UNDERSTANDING LOCAL PRODUCE SOURCING BY RESTAURATEURS IN HOUSTON, TEXAS

As of 2017, Americans are spending more per year on eating out at restaurants and bars than on grocery shopping (Baer, 2016). While restaurateurs have a substantial amount of influence over what foods are served and ultimately consumed by their patrons, they have received little attention as target populations for understanding or changing behavior. Health interventions taking place in restaurants have focused on changing restaurant patron behavior rather than changing the behavior of the restaurateur, the individual who owns and or operates the restaurant. Industrialization of food has been associated with a loss of biodiversity, environmental pollution, erosion, and over-use of fossil fuels. Conversely, local food systems are geographically localized, with consequently shorter distances between food production (i.e,. a farm or ranch) and consumption (i.e., restaurant food). Geographic localization has been associated with reduced nutrient degradation between harvesting and consumption, a lower environmental impact of both growing and transporting goods, and last but not least the potential to vitalize local economies through transactional exchanges with producers, such as local farmers (Christensen & O\u27Sulivan, 2015). In 2007, the term locavore first appeared in the Oxford dictionary to describe one who consumes locally sourced goods such as those provided by local farmers (Shin, 2005). This dissertation was intended to add to literature on the role of locavores in addressing national and global food concerns , in particular, by examining locavore restaurateurs as agents of change in the movement of locally produced goods across a community. Increasingly more restaurants advertise supporting farmers and their communities as primary goals. This dissertation was guided by the assumption that this sub-culture of locavore chefs and restaurateurs is playing a critical role in addressing the individual and social concerns associated with a global industrialized food system. This dissertation comprised three manuscripts, each contributing to the overall goal of this project to understand the determinants and features of restaurateur sourcing of local produce. In the first manuscript, we identified differences in sociodemographics, beliefs, and behaviors between restaurateurs who sourced produce directly from farmers (termed short food supply chain users) compared to those who did not have direct relationships with local farmers (termed long food supply chain users) in order to detect whether a specific set of characteristics, or restaurateur profile, was associated with sourcing directly from farmers. Importantly, we also evaluated the effectiveness of direct sourcing from local farmers by examining how it ultimately predicted overall level of local produce sourcing by restaurateurs. In the second manuscript, we utilized constructs from Social Network Theory to explore how competition and collaboration among restaurateurs were associated with local produce sourcing. Specifically, we compared indices of restaurateur influence based on collaboration and competition (measured by the social network constructs of prominence and position) and then assessed their joint and separate effects on local produce sourcing using ordinal logistic regression to gain insights into how restaurateurs interact with one another in ways that can hinder or promote local sourcing. The last manuscript examined the role of local food distributors or middlepersons in brokering the relationships between farmers and restaurateurs. Specifically, we looked at how having relationships with distributors influenced the interconnectedness of farm and restaurant network members. In the last study, we recognized the likely role that group cohesion played in the flow of goods from farmer to restaurateur and explored whether distributors reinforced or compromised group cohesion. The specific research questions addressed were: How do short food supply chain users compare to those who only use long food supply chains? (Manuscript 1). What are the individual and network-level determinants of local sourcing? (Manuscripts 1 and 2). Lastly, how does participating in brokered relationships influence group cohesion and collective action of the network (Manuscript 3)? The locavore movement was the focus of this dissertation, but is just one example of how restaurateurs can act as proponents, even leaders, for missions embraced by the communities in which they are situated. This dissertation aimed to understand determinants and features of local produce sourcing among “locavore” restaurateurs in Houston, Texas

Optimizing Antibiotic Stewardship in Nursing Homes: A Narrative Review and Recommendations for Improvement

The emerging crisis in antibiotic resistance and concern that we now sit on the precipice of a post-antibiotic era have given rise to advocacy at the highest levels for widespread adoption of programmes that promote judicious use of antibiotics. These antibiotic stewardship programmes, which seek to optimize antibiotic choice when clinically indicated and discourage antibiotic use when clinically unnecessary, are being implemented in an increasing number of acute care facilities, but their adoption has been slower in nursing homes. The antibiotic prescribing process in nursing homes is fundamentally different from that observed in hospital and clinic settings, with formidable challenges to implementation of effective antibiotic stewardship. Nevertheless, an emerging body of research points towards ways to improve antibiotic prescribing practices in nursing homes. This review summarizes the findings of this research and presents ways in which antibiotic stewardship can be implemented and optimized in the nursing home setting

SHEA Position Statement on Pandemic Preparedness for Policymakers: Introduction and Overview

Throughout history, pandemics and their aftereffects have spurred society to make substantial improvements in healthcare. After the Black Death in 14th century Europe, changes were made to elevate standards of care and nutrition that resulted in improved life expectancy.1 The 1918 influenza pandemic spurred a movement that emphasized public health surveillance and detection of future outbreaks and eventually led to the creation of the World Health Organization Global Influenza Surveillance Network.2 In the present, the COVID-19 pandemic exposed many of the pre-existing problems within the US healthcare system, which included (1) a lack of capacity to manage a large influx of contagious patients while simultaneously maintaining routine and emergency care to non-COVID patients; (2) a just in time supply network that led to shortages and competition among hospitals, nursing homes, and other care sites for essential supplies; and (3) longstanding inequities in the distribution of healthcare and the healthcare workforce. The decades-long shift from domestic manufacturing to a reliance on global supply chains has compounded ongoing gaps in preparedness for supplies such as personal protective equipment and ventilators. Inequities in racial and socioeconomic outcomes highlighted during the pandemic have accelerated the call to focus on diversity, equity, and inclusion (DEI) within our communities. The pandemic accelerated cooperation between government entities and the healthcare system, resulting in swift implementation of mitigation measures, new therapies and vaccinations at unprecedented speeds, despite our fragmented healthcare delivery system and political divisions. Still, widespread misinformation or disinformation and political divisions contributed to eroded trust in the public health system and prevented an even uptake of mitigation measures, vaccines and therapeutics, impeding our ability to contain the spread of the virus in this country.3 Ultimately, the lessons of COVID-19 illustrate the need to better prepare for the next pandemic. Rising microbial resistance, emerging and re-emerging pathogens, increased globalization, an aging population, and climate change are all factors that increase the likelihood of another pandemic

Bacteriuria in Older Adults Triggers Confusion in Healthcare Providers: A Mindful Pause to Treat the Worry

The evidence base for refraining from screening for or treating asymptomatic bacteriuria (ASB) in older adults is strong, but both practices remain prevalent. Clinical confusion over how to respond to a change from baseline, when to order a urinalysis and urine culture, and what to do with a positive urine culture fuels unnecessary antibiotic use for ASB. If the provider can take a mindful pause to apply evidenced-based assessment tools, the resulting increased clarity in how to manage the situation can reduce overtreatment of ASB

Concurrent Atlantoaxial Septic Arthritis and Septic Thrombosis of the Ophthalmic Vein due to Staphylococcus Aureus: A Case Report and Review of the Literature

Atlantoaxial joint septic arthritis and superior ophthalmic vein thrombosis are uncommon manifestations of Staphylococcus aureus infection. A 68-year-old man presented with acute-onset neck pain and diplopia. Imaging studies revealed atlantoaxial septic arthritis and right superior ophthalmic vein thrombosis. Blood cultures grew methicillin-susceptible S. aureus. We review the literature describing these 2 uncommon manifestations of a common pathogen

Implementation of an Antibiotic Stewardship Program in Long-Term Care Facilities Across the US

Importance: Antibiotic overuse in long-term care (LTC) is common, prompting calls for antibiotic stewardship programs (ASPs) designed for specific use in these settings. The optimal approach to establish robust, sustainable ASPs in LTC facilities is unknown. Objectives: To determine if the Agency for Healthcare Research and Quality (AHRQ) Safety Program for Improving Antibiotic Use, an educational initiative to establish ASPs focusing on patient safety, is associated with reductions in antibiotic use in LTC settings. Design, Setting, and Participants: This quality improvement study including 439 LTC facilities in the US assessed antibiotic therapy data following a pragmatic quality-improvement program, which was implemented to assist facilities in establishing ASPs and with antibiotic decision-making. Training was conducted between December 2018 and November 2019. Data were analyzed from January 2019 to December 2019. Interventions: Fifteen webinars occurred over 12 months (December 2018 to November 2019), accompanied by additional tools, activities, posters, and pocket cards. All clinical staff were encouraged to participate. Main Outcomes and Measures: The primary outcome was antibiotic starts per 1000 resident-days. Secondary outcomes included days of antibiotic therapy (DOT) per 1000 resident-days, the number of urine cultures per 1000 resident-days, and Clostridioides difficile laboratory-identified events per 10000 resident-days. All outcomes compared data from the baseline (January-February 2019) to the completion of the program (November-December 2019). Generalized linear mixed models with random intercepts at the site level assessed changes over time. Results: Of a total 523 eligible LTC facilities, 439 (83.9%) completed the safety program. The mean difference for antibiotic starts from baseline to study completion per 1000 resident-days was -0.41 (95% CI, -0.76 to -0.07; P =.02), with fluoroquinolones showing the greatest decrease at -0.21 starts per 1000 resident-days (95% CI, -0.35 to -0.08; P =.002). The mean difference for antibiotic DOT per 1000 resident-days was not significant (-3.05; 95% CI, -6.34 to 0.23; P =.07). Reductions in antibiotic starts and use were greater in facilities with greater program engagement (as measured by webinar attendance). While antibiotic starts and DOT in these facilities decreased by 1.12 per 1000 resident-days (95% CI, -1.75 to -0.49; P \u3c.001) and 9.97 per 1000 resident-days (95% CI, -15.4 to -4.6; P \u3c.001), respectively, no significant reductions occurred in low engagement facilities. Urine cultures per 1000 resident-days decreased by 0.38 (95% CI, -0.61 to -0.15; P =.001). There was no significant change in facility-onset C difficile laboratory-identified events. Conclusions and Relevance: Participation in the AHRQ safety program was associated with the development of ASPs that actively engaged clinical staff in the decision-making processes around antibiotic prescriptions in participating LTC facilities. The reduction in antibiotic DOT and starts, which was more pronounced in more engaged facilities, indicates that implementation of this multifaceted program may support successful ASPs in LTC settings

SHEA Position Statement on Pandemic Preparedness for Policymakers: Building a Strong and Resilient Healthcare Workforce

Throughout the COVID-19 pandemic, many areas in the United States experienced healthcare personnel (HCP) shortages tied to a variety of factors. Infection prevention programs, in particular, faced increasing workload demands with little opportunity to delegate tasks to others without specific infectious diseases or infection control expertise. Shortages of clinicians providing inpatient care to critically ill patients during the early phase of the pandemic were multifactorial, largely attributed to increasing demands on hospitals to provide care to patients hospitalized with COVID-19 and furloughs.1 HCP shortages and challenges during later surges, including the Omicron variant-associated surges, were largely attributed to HCP infections and associated work restrictions during isolation periods and the need to care for family members, particularly children, with COVID-19. Additionally, the detrimental physical and mental health impact of COVID-19 on HCP has led to attrition, which further exacerbates shortages.2 Demands increased in post-acute and long-term care (PALTC) settings, which already faced critical staffing challenges difficulty with recruitment, and high rates of turnover. Although individual healthcare organizations and state and federal governments have taken actions to mitigate recurring shortages, additional work and innovation are needed to develop longer-term solutions to improve healthcare workforce resiliency. The critical role of those with specialized training in infection prevention, including healthcare epidemiologists, was well-demonstrated in pandemic preparedness and response. The COVID-19 pandemic underscored the need to support growth in these fields.3 This commentary outlines the need to develop the US healthcare workforce in preparation for future pandemics