Bed Days Research Articles

Quantitative Study of Antibiotic Usage in Pneumonia Patients: Systematic Literature Review

Pneumonia caused more than 2,56 million deaths in 2017 worldwide. With the high number of pneumonia sufferers, the use of antibiotics will also increase. This study aims to describe the quantity of antibiotic use in pneumonia patients using the Systematic Literature Review method. The literature search was conducted through the PubMed, Sciencedirect, Mendeley, BMC, and Google Scholar databases. The literature used is a journal of the last 10 years that discusses the use of antibiotics in pneumonia patients calculated by the ATC/DDD system. Of the total 19 journals included in the study, 8 journals were from Indonesia. A total of 5 journals discussed antibiotics used in CAP (Community-Acquired Pneumonia), 2 journals in HAP (Hospital-Acquired Pneumonia), 2 journals in VAP (Ventilator-Associated Pneumonia), 2 journals were non-specific, and the remainder covered several types of pneumonia. The class of antibiotics with the highest DDD value is fluoroquinolones, with an average use of 41,81 DDD/100 patient-days; 17,29 DDD/100 bed days; and 0,0696 DDD/1000 inhabitants per day, and third-generation cephalosporins, with an average use of 15,86 DDD/100 patient-days and 28,31 DDD/100 bed days. The antibiotic with the highest DDD value was levofloxacin, with an average use of 31,29 DDD/100 patient-days; 12,22 DDD/100 bed days; and 0,0612 DDD/1000 inhabitants per day, and ceftriaxone, with an average use of 12,51 DDD/100 patient-days and 26,33 DDD/100 bed days. The most widely used antibiotics in the treatment of CAP and HAP are third-generation cephalosporins, while penicillin is the most commonly used in VAP.

A complication during chemotherapy of recurrence of acute lymphoblastic leukemia in a child

Acute lymphoblastic leukemia (ALL) is one of the most common malignant diseases of the hematopoiesis system in childhood, characterized by uncontrolled proliferation of a tumor clone from lymphocyte progenitor cells. At the same time, as a result of total immunosuppression, the most common complications are infectious. The purpose of the work: to describe a clinical case of nosocomial pneumonia, formed against the background of chemotherapy relapse of ALL. Materials and methods. A retrospective analysis of the medical records of patient L., 6 years old, who was being treated at the Department of Pediatric Pulmonology of the UKB No. 1 of the Razumovsky SSMU with the main diagnosis: Nosocomial polysegmental pneumonia with obstructive syndrome, acute course. Complications: 1. RF III art., 2. Pulmonary edema, 3. Exudative pleurisy. Background: ALL III phenotype; late bone marrow relapse, isolated (30.12.2022). Results. At the age of 2 (2019) - he made his ALL debut, received induction courses, and achieved remission within the prescribed consolidation period. In 2022, a reinduction course was conducted, and it was removed from the D-register. Relapse of leukemia (28.12.2022) - hospitalized in the V.Ya. Shustov UCB No. 3, 1 block of anti-relapse therapy of ALL in combination with hemotransfusion, massive antibacterial (AB) therapy was performed. On the 23rd day of hospitalization in the hematology clinic, nosocomial 2-sided polysegmental pneumonia was diagnosed, complicated by pulmonary edema, exudative pleurisy, RF III art. On 23.01.2023, the patient was urgently taken to the children’s Intensive care Unit (DORIT) in extremely serious condition UKB No. 1 named after S.R. Peacemakers SSMU, where over the next 15 bed days he received: erythrocyte suspension transfusion, oxygen therapy, combined AB therapy, GCS, bronchodilator and mucolytic therapy, against which the condition improved: symptoms of intoxication, DN were stopped, the inflammatory process in the lungs was resolved. For further treatment of relapse, ALL was transferred to the hematology clinic. Conclusion: The course of chemotherapy for relapse of ALL in the patient provoked a severe infectious complication - nosocomial pneumonia with DN III art., pulmonary edema, pleurisy. Timely diagnosis of pneumonia and intensive therapy in DORIT conditions contributed to a favorable outcome of the infectious process in the lungs. Taking into account the above, the tactics of ALL management were changed - allogeneic transplantation of hematopoietic stem cells from a haploidentical donor (father) was performed, 19.07.2023 - engraftment was achieved.

Psychiatric in-patient care in England: as safe as it can be? An examination of in-patient suicide between 2009 and 2020.

Psychiatric in-patients have a greatly elevated risk of suicide. We aimed to examine trends in in-patient suicide rates and determine if characteristics of in-patients who died by suicide have changed over time. We identified all in-patients in England who died by suicide between 2009 and 2020 from the National Confidential Inquiry into Suicide and Safety in Mental Health. Suicide rates were calculated using data from Hospital Episodes Statistics. The rate of in-patient suicide per 100 000 bed days fell by 41.9% between 2009-2011 and 2018-2020. However, since 2016 the rate has remained static with no significant fall. Rates fell in men, those aged 30-59, and those with schizophrenia and other delusional disorders or personality disorder. Rates also fell for suicide by hanging (including hanging on the ward) and jumping. No falls were seen in suicide rates among women, younger and older age groups, and those with affective disorder. There was no indication of a transfer of risk to the post-discharge period or to home treatment/crisis care. More in-patients in the latter part of the study were aged under 25, were on authorised leave, and had psychiatric comorbidity. In-patient suicide has significantly fallen since 2009, suggesting patient safety may have improved. The recent slowdown in the fall in rates, however, highlights that renewed preventative efforts are needed. These should include a greater focus on women, younger and older patients, and those with affective disorder. Careful reviews prior to granting leave are important to ensure a safe transition into the community.

Endonasal versus supraorbital approach for anterior skull base meningiomas: Results and quality of life assessment from a single-surgeon cohort

ObjectiveIn this prospective non-randomized study we reported our experience related to planum sphenoidale (PS) and tuberculum sellae (TS) meningiomas in a similar cohort of patients operated via the endonasal or the supraorbital route. A comprehensive quality of life analysis has been performed. MethodsBeing comparable in general features, between November 2017 to January 2020, a total of 20 patients with anterior skull base meningioma were included. Hence, 10 patients were treated using the supraorbital keyhole procedure (SO) while 10 patients received an endoscopic endonasal approach (EEA). Both surgical techniques were analyzed and compared. Quality of life has been analyzed with the SF-36 questionnaire. ResultsTwenty patients were identified who underwent either EEA (n=10) or SO (n=10). The average extent of resection achieved was not significantly different between the 2 groups. Post-operatively, the EEA group demonstrated a longer hospital stay and bed days compared with SO patients as well as a longer surgical time. There was a significant rate of more CSF leakage after EEA then after SO (20% vs 0%, p=0,0491). The follow-up period resulted shorter in the SO group, with a slight increased recurrence rate. Overall, no differences in visual outcome were detected. There were no differences in terms of quality of life between the two groups in all the explored items. ConclusionsIn this single-center single-surgeon study of similarly sized and located PS and TS meningiomas, EEA showed longer hospital stays with higher degree of CSF leak compared with the SO group. Supraorbital craniotomy via eyebrow incision reported a comparable quality of life results, even if with a slightly higher percentage of recurrence and less follow-up.

Preventing hospital falls: feasibility of care workforce redesign to optimise patient falls education.

To examine the feasibility of using allied health assistants to deliver patient falls prevention education within 48h after hospital admission. Feasibility study with hospital patients randomly allocated to usual care or usual care plus additional patient falls prevention education delivered by supervised allied health assistants using an evidence-based scripted conversation and educational pamphlet. (i) allied health assistants and (ii) patients admitted to participating hospital wards over a 20-week period. (i) feasibility of allied health assistant delivery of patient education; (ii) hospital falls per 1,000 bed days; (iii) injurious falls; (iv) number of falls requiring transfer to an acute medical facility. 541 patients participated (median age 81years); 270 control group and 271 experimental group. Allied health assistants (n = 12) delivered scripted education sessions to 254 patients in the experimental group, 97% within 24h after admission. There were 32 falls in the control group and 22 in the experimental group. The falls rate was 8.07 falls per 1,000 bed days in the control group and 5.69 falls per 1,000 bed days for the experimental group (incidence rate ratio = 0.66 (95% CI 0.32, 1.36; P = 0.26)). There were 2.02 injurious falls per 1,000 bed days for the control group and 1.03 for the experimental group. Nine falls (7 control, 2 experimental) required transfer to an acute facility. No adverse events were attributable to the experimental group intervention. It is feasible and of benefit to supplement usual care with patient education delivered by allied health assistants.

Inequity of healthcare access for patients with diabetic foot disease: a retrospective study in south-east Queensland

ObjectivesLogan local government area (LGA) in Queensland has the highest diabetes prevalence (6.5%) within Metro South Health (MSH). The study aimed to determine the burden of, and equity of access...

Length of stay and economic sustainability of virtual ward care in a medium-sized hospital of the UK: a retrospective longitudinal study

ObjectiveTo evaluate the length of stay difference and its economic implications between hospital patients and virtual ward patients.DesignRetrospective longitudinal study.SettingWrightington, Wigan and Leigh (WWL) Teaching Hospitals, National Health Service (NHS)...

Antimicrobial surveillance in South Australian prisons: a pilot study.

ObjectivesThis study aimed to determine the feasibility of capturing antimicrobial usage data from prisons for inclusion in the Antimicrobial Use and Resistance in Australia (AURA) surveillance system and to analyse 2021 and 2022 South Australian (SA) usage data for notable trends.MethodsMonthly antimicrobial supply data for eight SA prisons were collected. Antimicrobial volume was converted into the World Health Organization metric, defined daily doses (DDD). Usage rates were calculated relative to prison occupied bed days (OBD).ResultsAnnual usage of systemic antimicrobials across eight SA prisons totalled 26,448 DDD and 23,526 DDD in 2021 and 2022 respectively. Antibacterials accounted for 80.6% of all antimicrobials dispensed during the study period. The average antibacterial usage rate in female prisons was higher on average than in male prisons. The state-wide systemic antibacterial usage rate in SA prisons declined by 11.3% from 23.8 DDDs/1000 OBD in 2021 to 21.1 DDDs/1000 OBD. Doxycycline, amoxicillin, flucloxacillin, amoxicillin-clavulanic acid, and cefalexin accounted for 72% of the total systemic antibacterial usage rate. Variation in the oral and topical antifungal agents used and the rate of use was observed between prisons.ConclusionsThis SA pilot study demonstrates the feasibility of including prisons in routine national antimicrobial surveillance using similar methodology to hospital surveillance. The contributing facilities comprised 6.1% of all Australian prison beds, and extrapolation of the results suggests that the identified gap in surveillance may equate to over 400,000 DDD per annum in prisons nationwide, equating to approximately 5% of hospital inpatient antimicrobial usage.

Etiological differences in demographics, clinical course and consequences of acute pancreatitis: a retrospective study.

Aim: The study is intended to consider acute pancreatitis from the point of view of its etiological structure, as well as demographic description, features of the clinical course, distribution of morphological forms, severity and consequences of the disease in different etiological variants. Materials and Methods: The work was based on a retrospective analysis of the medical records of 677 patients with acute pancreatitis who underwent inpatient treatment from 2017 to 2022 in an emergency hospital and a tertiary regional hospital in Vinnytsia, Ukraine. Results: The etiological structure of the general sample was as follows: the alimentary factors - 37,5% of cases, biliary - 18,6%, alcohol - 14,0% and postoperative - 7,8%, respectively. The oldest patients were observed in the group with biliary AP (age [median, interquartile range] 61 [46-72] years), the youngest - in the group with alcoholic AP (age [median, interquartile range] 40 [35-47] years). Men significantly predominated in the groups with alimentary and alcoholic AP. A significant predominance of women was observed in the group with biliary AP (62,7% vs. 37,3%, p=0,0003). The highest mortality was in the alcoholic AP group (22,1%), also here was a significantly lower rate of inpatient bed days (6,0). Edematous AP was dominant in all etiological variants. While infected necrotic pancreatitis was significantly more often found in patients with alcoholic genesis (7,4%). Conclusions: The etiologic variations of acute pancreatitis differ by demographic and clinical indicators and require more detailed study to understand its prognosis, management, and development of effective prevention and treatment strategies.

Drug Utilization Evaluation of Analgesics Using Defined Daily Dose (DDD) and Defined Daily Dose/100 Bed-Days in the Surgical Department of a Teaching Hospital

Objective The objective of the study was to perform the drug utilization evaluation of analgesics in the Department of General Surgery at a teaching hospital by using Anatomical and Therapeutic classification ATC code and Defined daily dose DDD100 bed days. Methods A prospective observational study was conducted in the Department of General Surgery at a teaching hospital for a period of three months. Descriptive statistics were used in which quantitative variables were presented in proportions and percentages. Consumption of analgesics in the department was measured by using the technical unit of measurement Defined Daily Dose DDD and DDD100 bed-days.Results A total of 606 subjects were included in the study. The majority of patients in the Department of General Surgery were males 360 59.4 and the female subjects were 246 40.6. Paracetamol 1g IV was observed to be the most used analgesic in this department with the units consumed being 4811 48.63. Aceclofenac 100 mg oral drug was the least used analgesic with units consumed at 29 0.29. The DDD100 bed-days for each analgesic with ATC code was calculated and analysed.Conclusion Drug utilization evaluation of analgesics in the Surgery department of the hospital based on DDD and the DDD100 bed-days measurement showed that parenteral forms of analgesics like Paracetamol Tramadol and Diclofenac were consumed more than the oral dosage forms of these drugs. The study also revealed that consumption of drugs like Tramadol and Pregabalin in the oral dosage forms was low in the hospital included in the study which shows rationality in the use of controlled drugs

The Impact of Infection Control Policies on Hospital Acquired Infections by MDROs from 2016 to 2023.

Hospital-acquired infections (HAIs) caused by multidrug-resistant organisms (MDROs) pose a significant challenge to healthcare systems. The present study aimed to evaluate the impact of the infection policy to COVID-19 on the incidence of HAIs caused by MDROs. We conducted an eight-years retrospective analysis at a hospital in Shanghai, China. Bloodstream, sputum, and urinary tract cultures of MDROs obtained 48h after admission were collected monthly from January 2016 to Dec 2023. Occupied bed days (OBDs) were used to generate monthly HAI incidences per 10,000 OBDs. The study period was divided into pre-control, in-control, and post-control cohorts, in January 2020 and January 2022. The incidence was compared using interrupted time-series regression. In total, 6763 MDRO cultures were identified, comprising 1058 bloodstream, 4581 sputum, and 1124 urine cultures derived from 4549 patients. The incidence rates of all HAIs were 8.68 per 10,000 OBDs in the pre-control cohort, 9.76 per 10,000 OBDs in the in-control cohort and 12.58 per 10,000 OBDs in the post-control cohorts, respectively. A downward trend in the incidence of HAI was observed in the post-control cohort (p<0.05). This study demonstrates that while the COVID-19 pandemic poses a significant challenge to infection control within hospitals, it provides a unique opportunity to enhance infection control measures and evaluate their effectiveness. In addition, these findings highlight the need for more targeted prevention and control strategies against different pathogens in future epidemics.

Costs of primary healthcare presentations and hospital admissions for scabies and related skin infections in Fiji, 2018-2019.

Scabies and related bacterial skin and soft tissue infections (SSTIs) are highly prevalent in many tropical, low- and middle-income settings. These skin conditions contribute to higher healthcare costs and burdens on healthcare systems. The Big Skin Health Intervention Fiji Trial ("Big SHIFT") carried out surveillance for scabies and SSTIs from July 2018 to June 2019 in the Northern Division of Fiji, an area with high prevalence of scabies, prior to a division-wide ivermectin-based mass drug administration (MDA) campaign. Using data from Big SHIFT, we sought to estimate the annual direct healthcare costs of scabies and related SSTIs for the Northern Division and extrapolate these costs to the national level. We categorized SSTIs as being potentially scabies-related or unlikely scabies-related, based on a previous study. The analysis used a health system perspective, with the main resource use categories of outpatient visits, bed days during admissions, medicines, and diagnostic tests. We extrapolated the total annual number of cases and direct healthcare costs for all divisions in Fiji based upon previous scabies and impetigo prevalence data across all divisions. The average cost per PHC presentation for scabies was US$17.7, and for potentially scabies-related SSTI was $18.3. The average cost per hospital admission for a potentially scabies-related SSTI case was $439. The estimated annual healthcare costs of scabies and related SSTIs in Fiji was US$3.0 million, with cost per capita of $3.3. Scabies and related SSTIs lead to a heavy economic burden in Fiji and prevention would reduce these healthcare costs.

Моделирование «ковидного провала» плановой госпитализации в период разгара пандемии COVID-19: анализ и оценка потерь использованной коечной мощности специализированного оториноларингологического стационара

Introduction. In the midst of the COVID-19 pandemic, healthcare organizations around the world were forced to change their operating hours, and some, especially those providing specialized medical care, were forced to stop operating completely. The purpose of the study is to develop a year-by-year model of the movement of patients before the pandemic and at its height, based on long-term data on the movement of inpatients. With its help, analyze possible losses in bed capacity (expressed in the number of idle bed days, or unserved patients) from the pandemic during 2020 — the year of the height of the pandemic. Materials and methods. The study was carried out according to the design of an observational retrospective analytical study. As research materials, we used anonymized data on the number of patients in the hospital at the Federal State Budgetary Institution «St. Petersburg Research Institute of ENT» of the Ministry of Health of Russia, obtained from the medical registration form N 007/u-02 „Sheet of daily records of the movement of patients and the bed capacity of a round-the-clock hospital, day hospital at a hospital facility“). The R and RStudio software environment was used as the main software product for solving statistical problems. Results. A load model has been created (the number of daily inpatients undergoing treatment) during the year. An analytical model of the “Covid failure” of bed capacity utilization during the height of the pandemic has been created. The coordinates of the dynamic points of bed release and return to typical bed occupancy values for this period of time were calculated (using linear regression forecasting). The share of hospital losses during the pandemic was calculated and assessed. Discussion. The use of “Covid failure” data superimposed on “pre-Covid” indicators allows not only to estimate annual losses, but also to predictively minimize losses during planned closures of hospital beds, for example, for repairs, given that the resumption of work of a medical institution’s beds will often be slower than the speed at which work stops. Analysis of linear regression coefficients of bed release and occupancy rates can give an idea of the speed of reaching standard values for the volume of medical care. As studies have shown during the COVID-19 pandemic, the minimum value of the quarantine period after the complete vacancy of beds is 14 days, and for high-risk scenarios 21 days. Based on this, for the conditions of organizing medical otorhinolaryngological care, the minimum predicted value of the time from the closure of hospitalization to its opening may be about 37 days after the start of patient discharge. The approach and mathematical functionality presented in the article can be used on the initial data of other institutions, as well as in preparation for the “Disease X” pandemic.

Разработка мероприятий по совершенствованию медико-социальной реабилитации больных параноидной шизофренией

Aim. To substantiate the implementation effectiveness differential programs medical and social rehabilitation voluntarily hospitalized patients with paranoid schizophrenia to reduce the hospitalizations number. Design. Comparative prospective study. Materials and methods. The study included 100 patients with paranoid schizophrenia, the retrograde duration and anterograde observation was ≥ 3 years. Based on the clinical study clinical and social determinants, three patient’s groups were identified depending on the identified motives for self-seeking psychiatric care: a paranoid motive group (PM) associated with delusional behavior (35%); nonrare psychopathological motives group (NPM) associated with other mental disorders not associated with delusional symptoms (38%); non-psychopathological motives group (NM) not associated with psychopathological symptoms (27%). Further, based on the clinical indicators compliance assessment according to the Positive and Negative Syndrome Scale (PANSS) with the social adaptation level according to the Personal and Social Performance Scale (PSP), patients groups were identified based on the disease clinical picture, cognitive, negative and positive symptoms, as well as adaptation potential, social functioning level and life indicators quality: compensated group (compensation in clinical and social aspects — 15%); decompensated group (clinical and social decompensation — 53%); adapted group (severe clinical disorders with satisfactory social compensation — 20%); conflict group (mild clinical manifestations (the non-psychotic register disorders) and severe social decompensation — 12%). Results. Based on the clinical indicators compliance assessment with the social functioning level for various groups of patient’s social adaptation, differential programs have been developed aimed at reducing the hospitalizations number, including various psychosocial interventions kinds. The psychotic attacks frequency in the PM group did not change significantly with a sufficiently significant decrease in the independent requests number for psychiatric care from 1.6 ± 0.2 to 1.4 ± 0.3 (t &gt; 2, p &gt; 0.95). In the NPM group, both the psychotic attacks frequency and the number of independent visits decreased (in both cases, t &gt; 2, p &gt; 0.95). In the NM group, it was not possible to achieve a statistically significant decrease in the independent requests number for psychiatric care with an observed significant decrease in the psychotic attacks frequency (t &gt; 2, p &gt; 0.95). The hospitalizations duration in the NPM and NM groups was significantly reduced (72 ± 9 to 67 ± 6 and 38 ± 4 to 34 ± 6 bed days (t &gt; 2, p &gt; 0.95), respectively) while simultaneously increasing the outpatient treatment days’ number from 53 ± 4 to 59 ± 9 and from 42 ± 8 to 48 ± 6 (t &gt; 2, p &gt; 0.95), respectively. At the same time, the remission increased duration only in the NPM group from 0.62 ± 0.25 to 0.73 ± 0.19 year (t &gt; 2, p &gt; 0.95). Clinically, the affective (depressive) symptoms severity according to the Calgary Depression Scale for Schizophrenia decreased in the NPM and NM groups (10.2 ± 1.4 to 9.0 ± 1.6 score and 7.3 ± 0.8 to 6.6 ± 0.9 score (t &gt; 2, p &gt; 0.95), respectively), and the psychopathological symptoms severity according to the PANSS scale significantly decreased only in the NM group from 91 ± 4 to 87 ± 6 scores (t &gt; 2, p &gt; 0.95). Conclusion. Basically, the clinical and social medical care for patients with paranoid schizophrenia are the synergistic complementarity psychiatric care and social rehabilitation, mandatory psychotherapeutic and psychoeducational support for medicines prescriptions. Keywords: voluntary hospitalization, paranoid schizophrenia, medical and social rehabilitation, psychosocial interventions, number of hospitalizations, social adaptation.

Antimicrobial consumption in an acute NHS Trust during the COVID-19 pandemic: intervention time series analysis.

To determine the impact of the COVID-19 pandemic on antimicrobial consumption and trends of therapeutic drugs for COVID-19 treatments, including corticosteroids, remdesivir and monoclonal antibodies (tocilizumab) from April 2017 to September 2022 in a secondary care NHS Trust in England. A retrospective intervention time series analysis was conducted for April 2017 to September 2022 at the Mid Yorkshire Teaching NHS Trust. Data were retrieved from the pharmacy dispensing system as defined daily doses (DDDs) monthly and reported per 1000 occupied bed days (OBDs). Antimicrobial consumption and COVID-19 treatment options were measured. DDDs were calculated according to the classification of antimicrobials for systemic use (J01) and for other drugs classification. Trends for antimicrobial consumption and other therapeutic drugs for treating COVID-19 were also determined in each wave in England. During the pandemic: total antibiotic consumption decreased from 826.4 to 728.2 DDDs per 1000 OBDs (P = 0.0067); piperacillin/tazobactam use increased (P < 0.0001) and ciprofloxacin use decreased (P < 0.0001); there were no changes in Access, Watch, Reserve antibiotic use, and the proportion of antifungal consumption was consistent throughout the study. The use of total antibiotics (P = 0.024), levofloxacin (P = 0.0007), piperacillin/tazobactam (P = 0.0015) and co-amoxiclav (P = 0.0198) increased during wave one. Consumption of COVID-19 treatment drugs was highest during wave two, with 624.3 DDDs per 1000 OBDs for dexamethasone (P = 0.4441), 6.8 DDDs per 1000 OBDs for remdesivir (P < 0.0001) and 35.01 DDDs per 1000 OBDs for tocilizumab (P = 0.2544). This study determined the consumption of antimicrobials trends before and during the pandemic. The individual wave antimicrobial consumption indicates maximum consumption in the first wave, advocating for antimicrobial stewardship and preparedness for future pandemics.

Optimising Same Day Emergency Care (SDEC) Delivery Within a Leading Tertiary Cancer Centre in Southeast Wales

Expansion and enhancement of Same Day Emergency Care at Velindre Cancer Centre during 2022 compromises of Ambulatory Care Unit, Assessment Unit, Patient Support Unit and Immunotherapy toxicities service.&#x0D; To provide better value-based healthcare we have introduced an Immunotherapy Toxicities service plus expanded the existing Ambulatory Care Unit and Patient Support Unit providing 12-hour weekday working including a weekend service. &#x0D; The need for a dedicated Immunotherapy service was highlighted following NHS data which anticipated a growth of 240% in Immunotherapy treatments over the next 5 years with Immunotherapy treatments having already increased by 49% from 2018/19 to 2020/21. &#x0D; Without investment this would have led to increasing admissions in South East Wales Health Boards by over 320 patients per annum. This increase would perpetuate the strain on the Ambulatory Unit within VCC and Local Health Boards emergency departments due to the need to admit the patients experiencing toxic side-effects with no viable alternative.&#x0D; The development of the Immunotherapy service has allowed for a clear alternative to emergency/unscheduled admission by ensuring robust pathways are in place, 24/7 resilience and support of toxicities, increased patient and staff education in managing toxicities and rapid treatment and management of patients. &#x0D; The Ambulatory Care provision has expanded working hours as well as supporting a weekend service to ensure more timely interventions for patients on a same day basis, enhancing care and clinical outcomes plus removing additional demand on Local Health Boards by preventing admission. &#x0D; Since 2019 the Patient Support Unit has seen a 51% reduction for inpatient admissions for head and neck cancer with the average monthly bed days for patients reduced by 45%. Through service expansion it has been predicted that admissions and length of stay are likely to reduce by a further 10-15%. This will further decrease the burden on external services such as acute hospitals with an ever growing demand on the services.&#x0D; The expansion has improved access to a skilled multidisciplinary team including specialist nurses, dieticians, speech and language therapists, physiotherapists and occupational therapists who will all work together to ensure all patients are cared for through robust interventions with timely follow ups.&#x0D; The model of delivery is innovative and forward thinking and endorsed by patients and staff alike. The joint MDT allows professionals to anticipate, ameliorate and treat complex and rapidly changing symptoms as an outpatient. &#x0D; The services discussed are essential in reducing the burden on internal and external services whilst ensuring the patient has the best possible outcome. Through clear robust pathways and an upskilled workforce, the service will be sustainable for years to come whilst patients are dealt with in the best way possible in an Ambulatory manner.&#x0D; The outcome is a sustainably funded, evidence-based patient-centred service offered in a day case setting, that anticipates and manages complex toxicities and challenging symptoms that develop at different points during the treatment pathway. With these side effects managed on an ambulatory basis, it prevents patients requiring prolonged inpatient admission, a wider benefit for our partners in Local Health Boards.&#x0D;

Drug Utilization and Evaluation of Antibiotics and Classifying them based on WHO AWaRe Classification

Antibiotics are the most prescribed medicaments in medical practices worldwide. Indiscriminate use of antibiotics adds to the emergence of Antibiotic resistance (ABR) leading to inefficiency of antibiotics. WHO fostered three unique classification systems - Access, Watch, and Reserve (AWaRe classification)- a tool to identify the safe use of antibiotics. The study aimed to evaluate antibiotic use in the Department of Surgery using the WHO ATC/DDD method and further classified the antibiotics based on WHO AWaRe Classification. An observational study was carried out among 305 samples in the In-Patient Department of Surgery at a teaching hospital, in Bangalore. Data was collected from the patient’s case files using a self-designed data collection form. The collected data were entered in Microsoft Excel and appropriate statistical analysis were performed. It was found that most (28.53%) of the patients belonged to the age group of 38-47 years and most of them received antibiotic therapy as prophylaxis (69%). It was found that Ceftriaxone (28.51%), Metronidazole (21.15%), and Cefixime (18.52%) were the most frequently prescribed antibiotics. The most frequently prescribed antibiotic class was Beta-lactams (65.3%), and most prescribed antibiotics belonged to the Watch Group (53%). The most utilized antibiotics were Ceftriaxone (3.32 DDD/100 bed days) followed by Cefixime (2.15 DDD/100 bed days) and Metronidazole (1.59 DDD/100 bed days). This study shows a need to prepare and implement proper policies or guidelines for prescribing antibiotics in the hospital.

LOCAL ADAPTATIONS OF HIH: VARIATIONS IN STRUCTURE AND IMPLEMENTATION OF HIH MODEL ACROSS SIX VA PROGRAMS

Abstract A number of Department of Veterans Affairs (VA) medical centers have adopted the Hospital-In-Home (HIH) model of care to provide at home services to Veterans requiring acute-level hospital care. We aimed to identify similarities and variations in structure and implementation of the HIH model across VHA sites. Of 11 programs, six (55%) used a standardized presentation template to present their specific program characteristics, outcomes and goals at monthly national program meetings. Presentations were transcribed and abstracted into themes by two reviewers. Programs varied in their staffing, services provided, referral sources and clinical outcome metrics. While one site provided in person visits, 3 reported program adaptations such as virtual follow-up visits for COVID patients. Review of clinical outcome metrics also revealed substantial site to site variations including 30-day readmission rates, cost avoidance, bed days or emergency department visits. All sites offered complementary (from hospital) and substitutive (from other than hospital) HIH stays. Substitutive stays varied across referral sources admitting patients from emergency departments, outpatient clinics, home based primary care and inpatient settings. Additionally, variations in catchment area (driving distance), and staffing in the parent stations highlighted differing contexts of HIH programs. We hypothesize that variations among sites may exist due to factors such as the setting and unique needs of the population and facility. An in-depth understanding of the contextual factors that influence implementation can be achieved through interviews with key staff from each site. Future work will examine if such variations are related to program outcomes.

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.

Impact of Personal Protective Equipment usage and hand washing due to COVID-19 on the rate of HA-CDI

Background:&#x0D; Clostridium difficile infection (CDI) is one of the most common healthcare-associated (HA) infections. Advanced age, use of proton pump inhibitors, concomitant antibiotics, steroids, prolonged hospital stay, and gastrointestinal surgeries are associated with increased incidence of disease. CDI is transmissible via the fecal-oral route by ingestion of spores and is readily transmitted in the hospital between patients and caregivers. Strict contact precautions and handwashing are implemented in health care settings to prevent its transmission. The current pandemic of Coronavirus disease (COVID-19) has led to imposing restrictions on patient admission, visitor visit and implementing extra measures on handwashing along with the use of personal protective equipment (PPE). Therefore, the main objective of this study is to identify if additional preventive measures for COVID-19 have any impact on the rate of HA-CDI.&#x0D; Methods: &#x0D; A retrospective study was conducted on patients diagnosed with HA-CDI during the COVID-19 year (2020) and compared with patients of the pre-COVID-19 year (2019) from March to October. A comparison of baseline characteristics, risk factors and patient hospitalization were compared.&#x0D; Results:&#x0D; During the study period, a total of 148 cases were diagnosed with HA-CDI of which 75 cases were in the pre-COVID-19 and 73 cases in COVID-19 year accounting for a total of 149,092 and 136,982 inpatient bed days respectively. The rate of HA-CDI was 5.03 vs 5.33 per 10,000 hospitalized patients in the pre-COVID-19 year vs COVID-19 year. No significant differences in baseline demographic characteristics, (age, sex, race and BMI); comorbidities (diabetes and hypertension) and risk factors like cancer and steroid use were observed between the two groups. Factors associated with CDI like antibiotic use (p=0.001) and proton pump inhibitor use (p= 0.005) was significantly lower in COVID-19 year. However, there was a significantly high number of patients that had undergone gastrointestinal (GI) surgery (22.6% vs 6.6%, p=0.01) during COVID-19 year. Almost half of the patients in each group stayed in the intensive care unit (ICU) and the mean length of ICU stay was significantly higher in COVID-19 year (20.4± 34.3 days vs 11.6± 16.9 days, p= 0.03). The mortality rate was higher (20.5% vs 12%, p= 0.23) during COVID-19 period. A sub-analysis was done with 2020 data to identify if there lies any contributing factors to the increase CDI rate. 21 cases were positive for COVID-19, of which 28.5% underwent GI surgery; 19% received steroids (Dexamethasone), 76.1% stayed in ICU with median LOS (16± 20.2) and 52.3% died.&#x0D; Conclusions:&#x0D; Based on our observations, a slightly higher rate of symptomatic HA-CDI was observed during COVID-19 year when compared with pre-COVID-19 year. Implementation of measures to prevent the spread of COVID-19 e.g., use of PPE, handwashing, environmental cleaning, visitor restriction etc. were expected to help decrease HA-CDI, which was not observed in our study. We did observe longer ICU stay and higher rate of GI surgery among patients who had HA-CDI in 2020. Higher acuity patients and increased rate of these risk factors amongst patients admitted in year 2020 might have offset the expected benefit of COVID-19 prevention strategies.