Long-term Care Wards Research Articles

Comparison of the effectiveness of core genome multilocus sequence typing and polymerase chain reaction-based open reading frame typing in tracing nosocomial methicillin-resistant Staphylococcus aureus transmission

IntroductionA clonal shift from staphylococcal cassette chromosome mec (SCCmec) type II/ST5 methicillin-resistant Staphylococcus aureus (MRSA) to SCCmec type IV/clonal complex (CC)1 MRSA has occurred rapidly in Japan. Our previous research in a geriatric hospital found SCCmec type IV/CC1 MRSA prevalence in long-term care wards. Due to intensive personal care requirements, frequent contact with healthcare providers can potentially cause unintentional nosocomial MRSA transmission. We performed polymerase chain reaction-based open reading frame typing (POT) and core genome multilocus sequence typing (cgMLST) to investigate the occurrence of nosocomial transmission and to compare the results of these methods. MethodsPOT and whole genome sequencing were performed in 83 MRSA isolates. Commercial automated software (Ridom SeqSphere+) was used to perform cgMLST. MRSA isolates with 0–8 allelic differences were considered related, and medical records were consulted in these cases. ResultsSCCmec type IV/CC1 MRSA was the most frequently detected clone (n = 56, 67.5 %), which was divided into 14 POT types, followed by SCCmec type I/ST8 (n = 9) and SCCmec type IV/ST8 (n = 8). Identical POT types were found across 7 of 11 wards. However, cgMLST analysis identified only three cases (six strains) of high genetic similarity, indicating nosocomial transmission; only one involved SCCmec type IV/CC1 (two strains). The mean allelic difference in the core genomes between strains with identical POT types in the same ward was 55.3 ± 22.0. ConclusionsThe cgMLST method proved more effective for identifying nosocomial transmissions compared to POT, highlighting its utility in tracking MRSA spread in healthcare settings.

Informal judgement of delirium status underestimates delirium prevalence: World Delirium Awareness Day point prevalence results from Ireland

Introduction Delirium is an encephalopathy characterized by acute onset, fluctuation, and prominent deficits in attention and alertness, due to one or more physical disorders, interventions or medications. It is associated with increased mortality and morbidity, and with incidence and worsening of dementia; thus, delirium prevention and timely detection and appropriate management are crucial. Objective This study aimed to determine delirium prevalence in Irish clinical sites. Methods The overall study was an observational, cohort study of the point prevalence of delirium (and current delirium practice) in multiple clinical sites on a single day (i.e. World Delirium Awareness Day, March 2023). In this study, the point prevalence of delirium is reported in Irish sites. Results In total, 132 wards from 15 hospitals across Ireland participated in this study, including general medical, surgical and specialised wards, and some long-term care and rehabilitation wards. Overall, 27% of patients on wards which reported using a formal tool had not been assessed for delirium. Delirium prevalence, using a formal assessment tool, was 15.9% overall, with the highest rate in geriatric wards (20.5%). However, on wards where ‘personal judgment’ to detect delirium was utilized, the prevalence rate was 11.5%, implying that delirium may have been under-detected on these wards. Conclusions Delirium screening can quickly rule out delirium or lead to more formal assessment where screening is positive or equivocal. Delirium is prevalent in Irish hospitals and appears to be under-detected unless a formal screening tool is used; equally, delirium screening is not universally applied on wards reporting that they use a formal tool. Together, this indicates that delirium is still under-diagnosed in Irish hospitals.

Investigating Length of Stay Patterns and Its Predictors in the South Wales Trauma Network.

Length of stay (LOS) is frequently employed as a performance metric for trauma care. Following the establishment of the trauma network worldwide, the assessment and prediction of LOS in different levels of trauma centres have been extensively studied. However, assessing the total patient length of stay from a whole trauma network perspective is unclear. The objective of this study was to systematically analyse the overall Length of Stay (LOS) pattern within the SWTN before its establishment and in the immediate time after its foundation and, secondly, to assess the association between relevant impact factors and LOS. A retrospective secondary analysis based on the trauma admission dataset from Trauma Audit and Research Network(TARN) dataset was conducted. The studied sample covered around 18000 patients admitted to trauma centres from South Wales Major trauma network between January 2012 and October 2021. The primary outcome is the total length of stay in the trauma network. Statistical tests were applied to examine the difference between normal and outlier LOS. Data visualisation was utilised to demonstrate the LOS patterns and potential association between LOS and relevant demographic and clinical predictors. The distribution of length of stay in SWTN follows a right-skewed distribution with a median of 10 (IQR, 5-18) and a mean of 15.92 days. There were 1520 patients with outliers for LOS. A significant difference (p¡ 0.05) was found between the normal and outlier groups of LOS based on demographic (age, gender and residential information) and clinical characteristics(ward type, maximum of anatomically-based injury severity score(AIS) and probability of survival). Age group, maximum AIS score on specific injured region, ward type and its interaction effect with the number of admissions may associated with the LOS. Specifically, patients admitted to the geriatric ward exhibited notably prolonged LOS, and individuals with more than 2 admissions to long-term care and recovery-related wards such as neurosurgical rehabilitation, spinal injuries and burns wards also displayed elevated LOS. Our finding supports prior evidence indicating elderly people are vulnerable to longer stays. Moreover, concerning the types of admission wards, patients admitted to rehabilitation wards who underwent more than 2 hospitalisations also faced an increased risk of prolonged stay. Based on these results, policymakers and healthcare providers should contemplate expanding the allocation of medical resources to this demographic to mitigate the length of stay and optimise associated healthcare costs.

The clinical characteristics and molecular epidemiology of methicillin-resistant Staphylococcus aureus (MRSA) among very elderly people in Japan.

Methicillin-resistant Staphylococcus aureus (MRSA) is a major nosocomial infection-causing pathogen. The clonal shift from staphylococcal cassette chromosome mec (SCCmec) type II MRSA to SCCmec type IV MRSA has occurred rapidly in acute-care hospitals. However, the epidemiology and clinical impacts of MRSA in geriatric hospitals are poorly documented. We performed a molecular epidemiological analysis of the clinical isolates and retrospectively investigated the clinical characteristics of SCCmec type IV MRSA in elderly individuals. MRSA isolates were grouped according to the SCCmec type and virulence genes (tst, sea, seb, sec, and lukS/F-PV), and multi-locus sequence typing (MLST) was performed. Of the 145 MRSA isolates obtained from patients with a median age of 85 years, 100 (69.0%) were obtained from sputum samples, 22 (15.2%) from skin and soft tissues, and seven (4.8%) from blood samples. The most prevalent clone was SCCmec type IV/clonal complex (CC)1/sea+ (59.3%), followed by SCCmec type I/sequence type (ST) 8 (17.3%). Of the 17 (11.7%) strains to which an anti-MRSA drug was administered by a physician, only three were SCCmec type IV/CC1/sea+ (17.6%) and five were SCCmec type I/ST8 (29.4%). SCCmec type IV/CC1/sea+ MRSA was more frequently isolated in long-term care wards than were SCCmec type I/ST8 strains (odds ratio: 2.85, 95% confidence interval: 1.08-7.54) and was less frequently treated as the cause of MRSA infections (odds ratio: 0.15, 95% confidence interval: 0.03-0.73). SCCmec type IV/CC1/sea+ MRSA was the predominant clone and could be easily transmissible and be capable of colonization. Geriatr Gerontol Int 2023; 23: 744-749.

Measuring gerontological nursing competencies among aged care nurses: Cultural adaptation and psychometric validation.

Existing gerontological nursing competencies include the requisite knowledge and skills required for aged care nursing. What were not previously considered were legal and ethical aspects and access to technology, e-health and social media. This study aimed to validate an Australian gerontological nursing competencies scale and assess the factors associated with for aged care nurses in Taiwan. A methodological study design was used to validate the scale with a sample of 369 aged care nurses from aged care settings including nursing homes, long-term care facilities and aged care wards in Taiwan. The cultural adaptation and psychometric validation were evaluated. The content validity, construct validity through exploratory factor analysis and the internal consistency of the scale were assessed. The exploratory factor analysis extracted two levels of gerontological nursing practice, 'essential' and 'enhanced', which accounted for 80.8% of the total variance. The internal consistency, split-half reliability and test-retest reliability were excellent. Aged care nurses with higher levels of education, aged care education as their highest degree and continued education within 6 months, and certified long-term care education had higher gerontological nursing competencies scores than those who did not. This validated gerontological nursing competencies scale is a reliable and valid tool that can be implemented in future workforce planning, research and postgraduate and undergraduate curriculum and education in Taiwan and other Mandarin-speaking locales. Using validated gerontological nursing competencies scales to explain different levels of specialist practice is crucial for addressing negative views about aged nursing and explicitly demonstrate the possibilities for career pathways in gerontological nursing.

Physical Activity in People With Dementia Living in Long-Term Care Facilities and the Connection With Environmental Factors and Behavior.

This study is conducted in order to gain a better understanding of the relationship between physical activity and agitated behavior among older people with dementia, and physical activity and characteristics of long-term care wards. Data were collected among people with dementia living in long-term care facilities (N = 76) by conducting observations at the wards and distributing questionnaires among professional caregivers. The results show that participants are largely inactive (82.8%) and a significant relation was found between the degree of physical activity and characteristics of the ward such as "taking sufficient time," which relates to the time caregivers take when interacting with residents. This study supports the existing knowledge about the degree of physical activity among people with dementia in long-term care and adds information about the potential influence of organizational factors that could be valuable for daily practice.

Potentially inappropriate medication in long-term care wards of a veteran hospital in Taiwan: Investigation using a spreadsheet-based rapid assessment tool.

Multimorbidity and polypharmacy increase in the aging population and are accompanied by the use of potentially inappropriate medications (PIMs) and adverse drug events (ADEs). This study developed a rapid assessment tool to investigate PIM use among patients in long-term care wards. We retrospectively collected the data of patients in long-term care wards of a veteran hospital in Taiwan between July 2019 and June 2020. The patients with chronic diseases and medications were selected. The data, including gender, age, diagnosis, and medications, were deidentified. Nonchronic disease diagnosis and short-term and topical use medications were excluded. We used Microsoft Excel (Microsoft Corporation, Redmond, Washington, USA) and the 2019 version of the Beers Criteria to establish a rapid assessment tool. The correlations between the prevalence of PIM use and age, the number of diagnoses, and the number of medications were analyzed using SPSS version 23. A total of 176 patients were included in this study, of which 76.7% (n = 135) were male and 23.3% (n = 41) were female. The average age of men was 82.1 years and that of women was 83.4 years. The average number of diagnoses for men was 5.5, and that for women was 7.3. The average number of medications for men was 5.8, and that for women was 6.5. The prevalence of PIM use was 59.1% (n = 104). Logistic regression revealed that the prevalence of PIM use may be associated with the number of medications ( p < 0.001; odds ratio = 1.378). Decision tree analysis revealed that patients who simultaneously used more than four medications exhibited a higher risk of PIM. PIM use is a key factor causing ADEs among older adults. Therefore, comprehensive assessment of PIM use is necessary. This study designed a rapid assessment tool to simultaneously integrate and evaluate medications. Future studies may investigate the effectiveness of the proposed assessment tool.

1271 A NOVEL PRESSURE INJURY CARE BUNDLE FOR DEPENDENT PATIENTS WITH PRESSURE INJURIES IN BERMUDA

Abstract Introduction Pressure injury (PI) management is a challenge in dependent patients in acute care wards (ACW) despite standard care (regular pressure relief measures, incontinence management, debridement, optimisation of hydration and nutrition). Method A Pressure Injury Care Bundle (PICB), introduced by the Department of Geriatrics, enhanced standard care by diligent and regular interdisciplinary team monitoring of patients with PIs following transfer to Long Term Care (LTC) wards and thus may improve outcomes. The PICB was delivered by multiple PI Nurse Champions with education of all nurse assistants and medical staff into PI aetiology/management. Progress was monitored with weekly PI measurements/photography and Nurse Champion-lead team review of all PIs. Data are presented as mean+/-1SD. After 96+/-103 days in the ACW, the PICB was applied to 30 consecutive patients aged 80+/-14 years, (19(60 %) were female). All had stage 2-4 PIs (present in 25(83%) on admission to ACW). On transfer to LTC wards, all patients had severe physical dependency with a mean Charlson Comorbidity Index of 7+/-3, 27(90%) had palliative needs and 24(80%) were bedfast. Cognitive impairment was present in 22(68%) patients with 12(37%) dying due to advanced dementia. Patients were followed for 116+/-274 days. Results PI improvement by &amp;gt;2 stages occurred in 11(36%) patients after a mean of 103 days. Ulcers closed fully after 154+/-48 days in a further 15(50 %) patients. However, new ulcers emerged or preterminal (&amp;lt;21 days prior to death) deterioration occurred in 5(17%) patients, related to severe contractures, preterminal poor nutrition and sarcopenia with 16(54%) patients dying. Conclusion These results suggest that an intensive multimodal intervention involving best practice enhanced by PI Nurse Champions and delivered by educated staff with regular PI team progress reviews results in significant improvement/healing of PIs in severely dependent patients with palliative needs. Expansion of the PICB to other wards with prospective evaluation has been planned.

In-vitro Activity of Ceftazidime-Avibactam Against Carbapenem-Resistant K. pneumoniae in a Tertiary-Care Center in Al-Ahsa, KSA

Abstract Introduction/Objective Carbapenem-resistant Enterobacteriaceae (CRE) represents an urgent global threat. Klebsiella pneumoniae is a common cause of various clinical infections showing increased rates of resistance. Carbapenem-resistant Klebsiella pneumoniae (CR-KP) is often multi-drug resistant and sometimes becomes pan-drug resistant causing serious infections with substantial morbidity, mortality and cost. Ceftazidime-avibactam (CZA) is considered to be a good alternative to standard CRE therapy. In our region, CRE is mostly due to OXA-type carbapenemases which are inhibited by CZA, however, metallo-beta-lactamases (MBLs) are being increasingly reported and against which CZA is inactive. The aim of this study is to determine the activity of CZA against CRE-KP isolated in our hospital. Methods/Case Report Single-center, prospective study on consecutive non-duplicate CRE-KP isolates recovered from various clinical specimens in 2020 and 2021. BD Phoenix® system was used for initial Identification and susceptibility testing. E-test was done to confirm susceptibility and determine the minimum inhibitory concentration (MIC) for CZA. The standards of the Clinical and Laboratory Standards Institute were followed. Results (if a Case Study enter NA) 95 CRE-KP isolates were collected. CRE-KP was mostly isolated from: Respiratory samples: 36% (n=34), bedsores: 28% (n=27), urine: 23% (n=22) and 11% (10 isolates) were retrieved from blood cultures. 65% of patients were admitted to the intensive care unit (ICU), 13% were in long-term care wards and 13% were admitted for management of infected bedsores. 88 isolates were susceptible to CZA (93%) with MIC50= 1.5 μg/mL and MIC90= 4.0 μg/mL. 26 isolates (27%) were sensitive only to CZA. Susceptibility to tigecycline was 54%, amikacin 18% and gentamicin 17%. Other antimicrocbials including ceftolozane-tazobactam were basically ineffective. Conclusion Ceftazidime-avibactam shows excellent in-vitro activity against CR-KP isolates tested in this study. Further clinical studies on treatment efficacy and emergence of resistance are needed. Moreover, with the recent increase in reported MBLs-mediated resistance in our region, infection control measures, resistance-surveillance programs, and molecular testing may prove essential in the fight against carbapenem-resistant Enterobacteriaceae.

199 A NOVEL PRESSURE INJURY CARE BUNDLE FOR DEPENDENT PATIENTS WITH PRESSURE INJURIES IN BERMUDA

Abstract Background Pressure Injury (PI) management is challenging for dependent patients in Acute Care Wards (ACW) despite standard care (regular pressure relief measures, incontinence management, debridement, optimisation of hydration and nutrition). A Pressure Injury Care Bundle (PICB), introduced by the Department of Geriatrics, enhanced standard care by diligent and regular interdisciplinary team monitoring of patients with PIs following transfer to Long-Term Care (LTC) wards and thus may improve outcomes. Methods The PICB was delivered by multiple PI Nurse Champions with education of all nurse assistants and medical staff into PI aetiology/management. Progress was monitored with weekly PI measurements/photography and Nurse Champion-lead team review of all PIs. Data are presented as mean+/-1SD. After 96+/-103 days in the ACW, the PICB was applied to 30 consecutive patients aged 80+/-14 years, (60 % female; 19/30). All had stage 2-4 PIs (present in 83% on admission to ACW). On transfer to LTC wards, all had severe physical dependency with mean Charlson Comorbidity Index of 7+/-3, 27(90%) had palliative needs and 24(80%) were bedfast. Cognitive impairment was present in 22(68%) patients with 12(37%) dying due to advanced dementia. Patients were followed for 116+/-274 days. Results PI improvement by &amp;gt;2 stages occurred in 11(36%) patients after a mean of 103 days. Ulcers closed fully after 154+/-48 days in a further 15(50 %) patients. However, new ulcers emerged or preterminal (&amp;lt;21 days prior to death) deterioration occurred in 5(17%) patients, related to severe contractures, preterminal poor nutrition and sarcopenia with 16(54%) patients dying. Conclusion These results suggest an intensive multimodal intervention involving best practice enhanced by PI Nurse Champions and delivered by educated staff with regular PI team progress reviews results in significant improvement/healing of PIs in severely dependent patients with palliative needs. Expansion of the PICB to other wards with prospective evaluation is planned.

Outcomes of Physiotherapy on Activities of Daily Living and Discharge to the Community in Psychiatric Long-term Care Ward Patients.

The purpose of this study was to investigate the outcomes of physiotherapy on patients in psychiatric long-term care wards in Japan and to identify the characteristics of patients who have been discharged to the community. The subjects comprised 50 patients who were admitted to the psychiatric long-term care wards at four different hospitals in Japan and prescribed physiotherapy. General physiotherapy for the patients' diseases was provided. The main outcome was whether a patient was discharged to the community (discharged group) or remained hospitalized (hospitalized group) at the end of physiotherapy. Basic subject characteristics, including age, sex, F-code, classification of the diagnosis that led to physiotherapy, length of hospital stay, and length of physiotherapy, were collected from medical records. The Functional Independence Measure (FIM) tool was administered at the initial and final evaluations. At the end of physiotherapy, there were 14 subjects in the discharged group and 36 subjects in the hospitalized group. There were significant differences in the classification of diagnosis, length of stay (LOS), and classification of LOS between the two groups. Two-way analysis of variance showed interactions between the FIM subitems of self-care, transfer, and locomotion. The discharged group had higher FIM scores at the start of physiotherapy and a greater FIM gain.

One-day prevalence of asymptomatic carriage of toxigenic and non-toxigenic Clostridioides difficile in 10 French hospitals

Asymptomatic faecal carriage of Clostridioides difficile has been widely evaluated, but its prevalence across a wide range of clinical departments and related risk factors are not well described. The objectives of the PORTADIFF study were to evaluate the prevalence and identifying risk factors leading to asymptomatic carriage of both toxigenic and non-toxigenic C.difficile. The PORTADIFF study was a 1-day prevalence study carried out in 10 different French hospitals. Adult patients, who agreed to participate, were included in this study and provided a fresh stool sample. C. difficile strains isolated from carriage were characterized by polymerase chain reaction (PCR) detection of tcdA, tcdB, cdtA and cdtB, and PCR ribotyping. In total, 721 patients were included in this study. The median age was 73 years (range 18-101 years) and the male/female ratio was 1.06. C. difficile (either toxigenic or non-toxigenic strains) was isolated from 79 (11%) patients; 42 (5.8%) strains were toxigenic. The prevalence rates of asymptomatic carriage ranged from 5% on surgical wards to 19% on long-term care wards. The main risk factors associated with asymptomatic carriage were antibiotic treatment within the preceding 3 months (81.8% vs 53.7%; P<0.01), hospitalization within the preceding 2 months (55.8% vs 33%; P<0.01), cumulative duration of hospital stay before study inclusion (mean 50.1 vs 34.5 days; P<0.047), and hospitalization on a ward with high global incidence of C. difficile infection. Eleven percent of hospitalized patients were asymptomatic carriers of toxigenic or non-toxigenic C. difficile, and may constitute a potential reservoir of C. difficile strains.

The short-term effect of a modified comprehensive geriatric assessment and regularly case conferencing on neuropsychiatric symptoms in nursing homes: a cluster randomized trial

AimsTo investigate the short-term effect of implementing a modified comprehensive geriatric assessment and regularly case conferencing in nursing homes on neuropsychiatric symptoms.BackgroundNeuropsychiatric symptoms are common and may persist over time in nursing home residents. Evidence of effective interventions is scarce.DesignA parallel cluster-randomised controlled trial.MethodsThe intervention was monthly standardised case conferencing in combination with a modified comprehensive geriatric assessment. The control group received care as usual.Main outcome measure.The total score on the short version of the Neuropsychiatric Inventory (NPI-Q, 12-items).ResultsA total of 309 residents at 34 long-term care wards in 17 nursing homes (unit of randomisation) were included. The intervention care units conducted on average two case conference-meetings (range 1–3), discussing a mean of 4.8 (range 1–8) residents. After 3 months, there were no difference of NPI-Q total score between the intervention (-0.4) and the control group (0.5) (estimated mean difference = -1.0, 95% CI -2.4 to 0.5, p = 0.19). There was a difference in favour of the intervention group on one of the secondary outcome measures, the apathy symptoms (-0.5 95% CI: -0.9 to -0.1, p = 0.03).ConclusionIn this study there were no short-term effect of case conferencing and modified comprehensive geriatric assessments after three months on the total score on neuropsychiatric symptoms. The intervention group had less apathy at 3 months follow-up compared to those receiving care as usual. The findings suggest that a more comprehensive intervention is needed to improve the total Neuropsychiatric symptoms burden and complex symptoms.Trial registrationDue to delays in the organisation, the study was registered after study start, i.e. retrospectively in Clinicaltrials.gov # NCT02790372 at https://clinicaltrials.gov/; Date of clinical trial registration: 03/06/2016.

Health and healthcare variables associated with Italy's excess mortality during the first wave of the COVID-19 pandemic: An ecological study

BackgroundHealthcare factors have strongly influenced the propagation of COVID-19. This study aims to examine whether excess mortality during the first phase of the COVID-19 outbreak in Italy was associated with health, healthcare, demographic, and socioeconomic, provincial-level indicators. MethodsThis ecological study concerns the raw number of deaths reported from February 1 to April 30, 2020 and the mean number of deaths occurred during the same months from 2015 to 2019, per province. Information on socioeconomic factors and healthcare settings was extracted from updated databases on the Italian National Institute of Statistics (ISTAT) website. A multivariate model and four multilevel models were constructed to test the association between excess mortality and the analysed indicators across 107 Italian provinces. ResultsThe hospitalization rate in long-term care wards and the cardiovascular disease mortality rate correlate positively with excess mortality (p <0.05), while higher densities of licensed physicians and of general practitioners are associated with lower excess mortality (p <0.05). After controlling for the COVID-19 cumulative incidence in each province, only the density of licensed physicians remains negatively associated with excess mortality (p <0.01). ConclusionSome health and healthcare variables (in particular, the density of physicians) are strongly associated with excess mortality during the first wave of the COVID-19 pandemic in Italy and should be targeted to increase the resilience of health systems.

Identification of novel factors associated with inappropriate treatment of asymptomatic bacteriuria in acute and long-term care

BackgroundChart reviews often fall short of determining what drove antibiotic treatment of asymptomatic bacteriuria (ASB). To overcome this shortcoming, we searched providers’ free-text for documentation of their decision-making and for misleading signs and symptoms that may trigger unnecessary treatment of ASB. MethodsWe reviewed a random sample of 10 positive urine cultures per month, per facility, from patients in acute or long-term care wards at 8 Veterans Affairs facilities. Cultures were classified as urinary tract infection (UTI) or ASB, and as treated or untreated. Charts were searched for 13 potentially misleading symptoms, and free-text documentation of providers’ decision-making was classified into 5 categories. We used generalized estimating equations logistic regression to identify factors associated with ASB treatment. ResultsOne hundred fifty-eight (27.5%) of 575 ASB cases were inappropriately treated with antibiotics. Significant factors associated with inappropriate treatment included: abdominal pain, falls, decreased urine output, urine characteristics, abnormal vital signs, laboratory values, and voiding issues. Providers prescribed an average of 1.4 antimicrobials to patients with ASB, with cephalosporins (41%) and fluoroquinolones (21%) being the most common classes prescribed. ConclusionsChart reviews of providers’ decision-making highlighted new factors associated with inappropriate ASB treatment. These findings can help design antibiotic stewardship interventions for ASB.

Hospital acquired COVID-19 infections amongst patients before the rollout of COVID-19 vaccinations, a scoping review

BackgroundHospital settings are at increased risk of spreading Coronavirus Disease 2019 (COVID-19) infections, hence non-pharmaceutical prevention interventions (NPPIs) and prioritized vaccination of healthcare workers and resident patients are critical. The status of COVID-19 hospital acquired infections (HAIs) in low-income settings is unclear. We aimed to identify and summarize the existing evidence on COVID-19 HAIs amongst patients, prior to the rollout of vaccines in countries worldwide.MethodsWe conducted a scoping review of English peer-reviewed literature in PubMed, Web of Science and Scopus using a combination of selected search terms. Full texts articles presenting results on COVID-19 HAIs in hospitalised patients before the rollout of vaccines in countries worldwide were eligible. Data extracted from eligible articles included estimates of COVID-19 HAIs, country, and type of hospital setting, and was summarized narratively. Quality assessment of included articles was not possible.ResultsLiterature searches generated a total of 5920 articles, and 45 were eligible for analysis. Eligible articles were from Europe, North America, Asia, and Brazil and none were from low-income countries. The proportion of COVID-19 HAIs ranged from 0% when strict NPPIs were applied, to 65% otherwise. The estimates of COVID-19 HAIs did not differ by country but were lower in studies conducted after implementation of NPPIs and in specialized hospital settings for operative surgery. Studies conducted before the implementation of NPPIs or in long-term care and psychiatric wards often reported high estimates of HAI. Although there was no clear trend in general wards, those situated in academic hospitals managed to reduce HAI rates under strict NPPI protocols. Operative surgery settings, unlike psychiatric settings, effectively prevented COVID-19 HAI using tailored NPPIs.ConclusionThe available evidence shows a high risk of COVID-19 HAIs, the feasibility of preventing HAIs in different healthcare settings and the importance of appropriately tailored NPPIs. There were no data from low-income settings, therefore, it is unclear whether the reported NPPI approaches could be equally effective elsewhere. We recommend routine monitoring of COVID-19 HAIs in countries with low vaccination coverage, to identify and close gaps in NPPIs and understand gains made from vaccinating healthcare workers and hospitalized patients.

Awareness of“ DNAR” and“ DNAR Orders” among Nurses Working in Long-term Care Wards

Awareness of“ DNAR” and“ DNAR Orders” among Nurses Working in Long-term Care Wards

73. Identification of Novel Factors Associated with Inappropriate Treatment of Asymptomatic Bacteriuria Treatment in Acute and Long-term Care

BackgroundInappropriate treatment of asymptomatic bacteriuria (ASB) is a major driver of antibiotic overuse. Demographic and laboratory factors associated with inappropriate antibiotic treatment include older age, pyuria, leukocytosis and dementia. To gain a deeper understanding of inappropriate ASB treatment, we performed an in-depth review of provider documentation capturing a broader range of misleading factors associated with ASB treatment.MethodsWe reviewed a random sample of 10 positive urine cultures per month per facility from acute or long-term care wards at eight Veteran’s Administration (VA) facilities from 2017-2019 (n=960). Trained chart reviewers classified cultures as UTI or ASB and as treated or untreated. Charts were searched specifically for mention of 8 categories of potentially misleading symptoms that often lead to overtreatment of ASB (e.g. “prior history of UTI”) (Figure legend). We also created a ‘suspected systemic inflammatory response syndrome (SIRS)’ category that included any mention of leukocytosis, tachycardia, tachypnea, subjective or low-grade fever, or hypothermia. Generalized estimating equations logistic regression was used for analysis. ResultsOur study included 575 cultures from patients that were primarily white (71%) males (94%) from acute medicine units (75.7%) with a mean age of 76. Twenty-eight percent (n=159) of ASB cases received antibiotics. In addition to the usual known predictors, multiple new misleading symptoms were found to be associated with ASB treatment (Table). Novel, independent predictors of ASB treatment included behavioral issues, such as falls or fatigue (odds ratio (OR): 1.8; 95% CI: 1.05-3.07), urine characteristics, such as cloudy or odorous urine (OR: 1.41; 95% CI: 1.13-1.75), voiding issues (OR: 1.86; 95% CI: 1.43-2.41), and a single, free text mention of a SIRS criteria (OR: 1.63; 95% CI: 1.16-2.3). P-values extracted from multivariate regression model (ASB-asymptomatic bacteriuria; NS-not significant; SIRS- systemic inflammatory response syndrome). The following signs or symptoms compose each category: abnormal laboratory findings: acute kidney injury, abnormal creatinine, leukocytosis, pyuria/positive urinalysis, hyperglycemia; abnormal vital sign: bradycardia, tachycardia, atrial fibrillation, hypotension, hypertension, hypoxia, tachypnea, subjective fever or low-grade fever, syncope; behavior issues: falls, confusion lethargy, fatigue, weakness; nonspecific signs or symptoms: nonspecific gastrointestinal, genitourinary, neurological symptoms; voiding issues: decreased urine output, urinary retention, urinary incontinence; urine characteristics: change in color, foul smell, cloudy urine, sediment; SIRS: ordinal variable characterizing if 1 or ≥ 2 of the following were documented by the provider: leukocytosis, tachycardia, tachypnea, subjective or low-grade fever, hypothermia. ConclusionOur in-depth chart review, with attention to misleading symptoms and any documentation of the provider thought process, highlights new factors associated with inappropriate ASB treatment. Patients with even a single SIRS criteria are at risk for unnecessary treatment of ASB; this finding can help design antibiotic stewardship interventions.Disclosures Barbara Trautner, MD, PhD, Genentech (Consultant, Scientific Research Study Investigator)

Dignity and Predictors of Its Change Among Inpatients in Long-Term Care.

The purpose of this study was to identify any differences in the dignity evaluation of geriatric inpatients after 1 month of hospitalization in a long-term care wards (LTC) and predictors of this change. This follow-up study included 125 geriatric inpatients who filled the Patient Dignity Inventory (PDI-CZ), Geriatric Depression Scale, Barthel Index, and Mini-Mental State Examination. In the initial measurement, the patients rated of PDI-CZ item “Not able to perform tasks of daily living” the worst. One month after, the items “Not able to perform tasks of daily living,” “Not able to attend to bodily functions,” and “Not feeling worthwhile or valued” were improved. Patients with higher education, for whom self-sufficiency improved and depression decreased, rated their dignity more positively 1 month after the hospitalization in LTC. Our findings suggest that these factors are important for the maintenance of the dignity of older adults hospitalized in LTC.

Association Between the Swallowing Reflex and the Incidence of Aspiration Pneumonia in Patients With Dysphagia Admitted to Long-term Care Wards: A Prospective Cohort Study of 60 Days

ObjectiveTo investigate the association between the Simple Swallowing Provocation Test (SSPT) and the incidence of aspiration pneumonia in patients with dysphagia in long-term care (LTC) wards. DesignThe study design was a prospective cohort study. Participants were followed for 60 days from admission. SettingLTC wards. ParticipantsStudy participants were patients with dysphagia aged ≥65 years who were admitted to LTC wards between August 2018 and August 2019. In total, 39 participants were included in the analysis (N=39; 20 male, 19 female; mean age, 83.8±8.5y). Participants were divided into 2 groups based on SSPT results: normal swallowing reflex (SSPT normal group) and abnormal swallowing reflex (SSPT abnormal group). The covariates were age and sex, primary disease, history of cerebrovascular disease, Glasgow Coma Scale, body mass index, Geriatric Nutritional Risk Index, the Mann Assessment of Swallowing Ability, Food Intake Level Scale, FIM, and Oral Health Assessment Tool. InterventionsNot applicable. Main Outcome MeasuresThe outcome was the incidence of aspiration pneumonia during the first 60 days of hospitalization, and the predictive factor was SSPT: 0.4 mL. ResultsThe incidence of aspiration pneumonia was 33.3% in the SSPT normal group and 76.2% in the SSPT abnormal group. The φ coefficient (a measure of association for 2 binary variables) was 0.43, the risk ratio (the ratio of the probability of an outcome in an exposed group to the probability of an outcome in an unexposed group) was 2.29, and the 95% confidence interval was 1.14-4.58 for the SSPT abnormal group. ConclusionsOur findings suggest that the SSPT provides a valid index for the development of aspiration pneumonia in older patients with dysphagia admitted to LTC wards.