In response to the 2014-2015 Ebola virus disease outbreak in West Africa, Johns Hopkins Medicine created a biocontainment unit to care for patients infected with Ebola virus and other high-consequence pathogens. The unit team examined published literature and guidelines, visited two existing U.S. biocontainment units, and contacted national and international experts to inform the design of the physical structure and patient care activities of the unit. The resulting four-bed unit allows for unidirectional flow of providers and materials and has ample space for donning and doffing personal protective equipment. The air-handling system allows treatment of diseases spread by contact, droplet, or airborne routes of transmission. An onsite laboratory and an autoclave waste management system minimize the transport of infectious materials out of the unit. The unit is staffed by self-selected nurses, providers, and support staff with pediatric and adult capabilities. A telecommunications system allows other providers and family members to interact with patients and staff remotely. A full-time nurse educator is responsible for staff training, including quarterly exercises and competency assessment in the donning and doffing of personal protective equipment. The creation of the Johns Hopkins Biocontainment Unit required the highest level of multidisciplinary collaboration. When not used for clinical care and training, the unit will be a site for research and innovation in highly infectious diseases. The lessons learned from the design process can inform a new research agenda focused on the care of patients in a biocontainment environment.

Background Urine cultures are often positive in the absence of a urinary tract infection (UTI). Pyuria is generally considered necessary to diagnose a UTI. Problem Urine cultures are often positive in the absence of UTI leading to unnecessary antibiotics. Methods Quasi-experimental pre-post study of all patient urine cultures ordered in a VA acute care hospital, emergency department (ED), and two long-term care (LTC) facilities from August 2016 to August 2018. Urine cultures performed per 100 days were compared pre- (August 2016 to July 2017) versus post-intervention (August 2017 to August 2018) using interrupted time series negative binomial regression. Intervention We examined whether reflexing to urine culture only if a urinalysis (UA) found greater than 10 WBC/hpf decreased urine culturing. Results In acute-care, reflex culturing resulted in a 39% time series regression analysis adjusted decrease in the rate of cultures performed (pre-intervention, 3.6 cultures/100 days vs. Post-intervention, 1.8 cultures/100 days, p < 0.001). Pre-intervention, 29% (4/14) of Catheter-associated UTI (CAUTI) would not have been reported if reflex culturing was employed. In the ED, reflex culturing was associated with a 38% (p = 0.0015) regression analysis adjusted decrease in cultures, from 5.4/100 visits to 3.3/100 visits. In LTC, there was a small absolute, but regression analysis adjusted increase of 89% (p = 0.0018) in rates from (0.4/100 days to 0.5/100 days). Conclusion In acute care and ED, urine reflex culturing decreased the number of urine cultures performed. A small absolute increase was seen between pre-post time periods in LTC. Reflex testing generally decreases cultures and may lead to more accurate diagnoses of CAUTI.

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BackgroundUrine cultures are often positive in the absence of urinary tract infection (UTI) leading to unnecessary antibiotics. Reflex culturing decreases unnecessary urine culturing in acute care settings but the benefit in other settings is unknown.MethodsThis was a quasi-experimental study performed at a health system consisting of an acute care hospital, an emergency department (ED), and two long-term care (LTC) facilities. Reflex urine criterion was a urine analysis with > 10 white blood cells/high-power field. Urine cultures performed per 100 bed days of care (BDOC) were compared pre- (August 2016 to July 2017) vs. post-intervention (August 2017 to August 2018) using interrupted time series regression. Catheter-associated UTI (CAUTI) rates were reviewed to determine potential CAUTIs that would have been prevented.ResultsIn acute care, pre-intervention, 894 cultures were performed (3.6 cultures/100 BDOC). Post-intervention, 965 urine cultures were ordered and 507 cultures were performed (1.8 cultures/100 BDOC). Reflex culturing resulted in an immediate 49% decrease in cultures performed (P < 0.001). The CAUTI rate 2 years pre-intervention was 1.8/1000 catheter days and 1.6/1000 catheter days post-intervention. Reflex culturing would have prevented 4/14 CAUTIs. In ED, pre-intervention, 1393 cultures were performed (5.4 cultures/100 visits). Post-intervention, 1959 urine cultures were ordered and 917 were performed (3.3 cultures/100 visits). Reflex culturing resulted in an immediate 47% decrease in cultures performed (P = 0.0015). In LTC, pre-intervention, 257 cultures were performed (0.4 cultures/100 BDOC). Post-intervention, 432 urine cultures were ordered and 354 were performed (0.5 cultures/100 BDOC). Reflex culturing resulted in an immediate 75% increase in cultures performed (P < 0.001). The CAUTI rate 2 years pre-intervention was 1.0/1000 catheter days vs. 1.6/1,000 catheter days post-intervention. Reflex culturing would have prevented 1/13 CAUTIs.ConclusionReflex culturing canceled 16%-51% of cultures ordered with greatest impact in acute care and the ED and a small absolute increase in LTC. CAUTI rates did not change although reflex culturing would have prevented 29% of CAUTIs in acute care and 8% in LTC. Disclosures All authors: No reported disclosures.