Acute Care Hospitals In Connecticut Research Articles

A Statewide Assessment of Antifungal Stewardship Activities in Acute-Care Hospitals in Connecticut

Background: Morbidity and mortality associated with invasive fungal infections and concerns of emerging antifungal resistance have highlighted the importance of optimizing antifungal therapy among hospitalized patients. Little is known about antifungal stewardship (AFS) practices among acute-care hospitals. We sought to assess AFS activities within Connecticut and to identify opportunities for improvement. Methods: An electronic survey assessing AFS practices was distributed to infectious disease physicians or pharmacy antibiotic stewardship program leaders in Connecticut hospitals. Survey questions evaluated AFS activities based on antibiotic stewardship principles, including several CDC Core Elements. Questions assessed antifungal restriction, prospective audit and feedback practices, antifungal utilization measurements, and the perceived utility of a local or statewide antifungal antibiogram. Results: Responses were received from 15 respondents, which represented 20 of 31 hospitals (65%); these hospitals made up the majority of the acute-care hospitals in Connecticut. Furthermore, 18 of these hospitals (58%) include antifungals in their stewardship programs. Also, 16 hospitals (52%) conduct routine review of antifungal ordering and provide feedback to providers for some antifungals, most commonly for amphotericin B, voriconazole, micafungin, isavuconazole, and flucytosine. All hospitals include guidance on intravenous (IV) to oral (PO) conversions, when appropriate. Only 14 of hospitals (45%) require practitioners to document indication(s) for systemic antifungal use. Most hospitals (17, 55%) provide recommendations for de-escalation of therapy in candidemia, though only 4 (13%) have institutional guidelines for candidemia treatment, and only 11 hospital mandates an infectious diseases consultation for candidemia. Assessing outcomes pertaining to antifungal utilization is uncommon; only 8 hospitals (26%) monitor days of therapy and 5 (16%) monitor antifungal expenditures. Antifungal susceptibility testing on Candida bloodstream isolates is performed routinely at 6 of the hospitals (19%). Most respondents (19, 95%) support developing an antibiogram for Candida bloodstream isolates at the statewide level. Conclusions: Although AFS interventions occur in Connecticut hospitals, there are opportunities for enhancement, such as providing institutional guidelines for candidemia treatment and mandating infectious diseases consultation for candidemia. The Connecticut Department of Public Health implemented statewide Candida bloodstream isolate surveillance in 2019, which includes antifungal susceptibility testing. The creation of a statewide antibiogram for Candida bloodstream infections is underway to support empiric antifungal therapy.Funding: NoneDisclosures: None

Age Differences in Racial/Ethnic Disparities in Preventable Hospitalizations for Heart Failure in Connecticut, 2009-2015: A Population-Based Longitudinal Study.

Preventable hospitalizations for heart failure result in a large proportion of hospitalizations. The primary objective of this study was to describe longitudinal trends in the association of race/ethnicity with preventable hospitalizations for heart failure in Connecticut and differences in disparities by age. We analyzed data on hospitalizations in all civilian acute-care hospitals in Connecticut during a 7-year period, 2009 through 2015. We used raking methodology to weight the nonhospitalized population to create a reference population representative of the state's general population. Multivariate regression models examined racial/ethnic disparities among adults aged 35-64, controlling for age, sex, and type of health insurance. For adults aged ≥65, regression models controlled for age and sex. After controlling for age and sex, the non-Hispanic black to non-Hispanic white odds ratio for preventable hospitalizations for heart failure ranged from 5.2-6.4 during the study period among adults aged 35-64. Among adults aged ≥65, non-Hispanic black adults had significantly higher odds (range, 1.2-1.8) of preventable hospitalizations than non-Hispanic white adults. Rates among Hispanic adults were significantly higher than rates among non-Hispanic adults after controlling for age and sex among adults aged ≥65 in 2014 and 2015. This research provides information for clinical and population-based interventions targeting racial/ethnic gaps in heart failure hospitalizations. Demonstrating the persistent black-white disparity and age differences in racial/ethnic disparities, this study emphasizes the need for focused prevention among vulnerable populations. Raking methodology is an innovative approach to eliminating selection bias in hospital discharge data.

1162. An Evaluation of Metrics for Catheter-Associated Urinary Tract Infections (CAUTIs): A Statewide Comparison

BackgroundThe Standardized Infection Ratio (SIR) is a metric used to gauge catheter-associated urinary tract infection (CAUTI) prevention, both locally and nationally. The device utilization ratio (DUR) is a process metric that captures catheter harm. More recently, the cumulative attributable difference (CAD) was introduced, which identifies the number of excess infections that need to be prevented to reach the desired goal. Our objective was to evaluate these metrics across all acute care hospitals in Connecticut (CT) by facility size.MethodsA CAUTI Targeted Assessment for Prevention (TAP) Report for acute care hospitals across CT was generated from 1/1/2018 to December 31/2018, using the National Healthcare Safety Network (NHSN) database. CAUTI events, SIR, DUR, and CAD were compared across all hospitals. The SIR goal of 0.75 was used to calculate the CAD. Hospitals were stratified into large ( >425 beds), medium (250 to 424 beds), and small ( <249 beds) based on the Healthcare Cost and Utilization Project NIS Description of Data Elements, Agency for Healthcare Research and Quality for urban hospitals in the northeast region.ResultsA comparison of CAUTI metrics for 29 acute care hospitals across CT is shown in Table 1. Median SIR and DUR were 0.97, 1.02, 0.77, and 22%, 14%, 14.5% for large, medium and small hospitals, respectively. Of the 20 small hospitals, SIR could not be calculated for 5 hospitals, while 2 hospitals had an SIR = 0, as they had no reported infections. Median CAD for large, medium and small hospitals was 6.17, 1.3 and 0.25, respectively. Of note, 40% of small hospitals (J – CC, as in Table 1) had a negative CAD. Interestingly, 5 of these 8 hospitals with a negative CAD had a DUR higher than 16%.ConclusionBased on CT hospital data, metrics like CAD and SIR may be more suitable for larger hospitals or hospitals with higher CAUTI events, whereas DUR may be a more useful metric for smaller hospitals or hospitals with rare events. Hospitals with high SIR and low DUR may represent a population with high-risk catheter use, poor catheter care or higher rates of urine culturing. On the other hand, hospitals with high DUR and low SIR may represent low-risk populations, better catheter care practices or lower rates of urine culturing. Ultimately, we need a combination of metrics to measure preventable catheter harm. DisclosuresLouise Dembry, MD, MS, MBA, ReadyDock: Consultant, Stock options.

A Guideline-Based Policy to Decrease Intensive Care Unit Admission Rates for Accidental Hypothermia.

Despite guidelines advising passive rewarming for mild accidental hypothermia (AH), patients are frequently admitted to intensive care unit (ICU) for active rewarming using a forced-air warming device. We implemented a new policy at our institution aimed at safely reducing ICU admissions for AH. We analyzed our practice pre- and post-policy intervention and compared our experiences with acute care hospitals in Connecticut. A retrospective chart review was performed on 203 participants with AH identified by primary and secondary discharge codes. Our new policy recommended passive rewarming on the medical floors for mild hypothermia (>32°C) and ICU admission for moderate hypothermia (<32°C). Practices of other Connecticut hospitals were obtained by surveying ICU nurse managers and medical directors. Over a 3-year period, prior to rewarming policy change, 64% (n = 92) of patients with AH were admitted to ICU, with a mean ICU length of stay (LOS [SD]) of 2.75 (2.2) days. After the policy change, over a 3-year period, 15% (n = 9) were admitted to ICU (P < .001), with an ICU LOS of 2.11 (0.9) days (P = 0.005). In both groups with AH, altered mental status, infection, and acute alcohol intoxication were the most common diagnoses at presentation. Alcohol intoxication was more prevalent in the post-policy intervention group, pre 17% versus post 46% (P < .001). No complications such as dermal burns or cardiac arrhythmias were noted with forced-air warming device use during either time period. Among the 29 hospitals surveyed, 20 used active rewarming in ICU or intermediate care units and 9 cared for patients on telemetry units. Most hospitals used active external rewarming for core body temperature of <35°C; however, 37% of hospitals performed active rewarming at temperatures >35°Cor lacked a policy. Reserving forced-air warming devices for the treatment of moderate-to-severe hypothermia (<32°C) significantly reduced ICU admissions for AH.

Who Is Paying the Price? Loss of Health Insurance Coverage Early in Psychosis

Who Is Paying the Price? Loss of Health Insurance Coverage Early in Psychosis

Validation of the surveillance and reporting of central line-associated bloodstream infection data to a state health department

The primary goal of health care-associated infection reporting is to identify and measure progress towards achieving the irreducible minimum number of infections. Assessing the accuracy of reporting data using independent validation is critical to this goal. In January 2008, all 30 acute care hospitals in Connecticut began mandatory reporting of central line-associated bloodstream infections (CLABSI) to the National Healthcare Safety Network (NHSN) system. A state nurse epidemiologist performed a blinded retrospective chart review for NHSN-reported CLABSI based on positive blood cultures from October to December 2008. Of 476 septic events, 48 met the NHSN CLABSI definition, of which 23 (48%) had been reported to NHSN. Concordance of non-CLABSI events was 99% sensitive. Components of the case definition that were a source of misinterpretation included the following: NHSN surveillance definition of primary and secondary bacteremia (45%), CLABSI rules (19%), CLABSI terms (10%), and differentiation between laboratory-confirmed bloodstream criterion 1 (recognized pathogen) and criterion 2 (skin contaminant) (13%). The validation study identified >50% underreporting of CLABSI, most related to misinterpretation of components of the NHSN definition. Continued validation and training will be needed in Connecticut to improve completeness of reported health care-associated infection data and to assure that publicly reported data are valid.

Terrorism Preparedness: Web-based Resource Management and the TOPOFF 3 Exercise

The bombings of London on July 7, 2005 highlight the need for continued vigilance and readiness to respond to terrorist attacks. Trauma centers need to be at the core of preparedness activities. The State of Connecticut has taken a lead in preparedness and was selected as a site for the US Department of Homeland Security's Top Officials Three Exercise (TOPOFF 3), the largest and most extensive antiterrorism drill ever conducted. All 32 acute care hospitals in Connecticut took part in the drill. The simulated attacks were designed to test all aspects of emergency preparedness including the ability of hospitals to treat large numbers of victims and effectively monitor and implement mechanisms for surge capacity. In Connecticut, TOPOFF 3 tested the Bioterrorism Preparedness Web Application that was designed to be the primary communication and resource management tool during a terrorist event or public health emergency. This paper describes: 1) the impetus for the State of Connecticut Department of Public Health's Bioterrorism Preparedness Web Application; 2) the strategies used to ensure its readiness and appropriate utilization during a public health emergency; and 3) its use for communication and resource management by the Department of Public Health and the acute care hospitals during TOPOFF 3. The Bioterrorism Preparedness Web Application was successfully implemented and used during TOPOFF 3 to assess surge capacity and other resources. Careful development and implementation of the Web application, or any communication system, as well as training and regular practice are required to ensure effective use during a public health emergency.

Echocardiography in stroke and the prescription of new anticoagulation and cardiac medications: A pilot project

Previous research on echocardiography in patients with acute stroke has focused on identifying possible cardioembolic etiologies of the stroke, but physicians might also obtain echocardiography to guide the management of heart disease in stroke patients. The objectives of this study were to determine how frequently echocardiography is used in acute ischemic stroke patients, and to evaluate if receiving echocardiography is associated with new prescriptions for anticoagulant or cardiac medications. This secondary data analysis of a previous cohort study included medical records of acute ischemic stroke patients admitted to 1 of 10 acute-care hospitals in Connecticut from 1996 to 1998. A total of 58 of 119 (49%) acute ischemic stroke patients received echocardiography. Among these 58 patients, 43 (74%) received either a new prescription for anticoagulation or a new cardiac medication prescription (10 of 58 [17%] new anticoagulation only, 22 of 58 [38%] new cardiac medication only, and 11 of 58 [19%] both). New anticoagulant medications were prescribed more often in patients receiving echocardiography (21 of 58; 36%), than in patients not receiving echocardiography (10 of 61; 16%) (P = .014). In addition, new cardiac medications were prescribed more often in patients receiving echocardiography (34 of 58; 59%), than in patients not receiving echocardiography (24 of 61; 39%) (P = .035). Echocardiography is commonly obtained in patients with acute stroke, and its use is associated with both the prescription of new anticoagulation and new cardiac medications. Although previous research about the use of echocardiography in acute stroke has focused on its role in identifying stroke etiologies, future research should include an assessment of it use in treating concomitant heart disease.

Which Strategies Facilitate Improvement in Quality of Care for Elderly Hospitalized Pneumonia Patients?

A retrospective cohort study was conducted to elucidate which hospital-based quality improvement (QI) strategies are most effective in facilitating improvement in care for patients with community-acquired pneumonia. In 1999 telephone interviews were conducted with 29 acute care hospitals in Connecticut regarding their use of QI strategies for 1,234 patients at baseline and 1,081 patients at follow-up. Hospital-based QI strategies were grouped into two domains of implementation approach (epidemiologic and social influence). Hospitals scoring a 4 in either the epidemiologic or social influence approach (versus a score of < or = 3) experienced a greater-than-average increase in percentage of patients with blood culture collection within 24 hours of hospital presentation. Hospitals applying all four social influence QI strategies showed a greater-than-average increase in delivery of antibiotics within 8 hours of patients' hospital arrival when compared with all the other hospitals combined. The finding that an increased proportion of patients receiving antibiotics within 8 hours and blood cultures within 24 hours of hospital arrival when the greatest numbers of hospital-based QI strategies were implemented in suggestive of a possible "dose effect" of QI.

Temporal trends in outcomes of older patients with pneumonia.

It is unclear how outcomes of care for patients hospitalized for pneumonia have changed as patterns of health care delivery have changed during the 1990s. This study was performed to determine trends in outcomes of care for older patients hospitalized for pneumonia. This retrospective analysis was based on Medicare claims and included most patients with pneumonia who were older than 65 years and admitted to acute care hospitals in Connecticut between October 1, 1991, and September 30, 1997 (fiscal years 1992-1997). We assessed the trends in hospital costs, discharge destination, hospital mortality rates, mortality rates within 30 days of discharge, and 30-day readmission rates for pneumonia. Multivariate logistic regression analyses were used to adjust for differences in patient characteristics. The mean (+/- SD) length of stay declined from 11.9 + 11.4 days to 7.7 + 7.2 days between 1992 and 1997. During this period, adjusted in-hospital mortality rates declined (P =.02), while the adjusted risk of discharge to a nursing facility increased (P<.001) and the adjusted risk of hospital readmission for pneumonia within 30 days of discharge increased (P =.05). The adjusted risk of death 30 days after discharge increased, although the difference was not statistically significant (P =.09). Between 1992 and 1997, the adjusted risks of mortality after discharge, placement in a nursing facility, and hospital readmission for pneumonia increased among older patients hospitalized for pneumonia, in association with a decline in mean hospital length of stay. These findings raise the question of whether the declining hospital length of stay has negatively affected patient outcomes. Arch Intern Med. 2000;160:3385-3391.

Process of Care Performance, Patient Characteristics, and Outcomes in Elderly Patients Hospitalized With Community-Acquired or Nursing Home-Acquired Pneumonia

To compare process of care performance, patient characteristics, and outcomes in a contemporary cohort of elderly (> or = 65 years) patients hospitalized with community-acquired pneumonia (CAP) or with nursing home-acquired pneumonia (NHAP). State-wide retrospective cohort study. Thirty-four acute-care hospitals in Connecticut. Elderly Medicare patients hospitalized in 1995-1996 with CAP (1,131) or with NHAP (528). Antibiotic administration within 8 h of hospital arrival, blood culture collection within 24 h of hospital arrival, oxygenation assessment within 24 h of hospital arrival, demographic and clinical characteristics, in-hospital complications, mortality, and length of stay. Process of care performance rates for patients with CAP and NHAP were equivalent for antibiotic administration within 8 h of hospital arrival (76.8% vs 76.3%, respectively; p = 0.82), blood culture collection within 24 h of hospital arrival (78.1% vs 81.1%, respectively; p = 0.31), and oxygenation assessment within 24 h of hospital arrival (94.7% vs 95. 3%, respectively; p = 0.70). Patients with CAP were younger than those with NHAP (median age, 80 vs 84 years, respectively; p < 0. 001), had less cerebrovascular disease (16.8% vs 34.7%, respectively; p < or = 0.001), and lower mortality risk scores at hospital presentation (median, 100 vs 137, respectively; p < or = 0. 001) than patients with NHAP. The median length of stay was equivalent (7 days), but the in-hospital mortality rate was lower in patients with CAP than in patients with NHAP (8.0% vs 18.6%, respectively; p < or = 0.001). Initial hospital processes of care are performed at the same rate in patients hospitalized with CAP or NHAP. However, patients with CAP are younger, are less acutely and chronically ill, and have lower in-hospital mortality rates than patients with NHAP.

Reporting of vancomycin-resistant enterococci in Connecticut: implementation and validation of a state-based surveillance system.

To assess state-based surveillance for isolation from a sterile site of vancomycin-resistant enterococci (VRE) in Connecticut. Clinical laboratory reporting (passive surveillance) of VRE isolates to the Connecticut Department of Public Health (CDPH) was followed by state-initiated validation, laboratory proficiency testing, and review of hospital demographic characteristics. All 45 clinical laboratories and all 37 (36 for 1995 and 1996) acute-care hospitals in Connecticut were included in the study. The outcome measures included determination of the statewide incidence of VRE and the accuracy of passive reporting, determination of clinical laboratory proficiency in detecting VRE, and analysis of hospital characteristics that might be associated with an increased incidence of VRE. During 1994 through 1996, 29 (78%) of 37 hospital-affiliated clinical laboratories and 1 (11%) of 9 commercial or other laboratories in Connecticut reported to the CDPH the isolation of VRE from sterile sites; 158 isolates were reported for these 3 years. Based on verification, we discovered that these laboratories actually detected 58 VRE isolates in 1994, 104 in 1995, and 104 in 1996 (total, 266). The age-standardized incidence rate of VRE was 14.1 cases per million population in 1994 and 26.8 cases per million population for both 1995 and 1996. Laboratory proficiency testing revealed that high-level vancomycin resistance was identified accurately and that low- and moderate-level resistance was not detected. The incidence of VRE isolates was three times greater in hospitals with over 300 beds compared with categories of hospitals with fewer beds. Increases in the number of VRE isolates were at least twice as likely in hospitals located in areas with a higher population density, or with a residency program or trauma center in the hospital. Passive reporting of VRE isolates from sterile sites markedly underestimated the actual number of iso lates, as determined in a statewide reporting system. Statewide passive surveillance systems for routine or emerging pathogens must be validated and laboratory proficiency ensured if results are to be accurate and substantial underreporting is to be corrected.

Improving the Care of Patients with Community-Acquired Pneumonia: A Multihospital Collaborative QI Project

Performance of several processes of care was measured in eight acute care hospitals in Connecticut which provided inpatient treatment to 713 elderly patients with community-acquired pneumonia (CAP). BASELINE DATA ABSTRACTION AND FEEDBACK: Chart review feedback was provided, and the hospitals were requested to design their own quality improvement (QI) interventions, after which reexamination of process of care performance was conducted. HOSPITAL QI INTERVENTIONS: Six of the eight hospitals had submitted QI plans. The quality indicators dealing with timeliness of antibiotic delivery were specifically addressed by five hospitals. However, each hospital also picked one or two other processes of care for intervention. The mean time to antibiotic administration decreased from 5.5 hours (+/- 0.2) to 4.7 hours (+/- 0.3; p < 0.0001), and the percentage of patients who received antibiotics within four hours increased from 41.5% to 61.8% (p < 0.0001). This project called for obtaining buy-in from both the clinician and administrative representatives of each hospital early in the process. In this way, the targeted processes of care were likely to have relevance for each of the participating hospitals. Education of practicing physicians and other health professionals, as the method chosen by each hospital to address delays in antibiotic administration, appears to have been successful in this project as part of a multifaceted intervention. The project also helped establish a collegial environment that has served as the basis for more ambitious pneumonia QI projects. Widespread improvements in process of care performance can result from hospitals' participation in Quality Improvement Organization collaboration.

Quality of Care for Elderly Patients Hospitalized With Heart Failure

There is increasing interest in the development of explicit criteria to evaluate the quality of care for patients with heart failure. However, despite this interest, there is a paucity of information about the care of these patients in actual clinical practice across diverse sites. We conducted a retrospective medical record review across 9 acute care hospitals in Connecticut. We selected 200 random admissions from each hospital with a principal discharge diagnosis of heart failure in 1994. Hospitals with fewer than 200 cases had 100% of cases selected. Patients with heart failure secondary to severe aortic stenosis, mitral stenosis, or medical illness were excluded. We evaluated the percentage of patients receiving appropriate treatments and interventions as defined by quality-of-care indicators derived from the Agency for Health Care Policy and Research Clinical Practice Guidelines. Data were abstracted from 1623 hospitalizations and the presence of heart failure was validated by chart review in 1535 (95%). In cohorts of ideal candidates for specific interventions, 832 (75%) of 1110 had a left ventricular ejection fraction documented or measured; 346 (86%) of 401 received angiotensin-converting enzyme inhibitors; 38 (14%) of 271 received target doses of angiotensin-converting enzyme inhibitors; 1359 (97%) of 1400 had counseling about medications documented; 90 (6%) of 1400 had counseling about weight documented; 980 (70%) of 1400 had counseling about diet documented; 856 (61%) of 1400 had counseling about exercise and activity documented; and 14 (11%) of 128 smokers had counseling about cessation documented. These data demonstrate that the documentation of left ventricular systolic function and counseling for diet, weight, activity, and smoking may provide the best opportunities to improve the hospital care of elderly patients with heart failure. The use of angiotensin-converting enzyme inhibitors in appropriate patients is relatively high, indicating successful translation of trial results into clinical practice at these hospitals.