redness and pus.

Disclosures: None

Background: A regional decolonization intervention (SHIELD-OC) involving universal chlorhexidine for routine bathing and 5 days of twice-daily nasal iodophor every other week in nursing homes (NHs) recently demonstrated marked reductions in multidrug-resistant organisms, all-cause hospitalizations, and infection-related hospitalizations in Orange County, California. Specific to methicillin-resistant Staphylococcus aureus (MRSA), NH prevalence (nares, skin, or perirectal) decreased from 43% to 29%. Methods: We conducted a retrospective cohort study evaluating the impact of decolonization on factors associated with MRSA carriage. The cohort included residents from 18 SHIELD-OC NHs who were sampled for MRSA using nares, axilla, groin, and perirectal cultures. A point-prevalence survey was conducted in 2016–2017 (before decolonization, 50 randomly sampled residents per NH) and in 2018–2019 (decolonization, all residents sampled). Resident characteristics were obtained from their most proximal admission, quarterly, and/or discharge assessment using data mandated for NH reporting (CMS minimum data set), and included demographics, medical devices, comorbidities (including Alzheimer’s disease and related dementias or ADRD), and mobility and hygiene needs. We used generalized-linear mixed models stratified by decolonization and clustered by NH to identify differences in factors associated with MRSA carriage. Results: Of the 2,351NH residents, 2,255 (96%) had characteristics available in the CMS data set. Of the 2,255 residents included, 774 (34%) were MRSA carriers. Before decolonization, medical devices (OR, 2.5), limited mobility (OR, 1.6), and diabetes (OR, 1.4) were significantly associated with MRSA carriage in an adjusted model (Table). During decolonization, these effects were mitigated (medical device OR, 2.5–1.1; diabetes OR, 1.4–0.9) and were no longer significantly associated with MRSA carriage. Male sex appeared to have more of an effect in the decolonization phase (OR, 1.3–1.6), but limited mobility remained stable (OR, 1.6–1.7). Several variables were collinear. Presence of a medical device was collinear with postacute stays (<100 days) and Medicaid insurance. Limited mobility was associated with limited ability for hygienic self-care. ADRD was collinear with age. Final adjusted models accounted for medical devices, limited mobility, diabetes, ADRD, cancer, sex, and ethnicity. Conclusions: In a large interventional cohort of 18 NHs, factors associated with MRSA carriage changed after adoption of universal decolonization. Specifically, the increased risk of MRSA associated with medical devices and diabetes were substantially mitigated by decolonization, suggesting that these risks are modifiable. These long-term care findings are consistent with clinical trials showing reductions in MRSA carriage after implementing chlorhexidine bathing in ICUs and in non-ICU patients with devices. The ability of decolonization to attenuate the risk of MRSA carriage among diabetics or other potential high-risk groups deserves further study.

Disclosures: None

Infection prevention program leaders report frequent use of criteria to distinguish recently recovered coronavirus disease 2019 (COVID-19) cases from actively infectious cases when incidentally positive asymptomatic patients were identified on routine severe acute respiratory coronavirus virus 2 (SARS-CoV-2) polymerase chain reaction (PCR) testing. Guidance on appropriate interpretation of high-sensitivity molecular tests can prevent harm from unnecessary precautions that delay admission and impede medical care.

Previously published guidelines have provided comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format designed to assist acute-care hospitals in implementing and prioritizing efforts to prevent methicillin-resistant Staphylococcus aureus (MRSA) transmission and infection. This document updates the “Strategies to Prevent Methicillin-Resistant Staphylococcus aureus Transmission and Infection in Acute Care Hospitals” published in 2014.1 This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA). It is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the Association for Professionals in Infection Control and Epidemiology (APIC), the American Hospital Association (AHA), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.

Standardized observation of bed baths and showers for 100 residents in 8 nursing homes revealed inadequate cleansing of body sites (88%–100% failure) and >90% process failure involving lather, firm massage, changing dirty wipes or cloths, and following clean-to-dirty sequence. Insufficient water warmth affected 86% of bathing opportunities. Bathing training and adequate resources are needed.

In a survey of infection prevention programs, leaders reported frequent clinical and infection prevention practice modifications to avoid coronavirus disease 2019 (COVID-19) exposure that exceeded national guidance. Future pandemic responses should emphasize balanced approaches to precautions, prioritize educational campaigns to manage safety concerns, and generate an evidence-base that can guide appropriate infection prevention practices.