BackgroundPatients may be over-diagnosed with C. difficile infection (CDI) due to colonization, especially if laxatives are used. We had implemented an alert to prompt providers to discontinue C. diff orders in the setting of laxative use. This initially decreased orders by about 25%, but became less effective over time. Our objective was to strengthen our C. diff testing stewardship by creating a “hard stop” to require providers to think critically about C. diff testing in the presence of laxative use or the absence of documented diarrhea.MethodsOur two-hospital, >1100-bed community-based academic healthcare system performs all C. diff testing via PCR. We implemented our initial laxative alert, which notified providers but did not prohibit testing, in March 2015. In April 2017, we launched a new alert that fired >36 hours after admission, and assessed for documented diarrhea (>2 episodes/24 hours). If diarrhea was present, it would assess for any administered laxative within prior 24 hours. If neither criterion was met, the provider could only order C. diff testing by calling the laboratory and documenting the staff person’s name in the order; no further justification was required. We measured the number of C. diff tests completed per day, the number of calls made to lab, and CDI rates (using NHSN LabID definition). Balancing measures included monitoring oral vancomycin orders without C. diff testing, and delayed CDI diagnoses.ResultsAt baseline, we observed a mean of 9 (SD, 4–14) C. diff orders daily. After initiating the hard stop alert, daily testing decreased by 30% (Fig. 1). Frequency of hospital-onset CDI dropped by 45% during first month of implementation (Fig. 2), from mean 3.6/week to 2/week. To date we have not detected delayed diagnoses or empiric treatment without testing; 18 override laboratory calls have been documented.ConclusionGiven PCR’s high sensitivity for C. diff, testing stewardship is critical to minimize false-positive cases of CDI, which lead to inappropriate treatment, prolonged length of stay, and hospital penalties. Requiring a phone call to order C. diff testing in the setting of laxative use or minimal diarrhea effectively reduced testing, and was well-accepted by nurses and providers. To date, no adverse effects have been detected.Disclosures All authors: No reported disclosures.

Rhode Island, New Zealand, and southern California recently reported sharp increases in sexually transmitted diseases (STDs). Health department officials stated that these increases appeared to be due to the more widespread use of social media like Tinder, Grindr, and Facebook, which allow users to readily connect with and meet others. The purpose of this study was to see if U.S. states that have more users of social networking sites, dating sites, and dating apps like Match.com, Ashley Madison, Our Time, Down Dating, Bumble, Zoosk, Hinge, Score, At First Sight, Plenty of Fish, Eharmony, Adult Friend Finder, Tinder, Grindr, and Facebook have more cases of STDs after controlling for population, race, age, income, education, and population density. It was found that states with more users of Match.com, OKCupid, and Down Dating had a larger number of cases of STDs, while states with more users of Our Time, Ashley Madison, Facebook, How About We, Hinge, Adult Friend Finder, Grindr, Bumble, Score, Tinder, and At First Sight had fewer cases of STDs. While social networking sites make it easier for individuals to be exposed to an STD since in-network individuals may share an STD, many sites either attract individuals who are not interested in a short-term sexual relationship or who take precautions to avoid contracting an STD.

Purpose The purpose of this paper is to analyze the extent to which major US airlines respond to one another in quality of service improvements. Design/methodology/approach Utilizing monthly data, the authors estimate a five-equation vector autoregressive model to determine which airline leads or follows others in quality of service improvements. Findings This study found that the five major airlines make interrelated decisions when responding to customer complaints concerning flight problems, over-sales, reservations, ticketing, boarding, and customer service. Every airline either responds to or influences the changes in customer complaints faced by at least one other airline, while some airlines do both. However, only one such relationship was found when examining if airlines change the percent of flight delays they have control over in response to changes in flight delays faced by another airline. Practical implications The number of passenger complaints against an airline can be influenced by the airline, as can the number of carrier-caused flight delays. The industry leaders in responsiveness to consumer complaints are US Airways and United. However, airlines do not, as a group, respond to the carrier-caused delays of their competitors. The prescription to improve airline service vis-à-vis flight delays is simple: tell passengers why flights are delayed. To protect or gain market share, airlines would compete for customers by minimizing flight delays in a similar manor to how they respond to customer complaints. Originality/value No other paper that the authors are aware of has addressed the issue of identifying leaders and followers in the US airline industry regarding changes in service quality as reflected by changes in passenger complaints and flight delays.

Learning outside the classroom in an informal setting is a growing trend in geography education. This entry explores the basic concepts and importance of learning geography through community engagement and in informal settings such as field trips, museums, and exhibitions. Such informal learning and engagement with the public and local communities may enhance research, teaching, and learning outcomes. Examples of informal learning within geography are found mostly in the United States and Western Europe, but some types are also practiced in developing countries such as Pakistan. Although engaged and informal learning have some weaknesses and challenges, the strengths of these approaches make them the appropriate learning pedagogies to complement formal geography education.