Multihospital Infection Prevention Collaborative: Informatics Challenges and Strategies to Prevent MRSA

We formed a collaborative to spread effective MRSA prevention strategies. We conducted a two-phase, multisite, quasi-experimental study of seven hospital systems (11 hospitals) in IN, MT, ME and Ontario, Canada over six years. Patients with prior MRSA were identified at admission using regional health information exchange data. We developed a system to return an alert message indicating a prior history of MRSA, directed to infection preventionists and admissions. Alerts indicated the prior anatomic site, and the originating institution. The combined approach of training and coaching, implementation of MRSA registries, notifying hospitals on admission of previously infected or colonized patients, and change strategies was effective in reducing MRSA infections over 80%. Further research and development of electronic surveillance tools is needed to better integrate the varied data source and support preventing MRSA infections. Our study supports the importance of hospitals collaborating to share data and implement effective strategies to prevent MRSA

Integrating Clinical Decision Support into Workflow

Purpose: The aims were to (1) identify barriers and facilitators related to integration of clinical decision support (CDS) into workflow and (2) develop and test CDS design alternatives. Scope: To better understand CDS integration, we studied its use in practice, focusing on CDS for colorectal cancer (CRC) screening and followup. Phase 1 involved outpatient clinics of four different systems—120 clinic staff and providers and 118 patients were observed. In Phase 2, prototyped design enhancements to the Veterans Administration’s CRC screening reminder were compared against its current reminder in a simulation experiment. Twelve providers participated. Methods: Phase 1 was a qualitative project, using key informant interviews, direct observation, opportunistic interviews, and focus groups. All data were analyzed using a coding template, based on the sociotechnical systems theory, which was modified as coding proceeded and themes emerged. Phase 2 consisted of rapid prototyping of CDS design alternatives based on Phase 1 findings and a simulation experiment to test these design changes in a within-subject comparison. Results: Very different CDS types existed across sites, yet there are common barriers: (1) lack of coordination of “outside” results and between primary and specialty care; (2) suboptimal data organization and presentation; (3) needed provider and patient education; (4) needed interface flexibility; (5) needed technological enhancements; (6) unclear role assignments; (7) organizational issues; and (8) disconnect with quality reporting. Design enhancements positively impacted usability and workflow integration but not workload. Conclusions: Effective CDS design and integration requires: (1) organizational and workflow integration; (2) integrating outside results; (3) improving data organization and presentation in a flexible interface; and (4) providing just-in time education, cognitive support, and quality reporting

On the antiquity of metalloenzymes and their substrates in bioenergetics

Many metalloenzymes that inject and extract reducing equivalents at the beginning and the end of electron transport chains involved in chemiosmosis are suggested, through phylogenetic analysis, to have been present in the Last Universal Common Ancestor (LUCA). Their active centres are affine with the structures of minerals presumed to contribute to precipitate membranes produced on the mixing of hydrothermal solutions with the Hadean Ocean ~ 4 billion years ago. These mineral precipitates consist of transition element sulphides and oxides such as nickelian mackinawite ([Fe > Ni]_2S_2), a nickel-bearing greigite (~ FeSS[Fe_3NiS_4]SSFe), violarite (~ NiSS[Fe_2Ni_2S_4]SSNi), a molybdenum bearing complex (~ Mo^(IV/VI)_2Fe_3S^(0/2−)_9) and green rust or fougerite (~[Fe^(II)Fe^(III)(OH)_4]+[OH]^−). They may be respectively compared with the active centres of Ni–Fe hydrogenase, carbon monoxide dehydrogenase (CODH), acetyl coenzyme-A synthase (ACS), the complex iron–sulphur molybdoenzyme (CISM) superfamily and methane monooxygenase (MMO). With the look of good catalysts – a suggestion that gathers some support from prebiotic hydrothermal experimentation – and sequestered by short peptides, they could be thought of as the original building blocks of proto-enzyme active centres. This convergence of the makeup of the LUCA-metalloenzymes with mineral structure and composition of hydrothermal precipitates adds credence to the alkaline hydrothermal (chemiosmotic) theory for the emergence of life, specifically to the possibility that the first metabolic pathway – the acetyl CoA pathway – was initially driven from either end, reductively from CO_2 to CO and oxidatively and reductively from CH_4 through to a methane thiol group, the two entities assembled with the help of a further thiol on a violarite cluster sequestered by peptides. By contrast, the organic coenzymes were entirely a product of the first metabolic pathways. This article is part of a Special Issue entitled: Metals in Bioenergetics and Biomimetics Systems