2016 NHSN – Infection Prevention and Surveillance in LTC

2016 NHSN – Infection Prevention and Surveillance in LTC


>>Welcome to Atlanta
and the start of the 2016 NHSN
Annual Training. We tried to order
some pretty weather for those of you who have come from the north, and I hope we did alright. My name for those of
who I haven’t had the privilege to meet yet
is Nimalie Stone. And I’m the medical
epidemiologist for long-term care here
in the Division of Healthcare Quality
Promotion at the CDC. And I am thrilled
that we are beginning our annual training this year with long-term care content. This is our first
year where long-term care has had an
opportunity to present, so I appreciate all of
you being a part of this and we hope that
with your feedback, we can continue
to make this part of the agenda in the future. Some of you will be
here with us for the entire week of the training, but others will
just be here today focused on the long-term
care content, and we really appreciate
and thank you for your travel and spending
some time with us and welcome you again —
just a few housekeeping items to cover before we start
with the presentations. If there is an emergency, please
note the nearest exit sign and the locations around the room. Safety first, right? CDC and our planners,
presenters, as well as spouses and partners
wish to disclose that we have no
financial interests or other relationships
with the manufacturers of commercial products,
suppliers of commercial services or
commercial supporters. Our planners have reviewed
content to ensure there’s no bias. And presentations
will not include any discussion of the unlabeled
use of a product or a product under investigational use. CDC did not accept
commercial support for this continuing
education activity. And no specific
case studies will be addressed during
the training. Continuing Education
credits are available and instruction on how to apply for CE credits are in your folders. Please be sure to
scan in and scan out daily with Avaris so we can note your
attendance for the training. Also, note in the
resource manual a few handouts for long-term
care are in the back. Please feel free to
bring coffee, water and snacks into the
conference room. If you have any travel, parking, registration or
logistics questions, check with our colleagues
from Avaris at the front desk. Also, team members
from the NHSN Help Desk will be out front to answer or address other questions you may have. No photography inside the CDC is allowed. Please put your phones on
silent or vibrate mode. Also, we ask that all
of you hold your questions until the end
of each presentation. And with all that said,
why don’t we get started with our
preconference session? And in the next — So,
here in the next 30 minutes or so, I wanted
to have the opportunity to share with you
a perspective on some of the Infection
Surveillance and Prevention activities
have happening in long-term care
and I think many of you have heard me
talk before, so I was trying to think
of what I could say that would be novel
or interesting, and I thought, well since
this is our first time up here talking with you
as part of this NHSN training, let’s just do
a little retrospective and go back to 2009,
when in August, CDC hosted the Healthcare-Associated
Infections, HAI Surveillance in
Long-term Care Conference. And this was a group of academic partners, health
department partners, colleagues that represented
most of the nursing home professional
organizations like AMDA, the Society for Post-acute
and Long-term Care Medicine, the American
Healthcare Association, and the goal of the
discussion was to help guide CDC’s planning
around implementation of surveillance,
HAI surveillance infrastructure for
long-term care. This was before NHSN
had a component for long-term care facility
providers to report. And here were some of the takeaway, highlight summary statements
that came from that conference. CDC in partnership with national
collaborators is committed to developing a national HAI
Surveillance program tailored for an accessible to
long-term care facilities. In addition, the top
priority of this HAI Surveillance Program will be to provide information
and support for quality improvement
efforts among participating facilities. So it’s just a major
rationale for creating this surveillance
infrastructure. And we walked out with a proposed plan that there would be a
long-term care component designed within the
framework of NHSN based on the existing modules
we had available for hospitals and other
healthcare settings, but with adaptation
for the long-term care population and
for providers. So this was August 2009. That’s five and a half years ago. And then a few years
after that, about three years in fact, in 2012,
we saw the release of the long-term care
facility infection reporting component within NHSN. And right on the heels
of that came the updated infection
surveillance definitions for long-term care
facilities that was a joint effort published by
CDC and the Society for Healthcare Epidemiologist
of America/SHEA, and what was convenient
and not by accident was that these efforts informed
one another so as the criteria for surveillance were
being developed by our academic partners
and researchers and nursing home partners in the field as the McGeer definitions for long-term care
were being revised, we were integrating
those criteria into the infection
reporting events within NHSN, so there would be
congruence if you will and alignment between those efforts. And a few months
later, we looked at how many facilities had come in to the long-term
care facility component and this is three years ago
in February of 2013. So that’s about five,
roughly months after the component
had been released, and there 61 nursing homes
represented among 14 states. And you can see most of
the states had just one or two nursing homes that
had gotten enrolled, a couple which had
tried to maybe actively engage nursing
home providers in the conversation had gotten a few more. And Vermont was planning
this for a couple of years — for several years in fact
before NHSN came live. So they had quite a bit of
traction already in their state. So this is what the
map looked like three years ago when component
was pretty new. And here it is today. Three years later, we can
see we’ve got quite a few more states and quite
a few more facilities, 280 nursing homes that
have enrolled and are now actively
eligible to report. They may not all
be reporting and I think that’s important
to recognize, but one of the big hurdles,
right, is enrollment. So these have — these
280 facilities have actually made it through
the enrollment process with help and successfully,
and they represent 38 states, plus the
District of Columbia. And here you can see
more than a handful of states that have
worked intentionally with providers to engage nursing homes in this, supported them, and much of this
effort has been led by our state health department. How many of you are
here representing your state health
department today? Fantastic. Well, I applaud you
and thank you for all the work that you have
done in this effort. And then many of you
probably are representing quality improvement
organization or QINs. How many of you are representing QINs? Welcome. So it’s about half and half. That’s fantastic. Well hopefully you all
know each other already. If not, this is a
fabulous opportunity to meet and talk about
how your activities and efforts align with one another’s, especially in long-term care especially in the
next few years. So what were some
of the drivers for NHSN use in these
first three years of our experience with a component? I think as I mentioned
already, the state HAI programs engaging nursing
homes and promoting it as a tool for
supporting prevention efforts around C.
difficile infection and multidrug-resistant organisms. In addition, we
found that hospital systems or hospital
partners were working with their affiliated
nursing homes and long-term care facilities to help them start to
get involved in NHSN. There have been some policy
statements, probably written by folks who
are here in the room about the importance and
the opportunity that NHSN reporting offers
for long-term care when it comes to HAI Surveillance. One of the biggest statements
that came out from the Department of Health
and Human Services in the spring of 2013
was the HAI Prevention Roadmap and the Action
Plan to eliminate HAIs. And there was a chapter
specifically focused on long-term care that
made NHSN enrollment and reporting one of the top
priorities for this setting. And then not that long
ago, just nine months ago, I guess last summer,
the counsel for State and Territorial
Epidemiologists put a position statement
that also endorsed and encouraged the use of
NHSN as the standard setting for Infection Surveillance
in long-term care. So we’ve also seen in
this timeline a lot of awareness of the
role of NHSN reporting from state and federal incentive programs. For example, all of
you are intimately connected to the CMS
reporting programs and other post-acute
care settings like long-term acute
care hospitals and inpatient rehabilitation
facilities not — in addition to dialysis clinics
and acute care hospitals. About a year ago,
Nevada became the first state to require
NHSN reporting from skilled nursing
facilities, and they’re still in the midst of
implementing that. And then interestingly, you
know, the survey process and the regulatory process
is a very powerful driver of change in
the nursing homes. And if you are not
connected to and working with your state survey
agency and the folks that do oversight
of nursing homes, I would encourage you
to get to know them and make them aware of
the work you’re doing, because I think again,
there’s a lot alignment between everybody’s
goals to raise the quality and safety
in these facilities, but in Wisconsin,
there were surveyors starting to ask when the
visit nursing homes, they just ask about
NHSN — Do you know it? Have you heard of it? Do you use it? Just part of your
surveillance program, and although it was
not a requirement and there was not
citation or deficiency if you said, no, I’ve
never heard of it, the fact that people
were talking about it and being asked about
it really started to get facilities interested
in paying attention. So we have kind of had a
facelift, not that long ago. And our website has got
a lot of new training resources and Angela
and others will kind of walk you through those
resources later in this session. But one the strengths
and one of the reasons why we wanted to see
NHSN become an — you know, become a
resource for long-term care was the power of
standardization — the power of standardizing our
approach to identifying events and tracking our data
and reporting our data. And as you hopefully are
aware, the component current affords reporting
options for facilities in urinary tract
infection surveillance, as well as
multidrug-resistant organism and C. difficile
surveillance through laboratory identified
events surveillance, as well as some prevention
process measures such as adherence to hand hygiene and gown and glove use. And there’s a lot of
interconnectedness between use of antibiotics. For example in urinary
tract infections and how that has
impact on our rates of resistant C. diff that are
activities at the bedside. So there was some
strategy to how these initial early events
were rolled out. I wanted to share
briefly a little bit of information from analysis
that we did to look at some of our very,
very early adapters of the long-term care
facility component, and these were the facilities
that enrolled and reported data with the first two full
calendar years that the system was up and available,
and that’s January of 2013 through December of 2014. There are about 200
facilities that had enrolled in that time frame, and you can see the median
bed size was about a hundred. The daily census was comparable, 99. The median staff hours
per week that were given to Infection
Control was 14 — 14 hours a week for Infection
Control in these facilities. You can see the inner
core trial range there from as low as eight hours
a week to the high, well, you know — This
75 percent was 24 hours, so that’s still not a lot
of time if you think about how much work there is
to do in infection prevention and incorporate not
just surveillance, but all the teaching
and prevention work to make a change
if you’re looking at event outcomes that you want to see go down, so not a lot of time. And in that cohort,
three-quarters of them have submitted at least one
monthly reporting plan so the question is, okay, you’re enrolled, how many of them are actually
trying to use the system? And in this two-year
window, we saw 155 put at least one month of
reporting intention. Now submitting a
plan doesn’t mean that you completed the month, right, so there is more to see there. Let’s see, when we looked
at the month intended versus the month of
completed, you see a range, but actually it’s not that bad, right? Our sort of most
successful event reporting is actually urinary
tract infection, which kind of surprised
me a little because that’s one of the more
complex events to report. There’s more signs and
symptoms surveillance, in addition to looking at
laboratory data, right? So you have to do a
little more on the chart, but 81 percent of the
facilities that intended to report a month with the data completed that, and C.
difficile, I don’t think it
anyone was surprised as our most popular
event to report, and about 74 percent
of the time, people got it done
for that month. So pretty good, actually. So 83 percent of
facilities overall who had a reporting plan
or more submitted — completed at least one month of
data in this two-year period. But then we tried to
look at little bit more at the stability
of reporting. So is this a one and
done, or did I get it and start reporting
and stay reporting? So we defined consistent
reporters, people who had — or facilities I should say
that had completed at least six or more months of data in a calendar year. And there, you can
see in the red box that from calendar
year 2013 to ’14, we saw pretty substantial
drop in consistent reporting. In 2013, we had 70
facilities representing 75 or 76 percent of the
facilities intending to report one month
or more data actually consistently report,
so six months or more of reporting, but then
in 2014, we saw that fall off to less than 50 percent — 47 in 2014. So we wondered maybe
what could have accounted for that,
and we looked at — We don’t have a huge amount
of information about these facilities, right,
but we looked at, you know, well, how
did the consistent reporting cohort
change geographically? And what’s interesting,
you can see there are a couple of places in
particular where in 2013, we had a lot more folks consistently
reporting that they kind of fell off in calendar year 2014. And if those of you who work in the health
departments, you know, we have projects that pretty
much go from year to year. So, we are going to focus
on this effort for this calendar year and
then budgets change or priorities change
or we have finished this, and so we move
to our next effort. And what you’re
seeing is that when that external support goes away, then the internal
motivation to sustain engagement in the
system seems to fall. And I don’t if many of you are probably familiar
with long-term care. How many of you
work primarily with long-term care in
your positions? So not a huge number,
but for those of you who have worked with
nursing home providers, you know that there are reasons
why this could happen — that in fact, there
are quite a few barriers to sustaining
voluntary reporting. Now, remember there are no
incentives except in Nevada, there’s no other place
where this is a must-do. There’s not a penalty
or a financial driver to engage in NHSN
for nursing homes. And things like staff
turnover, limitations in Infection Prevention
staff and resources, and we looked at the current
landscape of these, and I consider these
facilities perhaps the higher end of
the curve in terms of their willingness
to dedicate time to infection prevention
because they actually went through the steps and hurdles
of getting enrolled. So here we are at
sort of the higher functional or more
committed group and yet there’s not a lot
of time being given to nursing home Infection
Prevention work. And there are a lot of
competing priorities. So as this project ends
and people move onto the next thing, it’s
very hard for them to maintain and sustain their engagement. In addition, I think this is an important message for all of us. Facilities, currently
nursing homes using NHSN may not be getting
the maximum value and benefit from their own data. And there are some reasons
for that we can explore. And I think some of you
who have experience already working
with nursing homes and NHSN reporting,
could probably teach us why some of those
challenges are there. But we have to make
NHSN more useful and valuable to the providers so that they want to stay involved. So external partners
like you and programs that drive NHSN use by nursing homes are
incredibly important right now to help
them become aware of the system but also to use it. And participation
and collaboratives really does help
maintain engagement and provide some scaffolding
if you will for accountability. It also really
creates a powerful forum for sharing experiences in seeing how individual
facilities experience may compare to peers, and
that’s again something that you all can bring to those providers that
you’re working with. So what’s going to
happen in the next few years, I just wanted
to highlight things, most of which you already are aware of. But just in case you
hadn’t heard, there are some great opportunities
in the next year or two coming to nursing
homes to help support these kinds of
activities and the work that you’ve already been doing,
lays the foundation for that. So, we’ve seen incredible
attention to reducing antibiotic-resistant organisms and C.
difficile in our communities, and
we have messaged quite a lot in the last year and
a half the importance of health departments
to be at the hub of coordinating work
and communities to reduce resistance and improve antibiotic use and stewardship and across the healthcare spectrum. And there are a lot of
different activities that colleagues in health
departments can engage within including looking
at the way transitions of care occur and
where do people move and how do they move,
and we know that there are certain dyads or
triads that share a lot of patients within a
community or region and if there’s a problem in one
of those facilities, it’s going to somehow
influence and impact those others that are
sharing that population. So understanding that continuum of care and how people
move is a critical piece to addressing prevention. Promoting NHSN Surveillance
as vehicle for mapping and tracking
facility-level data, we see the benefit of
this when we work at the hospital partners
who have a lot of data for a few years now,
and you can really see the way we can target
our prevention work with those facilities that
seem to have a bigger problem. And wouldn’t it be nice
to know where those pockets of needs might
be in other parts of the healthcare continuum
in particular nursing homes where we don’t have a lot of data yet. There are opportunities
for health department partners and quality
improvement organizations to help with implementation
of prevention and stewardship activities
to bring again community of care partners
together, to facilitate conversations, improve
quality of care and information flow
when people are moving, and there’s
an opportunity really to measure the impact, the
change of all of these activities and find those gaps and close those gaps. This is where we want to see our regional prevention
work take us. In addition and not by accident, our colleagues at
CMS are working to drive C. difficile
prevention in the same — using the similar,
very similar strategies around collaboration and
information sharing and identifying the strategic
communities that need support. So, the CMS C. difficile
reporting and reduction project which
has been announced and is in the early
stages of getting kicked off is happening
within the framework of the National
Nursing Home Quality Care Collaborative and
those of you work with the QIO
programs are already very much involved
in that effort. In fact, in its first
few years, the Nursing Home Quality Care
Collaborative has already brought a large
number of nursing homes into the group
— over 7,000. The CDI Project goal is
to recruit 15 percent of nursing homes
across the country. That’s roughly 2,000
— a little over 2,000 facilities to
enroll into NHSN and sustain CDI reporting over
the course of the project. And you can see it is a multiyear effort. And the participant
facilities working in this collaborative and this
CDI Project piece of it, which you could see is a subset,
right, at the larger group. They will receive
training and support on CDI reporting and then
everyone involved in the collaborative will
get education and resources around C. difficile prevention
and antibiotic stewardship. And you can see some
of the types of information and pieces
of that program that will be rolling out
over the next few years. So, why do it now? Because doing — getting involved now and doing this work
now will hopefully get these facilities prepared for whatever might come in the future. When we were at that
conference all those years ago in 2009
talking about well where else could we go with
HAI Surveillance data? Here were some of the things
that we could eventually get to. We could look at the scope,
the burden if you will of HAI’s in long-term care at national level. This is how we leverage the
powerful data of NHSN and all of the information
reported by hospitals. We can look at the HAI
incident rates in this setting and
inform our prevention and control policies and efforts. We can be strategic in
the places that we work. We can provide quality of care measures for regulatory
and licensing, which is how we’ve
seen NHSN evolve in hospitals and other
post-acute care settings over the last decade,
and eventually perhaps, there would
be the opportunity to use those same
measures to guide transparency in making
this data that is so powerful accessible to
all including our consumers and the patient’s themselves
who rely on these facilities. And there are step-stones
around — along that path. We’re not quite there yet, but
I do hope that you’re aware of large regulatory
update being made to the nursing home requirements
for participation at CMS released in
the summer, that incorporates quite a lot
of new expectations for Infection Prevention and Control programs
in nursing homes. This is just a quick
highlight of some of those new regulations, things
like a risk assessment of the population that
guides the resources and staffing planned for
care in that building, integrating Infection Prevention into the larger
Quality Assurance and Performance Improvement
program that every facility needs to have,
having an annual review and update of the
Infection Prevention Program including
policies and procedures, again that would keep up
with the changing population that you’re caring for in the building. Something very new is
the expectation of antibiotic use protocols
and monitoring as part of stewardship in every nursing home and designating
an individual to be the Infection Prevention control officer,
and in particular, making sure that individual has specific infection
prevention training, which is a huge
need and gap right now, which has to
be closed in order for any of this other stuff to work. And then having not
only that designated individual with infection
prevention training, but also making sure
that for the bedside frontline caregiving
staff, there is education and training as well
around infection prevention practice, so
very positive changes, but I do think this is a big,
big heavy lift as well — so to be aware that
your partners that you’re to, to bring
into a conversation about NHSN are also seeing this looming out there in the future. They have to see how
working with you and working within your
programs are going to help them achieve
these goals and actually service resources
to their programs and not as perhaps distractions,
right, that I’m not going to get this work done
that I must get done. So we have to do a lot
to align our efforts. I wanted to quickly
mention that there’s some legislation that came out
in the Fall of 2014, so it’s been out there for a little while. The Improving
Medicare Post-Acute Care Transformation
Act or IMPACT Act which was intended
to align measures of quality in
reporting among all of the providers delivering
post-acute care in this country and hopefully
this language — this terminology is
familiar to all of you that we have acute
care hospitals, right, and we used to just
focus so much of our work there because
people stayed there for a long time and generally by the time they were
ready to leave, they were safe enough to go home. But now as we’ve seen lengths of stay change and
shorten and shorten and we’ve seen different
payment incentives, we’ve got a whole new
crop of providers that help patients who
are leaving acute care hospitals but are
not ready to go back into their homes, be
safely transitioned, and this post-acute care arena
is probably the place where we need to be starting
to shift all of our focus because people are
still receiving high level acute care, right. So, these are
long-term acute care hospitals that are
all for intensive purposes like step-down ICUs. People are on ventilators. They’re receiving IVs. They’re — they have
wounds and we know that those are the
trifecta of risk factors for resistant organisms
and antibiotic exposure and the
complications from that. We have inpatient
rehab facilities that are trying to
strengthen somebody and get them independent
again before they can go back into their
environment and home and be strong enough and safe enough to recover
their function, and then skilled nursing
facilities which are the biggest
post-acute care provider, also providing more
and more not a destination for
care, but a bridge. So I’m only coming for
a few weeks to rehab or get my skilled
care needs met before I go back to my home
in the community. So right now, there’s a
lot of differences in the way payment is going
into post-acute care and also the way we track and measure quality in
these settings. The goal of this
legislation was frankly to better align and to
make it more equitable, because you may
be receiving very similar care in two
different places and getting very
different resources, and that’s kind of a problem. So, this was intended
to look at the whole post-acute care arena
and address some of those disparities in payment
and measures of quality. And so currently, we
know that CMS has quality reporting
incentive programs for long-term care
acute hospital and inpatient rehabilitation
facilities that include NHSN reporting, right? Everybody’s aware of that. And now we have kind
of a door open that if we want to see alignment
and standardization across post-acute
care, that NHSN reporting could be a
natural next step for skilled nursing
facilities, and that’s the reason I
raise this today. It’s not here yet
and we don’t know when, but I think
there’s precedent and there is potential now for
that to come in the future. So, just to summarize — I think all of you have seen yourself, that nursing homes are
really being expected more and more to take
action in tracking and preventing the spread of HAIs. And we hope that providers
will see NHSN as a resource to support their
prevention efforts by providing that data
for action and allowing them to track their
current opportunities for improvement and measure
the change in their efforts. Nursing homes are
starting to look at NHSN and thanks again to you, we’re starting to see reporting
and use of the system grow. We have evidence that consistent
reporting can be done. It’s feasible but it takes a lot of external support
and resources. And we need to continue
leveraging these opportunities coming
in the next year to grow the industry’s involvement. And the message — one
of the key messages I hope that you all agree
with and can take to frontline nursing
homes in your states is that this is an
exciting opportunity to get involved now,
take advantage of the help, take advantage
of the resources and the knowledge that
all of you are going to bring to them so
they will be prepared for whatever the future might look like. The facilities that
are now starting to get involved in surveillance and prevention programs will
be seen in their community as progressive forward
thinking leaders, and that they will
have in place a lot of the expectations the programs
to meet whatever regulatory or quality incentives
may come down the road. So I’m going to stop there, and thank you so much for your time. I think we have a
minute maybe or two for questions if
anyone has a question. [ Applause ] Yes, here in the front. [ Inaudible Question ] So the question for those of you in the back is in
long-term care, often times residents
may have a primary care physician that is not a
part of the facility, responsible for their
prescriptions, and if we’re talking about
antibiotic stewardship, how do we engage those
primary care providers in the discussion
and engage them? It’s a very good question. Long-term care is
a large spectrum, right and in nursing homes, generally there are physician leaders that can help corral
the provider’s practicing in their building. These are the medical
directors, the physician leaders in
those nursing homes. But, when you start
to move into some of the more community-based
facilities, residential care or assisted
living, then the model changes and you do have each
individual person has their own caregiver, their
own doc, and there may or may not be somebody
at the building itself, coordinating
those care decisions. There — Our division
does recognize that stewardship has to
come and the message around antibiotic use has to
be across all care settings, so hospitals, long-term
care and outpatient. And we do have actually
quite a lot already around improving antibiotic
use in primary care for pediatrics and
we’ve started to move that discussion
to look at adults who are receiving
antibiotics for respiratory tract infections. We know there’s a
large spectrum and a lot of overuse of antibiotics for things like bronchitis for example. So there are members of our team that are focused on outpatient and there are conversations
with some of those primary care
providers and even things like Minute Clinics, and
there’s a whole new world, right, of primary care evolving in Urgent Care. So we are talking to those
providers and figuring out how does stewardship
look in outpatient care. But you’re right,
we do have to make sure we continue to expand that. Anybody else brave
enough at the start to stand up — Yes in the back? [ Inaudible Question ] So — Help me see how that —
What could we do — I’d like — The question is how
do we help improve communication at Care
Transition actively sort of now, instead of trying
to look back at old data and say, oh,
there’s a problem here. We should go. There — We have put
some pieces of, I guess, tools out like there’s
an inner-facility communication transfer form, which actually I have to credit
our colleagues from Utah. They were the ones that
got us started and really very graciously
allowed us to share with the rest of everyone out
there that example form, right, that you can use to catch
key infection prevention and antibiotic use was there
and history of MDRO. Carriage or infection
was part of the tool. So we have health departments
who are trying to operationalize that
within in collaboratives that bring hospitals and
nursing homes together. It’s a little tricky to
have real-time data when we don’t have much data
yet from long-term care, but how many of you are familiar with the TAP analysis
within NHSN? I see several hands. Yes, good, that’s wonderful to hear. I’m sure it’ll come up
again probably this week. But that kind of — The
goal of that strategy is to target those
communities or facilities where there are — where they’re
having SIRs that are higher. That could become — be
— The more and more of you that have access to
that data in real time and have group-sharing
information with you, that can
be used perhaps to feedback more quickly
information to the community to get that conversation going,
but I — we can talk. I’d love to hear some thoughts, and I know many of you do work with cross collaborative settings, right? You bring groups
together already, so maybe there are forum
that exists to have that conversation and
to make that more of an active intervention
within your groups. So I want to be mindful
of the time and also I’m probably the least
important person up here this afternoon,
because my colleagues who are coming up next
are really the folks who make NHSN go and
provide the educational resources and tools and
content and slides that you hope — can
take advantage of as you got out and
engage nursing homes.

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