Kimberly McCoy

Percutaneous Injury, Blood Exposure, and Adherence to Standard Precautions: Are Hospital-Based Health Care Providers Still at Risk?

To examine factors associated with blood exposure and percutaneous injury among health care workers, we assessed occupational risk factors, compliance with standard precautions, frequency of exposure, and reporting in a stratified random sample of 5123 physicians, nurses, and medical technologists working in Iowa community hospitals. Of these, 3223 (63%) participated. Mean rates of hand washing (32%-54%), avoiding needle recapping (29%-70%), and underreporting sharps injuries (22%-62%; overall, 32%) varied by occupation (P<.01). Logistic regression was used to estimate the adjusted odds of percutaneous injury (aOR(injury)), which increased 2%-3% for each sharp handled in a typical week. The overall aOR(injury) for never recapping needles was 0.74 (95% CI, 0.60-0.91). Any recent blood contact, a measure of consistent use of barrier precautions, had an overall aOR(injury) of 1.57 (95% CI, 1.32-1.86); among physicians, the aOR(injury) was 2.18 (95% CI, 1.34-3.54). Adherence to standard precautions was found to be suboptimal. Underreporting was found to be common. Percutaneous injury and mucocutaneous blood exposure are related to frequency of sharps handling and inversely related to routine standard-precaution compliance. New strategies for preventing exposures, training, and monitoring adherence are needed.

Does Patient-centered Care Improve Provision of Preventive Services?

AbstractOBJECTIVES: While patient-centered care (PCC) is desirable for many reasons, its relationship to treatment outcomes is controversial. We evaluated the relationship between PCC and the provision of preventive services. METHODS: We obtained facility-level estimates of how well each VA hospital provided PCC from the 1999 ambulatory Veterans Satisfaction Survey. PCC delivery was measured by the average percentage of responses per facility indicating satisfactory performance from items in 8 PCC domains: access, incorporating patient preferences, patient education, emotional support, visit coordination, overall coordination of care, continuity, and courtesy. Additional predictors included patient population and facility characteristics. Our outcome was a previously validated hospital-level benchmarking score describing facility-level performance across 12 U.S. Preventive Services Task Force-recommended interventions, using the 1999 Veterans Health Survey. RESULTS: Facility-level delivery of preventive services ranged from an overall mean of 90% compliance for influenza vaccinations to 18% for screening for seat belt use. Mean overall PCC scores ranged from excellent (>90% for the continuity of care and courtesy of care PCC domains) to modest (<70% for patient education). Correlates of better preventive service delivery included how often patients were able to discuss their concerns with their provider, the percent of visits at which patients saw their usual provider, and the percent of patients receiving >90% of care from a VA hospital. CONCLUSION: Improved communication between patients and providers, and continuity of care are associated with increased provision of preventive services, while other aspects of PCC are not strongly related to delivery of preventive services.

Organizational predictors of adherence to ambulatory care screening guidelines

Objective. The purpose of this study was to identify hospital organizational characteristics consistently associated with adherence to multiple clinical practice guidelines (CPGs). We examined the relationship between organizational and patient population characteristics and adherence to three screening CPGs implemented throughout the Veterans Health Administration (VHA). Materials and methods. The study included 114 acute care facilities. Three sources of data were used: 1998 American Hospital Association data, VHA External Peer Review Program data for 1998 and 1999, and the 1999 Veterans Satisfaction Survey. Organizational characteristics likely to affect adherence with the CPGs were classified into five conceptual domains (clinical emphasis, operational capacity, patient population, professionalism, and urbanicity). Organizational characteristics were ranked, based on their standardized beta coefficients in bivariate logistic regressions predicting the likelihood of adherence. Within-domain multivariable logistic analyses assessed the robustness of individual predictors of CPG adherence, controlling for other organizational factors within the same domain. Results. Overall, 46 of 48 relationships in the bivariate logistic analyses were significant, and 43 of these remained significant in the within-domain multivariate analyses. The relative rankings of the variables as predictors of CPG adherence within conceptual domains were also quite consistent. Conclusions. Strong evidence was found for the importance of specific organizational factors, including mission, capacity, professionalism, and patient population characteristics that influence CPG adherence in a large multiinstitutional sample involving multiple provider practices. Research and programs to improve adherence to CPGs and other quality improvement activities in hospitals should incorporate these organizational factors.

Linked insurance-tumor registry database for health services research.

OBJECTIVE Breast cancer screening and treatment data are often limited to restricted populations, including women older than 65 years old. The goal of this project was to develop procedures to link tumor registry and insurance claims databases on women younger than 65 years old with breast cancer and to assess the accuracy and validity of the linked dataset. METHODS Iowa Cancer Registry (ICR) and Wellmark Blue Cross/Blue Shield of Iowa (BC/BS) membership files of women with incident in situ or invasive breast cancer from 1989 to 1996 were linked. An automated deterministic match was followed with visual inspection from three independent reviewers applying a matching protocol. Matched and overall registry data were compared to assess population representativeness. Claims from BC/BS for incident cases during 1994 were examined for coding of a recent breast cancer diagnosis or treatment. RESULTS The final dataset included 4,397 matched cases of patients aged 21 years and older from 1989 to 1996. The sociodemographic and tumor characteristics of the ICR population younger than 65 years old (n = 7,469) with breast cancer or carcinoma in situ were nearly identical with those of the matched patients younger than 65 years old (n = 3,449). Nearly all (96%) of the 445 matched incident cases in 1994 had claims data (CPT, DRG, or ICD-9 code) indicative of breast cancer. Treatment patterns varied by data source, with agreement ranging from 76% to 82%. CONCLUSIONS The validity and generalizability of these data demonstrate their potential for further health services research among younger insured women with breast cancer. Additionally, the process outlined may be useful for developing other datasets to study other cancers in the population younger than 65 years old.

Programmed Self-Assembly of an Active P22-Cas9 Nanocarrier System.

Clustered Regularly Interspaced Short Palindromic Repeats (CRISPR) RNA-guided endonucleases are powerful new tools for targeted genome engineering. These nucleases provide an efficient and precise method for manipulating eukaryotic genomes; however, delivery of these reagents to specific cell-types remains challenging. Virus-like particles (VLPs) derived from bacteriophage P22, are robust supramolecular protein cage structures with demonstrated utility for cell type-specific delivery of encapsulated cargos. Here, we genetically fuse Cas9 to a truncated form of the P22 scaffold protein, which acts as a template for capsid assembly as well as a specific encapsulation signal for Cas9. Our results indicate that Cas9 and a single-guide RNA are packaged inside the P22 VLP, and activity assays indicate that this RNA-guided endonuclease is functional for sequence-specific cleavage of dsDNA targets. This work demonstrates the potential for developing P22 as a delivery vehicle for cell specific targeting of Cas9.

Implementation of evidence-based practices: Applying a goal commitment framework

Background: The implementation of evidence-based practices translates research findings into practice to reduce inappropriate care. However, this process is slow and unpredictable. The lack of a coherent theoretical basis for understanding individual and organizational behavior limits our ability to formulate effective implementation strategies. Purpose: The study objectives are (a) to test the goal commitment framework that explains mechanisms impacting outcomes of major depressive disorder (MDD) screening guideline implementation and (b) to understand the effects of implementation outcomes on provider practice related to MDD screening. Methods: Using data from the Determinants of Clinical Practice Guideline Implementation Effectiveness Study, the national sample included 2,438 clinicians from 139 Veteran Affairs acute care hospitals with primary care clinics. We used hierarchical generalized linear modeling to assess the following implementation outcomes: agreement with, adherence to, improvement in knowledge of guidelines, and delivery of best practices as a function of clinician input into implementation, teamwork, involvement in quality improvement activities, participative culture, interdepartmental coordination, frequency, and utility of performance feedback. We then estimated self-reported MDD screening practices as a function of these four implementation outcomes. Findings: Results showed that having input into implementation, involvement in quality of care improvement, teamwork, and perceived value of performance feedback were positively associated with implementation outcomes. Provider self-assessed guideline adherence was positively associated with the likelihood of appropriate MDD screening. Implications: Factors related to increased goal commitment positively predicted key implementation outcomes, which in turn enhanced care delivery. This study demonstrates that the goal commitment framework is useful in assisting managers to assess factors that facilitate implementation. In particular, participation, feedback, and team work equip organizational participants with better information about implementation targets, thereby increasing adherence. Instituting or improving systems or programs to facilitate timely, appropriate performance feedback and provider participation may help enhancing organizational change and learning.

Constructing catalytic antimicrobial nanoparticles by encapsulation of hydrogen peroxide producing enzyme inside the P22 VLP

Here we examine a self-assembling virus like particle to construct catalytically active nanoparticles that can inhibit bacterial growth. The results suggest that encapsulation of enzymes inside VLPs can be exploited to develop new bionanomaterials with useful functionalities.

Structural and process factors affecting the implementation of antimicrobial resistance prevention and control strategies in U.S. hospitals

Background: To address increases in the incidence of infection with antimicrobial-resistant pathogens, the National Foundation for Infectious Diseases and Centers for Disease Control and Prevention proposed two sets of strategies to (a) optimize antibiotic use and (b) prevent the spread of antimicrobial resistance and control transmission. However, little is known about the implementation of these strategies. Purpose: Our objective is to explore organizational structural and process factors that facilitate the implementation of National Foundation for Infectious Diseases/Centers for Disease Control and Prevention strategies in U.S. hospitals. Methods: We surveyed 448 infection control professionals from a national sample of hospitals. Clinically anchored in the Donabedian model that defines quality in terms of structural and process factors, with the structural domain further informed by a contingency approach, we modeled the degree to which National Foundation for Infectious Diseases and Centers for Disease Control and Prevention strategies were implemented as a function of formalization and standardization of protocols, centralization of decision-making hierarchy, information technology capabilities, culture, communication mechanisms, and interdepartmental coordination, controlling for hospital characteristics. Findings: Formalization, standardization, centralization, institutional culture, provider-management communication, and information technology use were associated with optimal antibiotic use and enhanced implementation of strategies that prevent and control antimicrobial resistance spread (all p < .001). However, interdepartmental coordination for patient care was inversely related with antibiotic use in contrast to antimicrobial resistance spread prevention and control (p < .0001). Implications: Formalization and standardization may eliminate staff role conflict, whereas centralized authority may minimize ambiguity. Culture and communication likely promote internal trust, whereas information technology use helps integrate and support these organizational processes. These findings suggest concrete strategies for evaluating current capabilities to implement effective practices and foster and sustain a culture of patient safety.

Sortase-Mediated Ligation as a Modular Approach for the Covalent Attachment of Proteins to the Exterior of the Bacteriophage P22 Virus-like Particle

Virus-like particles are unique platforms well suited for the construction of nanomaterials with broad-range applications. The research presented here describes the development of a modular approach for the covalent attachment of protein domains to the exterior of the versatile bacteriophage P22 virus-like particle (VLP) via a sortase-mediated ligation strategy. The bacteriophage P22 coat protein was genetically engineered to incorporate an LPETG amino acid sequence on the C-terminus, providing the peptide recognition sequence utilized by the sortase enzyme to catalyze peptide bond formation between the LPETG-tagged protein and a protein containing a polyglycine sequence on the N-terminus. Here we evaluate attachment of green fluorescent protein (GFP) and the head domain of the influenza hemagglutinin (HA) protein by genetically producing polyglycine tagged proteins. Attachment of both proteins to the exterior of the P22 VLP was found to be highly efficient as judged by SDS-PAGE densitometry. These results enlarge the tool kit for modifying the P22 VLP system and provide new insights for other VLPs that have an externally displayed C-terminus that can use the described strategy for the modular modification of their external surface for various applications.

Modular Self-Assembly of Protein Cage Lattices for Multistep Catalysis

The assembly of individual molecules into hierarchical structures is a promising strategy for developing three-dimensional materials with properties arising from interaction between the individual building blocks. Virus capsids are elegant examples of biomolecular nanostructures, which are themselves hierarchically assembled from a limited number of protein subunits. Here, we demonstrate the bio-inspired modular construction of materials with two levels of hierarchy: the formation of catalytically active individual virus-like particles (VLPs) through directed self-assembly of capsid subunits with enzyme encapsulation, and the assembly of these VLP building blocks into three-dimensional arrays. The structure of the assembled arrays was successfully altered from an amorphous aggregate to an ordered structure, with a face-centered cubic lattice, by modifying the exterior surface of the VLP without changing its overall morphology, to modulate interparticle interactions. The assembly behavior and resultant lattice structure was a consequence of interparticle interaction between exterior surfaces of individual particles and thus independent of the enzyme cargos encapsulated within the VLPs. These superlattice materials, composed of two populations of enzyme-packaged VLP modules, retained the coupled catalytic activity in a two-step reaction for isobutanol synthesis. This study demonstrates a significant step toward the bottom-up fabrication of functional superlattice materials using a self-assembly process across multiple length scales and exhibits properties and function that arise from the interaction between individual building blocks.