The Vermont Healthcare Associated Infection Prevention Plan

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1 The Vermont Healthcare Associated Infection Prevention Plan Submitted to the Centers for Disease Control and Prevention on January 1, 2010 This plan was developed through a collaborative effort of the Vermont Department of Banking, Insurance, Securities and Health Care Administration; the Vermont Department of Health; the Vermont Program for Quality in Health Care; the Vermont Association of Hospitals and Health Systems; hospital infection preventionists; consumer representatives; and the Vermont Health Care Association (representing long-term care facilities). 1. Develop or Enhance HAI program infrastructure Successful HAI prevention requires close integration and collaboration with state and local infection prevention activities and systems. Consistency and compatibility of HAI data collected across facilities will allow for greater success in reaching state and national goals. Below are areas for development or enhancement of Vermont s HAI surveillance, prevention and control efforts. Table 1: State infrastructure planning for HAI surveillance, prevention and control. Planning I for (or currently underway) 1. Establish statewide HAI prevention leadership through the formation of multidisciplinary group or state HAI advisory council i. Collaborate with local and regional partners (e.g., state hospital associations, professional societies for infection control and healthcare epidemiology, academic organizations, laboratorians and networks of acute care hospitals and long term care facilities (LTCFs)) Target Dates for September 2005; Expanded work group began meeting in October

2 for (or currently underway) ii. Identify specific HAI prevention targets consistent with HHS priorities 1. Central line-associated bloodstream infection rates in intensive care units - reduce to 50% of baseline or zero within 5 years; strive for Vermont and its individual hospitals to be in the 25 th percentile or lower of reporting hospitals nationally. 2. Surgical site infection rates for abdominal hysterectomy, hip replacements, and knee replacements reduce baseline by 25% or to zero within 5 years; strive for Vermont and its individual hospitals to be in the 25 th percentile or lower of reporting hospitals nationally. 3. Surgical Care Improvement Project (SCIP) process measures Increase to at least 95% adherence within 5 years. 4. Clostridium difficile (C. diff or CDI) rates consider surveillance and prevention targets for one or more health care facilities in Vermont 5. Methicillin-Resistant Staphylococcus aureus (MRSA) rates As part of the 9th Scope of Work with the Centers for Medicare and Medicaid Services (CMS), Northeast Healthcare Quality Foundation, the QIO for Vermont, has worked with four Vermont hospitals in the collection and analysis of two MRSA metrics derived from the NHSN MDRO/CDAD Module. The focus is on a single unit in each facility. Data collection has occurred monthly since February The selection of metrics for monitoring was based upon recommendations put forth in the Society for Healthcare Epidemiology of America (SHEA) and The Healthcare Infection Control Practices Advisory Committee (HICPAC) Position Paper: Recommendation for Metrics for Multidrug-Resistant Organisms in Healthcare Settings (Infection Control and Hospital Epidemiology, October 2008). Metric 1: Nosocomial MRSA Infection Rate #NHSN MRSA infections/1,000 pt days (by selected patient care location; uses NHSN criteria to define infections) Metric 2: Incidence rate of hospital onset MRSA based on clinical cultures #1st MRSA cultures/1,000 pt days (Evaluating the same locations as Metric 1 may be most useful; uses positive culture data only) The goal is to expand data collection to other Vermont hospitals. Target Dates for December 2009 January 2015 January 2015 January 2015 July 2011 July

3 for (or currently underway) The Act 53 Infection Reporting Subcommittee (see addendum A for list of members and a copy of the Act) convened as a working group of interested persons to develop a hospital infection rate reporting system appropriate to Vermont s needs in September This group continues to meet regularly and expanded its membership as development of the State HAI Plan began. 2. Establish an HAI surveillance prevention and control program i. Designate a State HAI Prevention Coordinator ii. Develop dedicated, trained HAI staff with at least one FTE (or contracted equivalent) to oversee the four major HAI activity areas (Integration, Collaboration, and Capacity Building; Reporting, Detection, Response and Surveillance; Prevention; Evaluation, Oversight and Communication) The State Epidemiologist for Infectious Disease of the Vermont Department of Health will serve as the interim State HAI Prevention Coordinator. Target Dates for August 2009 February 2010 ARRA funding will support the creation of a new position within the Infectious Disease Epidemiology Section at the Vermont Department of Health. 3. Integrate laboratory activities with HAI surveillance, prevention and control efforts. 3

4 for (or currently underway) i. Improve laboratory capacity to confirm emerging resistance in HAI pathogens and perform typing where appropriate (e.g., outbreak investigation support, HL7 messaging of laboratory results) To enhance this and other laboratory-related efforts, Vermont invited a practicing laboratory professional to participate in the HAI Planning work group. A survey of clinical laboratory directors is being developed and will be fielded early in 2010 to determine current laboratory capacity and to determine where improvements in capacity can occur. Target Dates for December 2010 II The State Health Department Laboratory currently serves as a reference laboratory for the state s hospitals, performing identification and typing of bacterial isolates. Currently, the State lab is not capable of HL7 messaging of laboratory results, but the lab is implementing a new system that will provide the capacity to share information electronically through HL7 messaging. 4. Improve coordination among government agencies or organizations that share responsibility for assuring or overseeing HAI surveillance, prevention and control (e.g., State Survey agencies, Communicable Disease Control, state licensing boards) September 2005; Expanded work group began meeting in October

5 for (or currently underway) The Act 53 Infection Reporting Subcommittee (see addendum A for list of members) consists of representatives from government agencies, nonprofit agencies, hospitals, infection control professionals and consumers working together with the goal of HAI prevention and control. Target Dates for March 2010 A strong relationship between the Department responsible for public reporting of hospital-specific infection rates (Banking, Insurance, Securities, and Health Care Administration, BISHCA) and the Vermont Department of Health (VDH) has already been established as part of that work. In addition, the HAI Planning Work Group has conducted an survey of staff from the state s Division of Licensing and Protection, Medical Practice Board, Nursing Board, and Patient Safety Surveillance and Improvement System (PSSIS). The survey asked the following questions: 1. Does your program receive reports about hospital-acquired infections or breaches in infection prevention practices? 2. Does your program track events by category, so that any trends could be identified? If so, are those numbers public information? 3. If a trend regarding infections or breaches in infection prevention practices is identified, is that information provided to VDH s infectious disease staff? If not, could it be? 4. If an issue is identified, would your staff consider referring a facility and/or practitioner to educational programs offered as part of the State HAI Prevention Plan that is currently being developed? 5. Can you think of any other mechanisms for coordinating your program s activities with Healthcare-Acquired Infection Prevention activities? Based on the responses to these questions, all of the additional programs could identify HAI related issues. All except for PSSIS have some publicly available information, and could communicate that information to VDH s infectious disease staff and refer facilities or practitioners to educational programs; these mechanisms and accompanying processes will be formally outlined in

6 for (or currently underway) 5. Facilitate use of standards-based formats (e.g., Clinical Document Architecture, electronic messages) by healthcare facilities for purposes of electronic reporting of HAI data. Providing technical assistance or other incentives for implementation of standards-based reporting can help develop capacity for HAI surveillance and other types of public health surveillance, such as for conditions deemed reportable to state and local health agencies using electronic laboratory reporting (ELR). Facilitating use of standards-based solutions for external reporting also can strengthen relationships between healthcare facilities and regional nodes of healthcare information, such as Regional Health Information Organizations (RHIOs) and Health Information Exchanges (HIEs). These relationships, in turn, can yield broader benefits for public health by consolidating electronic reporting through regional nodes. Target Dates for January 2013 Developing standards for transforming information from paper records into electronic information (e.g. Clinical Document Architecture (CDA), HL7 messaging) would be very resource intensive for Vermont s small hospitals if it were to be done only for HAI data, but the development of such standards has the potential to improve the exchange of other information in addition to HAI information. Vermont s RHIO is called Vermont Information Technology Leaders (VITL). VITL is in the process of surveying the Chief Information Officers (CIOs) from the state s 14 6

7 for (or currently underway) hospitals to determine their current capacity to collect data electronically, and overall strategy for formatting data. In addition, VITL is beginning to obtain laboratory data electronically from 5 of the 14 hospitals. VITL s Director of Services met with the HAI Prevention Planning Work Group, and the organization is willing to share the relevant CIO survey results with the Work Group. Target Dates for Recognizing that a lack of resources may be a barrier, during the fiscal year, CDC funding will be used to award mini-grants to hospitals that report data to the National Healthcare Safety Network (NHSN). These grants, of up to $10,000 each, will be used to improve the efficiency of data collection and allow expansion of NHSN surveillance. It is possible that the grants could be used to purchase interface engines to allow hospitals to create CDA. They could also be used for implementation of CDA or HL7 messaging. Hospitals should be able to use these enhancements in areas in addition to HAI, leading to a greater return on investment. To provide context to Vermont s overall health information technology initiatives, VITL s Vermont Health Information Technology Plan can be accessed at: 7

8 2. Surveillance, Detection, Reporting, and Response Timely and accurate monitoring remains necessary to gauge progress towards HAI elimination. Increased participation in systems such as the National Healthcare Safety Network (NHSN) has been demonstrated to promote HAI reduction. This, combined with improvements to simplify and enhance data collection, and improve dissemination of results to healthcare providers and the public are essential steps toward increasing HAI prevention capacity. The HHS Action Plan identifies targets and metrics for five categories of HAIs and identified Ventilator-associated Pneumonia as an HAI under development for metrics and targets (Appendix 1): Central Line-associated Blood Stream Infections (CLABSI) Clostridium difficile Infections (CDI) Catheter-associated Urinary Tract Infections (CAUTI) Methicillin-resistant Staphylococcus aureus (MRSA) Infections Surgical Site Infections (SSI) Ventilator-associated Pneumonia (VAP) State capacity for investigating and responding to outbreaks and emerging infections among patients and healthcare providers is central to HAI prevention. Investigation of outbreaks helps identify preventable causes of infections including issues with the improper use or handling of medical devices; contamination of medical products; and unsafe clinical practices. 8

9 Table 2: State planning for surveillance, detection, reporting, and response for HAIs Planning I for (or currently underway) 1. Improve HAI outbreak detection and investigation i. Work with partners including CSTE, CDC, the state Legislature, and providers across the healthcare continuum to improve outbreak reporting to the Vermont Department of Health ii. Establish protocols for health department staff to investigate outbreaks, clusters or unusual cases of HAIs. iii. Ensure the protection of facility/provider/patient identity when investigating incidents and potential outbreaks where possible to promote reporting of outbreaks iv. Improve overall use of surveillance data to identify and prevent HAI outbreaks or transmission in healthcare settings (e.g., hepatitis B, hepatitis C, multi-drug resistant organisms (MDRO), and other reportable HAIs) December 2010 July 2010 Ongoing December

10 for (or currently underway) Vermont s Communicable Disease Regulations define as reportable to the Department of Health: Any unexpected pattern of cases, suspected cases, deaths or increased incidence of any other illness of major public health concern, because of the severity of illness or potential for epidemic spread, which may indicate a newly recognized infectious agent, and outbreak, epidemic, related public health hazard or act of bioterrorism. II While the Infectious Disease Epidemiology Section investigates outbreaks, clusters or unusual cases of HAIs, written protocols are not in place. Enhance laboratory capacity for state and local detection and response to new and emerging HAI issues. As noted above, the State Health Department Laboratory currently serves as a reference laboratory for the state s hospitals, performing identification and typing of bacterial isolates. Currently, the State lab is not capable of HL7 messaging of laboratory results, but the lab is implementing a new system that will provide the capacity to share information electronically through HL7 messaging. This will improve the ability of hospitals and local health care systems to respond to new and emerging HAI issues. 2. Improve communication of HAI outbreaks and infection control breaches i. Develop standard reporting criteria including, number, size and type of HAI outbreak January 2012 December

11 for (or currently underway) ii. Establish protocols for exchanging information about outbreaks or breaches among state and local governmental partners (e.g., Infectious Disease Epidemiology, Division of Licensing and Protection, Environmental Health Program (e.g., for legionellosis)) 3. Identify at least 2 priority prevention targets for surveillance in support of the HHS HAI Action Plan i. Central Line-associated Bloodstream Infections (CLABSI) ii. Clostridium difficile Infections (CDI) iii. Methicillin-resistant Staphylococcus aureus (MRSA) Infections At least four Vermont hospitals engage in surveillance of MRSA rates. July 2011 CLABSI 1: November 2006 Process measure- June 2007 Note: this process measure is not based on an NHSN module. TBD Process measure- June 2008 Note: this process measure is not based on an NHSN module. MRSA 1 and MRSA 2 February 2009 iv. Surgical Site Infections (SSI) SSI 1: Abdominal Hysterectomy- October 2007; Knee and Hip Replacements- April 2008 SCIP 1- June

12 for (or currently underway) Public reporting on these measures has begun and is available for review at: 4. Adopt national standards for data and technology to track HAIs (e.g., NHSN). i. Develop metrics to measure progress towards national goals (align with targeted state goals). (See Appendix 1). ii. Establish baseline measurements for prevention targets Vermont already uses NHSN for public reporting of central line- associated bloodstream infection rates in ICUs and surgical site infections. NHSN will continue to be the measurement standard of choice in Vermont for infection rate measures. Started using NHSN for CLABSI in 2007 and SSI in 2008 December Develop state surveillance training competencies i. Conduct local training for appropriate use of surveillance systems (e.g., NHSN) including facility and group enrollment, data collection, management, and analysis Initiated in November 2006; ongoing as needed 12

13 for (or currently underway) The Vermont Program for Quality in Health Care (VPQ) serves as the statewide helpdesk for NHSN data collection and reporting, serving as a liaison between local professionals and CDC staff. Training for hospital staff was completed during the initial NHSN training in November /December 2006 and consisted of 14 hours of webinar training. This was a requirement for all participating hospitals. Thirteen of the state s fourteen hospitals have completed the training; the only exception is one 19-bed hospital that does not perform surgery or central line insertions and that does not have enough central line days to engage in public reporting. 6. Develop tailored reports of data analyses for state or region prepared by state personnel The Vermont Department of Banking, Insurance, Securities and Health Care Administration initiated public reporting on HAI measures on a hospital-specific basis in 2006; the report is available for review at: Any additional reporting efforts will build on this report. June 2007 III 7. Validate data entered into HAI surveillance (e.g., through healthcare records review, parallel database comparison) to measure accuracy and reliability of HAI data collection i. Develop a validation plan December 2010 ii. Pilot test validation methods in a sample of March 2011 healthcare facilities iii. Modify validation plan and methods in accordance with findings from pilot project June

14 for (or currently underway) iv. Implement validation plan and methods in all healthcare facilities participating in HAI surveillance v. Analyze and report validation findings vi. Use validation findings to provide operational guidance for healthcare facilities that targets any data shortcomings detected The Vermont Department of Health and the Vermont Program for Quality in Health Care, in conjunction with the HAI Prevention Planning Work Group, will develop a plan for data validation of NHSN-reported information. The methodology and implementation of the data validation are dependent upon available resources and the qualifications of the to-be-hired State HAI Prevention Coordinator. 8. Develop plans for improved response to HAI i. Define processes and tiered response criteria to handle increased reports of serious infection control breaches (e.g., syringe reuse), suspect cases/clusters, and outbreaks September 2011 July 2012 September 2012 July

15 for (or currently underway) The protocols mentioned under item 1 (Improve HAI Outbreak Detection and Investigation) above will facilitate responding to increased reports of serious infection control breaches. The new HAI Prevention Coordinator position will provide increased capacity in the Infectious Disease Epidemiology Section. We will continue to rely on local infectious disease physicians, local infection preventionists, the CDC and other subject matter experts when responding to these incidents. 9. Collaborate with professional licensing organizations to identify and investigate complaints related to provider infection control practice in non-hospital settings, and to set standards for continuing education and training December Adopt integration and interoperability standards for HAI information systems and data sources i. Improve overall use of surveillance data to identify and prevent HAI outbreaks or transmission in HC settings (e.g., hepatitis B, hepatitis C, multi-drug resistant organisms (MDRO), and other reportable HAIs) across the spectrum of inpatient and outpatient healthcare settings ii. Promote definitional alignment and data element standardization needed to link HAI data across the nation. July 2011 Initiated in October 2006; ongoing 15

16 for (or currently underway) i. Reportable HAIs are entered into the NEDSS Base System and transmitted to CDC as appropriate. The HAI Prevention Coordinator will investigate possible uses of surveillance data to identify and prevent HAI transmission. ii. Vermont relies on NHSN definitions and data collection specifications to measure HAI infection rates, and has done so since October of Enhance electronic reporting and information technology for healthcare facilities to reduce reporting burden and increase timeliness, efficiency, comprehensiveness, and reliability of the data i. Report HAI data to the public Initiated in June 2007 Vermont reports hospital-specific infection rate data to the public, and has done so since June The information can be accessed through the following website: During the fiscal year, CDC funding will be used to award mini-grants to hospitals that report data to NHSN. These grants, of up to $10,000 each, will be used to improve the efficiency of data collection and allow expansion of NHSN surveillance. 12. Make available risk-adjusted HAI data that enables state agencies to make comparisons between hospitals. Initiated in June 2006; comparative data provided on an ongoing basis 16

17 for (or currently underway) Based on CMS and NHSN data, public reporting on HAI measures on a hospital-specific basis has begun and is available for review at: Such data is risk-adjusted according to NHSN specifications. 13. Enhance surveillance and detection of HAIs in nonhospital settings Nursing Facilities are required to comply with federal and state infection prevention and control practices and reporting requirements. They will continue to routinely report on resident cases or outbreaks of nosocomial and communicable diseases pursuant to federal and state requirements. December

18 3. Prevention State implementation of HHS Healthcare Infection Control Practices Advisory Committee (HICPAC) recommendations is a critical step towards the elimination of HAIs. CDC with HICPAC has developed evidence-based HAI prevention guidelines cited in the HHS Action Plan for implementation. These guidelines are translated into practice and implemented by multiple groups in hospital settings for the prevention of HAIs. CDC guidelines have also served as the basis the Centers for Medicare and Medicaid Services (CMS) Surgical Care Improvement Project. These evidence-based recommendations have also been incorporated into Joint Commission standards for accreditation of U.S. hospitals and have been endorsed by the National Quality Forum. Table 3: State planning for HAI prevention activities Planning I for (or currently underway) 1. Implement HICPAC recommendations. i. Develop strategies for implementation of HICPAC recommendations for at least 2 prevention targets specified by the state multidisciplinary group. 2. Establish prevention working group under the state HAI advisory council to coordinate state HAI collaboratives i. Assemble expertise to consult, advise, and coach inpatient healthcare facilities involved in HAI prevention collaboratives June 2006 February 2010 The Prevention Working Group will be led by VPQHC and serve in an advisory capacity for the HAI Collaborative. This working group will be composed of clinical experts in the field of infection prevention along with experts in the field of quality improvement. 3. Establish HAI collaboratives with at least 10 hospitals (i.e. this may require a multi-state or regional collaborative in low population density regions) 18

19 for (or currently underway) i. Identify staff trained in project coordination, infection control, and collaborative coordination ii. Develop a communication strategy to facilitate peer-to-peer learning and sharing of best practices iii. Establish and adhere to feedback of a clear and standardized outcome data to track progress The VPQHC staff has more than eight years of experience in designing and implementing Quality Improvement Collaboratives, beginning with a statewide Collaborative focused on improving diabetes care that was initiated in Based on the Association for Professionals in Infection Control and Epidemiology (APIC) guidelines, and the IHI Breakthrough Series Collaborative model, VPQHC will develop and implement a QI Collaborative to train infection prevention advocates from a variety of healthcare settings (hospitals, nursing homes, and home health) on infection prevention best practice. The Prevention Working Group (see above) will be responsible for the development and implementation of the Collaborative curriculum. Additionally, VPQHC will administer the stipend grants to support hospital participation in this Collaborative work. 4. Develop state HAI prevention training competencies February 2010 May 2010 May

20 for (or currently underway) i. Consider establishing requirements for education and training of healthcare professionals in HAI prevention (e.g., certification requirements, public education campaigns and targeted provider education) or work with healthcare partners to establish best practices for training and certification The HAI Prevention Planning Work Group recognizes the importance of education and training in decreasing Healthcare Associated Infections, and therefore will encourage individual hospitals to support the certification of their infection preventionists. The work group believes that certification represents best practice in ICP education and training. Further, the work group will encourage nursing homes and home health agencies to develop their own infection control professional capacity, as well as to consult other resources such as infection control consultants that businesses may employ or contract with, extensive information available online at CDC, professional organizations (e.g. APIC and SHEA), and reference material (i.e. texts and medical periodic literature). The Infectious Disease Epidemiology Section of the Vermont Department of Health (including the HAI Prevention Coordinator) can provide limited guidance, and hospital or community-based Certified Infection Preventionists may also be able to provide limited assistance. December 2011 It is the goal of this endeavor to foster collaboration between all health care institutions throughout Vermont. It is the belief of the work group that this collaboration will support HAI prevention in inpatient, outpatient and community settings. 20

21 for (or currently underway) II In addition, support will be provided to hospitals and other health care institutions to pilot new hand hygiene staff education programs. Support will also be provided to disseminate CDC information on infection prevention to healthcare personnel. 5. Implement strategies for compliance to promote adherence to HICPAC recommendations i. Work with healthcare partners to establish best practices to ensure adherence ii. Coordinate/liaise with regulation and oversight activities such as inpatient or outpatient facility licensing/accrediting bodies and professional licensing organizations to prevent HAIs Vermont has achieved a great deal in the area of infection reporting and prevention through a collaborative rather than a regulatory approach. Consequently, the state s planning efforts will focus on working with health care partners to establish and implement best practices. 6. Enhance prevention infrastructure by increasing joint collaboratives with at least 20 hospitals (i.e. this may require a multi-state or regional collaborative in low population density regions) Vermont has 14 acute care hospitals. As development of the HAI Collaborative progresses, VPQHC and the Prevention Working Group will work in collaboration with APIC to invite the participation of New Hampshire hospitals. December 2011 December 2011 December

22 for (or currently underway) 7. Establish collaborative to prevent HAIs in nonhospital settings (e.g., long term care, dialysis) See #3 above; this activity will be available to staff in non-hospital settings. Ongoing throughout

23 4. Evaluation and Communications Program evaluation is an essential organizational practice in public health. Continuous evaluation and communication of practice findings integrates science as a basis for decision-making and action for the prevention of HAIs. Evaluation and communication allows for learning and ongoing improvement to occur. Routine, practical evaluations can inform strategies for the prevention and control of HAIs. Table 4: State HAI communication and evaluation planning Planning I for (or currently underway) 1. Conduct needs assessment and/or evaluation of the state HAI program to learn how to increase impact i. Establish evaluation activity to measure progress towards targets and ii. Establish systems for refining approaches based on data gathered Vermont hospitals currently report CLABSIs in ICUs and SSIs for three surgical procedures. The Vermont Program for Quality in Health Care will work with the Vermont Department of Health to measure progress toward identified targets (see Table 1). 2. Develop and implement a communication plan about the state s HAI program and progress to meet public and private stakeholders needs i. Disseminate state priorities for HAI prevention to healthcare organizations, professional provider organizations, governmental agencies, non-profit public health organizations, and the public A Living With MRSA pamphlet was published in March 2006 with the support of the Infection Reporting Subcommittee December 2010 July 2011 Initiated in 2006; Communications efforts should be comprehensive and ongoing 23

24 (predecessor to the HAI Prevention Planning Work Group), the Vermont Department of Health, and the Vermont Infection Control Professionals Association. Individual hospitals have also begun outreach education on the MRSA issue. On January 12, 2006 the Infection Reporting Subcommittee submitted a letter outlining a consensus plan for the collection and reporting of data related to HAIs in the hospital setting to the Chair of the House Committee on Human Services. Recommendations were based on the HICPAC recommendations, and outlined priorities for data collection and reporting. Those priorities have been adjusted slightly over time, to reflect an increasing emphasis on MDROs. II A broader communications strategy is yet to be developed and implemented. Such a strategy might include developing a website and regular communications on HAI prevention; providing links to that website and to the public reporting website on related organizations websites; distributing information cards with the prevention and public reporting websites to libraries, physician offices, hospitals, health fairs and other locations; working with media outlets to develop feature stories, participate in public access TV and radio shows, and disseminate press releases; and providing materials and education to legislators and consumer organizations (e.g. AARP-VT, Office of Health Care Ombudsman, Human Resource professionals). 3. Provide consumers access to useful healthcare quality measures June

25 The Vermont Department of Banking, Insurance, Securities and Health Care Administration initiated public reporting on HAI measures on a hospital-specific basis in 2006; the report is available for review at: III 4. Identify priorities and provide input to partners to help guide patient safety initiatives aimed at reducing HAIs December

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