Bed Days Of Care Research Articles

Estimating the impact on patient safety of enabling the digital transfer of patients’ prescription information in the English NHS

ObjectivesTo estimate the number and burden of medication errors associated with prescription information transfer within the National Health Service (NHS) in England and the impact of implementing an interoperable prescription...

Early clinical and quality impacts of the Age-Friendly Health System in a Veterans Affairs skilled nursing facility.

Skilled nursing facilities (SNFs) are an ideal setting to implement the Age-Friendly Health System (AFHS) approach, an initiative by the Institute for Healthcare Improvement (IHI) centered on the 4Ms: what matters, mobility, mentation, and medication. AFHS implementation has not been well studied in SNFs. A 112-bed VA SNF implemented a facility-wide AFHS initiative including the following: (1) participating in a national IHI Age-Friendly Action Community; (2) establishing an AFHS workgroup centered on the 4Ms; (3) identifying meaningful clinical tools and frameworks for capturing each M; and (4) developing sustainment methods. Clinical (life-sustaining treatment, falls, disruptive behaviors, and medication deprescribing) and quality outcomes (rehospitalization, emergency department utilization, and discharge to the community) in addition to patient satisfaction were compared pre- and post-AFHS implementation (bed days of care [BDOC] 17413) to post-implementation (BDOC 20880). Clinical outcomes demonstrated improvements in the 4Ms, including: (1) what matters: 14% increase in life-sustaining treatment documentation (82%-96%; p < 0.01); (2) mobility: reduction in fall rate by 34% (8.15 falls/1000 BDOC to 5.41; p < 0.01); (3) mentation: decrease in disruptive behavior reporting system (DBRS) by 62% (5.11 DBRS/1000 BDOC to 1.96; p = 0.04); (4) medications: 53% increase in average potentially inappropriate medications (PIMs) deprescribing (0.38-0.80 interventions/patient; p < 0.01). Quality outcomes improved including rehospitalization (25.6%-17.9%) and emergency department utilization (5.3%-2.8%) within 30 days of admission. Patient satisfaction scores improved from a mean of 77.2 (n = 31, scale 1-100) to 81.3 (n = 42). Implementation of the AFHS initiative in a SNF was associated with improved clinical and quality outcomes and patient satisfaction. We describe here a sustainable, interprofessional approach to implementing the AFHS in a SNF.

Audit and Feedback to Ordering Providers to Reduce Inappropriate C. difficile Testing and Hospital Onset C. difficile Rate

Background: Inappropriate Clostridioides difficile (C. difficile) laboratory testing is common in hospitals and leads to over diagnosis, unnecessary treatment, and elevated hospital onset C. difficile infection (HO-CDI) metrics. Diagnostic stewardship is essential to avoid inappropriate testing, but limited data exists on optional interventions. Methods: A diagnostic stewardship intervention targeting CDI testing comprised of education and prospective audit with feedback was performed a VA facility (inpatient, outpatient, and long-term care units). Education on appropriate indications for CDI testing was provided in pre-intervention (9/2022 to 5/2023) and intervention periods (6/2023 to 12/2023). During the intervention period, all CDI tests (positive or negative) were audited after completion in real-time by an Infectious Diseases physician and feedback was given to ordering providers and/or their supervising physician (if trainee) for all tests not meeting an appropriate indication. Appropriate indication was defined as ≥3 liquid stools in 24 hours or symptoms of fulminant disease. Testing was considered inappropriate if no clinical symptoms, patient received laxatives within 48 hours, test was performed for test-of-cure or within 7 days of a prior test with no clinical change, or delayed testing in patients with diarrhea on admission. The rate of HO-CDI per 10,000 bed days of care (BDOC) per LabID event was compared during the pre-intervention and intervention periods, and ordering appropriateness was compared for all tests and hospital onset tests before (3/2023-5/2023) and after (6/2023-12/2023) feedback was performed. Results: After starting audit and feedback, HO-CDI rate decreased from 3.92 per 10,000 BDOC to 0.99 per 10,000 BDOC (p=0.03). HO-CDI rate among tests that were inappropriate was 2.19 and 0.80 per 10,000 BDOC during the pre-intervention and intervention periods, respectively (p=0.40). Average overall tests per month decreased from 37.8 to 28.1 after the intervention. Rate of all inappropriate tests decreased from 16.25 to 7.96 per 10,000 BDOC (p=0.04) and rate of hospital onset inappropriate tests trended toward decrease from 9.29 to 4.77 tests per 10,000 BDOC (p=0.07). The most common reasons for inappropriate testing were &lt; 3 episodes of diarrhea in 24 hours (54% pre-intervention, 65% intervention) and laxative use (57% pre-intervention, 45% intervention). No cases of delayed testing leading to worsened disease were identified during the intervention. Cost savings for decreased tests were estimated at $150-300 per month. Conclusion: An intervention comprised of education and real-time audit and feedback of all CDI tests obtained at a VA facility resulted in decreased inappropriate testing and reduced the rate of HO-CDI.

Antimicrobial prescribing in acute pancreatitis: Too much for too many?

BackgroundAcute pancreatitis (AP) is an inflammatory condition of the pancreas that varies widely in both clinical presentation and severity. Current international guidelines do not recommend the use of prophylactic antimicrobials in AP. AimTo review the compliance of antimicrobial prescribing in AP with international guidelines. MethodWe conducted a retrospective review of patients admitted with AP between 1st January 2021 and 31st December 2021, in Beaumont Hospital, Dublin, Ireland. For each case identified, the 2012 Revised Atlanta Criteria for AP were then applied on review of medical, laboratory and radiology records. ResultsThere were 98 patients, 52 % male (n = 51) with a median age of 53 years (range 18–88) who met the Revised Atlanta Criteria accounting for 1,032 hospital bed days inclusive of 82 critical care bed days. Gallstones were the most common aetiology; 48 % (n = 47). Antimicrobials were prescribed for 55 (56 %) patients with AP. Of those, only 38 % (n = 21) met the American Gastroenterological Association criteria for antimicrobials. The most common classes of antimicrobials prescribed were beta-lactams and carbapenems. Procalcitonin testing was conducted on just one patient (1 %). There were no cases of inpatient or 90-day mortality. ConclusionsOur findings are consistent with previously published reports of low mortality in mild acute AP and an excessive prescription of antimicrobials, highlighting this as an area for a targeted antimicrobial stewardship (AMS) intervention, including an increased use of procalcitonin as a biomarker.

THE BOSTON HOSPITAL-IN-HOME PROGRAM—A LOCAL PERSPECTIVE

Abstract The Hospital-in-Home (HIH) model provides patient centered care, may reduce complications and costs. VA Boston Healthcare System (VABHS) planned its HIH program in 2018 and enrolled its first patient in May 2019. HIH provided care to 45 patients in 2019 which grew to 185 in 2022. The team is comprised of 2 clinicians (a hospitalist physician and a physician assistant), a nurse manager, 5 registered nurses (RN), a social worker and a pharmacist. The program practices complementary HIH (admissions from inpatient care) and substitutive care (all other admissions). At this time, majority of the recruitment comes from the inpatient services, followed by heart failure and primary care clinics. The program catchment area is about 25 miles from the West Roxbury campus of VABHS. A hybrid visit approach is taken for clinician visits - initially, the veteran is seen in person or by video by the clinician on admission to the program. Subsequent visits are done with RN assessments in the home and the clinician conducting the visit by telephone or video. In FY 2021, conditions of patients treated by HIH include congestive heart failure (50%), chronic obstructive pulmonary disease (14%), wound care (6%), diabetes (2%) and other conditions (20%). In FY 2022, the average daily census was 15.9 veterans and average visits per day 4.8. The HIH program outcomes include reduction of bed days of acute care in the hospital and reduction in the use of unnecessary medications through deprescribing which may translate to cost avoidance for the medical center.

Excess Bed Days and Hospitalization Costs Associated With 30-Day Complications Following Catheter Ablation of Atrial Fibrillation.

The incidence and type of complications following catheter ablation of atrial fibrillation have been extensively examined, but the impact associated with these complications on the length of stay and hospitalization costs is unknown. This cohort study included 20 117 adult patients (mean age 62.6±11.4 years, 30.3% women, median length of stay 1 day [interquartile range 1-2 days]) undergoing atrial fibrillation ablation in financial years 2011 to 2017 in Australia with available cost data from the National Hospital Cost Data Collection, which determines government reimbursement of health services provided. The primary outcome was the costs associated with complications occurring up to 30 days postdischarge adjusted for inflation to 2021 Australian dollars. We used generalized linear models to estimate the increase in length of stay and cost associated with complications, adjusting for patient characteristics. Within 30 days of hospital discharge, 1151 (5.72%) patients experienced a complication with bleeding (3.35%) and pericardial effusion (0.75%) being the most common. On average, the occurrence of a complication was associated with an adjusted 3.3 (95% CI, 3.1-3.6) excess bed days of hospital care (totaling 3851 days), and a $7812 (95% CI, $6754-$8870) increase in hospitalization cost (totaling $9.0 million). Most of the total excess cost was attributable to bleeding ($3.8 million, 41.9% of total excess cost) and pericardial effusion ($1.6 million, 18.2%). Complications following atrial fibrillation ablation were associated with significant increase in length of stay and hospitalization costs, most of which were attributable to bleeding and pericardial effusion. Strategies to improve procedural safety and reduce health care costs should focus on these complications.

Change to hospitalist providers had a minimal influence on overall antibiotic use in a VA long-term care setting

Background: In long-term care settings, practice patterns among practitioners are stronger determinants of antibiotic use than resident characteristics. In July 2021, hospitalists from the acute medicine service replaced geriatricians and assumed the care of residents in a 110-bed community living center (CLC) at a large academic Veterans Affairs (VA) medical center. We assessed changes in antibiotic use associated with that change of practitioners to guide stewardship efforts. We hypothesized that antibiotic use in the CLC would shift, reflecting the practice pattern of practitioners accustomed to treating patients in acute-care settings. Methods: We conducted a retrospective cohort study from July 1, 2020, through June 30, 2022, 1 year before and after the change of practitioners on July 1, 2021. We assessed resident characteristics and the following metrics of antibiotic use at monthly intervals: days of therapy (DOT) per 1,000 bed days of care (BDOC), antibiotic starts per 1,000 BDOC, and mean length of therapy (LOT) in days. We also compared the DOT per 1,000 BDOC for various antibiotics, in groups and individually. Results: In the years before and after the change of practitioners on July 1, 2021, the characteristics of CLC residents were comparable. Before and after July 1, 2021, monthly DOT per 1,000 BDOC (Fig. 1A), antibiotic starts per 1,000 BDOC, and mean LOT (Fig. 1B) were similar. After July 1, 2021, the use of fluoroquinolones decreased (14.31 vs 5.83 DOT per 1,000 BDOC; P &lt; .01), and variations in anti-MRSA, narrow-spectrum, and broad-spectrum hospital agents were small, whereas the use of broad-spectrum community agents increased (29.42 vs 47.81 DOT per 1,000 BDOC; P &lt; .01) (Fig. 2A). Within this group, there was increased use of doxycycline (7.42 vs 19.13 DOT per 1,000 BDOC; P &lt; .01), ertapenem (2.03 vs 4.58 DOT per 1,000 BDOC; P &lt; .01), and, modestly, azithromycin (0.40 vs 1.80 DOT per 1,000 BDOC) (Fig. 2B). Conclusions: The overall use of antibiotics, as measured by DOT, antibiotic starts, and LOT did not change after hospitalists assumed care of CLC residents. However, a notable decrease was observed in the use of fluoroquinolones, and an increase was observed in the use of doxycycline and ertapenem. Stewardship that is tailored to the type of provider and incorporates their practice patterns is needed to reinforce the prudent use of antibiotics.Disclosures: None

Level of Care Appropriateness in VA Inpatient Surgery Cases.

Within the Veterans Health Administration, utilization management (UM) focuses on reducing unnecessary or inappropriate hospitalizations by applying evidence-based criteria to evaluate whether the patient is placed in the right level of care. This study examined inpatient surgery cases to classify reasons for not meeting criteria and to identify the appropriate level of care for admissions and subsequent bed days of care. There were 129 VA Medical Centers in which inpatient UM reviews were performed during that time, of which 109 facilities had UM reviews conducted in Surgery Service. All admissions to surgery service during fiscal year 2019 (October 1, 2018 to September 30, 2019) that had a UM review entered in the national database were extracted, including current level of care, recommended level of care, and reasons for not meeting criteria. The following demographic and diagnostic fields were supplemented from a national data warehouse: age, gender, marital status, race, ethnicity, and service connection status. Data were analyzed with descriptive statistics. Characteristics of patient demographics were compared using the χ2 test for categorical variables and the Student's t test. A total of 363,963 reviews met conditions to be included in the study: 87,755 surgical admission reviews and 276,208 continued stay reviews. There were 71,274 admission reviews (81.22%) and 198,521 (71.87%) continued stay reviews that met the InterQual criteria. The primary reason for not meeting admission criteria was clinical variance (27.70%), followed by inappropriate level of care (26.85%). The leading reason for not meeting continued stay criteria was inappropriate level of care (27.81%), followed by clinical instability (25.67%). Of the admission reviews not meeting admission criteria, 64.89% were in the wrong level of care and 64.05% of continued stay reviews were also in the wrong level of care. Half of the admission reviews not meeting criteria had a recommended level of care as home/outpatient (43.51%), whereas nearly one-third (28.81%) continued stay reviews showed a recommended level of care of custodial care or skilled nursing. This study identified system inefficiencies through admission and continued stay reviews of surgical inpatients. Patients admitted for ambulatory surgery or for preoperative testing prior to day of surgery resulted in avoidable bed days of care that may have contributed to patient flow issues and limited the available hospital beds for other patients. Through early collaboration with case management and care coordination professionals, alternatives can be explored that safely address the patient needs, such as temporary lodging options. There may be conditions or complications that can be anticipated on the basis of patient history. Proactive efforts to address these conditions may help avoid unnecessary bed days and extended lengths of stay.

Does the Type of Healthcare Financing Systems Matter for Efficiency?

This article aims to identify whether the type of healthcare system financing matters in terms of efficiency. The study covered 35 OECD countries, which follow either the Bismarck system or the Beveridge system. The span of analysis covers the year 2015. Data were derived from OECD statistics and Eurostat databases. In purpose to analyse the impact of the financing method on the overall efficiency of the healthcare system, the developed model of Anderson was employed. Thus, the model allowed us to examine both—the components of the healthcare system, resources, population characteristics, benefits and outcomes, and the relationship of individual components to each other, expressed through efficiency, effectiveness and equality. In addition, statistical methods were used such as descriptive analysis, the independent sample t-test and the Pearson correlation coefficient. It was found that countries of the Bismarck system possess more hospital beds and simultaneously more curative care bed days are provided. It could imply the existence of a supply-induced demand problem. In the case of efficiency, the Bismarck states were found to have a more efficient medical doctor as they provide more consultation per inhabitant than their Beveridge counterparts. However, the Beveridge states were found to have more efficient usage of curative care beds as their bed occupancy rate is higher than Bismarck counterparts.

2045. IVAC Plus in the Time of COVID-19: An Imperfect Metric?

Abstract Background Prior to the COVID-19 pandemic, the incidence of infection related ventilator associated complications plus possible ventilator associated pneumonias (IVAC+) was decreasing; however, as the number of COVID-19 hospitalizations increased, so did the number of IVAC+. Our goal was to investigate if there was a relationship between these two occurrences. Methods This was a retrospective study at the Audie Murphy VA Hospital (ALMVA) from October 2017 to December 2021. ALMVA is a level 1A facility with 232 beds and an active bone marrow transplant program in San Antonio, Texas. This study included acute care COVID-19 hospitalizations per 10,000 bed days of care and IVAC+ per 1000 ventilator days. Monthly acute and intensive care COVID-19 hospitalization rates were correlated with IVAC+ rates using Pearson correlation for the overall study period and in the subgroup of COVID pandemic months (Mar 2020-December 2021). Results During the overall study period, COVID-19 hospitalization rates were significantly associated with IVAC+ rates: acute care correlation 0.86 (p&amp;lt; 0.01) and intensive care correlation 0.33 (p=0.04). During the COVID-19 pandemic months, acute care COVID-19 hospitalizations but not intensive care COVID-19 hospitalizations, were correlated with IVAC+ (correlation 0.90, p&amp;lt; 0.01 and correlation 0.21, p=0.53, respectively). There were 0 IVAC+ before the pandemic months and this rose to 14 during (0 per 1000 ventilator days and 3.05 per 1000 ventilator days, respectively). All but 2 cases of IVAC+ had COVID-19. COVID-19 Hospitalizations and IVAC Plus, October 2017 to December 2021 A sharp increase in COVID-19 hospitalizations correlated with a rise in patients meeting criteria for IVAC Plus. Conclusion The natural history of COVID-19 disease has presented challenges for IVAC+ monitoring. COVID-19 can cause persistent fevers and worsening oxygenation, and antibiotic use is common during periods of clinical deterioration. These factors can fulfill criteria for IVAC+. In this study, each IVAC+ case was traced for safety bundle compliance. These bundles were followed, along with conservative fluid management, low tidal volume ventilation, and sedation breaks. Patients met NHSN criteria for IVAC+ despite these measures and most had COVID-19. Given the common occurrence of IVAC+ in COVID-19 patients, futures studies are needed to define if IVAC+ are preventable in this population and whether IVAC+ surveillance has any value among COVID-19 patients. Disclosures All Authors: No reported disclosures.

1223. The Impact of the COVID-19 Pandemic on the Prevalence of Multidrug-resistant Organisms in Veterans Affairs Nursing Homes

Abstract Background Multidrug-resistant organisms (MDRO) in long-term care facilities are prevalent and pose a major health concern for their residents. During the COVID-19 pandemic, infection control measures were justifiably heightened in every aspect of health care, including nursing homes. There are reports depicting decreasing prevalence of MDRO in hospital settings during the pandemic. We compared the prevalence of MDRO in our facility’s nursing homes in the two-year period before vs. the two years of the pandemic. Methods Northport Veterans Affairs Medical Center provides long-term nursing home care structured as community living centers including mental health and hospice care; a 139 total bed capacity. A retrospective review of culture data collected by infection control preventionists comparing the prevalence of MDROs between 1 March 2018 to 28 February 2022 was performed. Data included: Nasopharyngeal MRSA swabs, urine, wound, blood, sputum cultures, C. difficile toxin and PCR assays. MDRO included ESBL E. coli, K. pneumoniae, P. mirabilis, MDR Pseudomonas spp (resistance to 2/3 antibiotics: cefepime/piperacillin-tazobactam/ciprofloxacin), carbapenem-resistant Pseudomonas spp, and vancomycin-resistant Enterococcus spp. Results There were 75209 bed days of care from 1 March 2018 to 28 February 2020 vs. 77531 from 1 March 2020 to 28 February 2022. The MRSA rate per 1000 patient days decreased from 4.98 pre-COVID to 2.70 during-COVID, P &amp;lt; 0.001. Similarly, there was a decrease in C. difficile 0.69 vs. 0.13, P&amp;lt; 0.001, ESBL E. coli 0.53 vs. 0.51, P&amp;lt; 0.001 and S. maltophilia (no cases during COVID). There was an increase in ESBL K. pneumoniae 0.51 vs. 0.63, P&amp;lt; 0.001, MDR Pseudomonas 0.05 vs. 0.49, P&amp;lt; 0.001, carbapenem-resistant Pseudomonas 0.026 vs. 0.077, P&amp;lt; 0.001 and VRE 0.22 vs. 0.31, P&amp;lt; 0.001. There were no Candida auris or Acinetobacter spp detected in the study period. MDRO occurrences before and during COVID-19 pandemic Conclusion While increased awareness and implementation of infection control measures during the years of the COVID-19 pandemic led to decrease in certain infections in our nursing homes, like C. difficile, a surprising uptick in ESBL K. pneumoniae and MDR Pseudomonas was noted. This is a concerning trend that merits further study to identify molecular factors and increase stewardship efforts in diligent use of carbapenems. Disclosures All Authors: No reported disclosures.

Effectiveness of Ultraviolet-C Disinfection on Hospital-Onset Gram-Negative Rod Bloodstream Infection: A Nationwide Stepped-Wedge Time-Series Analysis.

The effectiveness of enhanced terminal room cleaning with ultraviolet C (UV-C) disinfection in reducing gram-negative rod (GNR) infections has not been well evaluated. We assessed the association of implementation of UV-C disinfection systems with incidence rates of hospital-onset (HO) GNR bloodstream infection (BSI). We obtained information regarding UV-C use and the timing of implementation through a survey of all Veterans Health Administration (VHA) hospitals providing inpatient acute care. Episodes of HO-GNR BSI were identified between January 2010 and December 2018. Bed days of care (BDOC) was used as the denominator. Over-dispersed Poisson regression models were fitted with hospital-specific random intercept, UV-C disinfection use for each month, baseline trend, and seasonality as explanatory variables. Hospitals without UV-C use were also included to the analysis as a nonequivalent concurrent control group. Among 128 VHA hospitals, 120 provided complete survey responses with 40 reporting implementations of UV-C systems. We identified 13 383 episodes of HO-GNR BSI and 24 141 378 BDOC. UV-C use was associated with a lower incidence rate of HO-GNR BSI (incidence rate ratio: 0.813; 95% confidence interval: .656-.969; P = .009). There was wide variability in the effect size of UV-C disinfection use among hospitals. In this large quasi-experimental analysis within the VHA System, enhanced terminal room cleaning with UV-C disinfection was associated with an approximately 19% lower incidence of HO-GNR BSI, with wide variability in effectiveness among hospitals. Further studies are needed to identify the optimal implementation strategy to maximize the effectiveness of UV-C disinfection technology.

TH4.5 The introduction of a custom made endograft service for patients with complex thoracoabdominal aneurysm

Abstract Introduction Custom made endografts represents a technological advance that has been widely adopted across vascular centres in the United Kingdom. The most recent National Vascular Registry report describes in-hospital mortality for complex as 2.3%. We have reviewed the outcome associated with the introduction of a custom made endograft program in a single Scottish Health Board. Methods Index cases were identified from a prospective radiology database with cases identified from 2008 to 2021. We collected patient demographics, pre-operative assessment, peri-operative and procedure related details and information on surveillance and re-intervention. Results There have been 49 cases performed. Most patients were males over the age of 70-years with significant medical co-morbidity. The mean AAA size was 5.8cm. Most of the procedures have been performed under general anaesthesia with percutaneous common femoral access. Procedural complications have included inability to stent target arteries (coeliac axis twice and right renal artery twice). Other complications have included limb ischaemia and haemorrhagic complications from access. Two critical care bed days have been used. The mean duration of hospital stay is 9-days. There have been no deaths on the index admission. During the follow-up period there have been 6 deaths. One of these deaths was from rupture of abdominal aortic aneurysm (secondary to Type III endoleak). Conclusion These data suggest that the case selection for custom made endografts is good. The cost of the device may be off set by a reduction in critical care utilization/hospital bed stay.

Cost effectiveness of temporary isolation rooms in acute care settings in Singapore.

To estimate the change to health service costs and health benefits from a decision to adopt temporary isolation rooms that are effective at isolating the patient within a general ward environment. We assess the cost-effectiveness of a decision to adopt an existing temporary isolation room in a Singapore setting. We performed a model-based cost-effectiveness analysis to evaluate the impact of a decision to adopt temporary isolation rooms for infection prevention. We estimated changes to the costs from implementation, the number of cases of healthcare associated infection, acute care bed days used, they money value of bed days, the number of deaths, and the expected change to life years. We report the probability that adoption was cost-effective by the cost by life year gained, against a relevant threshold. Uncertainty is addressed with probabilistic sensitivity analysis and the findings are tested with plausible scenarios for the effectiveness of the intervention. We predict 478 fewer cases of HAI per 100,000 occupied bed days from a decision to adopt temporary isolation rooms. This will result in cost savings of $SGD329,432 and there are 1,754 life years gained. When the effectiveness of the intervention is set at 1% of cases of HAI prevented the incremental cost per life year saved is $16,519; below the threshold chosen for cost-effectiveness in Singapore. We provide some evidence that adoption of a temporary isolation room is cost-effective for Singapore acute care hospitals. It is plausible that adoption is a positive decision for other countries in the region who may demonstrate fewer resources for infection prevention and control.

758. Increased Prevalence of Clostridioides difficile Infection During the COVID-19 Pandemic Among Hospitalized Veterans in South Texas, USA

Background Clostridioides difficile infection (CDI) continues to be a major global public health concern, particularly during the ongoing SARS-CoV-2 coronavirus disease 2019 (COVID-19) pandemic. Despite new social distancing guidelines and enhanced infection control procedures (e.g., masking, hand hygiene) being implemented since the beginning of COVID-19, little evidence indicates whether these changes have influenced the prevalence of CDI hospitalizations. This study aims to measure CDI prevalence before and during the COVID-19 pandemic in a local cohort of U.S. Veterans. MethodsThis was a cross-sectional study of all Veterans presenting to the South Texas Veterans Health Care System in San Antonio, Texas from Jan 1, 2019 to Apr 30, 2021. Monthly laboratory confirmed CDI events were collected overall and categorized as the following: hospital-onset, healthcare facility-associated (HO-HCFA-CDI), community-onset, healthcare facility-associated CDI (CO-HCFA-CDI), and community-associated CDI (CA-CDI). Monthly confirmed COVID-19 cases were also collected. CDI prevalence was calculated as CDI events per 10,000 bed days of care (BDOC) and was compared between pre-pandemic (Jan 2019-Feb 2020) and pandemic (Mar 2020-Apr 2021) periods.ResultsA total of 285 CDI events, 920 COVID-19 cases, and 104,220 BDOC were included in this study. The overall CDI rate increased from 20.33 per 10,000 BDOC pre-pandemic to 34.51 per 10,000 during the pandemic (p< 0.0001). This was driven primarily by a rise in CO-HCFA-CDI rates (0.95 vs 2.52 per 10,000 BDOC; p< 0.0001) during the pandemic, followed by increases in CA-CDI (15.58 vs. 18.61 per 10,000 BDOC; p< 0.0001) and HO-HCFA-CDI (2.66 vs. 5.43 per 10,000 BDOC; p< 0.0001). Lastly, CDI rates have tripled since the start of the pandemic (March-Apr 2020) compared to the current year (March-Apr 2021) (14.69 vs. 43.76 per 10,000 BDOC). ConclusionOverall, CDI prevalence increased during the COVID-19 pandemic, driven mostly by an increase in CO-HCFA-CDI. As COVID-19 rates increased, CDI rates also increased, likely due to greater healthcare exposures and antibiotic use. Continued surveillance of COVID-19 and CDI is warranted to further decrease infection ratesDisclosures All Authors: No reported disclosures

Economic Impact And SafetY of Same-Day Discharge Following Percutaneous Coronary Intervention: A Tertiary-Care Centre Experience From Northern India (EASY-SDD)

BackgroundThe literature about the safety and feasibility of same-day discharge (SDD) following complex percutaneous coronary intervention (PCI) and in acute coronary syndrome (ACS) is scarce. The economic impact of SDD has not been evaluated in this geographical region. We in the present study evaluated the safety, feasibility, and economic impact of SDD following PCI at a tertiary care centre of north India. MethodsIt was a single-centre, non-randomized, prospective study, in which all consecutive PCI patients during the study period of 15 months were evaluated for SDD using a “patient-centred” approach. The patients who were discharged on the next calendar day were included in the next day discharge (NDD) group. The baseline demographic data including coronary risk factors, clinical presentation, and management details were noted for all patients. All patients were followed up for 6 weeks. The Indian health system is only partially insured, hence most of the expendable costs are borne by patients. In the present study, we computed the total societal expenditure of each PCI which includes both the health system costs and the expenditure borne by the patients. A standardized tool and bottoms up costing method were used for recording out-of-pocket expenditure (OOPE) by the patients and health care expenditure respectively. ResultsOut of a total of 675 PCI patients, 617 patients were enrolled in the study, and 132/617 (21.39%) patients were discharged the same day. Sixty-five % of patients (86/132) in the SDD cohort and 70% of patients (337/485) in the NDD cohort presented with ACS. Baseline characteristics in the two cohorts were identical. A higher syntax score, greater number of stents, and longer stented segment predicted the NDD. The mean length of stay after PCI in patients with SDD and NDD was 8.71 ± 2.48 and 21.76 ± 2.42 h, respectively. In the SDD group, there were no readmissions or adverse events after discharge till 6 weeks of follow-up. The total mean cost of PCI (health care system and OOPE) for SDD and NDD was Indian Rupees (INR) 129,322.14 [United States dollar (US$) 1810.51] and INR 165500.71 [US$ 2317.01] respectively. An amount of INR 36178.57 (health system cost: INR 10242.76 and OOPE: INR 25935.71 was saved for each SDD. Besides 100 cardiac unit bed days including 85 intensive cardiac care bed days were saved with 21% SDD in the present cohort. ConclusionPost PCI SDD is safe and feasible in selected ACS/chronic stable angina patients using the “patient-centred” approach. Besides, decreasing OOPE for the patients, SDD also helps in the efficient use of scarce health system resources.

Focusing on the Medically Ready for Discharge Patient Using a Reliable Design Strategy: A Quality Improvement Project to Improve Length of Stay on a Medicine Service.

Length of stay is a common measure of efficiency of care. We aimed to reduce length of stay on a general medicine service through a structured quality improvement project. A reliable design strategy was implemented in successive stages at a 238-bed academically-affiliated VA hospital. Over a 2-year period, continuous improvement efforts were directed at discrete cohorts of patients deemed medically appropriate for discharge but who remained hospitalized because of discharge barriers. We compared the mean length of stay and medically-ready bed days of care for a hospital in statistical control charts. Pre- and post-intervention comparisons were made using t -tests. In total, 5321 discharges were included in this improvement project, accounting for 35 852 bed days of care. Overall, average length of stay was reduced by 15.7%, from 7.62 to 6.40 days ( P < .05). There was a significant reduction in the mean number of medically-ready bed days of care from 2.3 to 1.72. Statistical process control charts demonstrated special cause variation across patient cohorts. A quality improvement project using reliable design principles was associated with shorter length of stay.

The impact of universal cardiopulmonary exercise testing on perioperative pathways and short-term patient outcomes following elective pancreatic surgery: A retrospective cohort study.

The utility of Cardiopulmonary Exercise Testing (CPET) to identify higher risk surgical patients remains controversial. There is limited research investigating the value of preoperative CPET to plan perioperative pathways for patients undergoing major pancreatic surgery. Retrospective cohort study, comprising two groups before and after a change in referral policy for High Risk preoperative anaesthetic clinic with CPET. Period 1 discretionary referral and Period 2: universal referral. The primary aim was to investigate the impact of this policy change on critical care use (planned vs unplanned) on the day of surgery and on delayed critical care admission. Secondary end points included a comparison of the total number of critical care bed days, days in hospital, complication rates and mortality data between the two cohorts. 177 patients were included; 114 in Period 1 and 63 in Period 2. There was a reduction in unplanned day of surgery postoperative admissions to critical care (28.1% vs. 11.1%, p = 0.008). Seven (6.1%) of patients in Period 1 and 1 (1.6%) patient in Period 2 had delayed admission, though no p value was calculated due to the small numbers involved. Complication rates were similar in each group. The median critical care bed days was 1 (range 0-21) days in Period 1 and 1 (0-13) days in Period 2. A universal referral policy for preoperative CPET demonstrated a decrease in unplanned day of surgery critical care admissions and a trend towards reducing delayed (>24 h postop) critical care admission which could be investigated in a larger study. No measurable impact was seen on clinical outcomes.

Use of electronic pharmacy transaction data and website development to assess antibiotic use in nursing homes

BackgroundIn 2017, the Centers for Medicare and Medicaid Services required all long-term care facilities, including nursing homes, to have an antibiotic stewardship program. Many nursing homes lack the resources, expertise, or infrastructure to track and analyze antibiotic use measures. Here, we demonstrate that pharmacy invoices are a viable source of data to track and report antibiotic use in nursing homes.MethodsThe dispensing pharmacy working with several nursing homes in the same healthcare corporation provided pharmacy invoices from 2014 to 2016 as files formatted as comma separated values. We aggregated these files by aligning elements into a consistent set of variables and assessed the completeness of data from each nursing home over time. Data cleaning involved removing rows that did not describe systemic medications, de-duplication, consolidating prescription refills, and removing prescriptions for insulin and opioids, which are medications that were not administered at a regular dose or schedule. After merging this cleaned invoice data to nursing home census data including bed days of care and publicly available data characterizing bed allocation for each nursing home, we used the resulting database to describe several antibiotic use metrics and generated an interactive website to permit further analysis.ResultsThe resultant database permitted assessment of the following antibiotic use metrics: days of antibiotic therapy, length of antibiotic therapy, rate of antibiotic starts, and the antibiotic spectrum index. Further, we created a template for summarizing data within a facility and comparing across facilities. https://sunahsong.shinyapps.io/USNursingHomes/.ConclusionsLack of resources and infrastructure contributes to challenges facing nursing homes as they develop antibiotic stewardship programs. Our experience with using pharmacy invoice data may serve as a useful approach for nursing homes to track and report antibiotic use.

Antibiotic Consumption and Stewardship at a Hospital outside of an Early Coronavirus Disease 2019 Epicenter.

There are scant data on the impact of coronavirus disease 2019 (COVID-19) on hospital antibiotic consumption, and no data from outside epicenters. At our nonepicenter hospital, antibiotic days of therapy (DOT) and bed days of care (BDOC) were reduced by 151.5/month and 285/month, respectively, for March to June 2020 compared to 2018-2019 (P = 0.001 and P < 0.001). DOT per 1,000 BDOC was increased (8.1/month; P = 0.001). COVID-19 will impact antibiotic consumption, stewardship, and resistance in ways that will likely differ temporally and by region.