Bed Days Research Articles

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< 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< 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 < 0.001. Similarly, there was a decrease in C. difficile 0.69 vs. 0.13, P< 0.001, ESBL E. coli 0.53 vs. 0.51, P< 0.001 and S. maltophilia (no cases during COVID). There was an increase in ESBL K. pneumoniae 0.51 vs. 0.63, P< 0.001, MDR Pseudomonas 0.05 vs. 0.49, P< 0.001, carbapenem-resistant Pseudomonas 0.026 vs. 0.077, P< 0.001 and VRE 0.22 vs. 0.31, P< 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.

Estimation of the impact of hospital-onset SARS-CoV-2 infections on length of stay in English hospitals using causal inference.

From March 2020 through August 2021, 97,762 hospital-onset SARS-CoV-2 infections were detected in English hospitals. Resulting excess length of stay (LoS) created a potentially substantial health and economic burden for patients and the NHS, but we are currently unaware of any published studies estimating this excess. We implemented appropriate causal inference methods to determine the extent to which observed additional hospital stay is attributable to the infection rather than the characteristics of the patients. Hospital admissions records were linked to SARS-CoV-2 test data to establish the study population (7.5 million) of all non-COVID-19 admissions to English hospitals from 1st March 2020 to 31st August 2021 with a stay of at least two days. The excess LoS due to hospital-onset SARS-CoV-2 infection was estimated as the difference between the mean LoS observed and in the counterfactual where infections do not occur. We used inverse probability weighted Kaplan-Meier curves to estimate the mean survival time if all hospital-onset SARS-CoV-2 infections were to be prevented, the weights being based on the daily probability of acquiring an infection. The analysis was carried out for four time periods, reflecting phases of the pandemic differing with respect to overall case numbers, testing policies, vaccine rollout and prevalence of variants. The observed mean LoS of hospital-onset cases was higher than for non-COVID-19 hospital patients by 16, 20, 13 and 19days over the four phases, respectively. However, when the causal inference approach was used to appropriately adjust for time to infection and confounding, the estimated mean excess LoS caused by hospital-onset SARS-CoV-2 was: 2.0 [95% confidence interval 1.8-2.2] days (Mar-Jun 2020), 1.4 [1.2-1.6] days (Sep-Dec 2020); 0.9 [0.7-1.1] days (Jan-Apr 2021); 1.5 [1.1-1.9] days (May-Aug 2021). Hospital-onset SARS-CoV-2 is associated with a small but notable excess LoS, equivalent to 130,000 bed days. The comparatively high LoS observed for hospital-onset COVID-19 patients is mostly explained by the timing of their infections relative to admission. Failing to account for confounding and time to infection leads to overestimates of additional length of stay and therefore overestimates costs of infections, leading to inaccurate evaluations of control strategies.

EGS P13 Hot gall bladder service in NHS – clinical and financial implications in a retrospective analysis

Abstract Background Gallstone disease is one of the most common general surgical presentations, leading to index admissions at hospitals across NHS. The patients are usually managed conservatively with analgesia and antibiotics, as and when required, and are booked for elective cholecystectomy scheduled for a later date, which may at times drag on for months. In the meantime, the patients may present to the hospital again with the same symptoms and get managed similarly or may present with more severe symptoms like jaundice, gallbladder perforation or pancreatitis, which may lead to morbidity or mortality. This may be considered as patient harm. NICE recommends that every eligible patient with cholecystitis should be offered cholecystectomy in their index admission or within 7 days, for gallstone related pancreatitis, this is index admission and 14 days respectively. Financial and technical reasons can be attributed to the long waiting list and subsequent delayed management of such patients. We wanted to study the rate of admissions, readmissions and complications of the gallbladder disease management at our hospital and the overall clinical and financial implications of starting a hot gall bladder service. Methods A retrospective analysis was conducted at out hospital for the patients admitted with acute cholecystitis from a period of July 2019 to March 2020. Inclusion criteria were fit patients aged from 16 to 80 years and exclusion criteria was patients unfit for surgery. The patients who had first presentation admission and readmission were calculated. These patients were listed for elective cholecystectomy to be performed at a later date. The patients were also divided based upon the initial presentation. The total number of patient days per year and per week were calculated based upon the patients presented in the study time. Total length of stay of each patient along with the mean duration of stay during admission and readmission were calculated and bed cost per day was calculated. The financial burden for readmission patients were calculated for the period of study as well as the annual burden. The recommendation was to run hot gall bladder service at our hospital and hence the annual theatre cost for running two half day sessions per week for over 42 weeks per annum along with the surgeon cost were calculated for a grand annual total. Results A total of 108 patients who fit the inclusion criteria were studied during July 2019 to March 2020. 61 (56.5%) were first admission and 47 (43.5%) were readmission, out of which 32 (68%) had same presentation and 15 (32%) had disease progression (13 – cholecystitis and 2 – pancreatitis). The total length of stay for first admission patients were 229 days with a mean of 3 days and that for readmission patients was 169 days with a mean of 2 days. The bed cost per day was GBP 310 and hence the readmitted patients had a financial burden of £52,390 in 9 months or £70,000 annually. Of the readmitted patients with same presentation 22 (68.8%) developed cholecystitis and of the readmitted patients with disease progression 13 (86.5%) had developed cholecystitis and 2 (13.5%) had developed pancreatitis. The overall development of preventable complications was 35 (74.5%) cholecystitis and 2 (25.5%) pancreatitis, leading to 362 bed days including readmissions and 19 bed days including readmissions respectively. The annual theatre cost for running two half day sessions of acute cholecystectomy service per week for 42 weeks was calculated as approximately £80,000 and surgeons cost was about £24,000 with a total annual cost of £1,04,000. Conclusions The result of the study clearly demonstrates that by performing index admission cholecystectomy we could have prevented 47 patients from being re-admitted in 9 months or 63 patients in one year. It could have saved 169 bed days in 9 months or 225 bed days in 12 months. This could have prevented disease progression in 15 patients, prevented cholecystitis in 35 patients and pancreatitis in 2 patients. The total amount saved was about £52,390 in 9 months or approximately £70,000 in one year. On the other hand, the amount needed to run two half day sessions per week of acute cholecystectomy service is about £1,04,000 which greatly reduces the readmission rates, reduces hospital stay (bed costs) and can promote best practice tariff. This also has medico-legal implications as patients with gallstone disease are prone to pancreatitis and may be develop life threatening complications which may lead to the trusts facing severe criticism and costly settlements. Based on the findings of the study, our hospital has decided to start hot gallbladder service which will be twice a week half day session from May 2022.

EGS P06 Delays in Operating on General Surgery Patients Causes Increased Morbidity and Burden on the NHS

Abstract Background The number of patients waiting for an operation in the United Kingdom has never been higher, as of February 2022 over six million people were waiting for treatment. There is pressure nationally on trusts to implement strategies aimed at reducing the backlog of elective procedures. Long waiting lists can lead to a greater demand on acute surgical services as patients require treatment for their condition while they wait for their procedure. This study aims to determine the impact that long waiting lists have on patients, and how readmissions affect acute services in a busy tertiary General Surgical unit in England. Methods Snapshot data was captured on a single day in February 2022 using the trust patient records system combined with the General Surgical waiting list. Data was collected and analysed in a bespoke excel data management tool built by the trusts patient costings team. The tool allows detailed analysis of patients readmitted whilst on the waiting list, outcomes and total cost. It also allows the data set to be explored as a whole and detailed patient level analysis. Wait time for emergency procedures was also analysed by length of pre-op and post-op stay. Results A total of 2902 patients were awaiting a General Surgical procedure in February 2022, with an average wait of 34 weeks. 394 (14%) of these patients have attended acutely since being listed for elective surgery. The total cost implication of these reattendances is £563,766. Analysis of a single procedure, such as laparoscopic cholecystectomy revealed 183 patients waiting for a cholecystectomy. 20% of these presented acutely, of which 68% was directly related to the listed underlying pathology with 34 bed days lost. 261 patients were awaiting a hernia (inguinal, umbilical, incisional) repair. 20% of these patients presented acutely whilst on the waiting list, with 33 lost bed days. Acute attendances increase as the waiting time increases; 38% of patients waiting over 15 months attend acutely, increasing to 50% at 22 months. Data from emergency procedures showed that as inpatient length of stay (LOS) pre-operatively increased in number of days, the post-operative LOS increased proportionally. Pre-op LOS of 1–2, 2–3, 3–4, 4–5, ≥5 led to post-op LOS of 2.9, 2.9, 4.2, 5.9 and 8.7 respectively. Conclusions This study highlights that long waiting lists can lead to significant burden on acute General Surgical services as patients seek medical attention for the condition they are awaiting surgical management for, leading to costs of over half a million pounds. The problem becomes intensified by lost bed days due to these acute presentations, which can lead to cancelled elective procedures and pressure on acute surgical services. This results in emergency patients waiting longer in-hospital for an operation, who then have a longer post-operative LOS. Combined these findings suggest a higher morbidity for these patients. There is an urgent need for innovative strategies to reduce waiting lists, and increase theatre productivity. Data analysis tools like these allow trusts to nuance strategies to address these issues directly.

Estimating the economic cost of carbapenem resistant Enterobacterales healthcare associated infections in Singapore acute-care hospitals.

Quantifying the costs of hospital associated infections (HAIs) caused by carbapenem-resistant Enterobacterales (CRE) can aid hospital decision makers in infection prevention and control decisions. We estimate the costs of a CRE HAI by infection type and the annual costs of CRE HAIs to acute-care hospitals in Singapore. We used tree diagrams to estimate the costs (in Singapore dollar) of different CRE HAI types from the health service perspective and compared them to the costs of carbapenem-susceptible HAIs. We used two approaches to estimate costs-direct costs of consumables for infection prevention and treatment; and costs associated with lost bed days. Cost of a HAI were extrapolated to annual CRE HAI incidence in Singapore acute-care hospitals to estimate the annual cost to the hospitals. We found that the cost of a CRE HAI based on direct cost and lost bed days are SGD$9,913 (95% CI, SGD$9,431-10,395) and SGD$10,044 (95% CI, SGD$9,789-10,300) respectively. CRE HAIs are markedly higher than the carbapenem-susceptible HAIs for all infection types. In both approaches, CRE pneumonia was the costliest infection. Based on a CRE HAI incidence of 233 per 100,000 inpatient admissions, CRE HAIs costed SGD$12.16M (95% CI, SGD$11.84-12.48M) annually based on direct costs, and SGD$12.33M (95% CI, SGD$12.01-12.64M) annually based on lost bed days. In conclusion, we described the cost of CRE HAIs in Singapore hospitals and identified infections with the highest costs. The findings may be useful in informing future economic evaluations of competing CRE HAI prevention and treatment programmes.

OGBN P15 Covid-19's impact on delays to elective Cholecystectomy

Abstract Background Patients waiting for elective cholecystectomy for symptomatic gallstone disease may need admission with biliary symptoms or complications whilst on the waiting list. The longer the length from listing to procedure the higher the risk of symptoms and possible admission with complications. Many elective operations were cancelled or delayed during the pandemic leading to increased waiting times. The trust noticed a significant number of patients presenting to hospital who were already listed for surgery. This study looks at emergency admission data of 100 patients awaiting elective cholecystectomy. Methods Hospital admission data on 100 successive patients from the cholecystectomy waiting list were analysed from Dec 2021-January 2022. Data was collected on when were they added to the list and whether they had presented to hospital in the waiting period before cholecystectomy. Of those that were admitted, reasons for admission, demographics of people who needed admission and length of stay in hospital were recorded. Results Of the 100 patients many had been waiting more than a year with Covid 19 a predominant delaying factor (cholecystectomy is a P3 or P4 procedure and many elective procedures were cancelled or delayed during the pandemic). This cohort of patients had 32 separate presentations to hospital while on the waiting list (some patients presenting multiple times). 9 patients required emergency hospital admission for clinical reasons such as pancreatitis and cholecystitis. This totaled 67 bed days for the admitting hospital, some data was unavailable due to admissions to other hospitals. Conclusions NICE guidelines recommend laparoscopic cholecystectomy within 1 week for patients presenting with acute gallstone disease. Early elective cholecystectomy is recommended for patients with symptomatic gallstones. Delays in elective cholecystectomy operations during Covid 19 have caused delays to definitive treatment and led to excess bed usage during the treatment pathway with the associated financial costs and patient morbidity.

The effect of mild to moderate sleep restriction on subjective hunger in healthy young men

There is good evidence to indicate severe sleep restriction increases subjective feelings of hunger, but the impact of mild to moderate sleep restriction (i.e., 5–7 h) on hunger has not been systematically evaluated. Healthy male participants (n = 116; 22.8 ± 2.1 years; 22.9 ± 3.7 kg⋅m−2) were recruited to a ten-day laboratory study. In a between groups design, participants were allocated to one of five time in bed conditions (5 h, 6 h, 7 h, 8 h or 9 h) for seven consecutive nights. Participants were provided a eucaloric diet and ratings of hunger, nausea and desire to eat certain foods were collected using visual analogue scales prior to meals (breakfast, lunch, afternoon snack, dinner and evening snack) on four days during the study. Data were analysed using linear mixed models with time in bed, time of day and study day as fixed effects and participant as a random effect. There was no main effect of time in bed, and no interaction between time in bed and study day, on hunger, nausea, prospective hunger or desire to eat certain foods. However, post-hoc analyses indicated that participants in the 5-h condition had an elevated desire to consume sweet foods and fruit on the final morning of the protocol. There was a main effect of time of day and study day on hunger; participants were hungriest prior to lunch time and hunger decreased over consecutive days of the protocol. When provided with a eucaloric diet, only 5-h time in bed increased desire to consume sweet foods and fruit in healthy young men.

Proactive care post-discharge to reduce 30 day readmissions to hospital.

Healthwatch England estimated emergency readmissions have risen by 22.8% between 2012-13 and 2016-17. Some emergency readmissions could be avoided by providing patients with urgent out of hospital medical care or support. Sovereign Health Network (SHN) comprises of three GP practices, with a combined population of 38,000. We will decrease the number of SHN patients readmitted within 30 days of discharge from Portsmouth Hospitals Trust following a non-elective admission (excluding Emergency Department attendance) by 40-60% by July 2020. Four Plan, Do, Study, Act (PDSA) cycles were used to test the administrative and clinical processes. Our Advanced Nurse Practitioner reviewed all discharge summaries, added alerts to records, and proactively contacted patients either by text, telephone or home visit. 92 patients aged 23 days to 97 years were admitted onto the recent discharge scheme. Half of discharge summaries were received on the day of discharge, whilst 29% of discharge summaries were received more than 24 hours post-discharge, and one was received 11 days post-discharge. Following our interventions, there were 55% less than expected readmissions during the same time period. To allow proactive interventions to be instigated in a timely manner, discharge summaries need to be received promptly. The average readmission length of stay following a non-elective admission is seven days. Our proactive interventions saved approximately 102.9 bed days, with potential savings of 1,775 bed days over a year. We feel the results from our model are promising and could be replicated by other Primary Care Networks to result in larger savings in bed days.

Transurethral water vapor therapy for treatment of lower urinary tract symptoms secondary to benign prostatic hyperplasia: a cost-minimization and budget impact analysis from an Italian healthcare perspective.

The aim of this study was to compare the costs and budget impact of adopting water vapor thermal therapy with the Rezūm™ System, for treatment of lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) to transurethral resection of the prostate (TURP), from an Italian hospital healthcare perspective. A Markov model (4-year time horizon, 3-month cycle length), developed to support a submission to the National Institute of Health and Care Excellence (NICE) in England, was adapted to an Italian payer perspective. A cost minimization analysis was conducted, assuming equal efficacy between both therapies. Net difference in costs per patient was reported, considering procedure, adverse events and retreatment costs. Probabilistic and deterministic sensitivity analyses considered the uncertainty of the results. Population data and market share distribution assumptions were applied to a cohort of Italian patients treated in one year to report the budget and capacity impact of increased use of Rezūm. Over 4 years, the costs per patient with Rezūm were €2072 compared to €2836 with TURP, resulting in net savings of €764. Sensitivity analyses showed that this conclusion was robust. Replacing 10% of TURP procedures with Rezūm generates cost-savings of € 7,139,549 over 4 years and saves 4671 theatre hours and 26,856 bed days in one year. Replacing 30% of BPH surgical procedures with Rezūm generates cost-savings to € 21,418,647 over 4 years, saves 14,012 theatre hours and 80,567 bed-days in one year. This analysis demonstrates that Rezūm is highly likely to be cost-saving compared to TURP from an Italian hospital healthcare perspective.

Clinical-demographic characteristics of the institutional cohort of patients with ischemic stroke in the posterior territory

According to literature data, the prevalence of stroke in the posterior circulation represents 20 30% of all ischemic strokes. It represents a clinical syndrome associated with ischemia in the cerebral territory vascularized by the vertebrobasilar system. The most common etiologies include intrinsic atherosclerosis, cardio embolism, vertebrobasilar dolichoectasia and spontaneous or posttraumatic cervical artery dissection, subclavian steal syndrome, giant cell arteritis, Fabry disease.The purpose of the research the evaluation and analysis of clinical-demographic characteristics in patients with stroke in the posterior circulation within an institutional cohort. Materials and methods: A retrospective cohort study was performed. The medical records of patients hospitalized with the diagnosis of ischemic stroke (codes I64, I633) from the electronic institutional data register of the Institute of Neurology and Neurosurgery from October 2017 to February 2022 were analyzed and 367 patients were selected. Results: Average age 66.8±10.6 years, men - 62%, women - 38%, average duration of hospitalization 10.3±5.0 bed days. Of all the patients included in the study, 71.4% were diagnosed with primary stroke and 28.6% recurrent. The identified risk factors were arterial hypertension - 96.4%, DM - 35.4%, heart rhythm disorders - 34.1%, coronary ischemic disease - 27.8%, atherosclerosis of the major vessels - 59.9%, dyslipidemia - 27.2%, obesity - 18.5%, anamnestic cerebrovascular events 24.5%, smoking 6.5%. Comorbidities were infection 10.6%, cancer 3.3%, rheumatism 1.6%. Doppler of the extracranial and intracranial vessels detected stenotic atherosclerosis of the main vessels 60.5%, occlusion 4.4%, hypoplasia of the vertebral artery 13.1%. Brain imaging: ischemia 77.4%, leukoaraiosis 55%, atheromatous plaques at the level of carotid siphons 34.6%, cerebral atrophy 19.9%, old stroke 17.4% cases. Conclusions: This study describes the spectrum of risk factors, clinical and demographic characteristics of patients with ischemic stroke in the posterior circulation drawn from the institutional cohort.

Hywel Dda University Health Board antimicrobial pharmacist input into implementation, clinical and outcome monitoring of outpatient parenteral antimicrobial therapy (OPAT)

Abstract Introduction The finance team highlighted an increased spend on antibiotics used by the Acute Response Teams (ART) across Hywel Dda University Health Board (HDUHB). Antimicrobial pharmacists (AMPs) investigated the antibiotics issued to ART and their stock lists. A wide variety of antimicrobials including broad-spectrum, high-cost, and restricted antimicrobials were being prescribed as OPAT. A multi-disciplinary team (MDT) team was set up to implement and deliver good practice recommendations 1alongside providing care closer to home2. Aim To assess the number of patients accessing treatment through the service, evaluate uptake and adherence to OPAT guidelines, identify whether AMPs were having an impact on the service and evaluate patient outcomes. Methods The MDT included consultant microbiologists, AMPs, ART & infection control nurses, consultant anaesthetist and orthogeriatrician. A Standard Operating Procedure and guidelines were implemented. A data collection form was completed by nurses for each patient and monitored by AMPs. The data underwent descriptive statistical analysis. Ethical approval was not required for this service evaluation. Results The service saved 1685 bed days across two counties (Ceredigion and Carmarthenshire) over a 6-month period. Patients were treated with a variety of antimicrobial agents including ceftriaxone, ertapenem, teicoplanin and ceftazidime. Patients receiving OPAT received a clinical check by an AMP for clinical appropriateness, therapeutic drug monitoring and dosing according to blood results. AMPs undertook over 200 reviews, making 27 interventions, including advice on monitoring, when to take levels, bloods, or antibiotic choice. There were only 6 interventions on choice of antibiotic to include more stewardship wise options or options for reduced dosing frequency to increase the capacity of ART, highlighting good uptake and adherence to the guidelines. Outcome forms were collected for all 31 patients in Ceredigion 81% (26 patients) were cured of their infection. In 6% the treatment aim was not attained and required readmission, 6% had no information supplied, 3% were reviewed in clinic and switched to oral and 3% required readmission due to unrelated event. Discussion/Conclusion Collaboration within the MDT has led to an improvement in practice while delivering OPAT in HDUHB. Development of a working relationship between the ART nurses and AMPs has led to improved patient safety and monitoring whilst offering patients the opportunity to receive care closer to home. The availability of AMPs to provide answers and guidance in a timely manner to ART has made treatment in the community easier and safer. The guidelines launched at the beginning of the COVID-19 pandemic in an effort to reduce the number of patients occupying beds in secondary care however, this led to a reduced ability for education to be delivered on the guidelines compared to normal practice. Further work is needed to involve the Pembrokeshire team in the process and to increase awareness of the guidelines in both primary and secondary care. Discussions are also in place to investigate whether elastomeric devices offer better antimicrobial stewardship wise treatment options. The main limitation of this study is the inability to follow up long term outcomes.

Antibiotic consumption in hospitals during COVID-19 pandemic: a comparative study.

Coronavirus disease 2019 (COVID-19) results in similar clinical characteristics as bacterial respiratory tract infections and can potentially lead to antibiotic overuse. This study aimed to determine the changes in hospital antimicrobial usage before and during the COVID-19 pandemic. We compared antimicrobial consumption data for 2019 and 2020. Inpatient antibiotic consumption was determined and expressed as a defined daily dose (DDD) per 100 occupied bed days, following the World Health Organization (WHO) methods. The WHO Access, Watch, and Reserve (AWaRe) classification was used. The total antimicrobial consumption in 2020 increased by 16.3% compared to consumption in 2019. In 2020, there was a reduction in fourth-generation cephalosporins (-30%), third-generation cephalosporins (-29%), and combinations of penicillins (-23%). In contrast, antibiotics that were consumed more during 2020 compared with 2019 included linezolid (374%), vancomycin (66.6%), and carbapenem (7%). Linezolid is the only antibiotic from the Reserve group on the hospital's formulary. Antibiotic usage from the Access group was reduced by 17%, while antibiotic usage from the Watch group and the Reserve group was increased by 3% and 374%, respectively. The findings show a significant shift in antibiotic usage from the Access group to the Watch and Reserve groups. The Watch and Reserve groups are known to be associated with increased resistance to antibiotics. Therefore, antimicrobial stewardship should be increased and maintained during the pandemic to ensure appropriate antibiotic use.

Clinical and paraclinical features of the course of infection caused by SARS-CoV-2 in primary school-age children depending on gender

The COVID-19 pandemic has been going on for 2.5 years, which is a serious challenge for the health care systems of most countries of the world. The high frequency of mutations of the SARS-CoV-2 changes the epidemiological characteristics, clinical manifestations of the disease, as well as consequences after infection.Aim of the study. To conduct an analysis of the clinical and paraclinical features of the course of COVID-19 in primary school-age children, taking into account gender, to improve the prognosis of the severity and duration of the disease, to optimize the tactics of managing patients.Materials and methods. 55 clinical cases of COVID-19 in primary school-age patients were analyzed. The gender of the patients was considered a group-forming feature. The obtained results were analyzed by methods of descriptive statistics biostatistics, and clinical epidemiology.Results. It was established that half of the male patients and 44.4% of the girls had registered complications of the main disease, mainly in the form of acute respiratory failure. The onset of the disease was characterized by general weakness and fever. Cough was more likely to be noted among boys, while in girls, there was a tendency to increase the frequency of complaints of nasal congestion. In the hospital, during the physical examination, the pathological sounds under the lungs during auscultation were registered significantly more common in male patients (75.0±8.2 versus 48.1±9.6%, Рφ < 0,05). Male gender, residence in the cities, violation in vaccination schedule, dyspnea, the level of blood oxygen saturation below 95% during hospitalization are characterized with a high predictive value of a longer hospitalization period.Conclusion. The course of COVID-19 in primary school-aged children was not dependent on gender and was multisymptomatic, however, the average duration of hospitalization was significantly higher among male patients. Incomplete vaccination status increased the attributive relative risks of more bed days in the hospital with an odds ratio of 6.7:1.

Change in coronary heart disease hospitalization after chronic disease management: a programme policy in China.

This study aims at examining changes in coronary heart disease (CHD) hospitalization associated with a novel county-scale chronic disease management (CDM) programme policy implemented in March 2019 in China during the 13th Five-Year period (2016-2020). The CDM programme was designed to improve the health of populations with chronic diseases by means of an integrated way involving both county-level public hospitals and primary care institutes. Data originated from the medical files of CHD inpatients discharged from a secondary hospital from January 2017 to December 2020. A total of 6111 CHD patient records were collected. Univariate and multivariate regression analyses were performed to assess changes in hospitalization direct medical costs and length of stay of CHD patients. The mean direct medical cost of CHD hospitalization was 8419.73 Yuan, and the mean length of stay was 7.57 days. Results suggested that the implementation of CDM reduced hospitalization direct medical cost and bed days by about 23% (1956.12 Yuan at means) and 11.5% (almost 1 day at means), respectively. In addition, a further decreasing trend in medical costs over time was associated with chronic disease management. It is implied that chronic disease management is an effective way of relieving the medical and financial burden of hospitalization.

Pharmacologic restraint use for children experiencing mental health crises in pediatric hospitals.

Children in mental health crises are increasingly admitted to children's hospitals awaiting inpatient psychiatric placement. During hospitalization, patients may exhibit acute agitation prompting pharmacologic restraint use. To determine hospital-level incidence and variation of pharmacologic restraint use among children admitted for mental health conditions in children's hospitals. We examined data for children (5 to ≤18 years) admitted to children's hospitals with a primary mental health condition from 2018 to 2020 using the Pediatric Health Information System database. Hospital rates of parenteral pharmacologic restraint use per 1000 mental health bed days were determined and compared after adjusting for patient-level and demographic factors. Cluster analysis (k-means) was used to group hospitals based on overall restraint use (rate quartiles) and drug class. Hospital-level factors for pharmacologic restraint use were compared. Of 29,834 included encounters, 3747 (12.6%) had pharmacologic restraint use. Adjusted hospital rates ranged from 35 to 389 pharmacologic restraint use days per 1000 mental health bed days with a mean of 175 (standard deviation: 72). Cluster analysis revealed three hospitals were high utilizers of all drug classes. No significant differences in pharmacologic restraint use were found in the hospital-level analysis. Children's hospitals demonstrate wide variation in pharmacologic restraint rates for mental health hospitalizations, with a 10-fold difference in adjusted rates between highest and lowest utilizers, and high overall utilizers order medications across all drug classes.

CELPI: trial protocol for a randomised controlled trial of a Carer End of Life Planning Intervention in people dying with dementia

BackgroundDementia is a leading cause of death in developed nations. Despite an often distressing and symptom laden end of life, there are systematic barriers to accessing palliative care in older people dying of dementia. Evidence exists that 70% of people living with severe dementia attend an emergency department (ED) in their last year of life. The aim of this trial is to test whether a Carer End of Life Planning Intervention (CELPI), co-designed by consumers, clinicians and content specialists, improves access to end of life care for older people with severe dementia, using an ED visit as a catalyst for recognising unmet needs and specialist palliative care referral where indicated.MethodsA randomised controlled trial (RCT) enrolling at six EDs across three states in Australia will be conducted, enrolling four hundred and forty dyads comprising a person with severe dementia aged ≥ 65 years, and their primary carer.Participants will be randomly allocated to CELPI or the control group. CELPI incorporates a structured carer needs assessment and referral to specialist palliative care services where indicated by patient symptom burden and needs assessment. The primary outcome measure is death of the person with dementia in the carer-nominated preferred location. Secondary outcomes include carer reported quality of life of the person dying of dementia, hospital bed day occupancy in the last 12 months of life, and carer stress. An economic evaluation from the perspective of a health funder will be conducted.DiscussionCELPI seeks to support carers and provide optimal end of life care for the person dying of dementia. This trial will provide high level evidence as to the clinical and cost effectiveness of this intervention.Trial registrationACTRN12622000611729 registered 22/04/2022.

Remoteness and socioeconomic status reduce access to specialist mental health care across Australia.

Estimate impact of socioeconomic factors and remoteness from tertiary hospital on incidence/duration of Australian mental health admissions. Retrospective analysis of incidence/duration of public mental health unit admissions (2018-19). Covariates included Indigenous population, potentially preventable hospitalisations (PPH) and socioeconomic disadvantage. Regional distance from hospital was correlated with socioeconomic disadvantage (ρ: p < 0.01). Population identifying as Aboriginal or Torres Strait Islander was associated with distance from hospital, socioeconomic disadvantage and PPH (ρ: p < 0.01). Bed days per capita was explained (R2adj: 0.48) by distance and socioeconomic disadvantage (p < 0.0001). A 1% increase in distance from hospital was associated with a 0.37% decrease in per capita bed days. Admission rate per capita across Queensland and WA was explained (R2adj: 0.36) by distance, education/occupation and state (p < 0.05). Across Queensland and WA a 1% increase in distance from hospital was associated with a 0.05% decreased incidence of admission. Rural Australians face high mental illness burden, socioeconomic disadvantage and limited service provision. Overcoming the additional disadvantages of reduced likelihood of admission to and reduced time in hospital with increasing distance from hospital will require increased outreach proportional to remoteness.

Rapid Assessment and Treatment In Decompensated Aortic Stenosis (ASTRID-AS study)- A Pilot Study.

Acute decompensated aortic stenosis (ADAS) is common and associated with higher mortality, acute kidney injury (AKI) and longer hospital length of stay (LoS) compared to electively treated stable AS. The aim of this study was to assess the impact of a dedicated pathway that reduces time to transcatheter aortic valve implantation (TAVI) in ADAS, hypothesizing that LoS can be reduced without compromising patient safety. Using a prospective, open label, cluster design, patients from 5 referring centres were allocated to the ASessment and TReatment In Decompensated Aortic Stenosis (ASTRID-AS) pathway where the diagnosis, referral, investigations and treatment of ADAS were prioritised and expedited. 15 hospitals remained on the conventional pathway that followed the same process, albeit according to a waiting list. The primary efficacy endpoint was hospital LoS and the secondary safety endpoint, a composite of death or AKI at 30 days post-TAVI.58 conventional patients and 25 ASTRID-AS patients were included in this study. Time to TAVI in the conventional vs ASTRID-AS cohort was 22 (15-30) vs 10 (6-12) days; p<0.001, respectively. Length of hospital stay was 24 (18-33) vs 13 (8-18) days; p<0.001, respectively. 13.4 bed days were saved per patient using the ASTRID-AS pathway. Secondary safety endpoint occurred in 12 (20.7%) vs 1 (4.0%) patients; p=0.093, respectively. Procedural complications were similar between the two cohorts. A dedicated pathway for ADAS that shortens time to TAVI demonstrated reduced hospital LoS without compromising patient safety and a trend towards improving clinical outcomes.

Economic evaluation of a vision-based patient monitoring and management system in an acute adult and an older adult mental health hospital in England

Background and aims Patients on acute adult and older adult inpatient mental health wards are at an increased risk of accidental injuries and deliberate harm to self and others. A vision-based patient monitoring and management (VBPMM) system was designed by Oxehealth Limited to support ward staff to provide better and more efficient care and to reduce incidents. The VBPMM system uses an infrared-sensitive camera, installed in a patient’s room, that works with cleared medical device software to deliver contact-free vital sign and activity insights to clinical teams. Data from two studies undertaken at an English National Health Service (NHS) mental health trust were used to inform an early economic assessment of VBPMM implementation into acute adult and older adult mental health wards. Methods A cost calculator was used to compare the introduction of the VBPMM system as an adjunct to standard care versus standard care alone. Observational data were collected at two English NHS mental health trusts. Both compared data pre- and post-VBPMM implementation using a 12-month baseline period. The model estimated cost per occupied bed day, cost per patient, annual cost per average-sized ward, and total cost to NHS mental health trusts across England. Costs were modeled from an NHS perspective over a 12-month time horizon. Scenario analysis was conducted to test the uncertainty of results using statistical significance of key inputs. Results and conclusions This early analysis indicated that the VBPMM system is likely to be cost saving within both settings examined, with an estimated cost saving of £272 per acute adult mental health patient and £4,591 per older adult mental health patient. This translates to £22.3 and £63.3 million, respectively, across NHS mental health trusts in England every year. VBPMM, therefore, has the potential to augment standard care, leading to positive clinical outcomes and monetary savings.