Long-term Acute Care Facility Research Articles

Clinical epidemiology of carbapenem-resistant Enterobacterales in the Greater Houston region of Texas: a 6-year trend and surveillance analysis

ObjectivesCarbapenem-resistant Enterobacterales (CRE) remain an urgent public health priority in the United States. CRE poses a major threat to patients in healthcare and a potential risk to the community. This study examined the epidemiological trends, clinical, and microbiological data of CRE in the Greater Houston region of Texas. MethodsA multi-institutional retrospective observational study was conducted using surveillance data collected from 2015 to 2020. Predictors of incidence rates of CRE were determined by a negative binomial regression fit using a generalized estimation equation. ResultsOver a 6-year period, 4236 CRE cases were reported, of which Klebsiella pneumoniae accounted for 84.8%. The results show a steady increase in CRE cases, with a sharp rise since 2018. The majority of carbapenemase-producing Enterobacterales were Klebsiella pneumoniae carbapenemase (KPC)-producing (77.2%), followed by other rare carbapenemases, which includes OXA-48, NDM, IMP, VIM, coproduction of KPC with OXA-48, KPC with NDM, and NDM with OXA-48. Acute care hospitals (ACH) accounted for 68.5% of the source of CRE cases. The incidence rate of CRE cases reported from ACH and long-term acute care (LTAC) facilities was 1.16 times that of long-term care facilities (adjusted rate ratio [ARR] = 1.16, 95% confidence interval [CI]:1.04–1.30). The incidence rate of CRE among patients with indwelling devices was 15% (ARR = 0.85, 95% CI: 0.79–0.92) lower than that of patients without indwelling devices. ConclusionThe rise in the rate of CRE cases despite aggressive infection prevention and control strategies in the region is alarming. Evaluating and improving the current infection control strategies may be warranted.

Initiation of a Candida Auris Screening Program at a Large, Academic Medical Center

Background Candida auris is an emerging, multi-drug resistant, fungal pathogen known to cause facility-wide outbreaks, significant mortality, and is environmentally persistent. Rapid identification and isolation of this fungus prevents it from becoming normal flora in the local community. Methods The screening program began on January 25, 2021, at a large, urban, academic medical center. All patients transferred from high-risk facilities (long term acute care (LTAC), acute care, skilled nursing facilities, and nursing homes) from local counties, were screened for Candida auris. Initial screenings were tested via culture. On March 8, 2021, we began screening with a polymerase chain reaction test, which turned around results within one business day. Collection technique of each screening specimen followed guidance from the Centers for Disease Control and Prevention. Patients were placed on contact isolation until results finalized negative. Education was provided to both the healthcare worker and the patient. Partners within Information Technology were able to automate the screening program so that an alert would fire to the nurse in the Emergency Department or Transfer Center for patients meeting high-risk criteria. Results Screening results between 1/25/21 to 3/7/21 resulted in no positive cultures. Between 3/8/21 – 8/31/21, 195 patients were screened for Candida Auris. Three patients resulted positive, for a rate of 1.5%, over the course of 6 months. All positives had recent history of LTAC residency. These results demonstrated a lack of widespread local community transmission of Candida Auris. Conclusions In collaboration with the state health department, we were able to narrow our screening program to only patients directly transferred from LTAC facilities or resided at LTACs within 60 days, thus reducing the need for isolation, impediments to bed flow, and cost for lab testing, all without sacrificing public health. Candida auris is an emerging, multi-drug resistant, fungal pathogen known to cause facility-wide outbreaks, significant mortality, and is environmentally persistent. Rapid identification and isolation of this fungus prevents it from becoming normal flora in the local community. The screening program began on January 25, 2021, at a large, urban, academic medical center. All patients transferred from high-risk facilities (long term acute care (LTAC), acute care, skilled nursing facilities, and nursing homes) from local counties, were screened for Candida auris. Initial screenings were tested via culture. On March 8, 2021, we began screening with a polymerase chain reaction test, which turned around results within one business day. Collection technique of each screening specimen followed guidance from the Centers for Disease Control and Prevention. Patients were placed on contact isolation until results finalized negative. Education was provided to both the healthcare worker and the patient. Partners within Information Technology were able to automate the screening program so that an alert would fire to the nurse in the Emergency Department or Transfer Center for patients meeting high-risk criteria. Screening results between 1/25/21 to 3/7/21 resulted in no positive cultures. Between 3/8/21 – 8/31/21, 195 patients were screened for Candida Auris. Three patients resulted positive, for a rate of 1.5%, over the course of 6 months. All positives had recent history of LTAC residency. These results demonstrated a lack of widespread local community transmission of Candida Auris. In collaboration with the state health department, we were able to narrow our screening program to only patients directly transferred from LTAC facilities or resided at LTACs within 60 days, thus reducing the need for isolation, impediments to bed flow, and cost for lab testing, all without sacrificing public health.

110 Does Discharge to a Post-acute Facility Predispose Burn Patients to a Deterioration of Their Wounds?

IntroductionThe care of burn injuries requiring hospitalization is complex and highly specialized. In-hospital treatment results in discharging patients with stabilized, but unhealed wounds with the need for ongoing care. The expectation is that wounds continue to heal without complication. For patient who are unable to be discharged home, disposition is frequently dictated by finance and payor source. Post-acute facilities such as Skilled Nursing facilities (SNF), Acute Rehabilitation Centers (ARC) and Long-term Acute Care facilities (LTAC) are utilized. The purpose of this study was to evaluate the wound healing in patients being sent to SNF and ARC.MethodsA retrospective chart review of patients discharged to a SNF or ARC over a one-year period was performed. Photographic review was done comparing photos from the first clinic visit to those from hospital discharge. Wounds were designated as “Improved” (IM) or “Worsened/No Change” (W/NC) by a single burn surgeon.ResultsOf the 963 charts reviewed, 719 patients suffered burn injuries, and of these 127 were discharged to post-acute facilities, 54 were either discharged to a LTAC or did not have photos available for review at their first clinic visit. Thus 73 were evaluable. The majority, 51% (n=37) worsened or showed no change (W/NC) and 49% (n=36) improved (IM). All patients returned to clinic within the first 2 weeks of discharge. There were no significance differences for age, gender, BMI, comorbidities, substance abuse, living situation, ICU days, ventilator days, length of stay, number of surgeries, payor source or facility type (SNF vs ARC). Mean TBSA was greater in IM 13.99% vs W/NC 8.31% (p=0.018). There were no significant differences between groups for mechanism, although IM was more likely to have suffered a flame/flash injury (n=20) and W/NC contact burns (n=21). A total of 30 different facilities were utilized for discharge.ConclusionsDespite having smaller burn injuries, the majority of patients worsened if discharged to a post-acute facility. No patient factors were identified that were associated with worsening/no change in wound status at the first clinic visit post discharge. Given the number of discharge facilities utilized, we were unable to analyze the relationship between specific facilities and outcomes. The magnitude of the problem warrants further investigation. A Quality Improvement project is being developed to further identify areas for intervention.

5 Admission Frailty Is Associated with Acute Respiratory Failure and Mortality in Burn Patients > 50

IntroductionPre-injury frailty has been shown to predict mortality of older burn patients. Herein, we assessed the utility of the Canadian Study of Health and Aging Clinical Frailty Scale (CSHA-CFS) to predict burn-specific outcomes. We hypothesize that frail patients are at greater risk for complications such as graft loss, acute respiratory failure, and acute kidney injury and will require increased healthcare support at discharge.MethodsThis is a retrospective cohort study. Patients 50 years and older admitted to our Institution for burn injuries between July 2009 and June 2019 were included. Patients with inhalation injury only, no data on total burn surface area, or for whom medical history was incomplete were excluded. Demographics; comorbidities; pre-injury functional status; admission, injury, and hospitalization information; complications (graft loss, acute respiratory failure, and acute kidney disease (AKI)); mortality, and discharge disposition were collected. Patients were scored on the CSHA-CFS based on pre-admission health and functional status. The frail and non-frail groups were compared. Multivariate analyses were performed to assess the association between admission frailty and outcomes. P < 0.05 was considered significant.ResultsWe included 851 patients, 697 were not frail and 154 were frail. Frail patients were significantly older (66.1 ± 10.8 vs. 63.5 ± 10.9, p = 0.002), more likely Caucasian (98.1% vs. 91%, p = 0.027) and to have suffered flame burn injuries (68.8% vs. 59.8%, p < 0.001). Frail patients had a lower %TBSA (4.4 ± 8.1% vs. 10.1 ± 13.1, p < 0.001) but were more likely to stay longer in hospital relative to %TBSA (3.6 ± 6.7 vs. 1.9 ± 3.1, p < 0.001). Frail patients were less likely to have had skin graft procedures (27.3% vs. 57.4, p < 0.001). On multivariate analysis, controlling for age, sex, race, mechanism of injury, %TBSA, 2nd degree and 3rd degree burn surface, inhalation injury, frailty was associated with acute respiratory failure (OR = 2.599 [1.460-4.628], p = 0.001). Frailty was also associated with mortality (OR = 6.915 [2.455-19.980]; p < 0.001) when controlling for the same variables as well as acute respiratory failure and AKI. Frailty was also associated with discharge to home with healthcare services (OR = 2.678 [1.491-4.809], p = 0.001), to SNF, rehabilitation, or long-term acute care facilities (OR = 3.572 [1.933-6.602], p < 0.001), and to hospice (OR = 5.759 [1.519-21.827], p = 0.010) when compared to home without healthcare services.ConclusionsFrailty is associated with increased risk of acute respiratory failure, mortality, and requiring increased healthcare support post-discharge. Our data suggest frailty as a tool to predict morbidity and mortality as well as for goals of care discussions for the burn patient.

Phenazopyridine-Induced Methaemoglobinaemia The Aftermath of Dysuria Treatment.

IntroductionPhenazopyridine is an over-the-counter urinary analgesic commonly used to alleviate the burning and urgency associated with lower urinary tract infections. Methaemoglobinaemia is an uncommon adverse effect of phenazopyridine use. We report a case of methaemoglobinaemia in a patient prescribed daily phenazopyridine to treat urethral and bladder irritation caused by a chronic indwelling Foley catheter.Case descriptionA 55-year-old female resident of a long-term acute care facility with a chronic Foley, tracheostomy and ventilator-dependent respiratory failure was observed to have generalized dusky skin and hypoxia. Pulse oximetry was reading in the high 80s despite administration of 100% FiO2. ABG revealed paO2 of 451, oxyhaemoglobin level 75% and methaemoglobin level 22%. Medication review indicated that the patient was prescribed phenazopyridine 400 mg TID for the previous 2 months. This medication was discontinued. Considering she was chronically taking mirtazapine, she can increase risk of serotonin syndrome should she be administered first-line treatment with methylene blue. Vitamin C was thus instead administered as a second-line agent. Serial ABGs showed a rapid decline in methaemoglobin levels and an increase in oxyhaemoglobin within 2 days.DiscussionAcquired methaemoglobinaemia is a rare adverse effect of treatment with phenazopyridine. This risk increases when drug dosage and duration exceed manufacturer specifications. Treatment typically includes cessation of the offending drug and administration of methylene blue in severe cases. A thorough medication reconciliation should be performed prior to methylene blue initiation, as patients taking serotonergic medications (for example, MAOIs, SSRIs, SNRIs, TCAs) are at increased risk of serotonin toxicity with co-administration of methylene blue. In these instances, ascorbic acid/vitamin C can be chosen as an alternative treatment agent.ConclusionWork-up of refractory hypoxia should involve a thorough review of medications as even some over-the-counter drugs can cause the fatal side effect of methaemoglobinaemia. Treatment with vitamin C should be considered over methylene blue if serotonergic medications have been recently prescribed in order to avoid risk of serotonin syndrome.LEARNING POINTSMethaemoglobinaemia is an uncommon, life-threatening adverse effect of phenazopyridine use. Presentation depends on the severity of the disorder, ranging from headache, weakness, lightheadedness and dyspnoea, to arrhythmias, confusion, seizures and multiorgan failure.Workup of refractory hypoxia should involve a comprehensive medication review as even some over-the-counter drugs can cause methaemoglobinaemia.Management of methaemoglobinaemia involves cessation of the offending drug, administration of supplemental oxygen and treatment with methylene blue (1–2 mg/kg) if MetHb >30%, or for symptomatic patients with MetHb >20%. Vitamin C can be used as an alternative agent if there is a contraindication to methylene blue (for example, with patients simultaneously receiving serotonergic medications and/or those with G6PD deficiency).

Risk-Adjusted, 30-Day Home Time After Transcatheter Aortic Valve Replacement as a Hospital-Level Performance Metric

BackgroundPatient-centric measures of hospital performance for transcatheter aortic valve replacement (TAVR) are needed. ObjectivesThis study evaluated 30-day, risk-adjusted home time as a hospital performance metric for patients who underwent TAVR. MethodsThis study identified 160,792 Medicare beneficiaries who underwent elective TAVR from 2015 to 2019. Home time was calculated for each patient as the number of days alive and spent outside the hospital, skilled nursing facility (SNF), and long-term acute care facility for 30 days after the TAVR procedure date. Correlations between risk-adjusted, 30-day home time and other metrics (30-day, risk-adjusted readmission rate [RSRR], 30-day, risk-adjusted mortality rate [RSMR], and annual TAVR volume) were estimated using Pearson’s correlation. Meaningful upward or downward reclassification (≥2 quartile ranks) in hospital performance based on quartiles of risk-adjusted, 30-day home time compared with quartiles of other measures were assessed. ResultsMedian risk-adjusted, 30-day home time was 27.4 days (interquartile range [IQR]: 26.3-28.5 days). The largest proportion of days lost from 30-day home time was hospital stay after TAVR and SNF stay. An inverse correlation was observed between hospital-level, risk-adjusted, 30-day home time and 30-day RSRR (r = −0.465; P < 0.001) and 30-day RSMR (r = −0.3996; P < 0.001). The use of the 30-day, risk-adjusted home time was associated with reclassification in hospital performance rank hospitals compared with other metrics (9.1% up-classified, 11.2% down-classified vs RSRR; 9.1% up-classified, 10.3% down-classified vs RSMR; and 20.1% up-classified, 19.3% down-classified vs annual TAVR volume). ConclusionsRisk-adjusted, 30-day home time represents a novel patient-centered performance metric for TAVR hospitals that may provide a complimentary assessment to currently used metrics.

Rate of Infarct–Edema Growth on CT Predicts Need for Surgical Intervention and Clinical Outcome in Patients with Cerebellar Infarction

BackgroundUp to 20% of patients with cerebellar infarcts will develop malignant edema and deteriorate clinically. Radiologic measures, such as initial infarct size, aid in identifying individuals at risk. Studies of anterior circulation stroke suggest that mapping early edema formation improves the ability to predict deterioration; however, the kinetics of edema in the posterior fossa have not been well characterized. We hypothesized that faster edema growth within the first hours after acute cerebellar stroke would be an indicator for individuals requiring surgical intervention and those with worse neurological outcomes.MethodsConsecutive patients admitted to the neurological intensive care unit with acute cerebellar infarction were retrospectively identified. Hypodense regions of infarct and associated edema, “infarct–edema”, were delineated by using ABC/2 for all computed tomography (CT) scans up to 14 days from last known well. To examine how rate of infarct–edema growth varied across clinical variables and surgical intervention status, nonlinear and linear mixed-effect models were performed over 2 weeks and 2 days, respectively. In patients with at least two CT scans, multivariable logistic regression examined clinical and radiological predictors of surgical intervention (defined as extraventricular drainage and/or posterior fossa decompression) and poor clinical outcome (discharge to skilled nursing facility, long-term acute care facility, hospice, or morgue).ResultsOf 150 patients with acute cerebellar infarction, 38 (25%) received surgical intervention and 45 (30%) had poor clinical outcome. Age, admission National Institutes of Health Stroke Scale (NIHSS) score, and baseline infarct–edema volume did not differ, but bilateral/multiple vascular territory involvement was more frequent (87% vs. 50%, p < 0.001) in the surgical group than that in the medical intervention group. On 410 serial CTs, infarct–edema volume progressed rapidly over the first 2 days, followed by a subsequent plateau. Of 112 patients who presented within two days, infarct–edema growth rate was greater in the surgical group (20.1 ml/day vs. 8.01 ml/day, p = 0.002). Of 67 patients with at least two scans, after adjusting for baseline infarct–edema volume, vascular territory, and NIHSS, infarct–edema growth rate over the first 2 days (odds ratio 2.55; 95% confidence interval 1.40–4.65) was an independent, and the strongest, predictor of surgical intervention. Further, early infarct–edema growth rate predicted poor clinical outcome (odds ratio 2.20; 95% confidence interval 1.30–3.71), independent of baseline infarct–edema volume, brainstem infarct, and NIHSS.ConclusionsEarly infarct–edema growth rate, measured via ABC/2, is a promising biomarker for identifying the need for surgical intervention in patients with acute cerebellar infarction. Additionally, it may be used to facilitate discussions regarding patient prognosis.

40. Impact of an Antimicrobial Intake Process within a Post-acute Medical System

BackgroundImplementation of antimicrobial stewardship programs (ASPs) within long-term acute care facilities (LTACs) is challenging due to limited resources and missing patient data from transferring facilities. In October 2018, an ASP was established within a 43-hopital system consisting of LTACs and rehabilitation hospitals. Despite the presence of a restricted antimicrobial policy, increased utilization was observed for five restricted antimicrobials. The system ASP committee implemented a multipronged approach to optimize utilization of these five agents. Investigators sought to assess the impact of an antimicrobial intake process on antimicrobial consumption.MethodsThis was a retrospective analysis within a 43-hospital system of LTACs and rehabilitation hospitals, comparing use of five restricted antibiotics before (Jul19-Jun20) and after (Jul20-Apr21) implementation of a data-collection and system review process. An antibiotic intake form and process for review for five restricted antibiotics (ceftaroline, ceftazidime/avibactam, ceftolozane/tazobactam, fidaxomicin, meropenem/vaborbactam) was approved at the system ASP committee. The intake form consisted of a restricted antibiotic form, cultures and susceptibilities, physician notes, and other pertinent data. Any orders for the five antibiotics required completion of an intake form and submission to system ASP members for review and recommendations. Antibiotic consumption was measured in cost per acute patient day (cost/pd) using a 2-sided t-test.ResultsPost-implementation, the five restricted antibiotics comprised 29.1% of the total antibiotic expenditure for the healthcare system compared to 35.6% pre-implementation. Ten months after program implementation, the total antibiotic cost/PD decreased 29.45% [(&12.02 ± 2.29) vs. (&8.48 ± 1.45); p=0.0003]. The cost/PD of the five restricted antibiotics decreased 42.52% [(&4.28 ± 1.09) vs. (&2.46 ± 0.99) ; p=0.0005].ConclusionImplementation of an antimicrobial intake process within a post-acute medical system resulted in a significant reduction in antibiotic consumption for five targeted antibiotics as well as overall antibiotic expenditure.Disclosures All Authors: No reported disclosures

1261. Antimicrobial Susceptibilities of Carbapenem-Resistant Klebsiella pneumoniae (CRKP) Isolates from a Multi-state Network of Long-term Acute Care Hospitals (LTACHs)

Abstract Background CRKP infection is common among LTACH patients. However, CRKP antimicrobial susceptibility testing (AST) with newer antibiotics has not been described in this population. In this study, we performed AST on CRKP in LTACHs. Methods CRKP clinical cultures were collected from 21 Kindred Healthcare LTACHs (12 southern California, 6 Texas, 2 Florida, 1 Kentucky) from 8/1/14-7/25/15. AST was performed using a custom SensititreTM broth microdilution panel (ThermoFisher Scientific, Waltham, MA). 2021 Clinical &amp; Laboratory Standards Institute interpretive criteria were used for all agents except plazomicin (PLZ), for which US Food and Drug Administration breakpoints were used. Results 459 CRKP clinical isolates were collected, including 254 (55.5%) respiratory, 155 (33.8%) urine, 39 (8.5%) blood, and 10 (2.2%) wound cultures. Most (419, 91.0%) were from southern California. 151 (32.9%) were colistin-resistant. 42 (9.2%) isolates were non-susceptible to meropenem-vaborbactam (MVB), 16 (8.9%) to imipenem-relebactam (IPR), 4 (0.9%) to ceftazidime-avibactam (CZA), and 3 (0.7%) to PLZ. Cross-resistance patterns are shown in Table 1. Among southern California facilities, there was significant inter-facility variation in MVB non-susceptibility (Pearson’s chi-squared test, p=0.005) but not in CZA, IPR, or PLZ non-susceptibility. Table 1. Cross-resistance to antimicrobials among carbapenem-resistant Klebsiella pneumoniae isolates from 21 Kindred long-term acute care facilities, August 1, 2014 – July 25, 2015 (N=459). Number of isolates and column percentages reported. 2021 Clinical &amp; Laboratory Standards Institute interpretive criteria are used for all agents except for PLZ, for which US Food and Drug Administration breakpoints are used. Abbreviations: CST = colistin. CZA = ceftazidime-avibactam. I = intermediate. IPR = imipenem-relebactam. MIC = minimum inhibitory concentration. MVB = meropenem-vaborbactam. PLZ = plazomicin. R = resistant. S = susceptible. Conclusion In this sample of CRKP isolates from LTACHs in 2014-2015, nearly 10% of isolates were non-susceptible to MVB or IPR, respectively, despite neither agent being commercially available at the time. In contrast, there was a low prevalence of non-susceptibility to CZA, which received initial US Food and Drug Association approval in 2/2015, and PLZ, which was not commercially available during the study period. Cross-resistance between CZA and carbapenem/beta-lactamase combination antibiotics was uncommon. Future studies should evaluate CRKP susceptibilities to new agents in post-marketing cohorts and identify risk factors for resistance. Disclosures Jennifer Han, MD, MSCE, GlaxoSmithKline (Employee, Shareholder) Ebbing Lautenbach, MD, MPH, MSCE, Merck (Other Financial or Material Support, Member of Data and Safety Monitoring Board (DSMB))

Lymphocele after anterior lumbar interbody fusion: a review of 1322 patients.

Anterior lumbar interbody fusion (ALIF) is an effective surgical modality for many lumbar degenerative pathologies, but a rare and infrequently reported complication is postoperative lymphocele. The goals of the present study were to review a large consecutive series of patients who underwent ALIF at a high-volume institution, estimate the rate of lymphocele occurrence after ALIF, and investigate the outcomes of patients who developed lymphocele after ALIF. A retrospective review of the electronic medical record was completed, identifying all patients (≥ 18 years old) who underwent at a minimum a single-level ALIF from 2012 through 2019. Postoperative spinal and abdominal images, as well as radiologist reports, were reviewed for mention of lymphocele. Clinical data were collected and reported. A total of 1322 patients underwent a minimum 1-level ALIF. Of these patients, 937 (70.9%) had either postoperative abdominal or lumbar spine images, and the resulting lymphocele incidence was 2.1% (20/937 patients). The mean ± SD age was 67 ± 10.9 years, and the male/female ratio was 1:1. Patients with lymphocele were significantly older than those without lymphocele (66.9 vs 58.9 years, p = 0.006). In addition, patients with lymphocele had a greater number of mean levels fused (2.5 vs 1.8, p < 0.001) and were more likely to have undergone ALIF at L2-4 (95.0% vs 66.4%, p = 0.007) than patients without lymphocele. On subsequent multivariate analysis, age (OR 1.07, 95% CI 1.01-1.12, p = 0.013), BMI (OR 1.10, 95% CI 1.01-1.18, p = 0.021), and number of levels fused (OR 1.82, 95% CI 1.05-3.14, p = 0.032) were independent prognosticators of postoperative lymphocele development. Patients with symptomatic lymphocele were successfully treated with either interventional radiology (IR) drainage and/or sclerosis therapy and achieved radiographic resolution. The mean ± SD length of hospital stay was 9.1 ± 5.2 days. Ten patients (50%) were postoperatively discharged to a rehabilitation center: 8 patients (40%) were discharged to home, 1 (5%) to a skilled nursing facility, and 1 (5%) to a long-term acute care facility. After ALIF, 2.1% of patients were diagnosed with radiographically identified postoperative lymphocele and had risk factors such as increased age, BMI, and number of levels fused. Most patients presented within 1 month postoperatively, and their clinical presentations included abdominal pain, abdominal distension, and/or wound complications. Of note, 25% of identified lymphoceles were discovered incidentally. Patients with symptomatic lymphocele were successfully treated with either IR drainage and/or sclerosis therapy and achieved radiographic resolution.

The Association between Patient Health Status and Surrogate Decision Maker Post-Traumatic Stress Disorder Symptoms in Chronic Critical Illness.

Rationale: Surrogate decision-makers of patients with chronic critical illness (CCI) are at high risk for symptoms of post-traumatic stress disorder (PTSD). Whether patient health status after hospital discharge is a risk factor for surrogate PTSD symptoms is not known. Objectives: To determine the association between patient health status 90 days after the onset of CCI and surrogate symptoms of PTSD. Methods: We performed a secondary analysis of the data from a multicenter randomized trial of a communication intervention for adult patients with CCI and their surrogate decision-makers. Results: Surrogate PTSD symptoms were measured at 90 days using the Impact of Events Scale-Revised. For patients who were alive at 90 days, location was used as a marker of health status and included the following categories: 1) home (relatively good health and low acuity), 2) acute rehabilitation (moderate care needs and impairments, generally expected to improve), 3) skilled nursing facility (moderate care needs and impairments, generally not expected to improve significantly or quickly), 4) long-term acute care facility (persistently high acute care needs and functional impairment), and 5) readmission to an acute care hospital (suggesting the highest acuity of illness and care needs of the cohort). Patients who died before 90 days were categorized as deceased. In the analyses, 365 surrogates and 256 patients were included. Among patients, 49% were female, and the mean age was 59 years. Among surrogates, 71% were female, and the mean age was 51 years. A directed acyclic graph was constructed to identify covariates to be included in the model. Compared with symptoms seen among surrogates of patients living at home, heightened PTSD symptoms were seen among surrogates of patients who were readmitted to an acute care hospital (β coefficient, 15.9; 95% confidence interval [CI], 4.5 to 27.3) or had died (β coefficient, 14.8; 95% CI, 8.8 to 20.9) at 90 days. Conclusions: Surrogates of patients with CCI who have died or have been readmitted to an acute care hospital at 90 days experience increased PTSD symptoms as compared with surrogates of patients who are living at home. These patients and surrogates represent a readily identifiable group who may benefit from enhanced emotional support.

Paradoxical and Retrograde Air Embolism from Pressurized Peripheral Bolus

Introduction Cerebral air embolism is a rare, yet serious neurological occurrence with unclear incidence and prevalence. Here, we present a case of fatal cerebral arterial and venous cerebral gas embolism in a patient with infective endocarditis and known large right-to-left shunt and severe tricuspid regurgitation following pressurized fluid bolus administration. Case Presentation. A 32-year-old female was admitted to the medical intensive care unit from a long-term acute care facility with acute on chronic respiratory failure. Her medical history was significant for intravenous heroin and cocaine abuse, methicillin-sensitive Staphylococcus aureus tricuspid valve infective endocarditis on vancomycin, patent foramen ovale, septic pulmonary embolism with cavitation, tracheostomy with chronic ventilator dependence, multifocal cerebral infarction, hepatitis C, nephrolithiasis, anxiety, and depression. After intravenous fluid administration, she became unresponsive with roving gaze, sluggish pupils, and hypotensive requiring vasopressors. CT of the brain showed diffuse arterial and venous cerebral air embolism secondary to accidental air administration from fluid bolus. Magnetic resonance imaging of the brain showed diffuse global anoxic injury and flattening of the globe at the optic nerve insertion. Given poor prognosis, her family chose comfort measures and she died. Conclusions Fatal cerebral air embolism can occur through peripheral intravenous routes when the lines are inadequately primed and fluids administered with pressure. Caution must be exercised in patients with right-to-left shunting as air may gain access to systemic circulation.

SUCCESSFUL USE OF EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO) IN MORBIDLY OBESE PATIENTS

TOPIC: Critical Care TYPE: Original Investigations PURPOSE: In 2020, ELSO published guidelines to assist providers with patient selection for ECMO in COVID ARDS. A BMI > 40 was listed as a relative contraindication for ECMO support without any supporting data in this specific patient population. Two major reports on ECMO patients from France and the ELSO database that included a total of 1118 patients with COVID ARDS, all with BMIs of 40 to be ECMO candidates. We aim to demonstrate the outcomes and feasibility of using ECMO in ARDS patients with extreme obesity METHODS: Data was collected from the ELSO database outlining outcomes of patients cannulated at Advent Health-Orlando for ECMO due to COVID ARDS between March 2020 – April 2021. The data included only patients with a BMI > 40. Data collected included age, length of stay, survival, discharge disposition, and expiration RESULTS: We have cannulated a total of 33 morbidly obese patients (BMI >40). 19/33 (57%) have survived and transitioned to either home, long-term acute care facility, rehab, or original referring hospital. 11/33 (33%) expired while on ECMO, 1/33 (3%) expired post-ECMO, resulting in an overall mortality of (12/33) 36%. The average LOS for all patients was 39.9 days. The survival group had an average LOS of 46.1 days. The average age for our cohort was 41 years CONCLUSIONS: It is our experience at Advent Health Orlando, that providing ECMO support to patients with BMI >40 has similar outcomes to patients who are not morbidly obese, our 59% survival rate compares to 60% in the ELSO historical database. Our 36% mortality rate compared to a range of 31-37% reported in the recent literature for COVID ARDS. Based on our results, we suggest that BMI > 40 be removed as a relative contraindication to ECMO. We also urge other centers to re-consider denying morbidly obese patients ECMO support based on the assumption that they may have a worse outcome than the rest of the population CLINICAL IMPLICATIONS: Based on our data, we demonstrate patients with COVID-19 ARDS with BMI > 40 benefited from ECMO support. In order to effectively ventilate morbidly obese patients, higher plateau pressures are required and may result in barotrauma and hemodynamic compromise. Supporting obese patients with ECMO to maintain protective lung settings can ultimately lead to better long-term outcomes. More data is needed to fully assess the survivability and overall quality of life in morbidly obese patients who are placed on ECMO, however, while this information is collected, we hope that the medical community will start offering the same opportunities to all patients regardless of weight DISCLOSURES: No relevant relationships by Nicholas Cavarocchi, source=Web Response No relevant relationships by Sergio Ramirez, source=Web Response No relevant relationships by Mai Vo, source=Web Response

ACTIVE TB AFTER THE USE OF TOCILIZUMAB FOR COVID-19 INFECTION

TOPIC: Chest Infections TYPE: Fellow Case Reports INTRODUCTION: Tocilizumab is a humanized anti-IL-6 receptor antibody and inhibits the binding of IL-6 to its receptors, associated with Th17 and Th22 cell differentiation which is critical for anti-mycobacterial activity. It is commonly used in patients with active rheumatoid arthritis. During the COVID-19 pandemic, tocilizumab has been widely used in severe COVID-19 infection with elevated markers of systemic inflammation. We report a case of active tuberculosis after the use of tocilizumab for COVID-19 pneumonia. CASE PRESENTATION: An 80-year-old Asian female with hypertension, coronary artery disease presented to the emergency department(ED) due to a one-day duration of fever, cough, and altered mental status. About three months prior to presentation, she had COVID-19 pneumonia requiring prolong hospitalization which was complicated by acute respiratory distress syndrome. She received tocilizumab, remdesivir, steroids and hydroxychloroquine for COVID-19 infection. Following the hospital stay, she was discharged to a long-term acute care facility, and then went home. She is originally from China and moved to the United States 50 years ago. In the ED she was febrile (100.4°F) and hypoxemic, subsequently placed on 4L of nasal cannula. The laboratory data was remarkable for leukocytosis and lactic acidosis. The chest radiograph showed bilateral reticular nodular patchy opacities. The patient was admitted and empiric antibiotics were started for possible pneumonia. Despite this treatment, her respiratory status deteriorated and she was intubated on day 4, with CT chest (figure1) revealing innumerable bilateral micronodules with centrilobular distribution and tree-in-bud opacities. There were also 2 large cavitary lesions in the right upper lobe. The sputum specimen was sent, which returned positive for Acid-Fast Bacillus. In addition, Mycobacterium tuberculosis PCR on sputum was positive. Therefore, the first-line anti-tuberculosis agents including rifampin, isoniazid, pyrazinamide, and ethambutol were started. The Mycobacterium tuberculosis Complex was isolated on sputum 3 weeks later. DISCUSSION: The data from clinical trials indicate that the use of tocilizumab is associated with a very low or absent risk of tuberculosis reactivation. However, this case highlights the judicious use of tocilizumab in patients who are at high risk of exposure or reactivation such as immigrants from endemic regions, IV drug users and health care workers, etc. In our case, the patient had other factors including severe COVID-18 infection, use of steroids, prolonged hospital stay, and malnutrition which might compromise the immune system, and predispose to active tuberculosis. CONCLUSIONS: We suggest that tests be performed to rule out latent tuberculosis in selected patients prior to tocilizumab use and monitor all patients for active tuberculosis during treatment. REFERENCE #1: Scriba TJ, Kalsdorf B, Abrahams DA, Isaacs F, Hofmeister J, Black G, et al. Distinct, specific IL-17- and IL-22-producing CD4+ T cell subsets contribute to the human anti-mycobacterial immune response. J Immunol. 2008;180(3):1962-70. REFERENCE #2: Cantini F, Nannini C, Niccoli L, Petrone L, Ippolito G, Goletti D. Risk of Tuberculosis Reactivation in Patients with Rheumatoid Arthritis, Ankylosing Spondylitis, and Psoriatic Arthritis Receiving Non-Anti-TNF-Targeted Biologics. Mediators Inflamm. 2017;2017:8909834. REFERENCE #3: Koike T, Harigai M, Inokuma S, Ishiguro N, Ryu J, Takeuchi T, et al. Postmarketing surveillance of tocilizumab for rheumatoid arthritis in Japan: interim analysis of 3881 patients. Ann Rheum Dis. 2011;70(12):2148-51. DISCLOSURES: No relevant relationships by Goutham Dronavalli, source=Web Response No relevant relationships by Sungryong Noh, source=Web Response

Ventilator Weaning Outcomes in SARs-CoV-2 (+) Individuals in the LTACH Setting-A Retrospective Cohort Study

Research ObjectivesTo examine weaning outcomes of patients with a history of COVID-19 on prolonged mechanical ventilation (PMV) in the LTACH setting.DesignRetrospective cohort.SettingA long-term acute care facility.ParticipantsParticipants (N=25; mean±sd age, 58±13.2 yr) mostly consisted of overweight diabetic men with diaphragmatic dysfunction (DD) and no history of COPD or sleep apnea.InterventionsPulmonary function was determined using spirometry and arterial blood gas measurements. Diaphragmatic dysfunction was assessed using fluoroscopy; neuromuscular function measured via EMG.Main Outcome MeasuresThe primary outcome was weaned status at discharge. Weaning success was defined as MV liberation for over 48 hours at time of discharge. Variables included MIP, MEP, FVC, FEV1/FVC, DD (bilateral/unilateral/none) and PCO2.ResultsMost participants (57.7%) had either unilateral or bilateral diaphragmatic dysfunction. The proportion of participants with ventilator liberation success was 53.8% at time of discharge with a median [IQR] LOS of 41 [33-68] days. The mean (sd) FVC and PCO2 were 0.6 (±0.3)% and 51.4 (±9.7), respectively; the MEP and MIP were 43.9 (±16.7) and -36.5 (±15.9) cmH2O. Univariate logistic regression analyses found a significant association with MIP (OR 95% CI = (0.87-0.99); p-value = 0.0391) on wean status.ConclusionsLiberation from MV has been a challenge in the COVID-19 population with a large number of individuals subjected to PMV. Many studies have sought to examine the parameters for weaning in the ICU setting, but few have discussed weaning strategies in LTACHs. MIP may have the potential to help prognosticate weaning outcomes in the COVID-19 population. Further studies are needed to confirm and identify other parameters associated with successful weaning.Author(s) DisclosuresThe authors have no conflicts of interest.

The Scope and Impact of a Novel, Urban, Rapid Patient Interhospital Transfer System to Improve Neuroemergent Care: The Design and Development of the Neuroemergency Transfer Program

Background: Access to neuroemergent care in the United States represents a significant public health concern, with limited neurosurgery and/ or neurocritical care coverage in both rural and urban settings. Inadequate access to neuroemergent providers, even in urban settings, may result in prolonged patient transfer time, associated neurological decline and translate into increased morbidity and mortality. Methods: A single center retrospective analysis of prospectively collected data of interhospital patient transfers to a neuroscience ICU between 2008-2018 was performed. Results: 9637 patients were included for analysis. A substantial increase in transfer requests were observed, 610 to 1221 from 2008 to 2018 respectively, with concurrent increase in the number and geographic distribution of referral centers. Ultimately, 7726 (80.2%) patients were discharged home or to outpatient or acute rehabilitation while 1820 (18.9%) were discharged to a long-term acute care facility (LTAC), hospice, or expired during the index admission. The leading diagnoses for transfer were: 1. intracerebral hemorrhage, 2. subarachnoid hemorrhage, 3. ischemic stroke, 4. subdural hematoma and 5. brain tumor. Transfer from an ED or ICU constituted 93.3% of requests. Mean total transfer time between 2012-2018 was &lt; 155 minutes annually (range 128-155 minutes). In 2018, 91.5% of patients had health insurance with 68.7% covered by some form of Medicaid or Medicare. Conclusions: The ongoing evolution and overall success of the NTP draws chiefly from the designation of an easily accessible central operator to orchestrate transfer, establishing a network of community referral centers and optimization of regional patient transportation - all with the solitary goal of improving patient outcomes.

Modeling Interventions to Reduce the Spread of Multidrug-Resistant Organisms Between Health Care Facilities in a Region

Multidrug-resistant organisms (MDROs) can spread across health care facilities in a region. Because of limited resources, certain interventions can be implemented in only some facilities; thus, decision-makers need to evaluate which interventions may be best to implement. To identify a group of target facilities and assess which MDRO intervention would be best to implement in the Shared Healthcare Intervention to Eliminate Life-threatening Dissemination of MDROs in Orange County, a large regional public health collaborative in Orange County, California. An agent-based model of health care facilities was developed in 2016 to simulate the spread of methicillin-resistant Staphylococcus aureus (MRSA) and carbapenem-resistant Enterobacteriaceae (CRE) for 10 years starting in 2010 and to simulate the use of various MDRO interventions for 3 years starting in 2017. All health care facilities (23 hospitals, 5 long-term acute care hospitals, and 74 nursing homes) serving adult inpatients in Orange County, California, were included, and 42 target facilities were identified via network analyses. Increasing contact precaution effectiveness, increasing interfacility communication about patients' MDRO status, and performing decolonization using antiseptic bathing soap and a nasal product in a specific group of target facilities. MRSA and CRE prevalence and number of new carriers (ie, transmission events). Compared with continuing infection control measures used in Orange County as of 2017, increasing contact precaution effectiveness from 40% to 64% in 42 target facilities yielded relative reductions of 0.8% (range, 0.5%-1.1%) in MRSA prevalence and 2.4% (range, 0.8%-4.6%) in CRE prevalence in health care facilities countywide after 3 years, averting 761 new MRSA transmission events (95% CI, 756-765 events) and 166 new CRE transmission events (95% CI, 158-174 events). Increasing interfacility communication of patients' MDRO status to 80% in these target facilities produced no changes in the prevalence or transmission of MRDOs. Implementing decolonization procedures (clearance probability: 39% in hospitals, 27% in long-term acute care facilities, and 3% in nursing homes) yielded a relative reduction of 23.7% (range, 23.5%-23.9%) in MRSA prevalence, averting 3515 new transmission events (95% CI, 3509-3521 events). Increasing the effectiveness of antiseptic bathing soap to 48% yielded a relative reduction of 39.9% (range, 38.5%-41.5%) in CRE prevalence, averting 1435 new transmission events (95% CI, 1427-1442 events). The findings of this study highlight the ways in which modeling can inform design of regional interventions and suggested that decolonization would be the best strategy for the Shared Healthcare Intervention to Eliminate Life-threatening Dissemination of MDROs in Orange County.

Antimicrobial Stewardship in Acute-Care Hospitals: A Report of the California Healthcare-Associated Infections Honor Roll

Background: Antimicrobial stewardship has been demonstrated to improve patient outcomes and reduce unwanted consequences, such as antimicrobial resistance and Clostridioides difficile infection. The California Department of Public Health (CDPH) Healthcare-Associated Infection (HAI) Program developed an honor roll to recognize facilities with the goal of promoting antimicrobial stewardship programs and encouraging collaboration and research. Methods: The first open enrollment period in California was from August 1 to September 1, 2020, and was only open to acute-care hospitals (ACHs). Enrollment occurs every 6 months. Applicants completed an application and provided supporting documentation for bronze, silver, or gold designations. The criteria for the bronze designation were at least 1 item from each of CDC’s 7 core elements for ACHs. The criteria for silver were bronze criteria plus 9 HAI program prioritized items (based on published literature) from the CDC Core Elements and demonstration of outcomes from an intervention. The criteria for gold designation were silver criteria plus community engagement (ie, local work or collaboration with healthcare partners). Applications were evaluated in 3 phases: (1) CDPH reviewed core elements and documentation, (2) CDPH and external blinded antimicrobial stewardship experts reviewed outcomes as scientific abstracts, and (3) CDPH reviewed each program for overall effectiveness in antimicrobial stewardship and final designation determination. Designations expire after 2 years. Results: In total, 119 applications were submitted (30% of all ACHs in California), of which 100 were complete and thus were included for review. Moverover, 33 facilities were from northern California and 67 were from southern California. Also, 85 facilities were part of a health system or network, 14 were freestanding, and 1 was a district facility. Facility types included 68 community hospitals, 17 long-term acute-care (LTAC) facilities, 17 academic or teaching hospitals, 4 critical-access hospitals, and 4 pediatric hospitals. There was an even distribution of hospital bed size: 35 facilities had &lt;250 beds. The final designations included 19 gold, 35 silver and 43 bronze designations. There was 44% incongruency in applicants not receiving the designation for which they applied. Community hospitals were 63%–74% of all designations, and no LTACs received a gold designation. Moreover, 63% of hospitals with gold designations had &gt;250 beds, and 47% of hospitals with bronze designations had &lt;1 25 beds. Conclusions: The number of applicants was higher than expected because the open enrollment period occurred during the COVID-19 pandemic. This finding demonstrates the high importance placed on antimicrobial stewardship among ACHs. It also provides insight into how facilities are performing and collaborating and how CDPH can support facilities to improve their ASP.Funding: NoDisclosures: None

Incorporating Early Palliative Medicine Consultation Into Daily Morning Huddle in the ICU.

OBJECTIVES:Early palliative medicine consult in the ICU can significantly improve outcomes in high-risk patients. We describe a pilot study of including a recommendation for palliative medicine consult in the ICU morning huddle.DESIGN:A prospective, observational, quality improvement study.PATIENTS AND SETTING:Adult patients (age above 18 yr) admitted with cardiac arrest, stage IV cancer, admission from a long-term acute care facility, and circulatory shock on mechanical ventilation to the medical ICU.INTERVENTIONS:We aim to assess the effect of an early palliative medicine consultation in selected high-risk patients on change in code status, referral to hospice, tracheostomy, and or percutaneous gastrostomy tube placement.MEASUREMENTS AND MAIN RESULTS:There were 83 patients who triggered an early palliative medicine consult. Palliative medicine consultation occurred in 44 patients (53%); 23 patients (28%) had a palliative medicine consult within the first 48 hours, 21 (25%) had a palliative medicine consult afterwards. There was a significantly higher number of patients who de-escalated their code status in the palliative medicine consult group compared with the no palliative medicine consult group (63.6% vs 7.7%); however, the number was higher in the late palliative medicine consult group (71.4% vs 56.5%). There were more patients referred to hospice in the palliative medicine consult group. No difference in length of stay was observed.CONCLUSIONS:Early palliative medicine consultation in the daily ICU morning huddle is achievable, can produce a palliative medicine consultation in most cases, and results in a significant change in code status toward less aggressive measures.

Characteristics, Comorbidities, Complications, and Outcomes Among 802 Patients With Severe Acute Respiratory Syndrome Coronavirus 2 in a Community Hospital in Florida.

Coronavirus disease 2019 continues to increase throughout the United States. Despite the rapid progression of the disease, there is limited information of the factors associated with mortality in Florida. This study aims to review the demographics, characteristics, comorbidities, complications, and outcomes of hospitalized patients, and their association with mortality. Cohort study. A community-based tertiary-care hospital of Orlando Health, Orlando Regional Medical Center. Data of hospitalized patients who tested positive for severe acute respiratory syndrome coronavirus 2 between March 1, 2020, and August 31, 2020, at the Orlando Regional Medical Center. None. Main data assessed included patient demographics, clinical characteristics, comorbidities, complications, outcomes, and inhospital mortality. The median age for hospitalized patients was 61 years; among them, 56% were males. Most were of African American (n = 288, 35.9%), Hispanic (n = 237, 29.6%), and Caucasian (n = 217, 27.1%) descent. More patients presented with symptoms developing at home (n = 589, 75.9%) than from skilled nursing and long-term acute care facilities. The most common comorbidities were diabetes mellitus (42.8%), obesity (39.2%), lung disease (23.3%), coronary artery disease (20.2%), and congestive heart failure (18.3%). Complications with higher odds of mortality were mechanical ventilation (odds ratio, 148.00, p < 0.001), coinfections (odds ratio, 56.42, p < 0.001), acute kidney injury (odds ratio, 84.01, p < 0.001), atrial fibrillation (odds ratio, 28.30, p < 0.001), acute myocardial infarction (odds ratio, 23.29, p < 0.001), and acute venous thromboembolism (odds ratio, 26.43, p < 0.001). We identified an increase of severity of coronavirus disease 2019 within older patients of African American and Hispanic descent with comorbidities such as diabetes, coronary artery disease, congestive heart failure, chronic kidney disease, cancer, liver disease, or cerebrovascular disease. Noninvasive positive-pressure ventilation and high-flow nasal cannula oxygen may have helped avert mechanical ventilation, and this may have improved patient outcomes over the course of the study period.