Long-term Acute Care Hospitals Research Articles

169. The Resurgence of Candida auris in California during the Novel Coronavirus (COVID-19) Pandemic, May 2020–May 2021

BackgroundIn February 2019, California (CA) experienced its first C. auris outbreak in Orange County (OC). The CA Department of Public Health (CDPH) and OC with the Centers for Disease Control and Prevention (CDC), mounted a successful containment response; by November 2019, cases were limited to low-level spread in OC long-term acute care hospitals (LTACH).In May 2020, C. auris cases began to surge in OC, followed by extensive spread in six other southern CA local health jurisdictions (LHJ). CDPH with LHJ and CDC, initiated an aggressive, interjurisdictional containment response.MethodsWe carried out response and preventive point prevalence surveys (PPS), onsite infection prevention and control (IPC) assessments, and in-service trainings at outbreak and interconnected hospitals and skilled nursing facilities in six LHJ. Other regional activities included: epidemiologic investigation, contact and discharge tracking and screening; increasing laboratory testing capacity; screening patients admitted to and from LTACH; statewide healthcare facility (HCF) education and outreach; sending regional outbreak HCF lists to all HCF; and biweekly state-LHJ coordination calls. The Antibiotic Resistance (AR) Lab Network supported testing.ResultsFrom May 2020—May 2021, we conducted screening at 226 HCF, and identified 1192 cases at 93 HCF, mostly through screening (n=1109, 93%) and at LTACH (n=906, 76%); we identified 113 (10%) cases at ACH, including 35 (31%) in COVID-19-burdened units. Cases peaked in August 2020 (n=93) and February 2021 (n=191) and have since declined, with C. auris resurgence mirroring COVID-19 incidence.We conducted 98 onsite IPC assessments, and identified multiple, improper IPC practices which had been implemented in response to COVID-19, including double-gloving and -gowning, extended use of gowns and gloves outside patient rooms, and cohorting according to COVID-19 status only.Figure 1. C. auris and COVID-19 Cases in California through May 2021, and C. auris Cases by Local Health Jurisdiction (LHJ) May 2020–May 2021 Table 1. By Facility Type: Colonization Testing May 2020–May 2021, and Total Case Counts before and from May 2020 Table 2. COVID-19-related Infection Control Practices Affecting C. auris Spread, and Associated Public Health Recommendations ConclusionThe C. auris resurgence in CA was likely a result of COVID-19-related practices and conditions. An aggressive, coordinated, interjurisdictional C. auris containment response, including proactive prevention activities at HCF interconnected with outbreak HCF, can help mitigate spread of C. auris and potentially other novel AR pathogens.Disclosures All Authors: No reported disclosures

90. Impact of Infection Control Assessment and Response (ICAR) Visit on Candida auris Colonization Rates at Seven Long Term Acute Care Hospitals (LTACH) in Los Angeles County

Abstract Background Public health authorities often use Infection Control Assessment and Response (ICAR) visits during Candida auris (C. auris) outbreak investigation to identify facility-level infection prevention and control (IPC) practice gaps and make recommendations to address those gaps. As an adjunct to ICAR visit, point prevalence surveys (PPS) provide an objective measure to determine if IPC recommendations are implemented. Because they require significant public health resources to perform, we evaluated the impact of ICAR visits on C. auris colonization rates. Methods PPS were conducted at seven long-term acute-care hospitals (LTACH) with C. auris outbreaks in Los Angeles County from July 2020 to May 2021. Skin swabs collected at PPS were tested for C. auris colonization by PCR technique. Pre-ICAR PPS results were compared with the average of two serial post-ICAR PPS results using repeated measures ANOVA test. Linear regression was used to estimate associations between individual ICAR domains and C. auris colonization. Results 54 PPS were conducted at seven LTACHs with at least one ICAR visit made for every two PPS. On average, PPS were conducted 14 days (range 1-15 days) before and 10 days (range 4-33 days) after an ICAR visit. PPS positive rates with ICAR visit dates for each LTACH are shown in figure 1. Overall, ICAR visits were associated with a significant decrease (p=0.035) in the average of the positive rates in two serial post-ICAR PPS. When individual domain (hand hygiene, contact precautions, and environmental disinfection) of ICAR tool was analyzed, only adherence to environmental disinfection was significantly associated (p=0.038) with decrease in C. auris colonization rates. There was a moderate negative correlation (R2 = 0.26, β= -0.33) between environmental disinfection adherence and the magnitude of decrease in the colonization rates across all LTACHs (Figure 2). Figure 1 Figure 2 Conclusion ICAR visits were found to be significantly associated with a decrease in the average PPS positive rate on serial PPS. Parts of the ICAR tool that assessed environmental disinfection at the facility seemed most correlated with decrease in C. auris colonization rate. Streamlining the ICAR process to focus on the most impactful parts of ICAR tool may be a more efficient intervention to control C. auris outbreaks. Disclosures All Authors: No reported disclosures

Factors predicting futility of liver transplant in elderly recipients: A single-center experience.

BACKGROUNDAs the population of the United States ages, there has been an increasing number of elderly patients with cirrhosis listed for transplant. Previous studies have shown variable results in terms of the relative survival benefit for elderly liver transplant (LT) recipients. There may be factors that are associated with a poor post-transplant outcome which may help determine which elderly patients should and should not be listed for LT.AIMTo identify factors associated with futility of transplant in elderly patients. METHODSThis was a retrospective study of all patients above the age of 45 who underwent liver transplantation at our tertiary care center between January 2010 and March 2020 (n = 1019). “Elderly” was defined as all patients aged 65 years and older. Futile outcome was defined as death within 90 d of transplant. Logistic regression analysis was performed to determine what variables, if any were associated with futile outcome in elderly patients. Secondary outcomes such as one year mortality and discharge to facility (such as skilled nursing facility or long-term acute care hospital) were analyzed in the entire sample, compared across three age groups (45-54, 55-64, and 65 + years). RESULTSThere was a total of 260 elderly patients who received LT in the designated time period. A total of 20 patients met the definition of “futile” outcome. The mean Model of End-Stage Liver Disease scores in the futile and non-futile group were not significantly different (21.78 in the futile group vs 19.66 in the “non-futile” group). Of the variables tested, only congestive heart failure was found to have a statistically significant association with futile outcome in LT recipients over the age of 65 (P = 0.001). Of these patients, all had diastolic heart failure with normal ejection fraction and at least grade I diastolic dysfunction as measured on echocardiogram. Patients aged 65 years and older were more likely to have the outcomes of death within 1 year of LT [hazard ratio: 1.937, confidence interval (CI): 1.24-3.02, P = 0.003] and discharge to facility (odds ratio: 1.94, CI: 1.4-2.8, P < 0.001) compared to patients in younger age groups.CONCLUSIONDiastolic heart failure in the elderly may be a predictor of futility post liver transplant in elderly patients. Elderly LT recipients may have worse outcomes as compared to younger patients.

Impact of admitting diagnosis on survival from in-hospital cardiac arrest

Abstract Background In-hospital cardiac arrest (IHCA) has an incidence of approximately 200,000 adults per year in the United States. Most events occur in patients without known heart disease. The majority of IHCA data is heterogenous from registries, pooled databases, and insurance claims. We sought to examine single-center data from our institution over a 5-year period. Purpose Does the category of admitting diagnosis impact the outcome of IHCA? We hypothesized that patients with cardiac admitting diagnoses would have higher rates of survival to discharge and discharge home due to an increased amount of shockable (ventricular) rhythms. Methods All IHCA events over 5 years were identified, and 1,105 charts were examined. Charts with missing information were excluded. Admitting diagnoses were reviewed and categorized by organ system. If there were multiple categories, the most causative was chosen. If equally causative, the most severe was chosen. Charts were organized by survival and sorted by the organ system of the admitting diagnosis. Categories with &amp;lt;10 patients were excluded from analysis. The primary outcome was survival to discharge. Secondary outcomes were initial rhythm, immediate survival, and discharge disposition. Initial rhythms were classified as asystole, pulseless electrical activity (PEA), and ventricular (ventricular tachycardia and fibrillation). Results Patients with a cardiac category of admitting diagnosis (Table 1) had the highest rate of IHCA (29.68%) while hematologic had the lowest (1.45%). Immediate survival and survival to discharge respectively were highest for transplant patients (85.71%, 32.14%) and lowest for vascular (37.5%, 12.5%). The initial rhythm was predominantly PEA across all groups. Patients with cardiac and pulmonary diagnoses had higher rates of ventricular rhythms than asystole, which was reversed in the other groups. Discharge disposition (Table 2) home was highest for transplant (55.56%), cancer (52%), and cardiac (49.35%). Cardiac patients were nearly as likely to be discharged to an inpatient facility (45.46%). Pulmonary and gastrointestinal patients were most likely to be discharged to a long-term acute care hospital (28.89% and 28.57%, respectively). Neurologic patients were all, and trauma patients were mostly, discharged to inpatient facilities. Conclusion(s) In keeping with established data, cardiac patients were most likely to suffer an IHCA and had more ventricular rhythms than the other groups. However, their initial rhythm was predominantly PEA, they had the third-highest survival to discharge, and were predominantly discharged home. Transplant and trauma patients surprisingly had the highest survival to discharge while gastrointestinal and infectious patients had the lowest. The data presented herein can serve as a guide for clinicians to better predict survival to discharge and disposition for their patients who suffer an IHCA. Funding Acknowledgement Type of funding sources: None.

Inpatient Rehabilitation Outcomes After Severe COVID-19 Infections: A Retrospective Cohort Study.

The aim of the study was to describe the characteristics and functional outcomes of patients undergoing acute inpatient rehabilitation after hospitalization for COVID-19. Using a retrospective chart review, patients were identified who were admitted to inpatient rehabilitation after COVID-19. Patient information collected included sociodemographic characteristics, comorbidities, length of stay, discharge disposition, self-care, mobility, and cognitive functioning. These patients were compared with patients (controls) without COVID-19 with similar impairment codes treated at the same facility before the COVID-19 pandemic. There were 43 patients who were admitted to the inpatient rehabilitation hospital after COVID-19 infection and 247 controls. Patients who had COVID-19 were significantly more likely to be African American and to have been admitted to a long-term acute care hospital. They also had a longer length of rehabilitation stay. The groups did not differ by age, sex, or insurance. Functionally, although presenting with significantly worse mobility, self-care, and motor scores, the patients previously infected with COVID-19 had similar functional outcomes at time of discharge to the control group. Although patients with a history of COVID-19 had worse function at time of admission to acute rehabilitation, inpatient rehabilitation significantly improved their function to comparable levels as patients who did not have COVID-19. Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME. Upon completion of this article, the reader should be able to: (1) Identify how characteristics of patients with COVID-19 admitted to acute rehabilitation differ from those with similar admission codes but without COVID-19; (2) Describe changes in functional measures at admission and discharge of COVID-19 patients compared with patients without COVID-19; and (3) Recognize how inpatient rehabilitation may help reduce inequities in outcomes after severe COVID-19 infection. Advanced. The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

DELAYED DIAGNOSIS OF COCCIDIODES IMMITIS INFECTION WITH PULMONARY ABSCESS AND ARDS DIAGNOSED IN CHICAGO

TOPIC: Chest Infections TYPE: Fellow Case Reports INTRODUCTION: Coccidiodes immitis is a highly pathogenic fungus that is found in western and southern California's desert's regions. It frequently presents as a pneumonia that does not get better after anti-biotic therapy. With less than 5% of immunocompetent patient's progressing to have disseminated or severe infections (1). A disseminated Coccididiodes infection can be treated with liposomal amphotericin B, fluconazole, and steroids when there is Acute Respiratory Distress Syndrome (ARDS) (1,2). CASE PRESENTATION: In this case, a relatively healthy 80-year-old male with a past medical history of gastroesophageal reflux disease, hypertension, and hyperlipidemia who comes in shortness of breath, cough, and congestion. He had completed a course of azithromycin without resolution of symptoms. His initial chest x-ray showed a right upper lobe consolidation (Figure 1a). Bronchoscopy with transbronchial biopsies was performed which showed an acute organizing pneumonia (Figure 2). Despite antibiotic therapy and steroids, the patient did not have significant clinical improvement. So liposomal amphotericin B was started. An open lung biopsy was performed on day 14 as his chest X-ray was significantly worse with significant hypoxia (Figure 1b). Open lung biopsy showed a large abscess. A chest tube was placed. The abscess was irrigated with saline containing antibiotics. Pathology reported numerous coccidiodes spores (Figure 3). Antibiotics were discontinued. The patient's hospital course was complicated by a persistent air leak post lung biopsy and ARDS. Adjunctive steroids were added with improvement of his hypoxia. The patient was transitioned to a lower dose of steroids and to high dose fluconazole for long term treatment of his Coccidiodes infection. He was stable for placement of a tracheostomy and discharged to a long term acute care hospital (LTACH) for further care. His chest x-ray showed significant fibrosis (Figure 1c). DISCUSSION: When we re-examined the patient's history, he had a short trip to the southwestern United states for a total of 10 days with his family. This is the source of the patient's exposure. A thorough history may have helped, but urine Coccidiodes antigen testing was negative even after the open lung biopsy was performed. Despite clinical improvement, the patient passed 6 weeks after discharge to long term acute care hospital. CONCLUSIONS: Severe Coccoidiodes pulmonary infections can progress to ARDS. While, it is responsive to liposomal amphotericin B and steroids, it is still associated with a high morbidity and mortality (2). A high index of suspicion for a fungal infection should be maintained in patient's who have pneumonia refractory to antibiotic therapy. Speaking directly with the pathologist will also aide in the diagnosis of fungal infections non-endemic to the area especially like in this case (3). REFERENCE #1: Kirkland TN, Fierer J. Coccidioides immitis and posadasii; A review of their biology, genomics, pathogenesis, and host immunity. Virulence. 2018;9(1):1426-1435. doi:10.1080/21505594.2018.1509667 REFERENCE #2: Shibli M, Ghassibi J, Hajal R, O'Sullivan M. Adjunctive corticosteroids therapy in acute respiratory distress syndrome owing to disseminated coccidioidomycosis. Crit Care Med. 2002 Aug;30(8):1896-8. doi: 10.1097/00003246-200208000-00037. PMID: 12163812. REFERENCE #3: Pitcher JH, Zuckerman JB. Coccidioides Immitis Infection with Involvement of the Airway. Conn Med. 2016 Oct;80(9):539-541. PMID: 29772139 DISCLOSURES: No relevant relationships by Justin Ching, source=Web Response

TRENDS OF VTE AMONG HIV-RELATED HOSPITALIZATIONS IN THE UNITED STATES

TOPIC: Pulmonary Vascular Disease TYPE: Original Investigations PURPOSE: Chronic infections such as HIV and increasing age have been independently associated with higher venous thromboembolism (VTE) risk. Given the increasing survival of people living with HIV with the advent of antiretroviral treatment, it is important to examine the current trend of VTE among this unique population. METHODS: We queried the National Inpatient Database (NIS), Healthcare Cost and Utilization Project (HCUP) which is a stratified random representative sample of discharges from all hospitals nationwide except for rehabilitation and long-term acute care hospitals. We then identified all individuals with a diagnosis of HIV as defined by ICD9 codes 042 from 2005-2014. VTE was defined by ICD9 codes 415, 416, 451, and 453. We calculated annual rates of inpatient VTE by patient characteristics (age, sex, and race) and type of VTE. We then performed a logistic regression to assess risk factors for the occurrence of VTE among hospitalized patients with HIV adjusting for significant predictors such as age, race, socioeconomic factors, obesity, diabetes, other medical comorbidities, and length of stay, and in-hospital mortality. Comorbidity burden was captured using the Charleston comorbidity index. RESULTS: From 2005-2014, the NIS contained data on approximately 247,467 weighted (approx 608,387 actual) HIV-related hospitalizations. Among these, about 3% (8,587, approx 18, 668 actual) had a concurrent diagnosis of VTE. In general, there was an overall increasing trend in the prevalence of VTE from 2.45% in 2005 to 4.1% in 2015 (P<0.001). There was a persistently higher prevalence among older age groups, men, and Blacks. Multivariable regression analysis shows the odds of VTE occurrence increased over time (OR 1.04; 95%CI 1.04 -1.05; P<0.001) for each year and was higher among older(OR 1.01; 95%CI 1.00-1.01; P<0.001), Black (OR 1.13; 95%CI 1.07-1.19; P<0.001), obese (OR 1.26; 95%CI 1.12-1.40; P<0.001), and complication with AIDS (OR 1.47; 95%CI 1.40-1.54; P<0.001). Female gender (OR 0.88; 95%CI 0.83-0.92; P<0.001), Hispanic ethnicity (OR 0.91; 95%CI 0.84-0.98; P=0.009) and Asian race (OR 0.65; 95%CI 0.46-0.89; P=0.01) were associated with lower VTE risk. In-hospitality mortality (OR 1.99; 95%CI 1.83-2.15, P<0.001) and longer length of stay (OR 1.03, 95%CI 1.02-1.03; P<0.001) were also associated with a diagnosis of VTE. CONCLUSIONS: The trend of VTE prevalence among HIV-related hospitalizations in the US continues to increase over time. Age, obesity, and Black race were the most significant risk factors for VTE, and VTE was associated with increased mortality. CLINICAL IMPLICATIONS: The increasing incidence of VTE and its resultant burden on the healthcare system require more concerted prevention efforts. DISCLOSURES: No relevant relationships by Alem Mehari, source=Web Response No relevant relationships by Dwayne Nelson, source=Web Response No relevant relationships by Daniel Nepaul, source=Web Response No relevant relationships by Kelechi Weze, source=Web Response

COVID-19 LEUKOENCEPHALOPATHY: THE MIDDLE CEREBELLAR PEDUNCLE SIGN

TOPIC: Imaging TYPE: Medical Student/Resident Case Reports INTRODUCTION: Although the pulmonary manifestations of the coronavirus disease 2019 (COVID-19) are commonly recognized, a rapidly accumulating body of evidence also supports multiple neurological manifestations. In addition to nonspecific headache and myalgia, complications include cranial/peripheral neuropathy, meningoencephalitis, and acute demyelination. We now present a case of acute encephalomyelitis associated with COVID-19. CASE PRESENTATION: A 69-year-old male with a history of diabetes mellitus and was admitted to the intensive care unit. He initially presented to the emergency room four days prior for fevers at which time COVID-19 PCR rapid antigen testing was positive. He was discharged home given the absence of other symptoms. Four days later he was found unresponsive and intubated for airway protection. On arrival to the hospital, the patient was unresponsive with roving eye movements but withdrew to stimulation in all extremities. He was started on dexamethasone and remdesivir. Computed tomography head demonstrated mild chronic small vessel ischemic periventricular leukomalacia. Given the degree of his encephalopathy, an magnetic resonance imaging (MRI) T2 of the brain was obtained demonstrating bilaterally symmetric restricted diffusion at the middle cerebellar peduncles and corticospinal tracts without microbleeds (Figure 1). FLAIR hyperintense lesions in the dorsal aspects of the internal capsules extending into the corticospinal tracts at the midbrain were also noted. A lumbar puncture was remarkable for 100% lymphocytic predominance cell count with normal glucose and protein. Steroid therapy was transitioned to methylprednisolone 1 gram daily for 5 days. Although repeat MRI (Figure 2) one week later showed lessened restriction diffusion without new pathology, the patient remained profoundly encephalopathic. Given the stability on MRI, intravenous immunoglobulin was deferred. He was started on a prednisone taper. He subsequently had a tracheostomy and percutaneous gastrostomy tube placed and transferred to a long-term acute care hospital. DISCUSSION: This case highlights an important finding of middle cerebellar peduncle lesions on MRI in the setting of COVID-19. Neurologic symptoms from COVID-19 are becoming better understood, with multiple recent papers examining neurological sequelae. The mechanism by which COVID-19 causes demyelination is not entirely clear. One idea is that leukocytes that become infected can serve as a reservoir and a vector of the disease that are subsequently able to enter the CNS through the bloodstream. Another theory is that viruses will infect peripheral neurons and then using axonal transport machinery will access the central nervous system. CONCLUSIONS: More research needs to be done to identify a precise mechanism of how demyelination occurs, but it is clear that demyelination is an unfortunate outcome of infection with respiratory viruses, like COVID-19. REFERENCE #1: Kremer S et al (Neurology 2020; 95: e1868-e1882) reported radiographic ADEM with COVID-19; MCP involvement reported as well as meningeal enhancement. REFERENCE #2: Desforges M, Coupanec AL, Dubeau P, et al. Human Coronaviruses and Other Respiratory Viruses: Underestimated Opportunistic Pathogens of the Central Nervous System? Viruses. 2019, 12, 14. DISCLOSURES: No relevant relationships by HANAD BASHIR, source=Web Response No relevant relationships by Mark Metry, source=Web Response No relevant relationships by Aidan Neustadtl, source=Web Response No relevant relationships by Christopher Newey, source=Web Response

“Early results after initiation of a rib fixation programme: A propensity score matched analysis”

IntroductionChest wall injuries are very common in blunt trauma and development of treatment protocols can significantly improve outcomes. Surgical stabilisation of rib fractures (SSRF) is an adjunct for the most severe chest injuries and can be used as a part of a comprehensive approach to chest injuries care. We hypothesized that implementation of a SSRF programme program would result in improved short-term outcomes. Materials and methodsThe characteristics of the initial group of SSRF patients (Early-SSRF) were used to identify matching factors. Patients prior to SSRF protocol underwent a propensity score match, followed by screening for operative indications and contraindications. After exclusions, a non-operative (Non-Op) cohort was defined (n=36) resulting in an approximately 1:1 match. An overall operative cohort, inclusive of Early-SSRF and all subsequent operative patients, was defined (All- SSRF). A before-and-after analysis using chi-squared, Students T-tests, and Mann-Whitney U-tests were used to assess significance at the level of 0.05. ResultsEarly-SSRF (n=22) and All-SSRF (n=45) were compared to Non-Op (n=36). The selection process resulted in well matched groups, and equally well-balanced operative indications between the groups. The Early-SSRF group demonstrated shortened duration of mechanical ventilation and a decreased frequency of being discharged a long-term acute care hospital. The All-SSRF group again demonstrated markedly shorter duration of mechanical ventilation compared to Non-Op (median 6 days vs 16 days, p < 0.01), more decrease discharge to a long-term acute care hospital (9% vs. 36%, p=0.01), and reduced risk for tracheostomy (8.9% vs. 33.3% respectively, p<0.01) ConclusionThe introduction of an operative rib fixation to a comprehensive chest wall injury protocol can produce improvements in clinical outcomes that decrease time on the ventilator and tracheostomy rates, and result in more patients being discharged to home. Creation and implementation of a chest wall injury protocol to include SSRF requires a multidisciplinary approach and thoughtful patient selection.

Rapid Assessment and Containment of Candida auris Transmission in Postacute Care Settings-Orange County, California, 2019.

Candida auris, a multidrug-resistant yeast, can spread rapidly in ventilator-capable skilled-nursing facilities (vSNFs) and long-term acute care hospitals (LTACHs). In 2018, a laboratory serving LTACHs in southern California began identifying species of Candida that were detected in urine specimens to enhance surveillance of C auris, and C auris was identified in February 2019 in a patient in an Orange County (OC), California, LTACH. Further investigation identified C auris at 3 associated facilities. To assess the prevalence of C auris and infection prevention and control (IPC) practices in LTACHs and vSNFs in OC. Point prevalence surveys (PPSs), postdischarge testing for C auris detection, and assessments of IPC were done from March to October 2019. All LTACHs (n = 3) and vSNFs (n = 14) serving adult patients in OC. Current or recent patients in LTACHs and vSNFs in OC. In facilities where C auris was detected, PPSs were repeated every 2 weeks. Ongoing IPC support was provided. Antifungal susceptibility testing and whole-genome sequencing to assess isolate relatedness. Initial PPSs at 17 facilities identified 44 additional patients with C auris in 3 (100%) LTACHs and 6 (43%) vSNFs, with the first bloodstream infection reported in May 2019. By October 2019, a total of 182 patients with C auris were identified by serial PPSs and discharge testing. Of 81 isolates that were sequenced, all were clade III and highly related. Assessments of IPC identified gaps in hand hygiene, transmission-based precautions, and environmental cleaning. The outbreak was contained to 2 facilities by October 2019. Acute care hospitals were not assessed, and IPC improvements over time could not be rigorously evaluated. Enhanced laboratory surveillance and prompt investigation with IPC support enabled swift identification and containment of C auris. Centers for Disease Control and Prevention.

Prevalence of Diaphragmatic Dysfunction in the Long-Term Acute Care Setting and Its Effects on Ventilator Weaning Outcomes: A Retrospective Cohort Study.

To determine the prevalence of undiagnosed diaphragmatic dysfunction in a long-term acute care hospital setting in patients on prolonged mechanical ventilation and its association with weaning outcomes. This is a single-center, retrospective cohort study including 451 patients on prolonged mechanical ventilation admitted to a long-term acute care hospital facility between 2012 and 2017. Diaphragmatic dysfunction was assessed using fluoroscopy. Three hundred nineteen patients on prolonged mechanical ventilation were assessed for diaphragmatic dysfunction. Nine patients were diagnosed with diaphragmatic dysfunction before admission. Eighty (72.7%) without diaphragmatic dysfunction were successfully weaned and 30 (27.3%) failed to wean, whereas 51 participants (31.9%) with diaphragmatic dysfunction were successfully weaned and 109 (68.1%) failed to wean (P < 0.001). When analyzing days to wean, the median was 13 days for those with no diaphragmatic dysfunction, 19 days with unilateral diaphragmatic dysfunction, and 28 days with bilateral diaphragmatic dysfunction (P < 0.001). Weaning success was not statistically associated with generalized neuromuscular disorders, age, sex, body mass index, smoking history, or diabetes. Diaphragmatic dysfunction was found to be strongly associated with time to wean and weaning success in the long-term acute care hospital setting. Very few patients despite being on prolonged mechanical ventilation were diagnosed with diaphragmatic dysfunction before long-term acute care hospital admission. Given this information, early diagnosis of diaphragmatic dysfunction among prolonged mechanical ventilation patients in the long-term acute care hospital setting is paramount in preventing secondary complications associated with mechanical ventilation.

Respiratory Microbiome Disruption and Risk for Ventilator-Associated Lower Respiratory Tract Infection.

Ventilator-associated lower respiratory tract infection (VA-LRTI) is common among critically ill patients and has been associated with increased morbidity and mortality. In acute critical illness, respiratory microbiome disruption indices (MDIs) have been shown to predict risk for VA-LRTI, but their utility beyond the first days of critical illness is unknown. We sought to characterize how MDIs previously shown to predict VA-LRTI at initiation of mechanical ventilation change with prolonged mechanical ventilation, and if they remain associated with VA-LRTI risk. We developed a cohort of 83 subjects admitted to a long-term acute care hospital due to their prolonged dependence on mechanical ventilation; performed dense, longitudinal sampling of the lower respiratory tract, collecting 1066 specimens; and characterized the lower respiratory microbiome by 16S rRNA sequencing as well as total bacterial abundance by 16S rRNA quantitative polymerase chain reaction. Cross-sectional MDIs, including low Shannon diversity and high total bacterial abundance, were associated with risk for VA-LRTI, but associations had wide posterior credible intervals. Persistent lower respiratory microbiome disruption showed a more robust association with VA-LRTI risk, with each day of (base e) Shannon diversity <2.0 associated with a VA-LRTI odds ratio of 1.36 (95% credible interval, 1.10-1.72). The observed association was consistent across multiple clinical definitions of VA-LRTI. Cross-sectional MDIs have limited ability to discriminate VA-LRTI risk during prolonged mechanical ventilation, but persistent lower respiratory tract microbiome disruption, best characterized by consecutive days with low Shannon diversity, may identify a population at high risk for infection and may help target infection-prevention interventions.

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.

Long-Term Acute Care Hospital Outcomes of Mechanically Ventilated Patients With Coronavirus Disease 2019.

To describe the clinical characteristics and outcomes of adult patients with coronavirus disease 2019 requiring weaning from prolonged mechanical ventilation. Observational cohort study of patients admitted to two long-term acute care hospitals from April 1, 2020, to March 31, 2021. Two long-term acute care hospitals specialized in weaning from prolonged mechanical ventilation in the Chicagoland area, Illinois, United States. Adult (≥ 18 yr old) ICU survivors of respiratory failure caused by severe acute respiratory syndrome coronavirus 2 pneumonia receiving prolonged mechanical ventilation. None. During the study period, 158 consecutive patients were transferred to the long-term acute care hospitals for weaning from prolonged ventilation. Demographic, clinical, and laboratory data were collected and analyzed. Final date of follow-up was June 1, 2021. Prior to long-term acute care hospital transfer, median length of stay at the acute care hospital was 41.0 days and median number of ventilator days was 35. Median age was 60.0 years, 34.8% of patients were women, 91.8% had a least one comorbidity, most commonly hypertension (65.8%) and diabetes (53.2%). The percentage of weaning success was 70.9%. The median duration of successful weaning was 8 days. Mortality was 9.6%. As of June 1, 2021, 19.0% of patients had been discharged home, 70.3% had been discharged to other facilities, and 1.3% were still in the long-term acute care hospitals. Most patients with coronavirus disease 2019 transferred to two Chicago-area long-term acute care hospitals successfully weaned from prolonged mechanical ventilation.

English

BACKGROUND The Carbapenemase Resistant Enterobacteriaceae (CRE) are associated with high rates of morbidity and mortality particularly amongst critically ill patients. Hence rapid laboratory detection of CRE hospitalized patients is highly desirable. The vast majority of carbapenemases belong to three of the four known classes of beta lactamases namely Ambler class A, Ambler class B metallobetalactamases (MBL) and Ambler class Doxacillinases (OXAs). The purpose of this study was to determine the prevalence of carbapenemases producing Enterobacteriaceae in clinical isolates in MBS hospital, Kota. METHODS This study was conducted in the Department of Microbiology at MBS Hospital, Kota from June 2020 to December 2020. 68 non repeat isolates (MDR) that were resistant to imipenem (10 mg) according to CLSI breakpoint were included in the present study. RESULTS Out of 68 imipenem resistant Enterobacteriaceae, 52 were carbapenemase producing as detected by Modified Hodge Test. As per our study, the prevalence of carbapenemase producing Enterobacteriaceae was 20.8%. Most commonly seen in K. pneumoniae isolated from urine and swab of critically ill and debilitated patients of surgical ward. CONCLUSIONS Curbing irrational usage of antimicrobials in India is urgently required. Thus, aggressive infection control efforts have been effective at decreasing rates of infections with KPC-producing bacteria in intensive care units and long-term acute care hospitals. Bundled interventions including enhanced environmental cleaning, active surveillance culturing and contact precautions, as well as antimicrobial stewardship are important in controlling KPC-producing bacteria. KEY WORDS Multi Drug Resistance Enterobacteriaceae (MDRE), Klebsiella Producing Carbapenemase (KPC), Carbapenem Resistant Enterobacteriaceae (CRE), Metallo Beta Lactamase (MBL), Modified Hodge Test (MHT)

The Short and the Long of it: Timing of Mortality for Older Adults in a State Trauma System

BackgroundThe impact of injury extends beyond the hospital stay, but trauma center performance metrics typically focus on in-hospital mortality. We compared risk adjusted rates of in-hospital and long-term mortality among Pennsylvania trauma centers. We hypothesized that centers with low rates of in-hospital mortality would also have low rates of long-term mortality. MethodsWe identified injured patients (age ≥ 65) admitted to Pennsylvania trauma centers in 2013 and 2014 using the Pennsylvania Trauma Outcomes Study, a robust, state-wide trauma registry. We matched trauma registry records to Medicare claims from the y 2013 to 2015. Matching variables included admission date and patient demographics including date of birth, zip, sex, and race and/or ethnicity. Outcomes examined were inpatient, 30-day, and 1-y mortality. Multivariable logistic regression models including presenting physiology, comorbidities, injury characteristics, and demographics were developed to calculate expected mortality rates for each trauma center at each time point. Trauma center performance was assessed using observed-to-expected ratios and ranking for in-hospital, 30-day, and 1-y mortality. ResultsOf the 15,451 patients treated at 28 centers, 8.1% died before discharge or were discharged to hospice. Another 3.4% died within 30 d, and another 14.7% died within 1 y of injury. Of patients who survived hospitalization but died within 30 d, 92.5% were injured due to fall, and 75.0% sustained head injuries. Survival at 1 y was higher in patients discharged home (88.4%), compared to those discharged to a skilled nursing facility or long-term acute care hospital (72.7% and 52.6%, respectively). Three centers were identified as outliers (two low and one high) for in-hospital mortality, none of which were outliers when the horizon was stretched to 30 d from injury. At 30 d, two different low and two different high outliers were found. ConclusionNearly one-in-three injured older adults who die within 30 d of injury dies after hospital discharge. Hospital rankings for in-hospital mortality correlate poorly with long-term outcomes. These findings underscore the importance of looking beyond survival to discharge for quality improvement and benchmarking.

Assessing calorie and protein recommendations for survivors of critical illness weaning from prolonged mechanical ventilation – can we find a proper balance?

SUMMARYBackground & aims:Survivors of critical illness requiring prolonged mechanical ventilation (PMV) are predisposed to malnutrition, muscle wasting, and weakness. There is a lack of data regarding nutrition adequacy among these patients, and although nitrogen balance has been studied as a marker of adequate protein intake in healthy individuals and acutely critically ill patients, it has not been well studied in critically ill patients with PMV. The purpose of this study was to determine if patients requiring PMV admitted to a long-term acute care hospital (LTACH) achieved registered dietitian (RD) recommended goals for energy and protein intake and if the recommendations were adequate to avoid negative nitrogen balance.Methods:Using a retrospective, cohort study design, patients requiring PMV who had orders for 24-h urine collections for urea nitrogen (24hrUUN) were included. Energy and protein intake was calculated from chart documentation of dietary intake for the 24-h period during which patients underwent a 24hrUUN. Nitrogen intake was estimated from protein intake. Dietary intake was compared to RD-recommendations to determine the percentage of RD-recommendations achieved. Nitrogen balance was calculated as nitrogen intake minus nitrogen loss, with negative balance categorized as less than −1.Results:Subjects (n = 16) were 38% male and 75% African American (mean age 61.5 ± 3.2 years; mean BMI 27.5 ± 2.5 kg/m2). Duration of LTACH hospitalization was 26.5 (6–221) days. Mean energy and protein intake was 21.7 ± 2.9 kcal/kg/d and 1.1 ± 0.1 g/kg/d, respectively, which corresponded to 86% of both RD energy and protein recommendations. Ten patients achieved a positive nitrogen balance (mean 0.9 ± 1.1 g). In addition, there was a positive linear relationship between protein intake and nitrogen balance (r = 0.59, p = 0.016).Conclusion:Survivors of critical illness requiring PMV achieved a high percentage of RD-recommended protein and calories, and prevented a negative nitrogen balance in a majority of patients. Increasing protein intake can prevent a negative nitrogen balance. Future studies should evaluate whether these patients are able to maintain a steady state of nitrogen intake and excretion over time and how this affects time to and/or success of weaning.

The DEPARTS Score: A Novel Tool for Predicting Discharge Disposition in Geriatric Trauma Patients.

Geriatric trauma patients (GTPs) represent a high-risk population for needing post-acute care, such as skilled nursing facilities (SNFs) and long-term acute care hospitals (LTACs), due to a combination of traumatic injuries and baseline functional health. As there is currently no well-established tool for predicting these needs, we aimed to create a scoring tool that predicts disposition to SNFs/LTACs in GTPs. The adult 2017 Trauma Quality Improvement Program database was divided at random into two equal sized sets (derivation and validation sets) of GTPs >65years old. First, multiple logistic regression models were created to determine risk factors for discharge to a SNF/LTAC in admitted GTPs. Second, the weighted average and relative impact of each independent predictor was used to derive a DEPARTS (Discharge of Elderly Patients After Recent Trauma to SNF/LTAC) score. We then validated the score using the area under the receiver-operating curve (AROC). Of 66479 patients in the derivation set, 36944 (55.6%) were discharged to a SNF/LTAC. Number of comorbidities, fall mechanism, spinal cord injury, long bone fracture, and major surgery were each independent predictors for discharge to SNF/LTAC, and a DEPARTS score was derived with scores ranging from 0 to 19. The AROC for this was .74. In the validation set, 66477 patients also had a SNF/LTAC discharge rate of 55.7%, and the AROC was .74. The DEPARTS score is a good predictor of SNF/LTAC discharge for GTPs. Future prospective studies are warranted to validate its accuracy and clinical utility in preventing delays in discharge.

Fatigue and functional outcomes in cancer rehabilitation.

Cancer-related fatigue (CRF) is one of the most common symptoms experienced by oncology patients, though its impact on functional outcomes during inpatient rehabilitation is relatively unknown. The purpose of this study is to determine whether CRF severity on admission is related to functional gains following standard rehabilitation care in an inpatient oncology rehabilitation population. A retrospective cohort study was conducted within an inpatient oncology unit at a long-term acute care hospital. Seventy-six patients admitted to the hospital between April and December 2015 with an oncology diagnosis, planned discharge, and completed standardized assessments of CRF and functional ability were included in this study. Patients received standard interdisciplinary rehabilitation services including physical and occupational therapy. CRF was assessed on admission using the Brief Fatigue Inventory, and functional abilities were assessed on admission and discharge using the basic mobility and daily activity domains of the Activity Measure for Post-Acute Care inpatient short forms (AM-PAC). Ninety-seven percent of patients reported CRF, and 57% reported severe CRF upon admission. Patients demonstrated on average a 30% and 14% reduction in functional impairment in basic mobility and daily activity respectively during their admission. There was no significant correlation found between CRF on admission and change in functional impairment. This study contributes to existing literature in that it found patients who received inpatient rehabilitation services demonstrate significant improvement in their functional status despite reporting CRF upon admission to a long-term acute care hospital oncology unit.

Verona Integron-Encoded Metallo-Beta-Lactamase (VIM)–Producing Pseudomonas aeruginosa Outbreak Associated with Acute Care

Background: Contaminated healthcare facility plumbing is increasingly recognized as a source of carbapenemase-producing organisms (CPOs). In August 2019, the Tennessee State Public Health Laboratory identified Tennessee’s twelfth VIM-producing carbapenem-resistant Pseudomonas aeruginosa (VIM-CRPA), from a patient in a long-term acute-care hospital. To determine a potential reservoir, the Tennessee Department of Health (TDH) reviewed healthcare exposures for all cases. Four cases (33%), including the most recent case and earliest from March 2018, had a history of admission to intensive care unit (ICU) room X at acute-care hospital A (ACH A), but the specimens were collected at other facilities. The Public Health Laboratory collaborated with ACH A to assess exposures, perform environmental sampling, and implement control measures. Methods: TDH conducted in-person infection prevention assessments with ACH A, including a review of the water management program. Initial recommendations included placing all patients admitted to room X on contact precautions, screening for CPO on room discharge, daily sink basin and counter cleaning, and other sink hygiene measures. TDH collected environmental and water samples from 5 ICU sinks (ie, the handwashing and bathroom sinks in room X and neighboring room Y [control] and 1 hallway sink) and assessed the presence of VIM-CRPA. Moreover, 5 patients and 4 environmental VIM-CRPA underwent whole-genome sequencing (WGS). Results: From February to June 2020, of 21 patients admitted to room X, 9 (43%) underwent discharge screening and 4 (44%) were colonized with VIM-CRPA. Average room X length of stay was longer for colonized patients (11.3 vs 4.8 days). Drain swabs from room X’s bathroom and handwashing sinks grew VIM-CRPA; VIM-CRPA was not detected in tap water or other swab samples. VIM-CRPA from the environment and patients were sequence type 253 and varied by 0–13 single-nucleotide variants. ACH A replaced room X’s sinks and external plumbing in July. Discharge screening and contact precautions for all patients were discontinued in November, 5 months following the last case and 12 consecutive negative patient discharge screens. Improved sink hygiene and mechanism testing for CRPA from clinical cultures continued, with no new cases identified. Conclusions: An ICU room with a persistently contaminated sink drain was a persistent reservoir of VIM-CRPA. The room X attack rate was high, with VIM-CRPA acquisition occurring in &gt;40% of patients screened. The use of contaminated plumbing fixtures in ACH have the potential to facilitate transmission to patients but may be challenging to identify and remediate. All healthcare facilities should follow sink hygiene best practices.Funding: NoDisclosures: None