Non-critical Care Research Articles

The effect of a tiered provider staffing model on patient outcomes during the coronavirus disease 2019 pandemic: A single-center observational study.

Background:During the coronavirus disease 2019 (COVID-19) pandemic, our hospital experienced a large influx of critically ill patients with acute respiratory failure. In order to increase intensive care unit (ICU) surge capacity, we adopted a “tiered model” for ICU provider staffing where multiple ICUs were staffed by noncritical care providers under the direction of an intensivist. We hypothesized that ICUs staffed with a tiered model would result in similar patient outcomes as ICU staffed with a traditional intensivist model.Methods:We performed a single-center, observational study in seven ICUs at a tertiary care center. We included consecutive adults admitted to the ICU with acute respiratory distress syndrome (ARDS) due to COVID-19 infection. We collected baseline demographics, treatments, and outcomes of interest in traditionally staffed ICUs versus ICUs staffed with a tiered model. The primary outcome was inpatient mortality. All outcomes were censored at day 28.Results:We included a total of 138 patients in our study: 66 patients were admitted to traditionally staffed ICUs and 52 were admitted to tiered staffing ICUs. Baseline characteristics were similar between groups. ARDS treatments were similar in traditionally staffed ICUs versus tiered staffing model ICUs, including daily mean tidal volume (6.2 mL/kg vs. 6.2 mL/kg, P = 0.95), median daily fluid balance (159 mL vs. 92 mL, P = 0.54), and use of prone ventilation (58% vs. 65%, P = 0.45). There was no difference in inpatient mortality between groups (50% vs. 42%, P = 0.46). We also found no difference in ventilator-free, ICU-free, vasopressor-free, and dialysis-free days between groups.Conclusions:Our results suggest that patient outcomes are similar in ICUs with traditional staffing models when compared to ICUs with a tiered staffing mode during a pandemic.

Impact of an Inpatient Nurse-Initiated Penicillin Allergy Delabeling Questionnaire

Background: Penicillin allergy is the most common drug allergy, with ~10% of all patients in the United States reporting a penicillin allergy. A penicillin allergy label is associated with the use of inappropriate or broad-spectrum antibiotics, worse patient outcomes, increased bacterial resistance, and increased healthcare costs, yet no studies have explored the unique role nurses may play in allergy delabeling through history taking as a part of broader antimicrobial stewardship efforts. Here, we describe the impact of using an inpatient nurse-initiated penicillin-allergy questionnaire. Methods: We implemented a nurse-driven intervention focused on penicillin allergy delabeling in inpatient noncritical care units (surgery, neurology, medicine, oncology, and cardiovascular medicine) at an academic hospital from July 9, 2019, to July 24, 2020. Patients with a penicillin allergy listed in the electronic health record (EHR) were identified and invited to participate. The intervention consisted of a questionnaire administered by nurses who elicited details of penicillin allergy history. If a patient was deemed eligible for penicillin allergy removal, nurses requested approval from both the patient as well as a physician member of the study team. Results: In total, 306 patients with a penicillin allergy label were identified in the EHR, of whom 242 patients were eligible for and agreed to participate in the delabeling interview (Figure 1). Of the 34 (14%) of 242 patients potentially eligible for delabeling by the questionnaire based on their history, the study physicians agreed with delabeling for 23 (68%) of 34 patients. Of these 34 patients, 18 (53%) agreed with delabeling (pending physician approval), and 16 (47%) of these 34 patients were ultimately delabeled. For those who declined delabeling, never wanting the label removed under any circumstance and uncertainty about accuracy of the survey results were common reasons for refusal (Figure 2). Additionally, for the 13 patients who refused delabeling, 9 patients did not want or were unsure about following up with an allergy specialist. Conclusions: The nurse-driven penicillin-allergy delabeling questionnaire is a no-cost intervention that can successfully identify patients to delabel. In this study, this measure resulted in the removal of 16 (7%) of 242 penicillin allergy labels. However, patients frequently opted to keep penicillin allergy labels, expressing uncertainty and fear of removal. Future work should explore optimal methods to engage nurses and patients in allergy delabeling, as well as the impact on antibiotic use and patient outcomes.Funding: NoDisclosures: None

Long term outcomes following critical care hospital admission: A prospective cohort study of UK biobank participants✰,★.

BackgroundThis study aimed to understand the impact of a critical care admission on long-term outcomes, compared to other hospitalised patients without a critical care encounter. A secondary aim was to examine the interrelationship between emotional, physical, and social problems during recovery.MethodsWe utilised data from the UK Biobank, an on-going, prospective population-based cohort study. We employed propensity score matching to assess differences in outcomes between patients with a critical care encounter and patients admitted to the hospital (first admission to hospital available) without critical care. Structural equation modelling was used to analyse emotional, physical and social outcomes following critical illness and the relationships between these health domains.FindingsData from 1,618 patients were analysed. The median time to follow-up in the critical care cohort was 4427 days (IQR:788–6146) vs 4516 days (IQR: 811–6369) in the non-critical care, hospitalised cohort. Across the two time periods assessed (pre and post 2000), patients exposed to critical care were more likely to experience mental health issues such as depression (p < 0.01) and social isolation (p = 0.01) following discharge from hospital. The critical care cohort were also more likely to have social problems such as the requirement for government funded welfare support (p = 0.02). In the critical care cohort, social and emotional health were closely correlated (p < 0.001, 95% CI:0.33–0.54). The nature of physical problems changed over time; pre-2000 there was a significant difference between the critical and non-critical care in physical outcomes following discharge from hospital, however, there was no difference detected between the two cohorts post-2000.InterpretationThis cohort study has demonstrated that survivors of critical illness have different psycho-social outcomes to matched patients, hospitalised without a critical care encounter.FundingJM is funded by a THIS.Institute (University of Cambridge) Research Fellowship (PD-2019–02–16). AHL is part of the Social and Public Health Sciences Unit, funded by the Medical Research Council (MC_UU_12017/13) and the Scottish Government Chief Scientist Office (SPHSU13).

Upgrades to intensive care: The effects of COVID-19 on decision-making in the emergency department.

IntroductionThe initial surge of critically ill patients in the COVID-19 pandemic severely disrupted processes at acute care hospitals. This study examines the frequency and causes for patients upgraded to intensive care unit (ICU) level care following admission from the emergency department (ED) to non-critical care units.MethodsThe number of ICU upgrades per month was determined, including the percentage of upgrades noted to have non-concordant diagnoses. Charts with non-concordant diagnoses were examined in detail as to the ED medical decision-making, clinical circumstances surrounding the upgrade, and presence of a diagnosis of COVID-19. For each case, a cognitive bias was assigned.ResultsThe percentage of upgraded cases with non-concordant diagnoses increased from a baseline range of 14–20% to 41.3%. The majority of upgrades were due to premature closure (72.2%), anchoring (61.1%), and confirmation bias (55.6%).ConclusionConsistent with the behavioral literature, this suggests that stressful ambient conditions affect cognitive reasoning processes.

PIN20 Predicting the IMPACT of Vaccination Strategies in the COVID-19 Pandemic Using a Susceptible-Exposed-Infectious-Removed (SEIR) MODEL

Coronavirus (COVID-19) has resulted in 84.53 million infections and 1.85 million deaths world-wide in 2020 and both numbers are still increasing. Using a Susceptible-Exposed-Infectious-Removed (SEIR) model, this study aimed to predict the impact of different vaccination strategies in the UK on mortality, productivity loss, and healthcare burden. A SEIR model was built in R using the UK estimated age-group specific proportions of asymptomatic infections, probability of severe symptoms and death rate from published literature. Assuming vaccine supply covers 20% or 50% of the UK population as two base scenarios, three population-wide vaccination strategies with different age group priorities were modelled. Total number of infections, COVID-19 related deaths, quality-adjusted life years (QALYs) lost, cost for critical and non-critical care, and productivity loss were estimated. In the 20% population coverage scenario, 2 million more infections were prevented by vaccinating the 15-34 age group first, compared to vaccinating those over 65 first. A £6.6 billion reduction (13%) in direct healthcare costs was predicted by prioritising people over 65. Productivity and QALY losses were minimised by prioritising the 15-34 age group, while only vaccinating those over 65 resulted in the lowest number of deaths. Increasing population coverage from 20% to 50% resulted in drops in QALY loss and healthcare burden, but did not affect the age group strategy. A strategy that prioritises elderly vaccination would minimise QALY losses only if the death rate amongst 15-34s dropped by 17.4% (from 10.9% to 9%). With constraints in vaccine supplies, greater reductions in hospitalisation costs related to COVID-19 and deaths were associated with a vaccination strategy prioritising older age groups. Lower QALY and productivity losses were associated with a vaccination strategy prioritising younger cohorts. Future research adding age-group specific social distancing measures may provide further insights.

695-P: Comparison of Inpatient Glycemic Control in Hybrid Closed-Loop vs. Sensor-Augmented Insulin Delivery Systems

The hybrid closed-loop (HCL) insulin delivery system is at the forefront of continuous subcutaneous insulin infusion technology. However, to our knowledge, no studies to date have compared inpatient glycemic control between the HCL and non-HCL delivery systems of the HCL insulin pumps. We aim to compare the efficacy and safety of glycemic control between these two insulin delivery systems in the hospital setting. We are performing a prospective study on patients using a HCL insulin pump who are admitted to a non-critical care floor. We included patients who were ≥18 years of age, diagnosed with type 1 or type 2 diabetes, on a HCL insulin pump for more than 4 weeks, and admitted for ≥2 days. The primary outcome is the comparison of percentage of point of care blood glucose readings between 70 and 180 mg/dL in the HCL system versus the non-HCL system. Secondary outcomes include percentage of glucose readings >180 mg/dL and Here, we report preliminary findings of 9 patients using the non-HCL system and 4 patients using the HCL system (Table 1). In the HCL group, >70% of the time was spent in the target blood glucose range of 70-180 mg/dL, 180 mg/dL, and Disclosure Y. Tsushima: None. A. Iqbal: None. J. F. Bena: None. M. Lansang: Consultant; Self; Sanofi. Research Support; Self; Dexcom, Inc.

High-flow nasal oxygen therapy in the treatment of acute respiratory failure in severe COVID-19 pneumonia: a prospective observational study

A significant proportion of patients with COVID‑19 present with a rapidly progressing severe acute respiratory failure. We aimed to assess the efficacy of high‑flow nasal oxygen (HFNO) therapy in severe acute respiratory failure in the course of COVID‑19 in a noncritical care setting as well as to identify predictors of HFNO failure. This prospective observational study was conducted between March and December 2020. We enrolled all consecutive patients hospitalized with confirmed SARS‑CoV‑2 infection in whom HFNO therapy was used. The primary outcome was death or endotracheal intubation within 30 days from admission. Of the 380 patients with COVID‑19 hospitalized at our tertiary center, 116 individuals (30.5%) requiring HFNO due to severe pneumonia were analyzed. The primary outcome occurred in 54 patients (46.6%). The overall 30‑day mortality rates were 30.2% (35 out of 116 patients) in the entire cohort and 64.7% (34 out of 51 patients) among individuals requiring endotracheal intubation. A multivariable analysis revealed that the ROX index (the ratio of oxygen saturation / fraction of inspired oxygen to respiratory rate) below 3.85 measured within the first 12 hours of therapy was related to increased mortality (hazard ratio, 5.86; 95% CI, 3.03-11.35) compared with the ROX index of 4.88 or higher. The results of our study suggest that nearly half of patients treated with HFNO due to severe COVID‑19 pneumonia will require mechanical ventilation. The ROX index is a useful tool for predicting HFNO failure in this population.

The association between glycaemic control during hospitalization and risk of adverse events: A retrospective cohort study

IntroductionHyperglycaemia is common during hospitalization; glycaemic targets in non‐critical care settings have not been well studied. We assessed associations between inpatient glycaemic control and adverse events.MethodsWe conducted a retrospective cohort study on non‐critically ill medical patients hospitalized in a tertiary care hospital between 2015 and 2018. Mean glycaemia during the first four days of hospitalization was categorized as 4.0–7.0 mmol/L, 7.1–10.0 mmol/L and >10.0 mmol/L. The primary outcome was a composite of adverse events including mortality, infections, acute kidney injury, thromboembolic and cardiovascular events. The secondary outcome was hypoglycaemia, defined as any glycaemia <4.0 mmol/L. Logistic regression was used to assess adverse events, and a Cox proportional hazards model was used to estimate hypoglycaemia risk.ResultsOur cohort included 1,368 patients, of whom 407 (29.8%) experienced an adverse event. We did not find associations between glycaemia of 4.0–7.0 mmol/L (adjusted odds ratio [OR]: 0.88, 95% confidence interval [CI]: 0.63–1.23) or glycaemia of >10.0 mmol/L (adjusted OR: 0.98, 95% CI: 0.75–1.28) and the occurrence of adverse events, compared to a glycaemia of 7.1–10.0 mmol/L. Glycaemia of >10.0 mmol/L was associated with an increased risk of hypoglycaemia (adjusted hazard ratio [HR]: 1.72, 95% CI: 1.21–2.45). Hypoglycaemia was associated with adverse events (adjusted OR 1.85, 95% CI 1.31–2.60).ConclusionsNeither glycaemia of 4.0–7.0 mmol/L nor glycaemia of >10.0mmol/L during non‐critical care hospitalization was associated with increased adverse events. Glycaemia of >10.0 mmol/L was associated with increased hypoglycaemia, likely due to aggressive glucose lowering. These findings highlight the need for further studies to discern optimal inpatient glycaemic targets.

Responding to the COVID-19 pandemic: Development of a critical care nursing surge model to meet patient needs and maximise competencies

BackgroundThe current coronavirus disease 2019 (COVID-19) pandemic is creating unprecedented and unchartered demands on critical care units to meet patient needs and adapt the delivery of health services. Critical care nurses play a pivotal role in developing models of care that are effective, flexible, and safe. ObjectivesWe report on the accelerated development of a critical care nursing surge model responsive to escalating needs for intensive care capacity. MethodsWe conducted an exploratory prospective observational cohort study that included (i) a self-assessment and survey of learning needs of noncritical care nurses identified as candidate groups for redeployment in the intensive care unit and (ii) a pilot implementation of a team nursing model evaluated by individual questionnaires and the conduct of focus groups. We used descriptive statistics and qualitative content analysis to analyse the exploratory findings. ResultsWe surveyed 147 noncritical care nurses; 99 (67.3%) self-assessed at the lowest level of critical care competency, whereas 33 (24.3%) reported feeling able to help care for a critically ill patient under the direction of a critical care nurse. Identified learning needs included appropriate use of personal protective equipment in the intensive care unit (n = 123, 83.7%), use of specialised equipment (n = 103, 85.1%), basic mechanical ventilation, and vasoactive medication. We completed 11 team nursing pilot assignments with dyads of critical care and noncritical care nurses categorised in tiers of competencies. Nurses reported high levels of perceived support and provision of safe care; multiple recommendations were identified to improve the model of care delivery and communication. ConclusionsThe complexity, acuity, and unpredictability of the COVID-19 pandemic is placing new demands on critical care nurses to modify existing processes for care delivery while ensuring excellent outcomes and professional satisfaction. The study findings provide a road map to support nursing engagement in meeting patient needs.

Predictors and outcomes of patients that return unplanned to the Emergency Department and require critical care admission: A multicenter study

ObjectiveTo determine the incidence, characteristics (including timeframe) and predictors of patients discharged from the Emergency Department (ED) that later return and require admission. MethodsA retrospective cross-sectional study examining all return visits to three EDs in Sydney, Australia, over a 12-month period. Patients returning within 28 days from ED discharge with the same or similar complaint were classified as a return visit to ensure capture of all return visits. Descriptive and inferential statistics were used to analyse the data and logistic regression was performed to predict factors associated with return visits with general admission, and return visits admitted to critical care. ResultsThere were 1,798 (30%) return visits which resulted in admission, mostly to a non-critical care area (1,679, 93%). The current NSW 48 -h time frame used to define a return visit in NSW captured half of all admitted returns (49.5%) and just over half (59.2%) of critical care admissions. Variables associated with an admission to critical care were age (OR 1.02, 95% CI 1.01, 1.03), initial presentation (index visit) made to a lower level ED (OR 3.76 95% CI 2.06, 6.86), Triage Category 2 (OR 3.67 95% CI 2.04, 6.60) and a cardiac diagnosis (OR 5.76, 95% CI 3.01, 11.01). This model had adequate discriminant ability with AUROC = 0.825. ConclusionA small number of return visits result in admission, especially to critical care. These patients are at risk of poor outcomes. As such, clinicians should have increased index of suspicion for patients who return that are older, present with cardiac problems, or have previously presented to a lower level ED. Revision of the current timeframe that defines a return visit ought to be considered by policy makers to improve the accuracy of this widely used key performance indicator.

Addressing Hospital-Acquired Hypoglycemia.

Hospitalized patients who have diabetes often experience hospital-acquired hypoglycemia, a potentially serious adverse event; as a result, management of this condition has become an important quality of care indicator in the inpatient environment. A growing body of research and evidence-based clinical guidelines support proper timing of point of care (POC) blood glucose (BG) measurements, mealtime insulin administration, and meal delivery to reduce the incidence of both hypoglycemic and hyperglycemic events. Monitoring and improving the timing of these three patient care interventions are recognized as a crucial step in the safe and effective care of patients with diabetes. The objective of the QI project was to improve the timing of mealtime insulin administration related to bedside BG monitoring and meal delivery for patients with diabetes who receive mealtime insulin; a secondary goal was to decrease the number of episodes of recurrent hypoglycemia. The overall strategy was to change staff members' approach to mealtime insulin management from a series of individual tasks to a process-oriented collaborative approach. Nurses on the medical-surgical unit at one hospital within a large health system formed a QI team with staff members in information technology and food and nutrition services. The team implemented an eight-week QI pilot project (July 3 to August 26, 2017) using a multidisciplinary approach to coordinate between POC BG measurement, mealtime insulin administration, and meal delivery. More than two years after the hospital-wide rollout of the practice change, follow-up analysis has shown that, on both noncritical and critical care units, recurrent hypoglycemia has decreased. For example, comparing data obtained in a six-month period before the pilot project (November 2016 through April 2017) with the same six-month period in 2018 and 2019, more than a year after the pilot project, the percentage of patient stays (admissions) on noncritical care units in which there was a recurrence of hypoglycemia fell from 41.8% (of 1,162 total hospital admissions) to 35.1% (of 792 total hospital admissions); similarly, the percentage of patient stays on critical care units in which recurrent hypoglycemia occurred decreased from 36.8% to 22.8%. Findings suggest that ensuring a consistent 30-minute window between POC BG measurement and meal delivery enabled nursing staff to perform timely POC BG measurements and administer a more optimal mealtime insulin dose. Increasing interdisciplinary communication, collaboration, and awareness of best practice guidelines relating to proper mealtime insulin administration resulted in a sustained improvement in timing between POC BG measurements and mealtime insulin administration and between mealtime insulin administration and meal delivery.

Pharmacist-led diabetes stewardship program improves patients' lives

Five years ago, the University of Nebraska Medical Center (UNMC) in Omaha started a diabetes stewardship pharmacist program led by Jon Knezevich, PharmD. Since the beginning, the program has improved patients’ glycemic control and resulted in cost savings for the health care system through technological and process advancements. Between January 2015 and June 2020, UNMC reported significant reductions in hypoglycemic (<70 mg/dL) events in both critical and noncritical care units—about 65% and 50%, respectively. “This translates to an estimated cumulative length of stay reduction of 0.46 days and greater than $690,000 in cost avoidance annually, along with an additional $150,000 in cost savings from formulary management strategies,” said Knezevich. Specially trained pharmacists at UNMC monitor blood glucose levels in hospitalized patients to help maintain glycemic control. “While diabetes may not be the reason a patient is hospitalized, it often contributes to complexity in managing their health care during their inpatient stay,” said Knezevich. There is considerable evidence to suggest that regardless of cause, hyperglycemia among hospitalized patients with or without diabetes is often associated with poor outcomes. According to a June 2009 consensus statement in Diabetes Care from the American Association of Clinical Endocrinologists and the American Diabetes Association, patients with diabetes are more likely to be hospitalized and have longer hospital stays than patients without diabetes. How pharmacists can improve the lives of patients with diabetes at their institutions□Implement a team-based approach to achieve positive outcomes for the high number of patients with diabetes.□Recognize that administrative support is vital to champion initiatives surrounding improvement in glycemic outcomes.□Identify major objectives that are measurable at the onset and throughout project implementation to demonstrate achievement of institutional goals.This is a marathon, not a sprint! Empowering colleagues across disciplines helps ensure buy-in and accountability.—Jon Knezevich, PharmD □Implement a team-based approach to achieve positive outcomes for the high number of patients with diabetes.□Recognize that administrative support is vital to champion initiatives surrounding improvement in glycemic outcomes.□Identify major objectives that are measurable at the onset and throughout project implementation to demonstrate achievement of institutional goals. This is a marathon, not a sprint! Empowering colleagues across disciplines helps ensure buy-in and accountability. —Jon Knezevich, PharmD The UNMC program has minimized glycemic excursions—hypoglycemia and hyperglycemia—during a patient's hospital stay, said Knezevich, thus reducing health care waste that may have resulted due to blood glucose abnormalities. According to Knezevich, many factors have played a role in the program's ongoing success. Major ones are educational and training efforts to help pharmacists feel empowered to make clinical decisions, use of technological advancements to streamline workflow processes, and interdisciplinary communication within the organization to promote collaboration hospital-wide. “I am extremely proud of our commitment to patient care, including the coordinated efforts our pharmacy service line has contributed to improving blood glucose control,” said Knezevich. “This program illustrates the impact pharmacists can have when working collaboratively with the health care team.” Other factors that have contributed to the program's success include □Development of an acute glycemic management credentialing competency training program to help pharmacists feel more confident in making clinical decisions.□Creation of a novel dashboard using the hospital's electronic health record system for timely decision support to allow for decentralized pharmacy services.□Identification of high-risk medications in the updated system to require lab monitoring for medications to ensure appropriate therapy regimens. In addition, the hospital reviewed and revised the inpatient formulary and began using larger (10 mL) multiuse insulin vials, which led to about $10,000 in cost savings over a 1-month period. While it was not a quick win for UNMC's diabetes stewardship pharmacist program, with perseverance, collaboration, and determination, other stewardship programs can have similar or even greater impacts. As the medication experts, pharmacists should feel empowered to use their knowledge and training to help patients maximize their health outcomes. Showing organizations and other providers that pharmacists bring considerable value to the health care system helps pharmacists do their best work, while saving costs along the way. “Although our rates of hypoglycemia have been substantially reduced since program implementation, we would like to avoid all episodes,” said Knezevich.

Benzodiazepine exposures among women of reproductive age in the US, 2004-2018.

Benzodiazepines, often used to treat anxiety, insomnia, and other conditions, are prescribed more frequently to women than men, and emergency department visits and overdose deaths involving benzodiazepines have increased significantly among women in recent years. This study describes characteristics and trends associated with benzodiazepine exposures among women of reproductive age (15-49 years old) that were reported to United States poison control centers from 2004 through 2018. The National Poison Data System recorded 258,370 first-ranked benzodiazepine exposures among women 15-49 years old during the study period. More than one-half (56.9%) of exposures involved a single-substance and one-third (34.0%) occurred among women 20-29 years old. The majority were categorized as "intentional, suspected suicide" (73.2%) or "intentional" (12.9%). Exposures frequently resulted in admission to a psychiatric facility (20.6%), critical care unit (18.1%), or non-critical care unit (9.3%). Twenty percent of cases resulted in a serious medical outcome, including 205 deaths. The substantial percentage of benzodiazepine exposures among women of reproductive age that were intentional and associated with suicide attempts or suicide deaths indicate that increased prevention efforts are needed to address this issue.

Chlorhexidine Wipes to Reduce Multidrug-Resistant Gram-negative Bacterial Colonization and Healthcare-associated Infections among Medical Inpatients: A Cluster-Randomized Trial

Objective: To evaluate efficacy of chlorhexidine gluconate (CHG) to decolonize multidrug-resistant (MDR) gram-negative bacilli (GNB) bacteria, and to reduce healthcare associated infections (HAIs) in general medical inpatients. Materials and Methods: A 1-year, cluster-randomized study was conducted in a university hospital-based general medical unit. Eligible patients were randomized by study ward for routine daily and extra wiping with non-rinsed CHG-cloths (CHG group, n=145) or rinsed, non-medicated soap bath (control group, n=145), consecutively to the end of study. Study nurses received training and audits per CHG protocol. In all participants, axillae, groins, and perianal area were sampled to detect GNB colonization, on day 4 to 7 and day 11 to 14 of admission, by surveillance culture. All were followed for incidence rates of HAIs to day 14 of the study, or study exclusion. Results: MDR GNB colonization were significantly lower in CHG group than those of control group, both day 4 to 7 (15.9% versus 43.4%, respectively, p&lt;0.01), and day 11 to 14 of admission (20.6% versus 65.4%, respectively, p&lt;0.01). The incidence rates of overall HAIs did not differ between groups (5.80 versus 7.10 episodes per 1,000 patient-day, respectively, p=0.84). Three patients developed minor skin irritation in CHG group. Discussion: To the investigators’ knowledge, the present study is the first to demonstrate significant CHG reduction of MDR GNB colonization among medical patients in non-critical care unit. Use of non-rinsed CHG bath, personnel training, and audits, may maintain adequate skin concentration of CHG, and lower risk of cross-transmission. To effectively reduce HAIs, combined CHG bath and bundle of care may be required. Conclusion: Non-rinsed chlorhexidine baths are safe, well-tolerated, and effective to reduce MDR gram-negative bacterial colonization among general medical inpatients, and possible to lower risk of subsequent HAIs and cross-transmission, by day 14 of admission. Keywords: Multidrug-resistant gram-negative bacilli, Chlorhexidine bath, Decolonization, Healthcare associated infections, General medical inpatients

Quality improvement for self-confidence, critical-thinking, and psychomotor skills in basic life support of nursing health professionals through case-scenario simulation training

Background: Recognition and timely management of medical emergencies in non-critical care units are essential in initiating and delivering high quality care. Simulation training is a constructive tool that can be utilized to refresh and maintain knowledge and skills for staff that may not encounter medical emergencies frequently. This study examined staff that work at the John D. Dingell VA Medical Center Community Living Center (CLC), a subacute and inpatient rehabilitation unit, on their critical thinking skills, knowledge, role responsibilities and confidence levels prior to and after implementation of a mixed intervention of a one-hour webinar didactic and one-hour case-based simulation with debriefing. The purpose of the study was to improve non-critical care staff critical thinking, knowledge and confidence when working with a deteriorating patient.Methods: A pretest-posttest study design was used to conduct the study. Pre and post surveys were given to 42 health professionals which included registered nurses (RN), licensed practical nurses (LPN) and nursing aides after participating in a case scenario using a high-fidelity mannequin to simulate a medical emergency. Analyses were performed using the two-tailed t-test with p-value significance of less than .05 using Excel and JMP by SAS.Results: Among the 42 participants, there was a significant improvement in confidence for recognizing signs of patient deterioration for timely activation of code team (p &lt; .001). Critical thinking skills and knowledge on appropriate activation of the type of response team based on patients’ speed of deterioration also improved after the intervention (p &lt; .001). Overall, the staff felt more comfortable, confident and knowledgeable concerning their roles and local policy of emergent situations.Conclusions: A team-based case scenario simulation course may improve non-critical care nursing staff confidence, knowledge and critical thinking as it pertains to activation of code teams and willingness to actively participate in medical emergencies.

Mass Casualties and Disaster Implications for the Critical Care Team.

Preparing for disasters both natural and anthropogenic requires assessment of risk through hazard vulnerability analysis and formulation of facility and critical care-specific disaster plans. Disaster surge conditions often require movement from conventional to contingency or crisis-level operations to meet the needs of the many under our care. Predisaster planning for modification of critical care space, staffing, and supplies is essential to successful execution of operations during a surge. Expansion of intensive care unit beds to nonconventional units such as perioperative areas, general care units, and even external temporary units may be necessary. Creative, tiered staffing models as well as just-in-time education of noncritical care clinicians and support staff are important to multiply capable personnel under surge conditions. Finally, anticipation of demand for key equipment and supplies is essential to maintain stockpiles, establish supply chains, and sustain operations under prolonged disaster scenarios.

Collaboration Between Tele-ICU Programs Has the Potential to Rapidly Increase the Availability of Critical Care Physicians-Our Experience Was During Coronavirus Disease 2019 Nomenclature.

Objectives:Implement a connected network between two Tele-ICU programs to support staffing and rounding during the first wave of the coronavirus disease 2019 pandemic in the United States.Design:Proof of Concept model.Setting:Northwell Health; a 23 Hospital, 40 ICU (500 ICU beds) healthcare organization serving the downstate NY area. During the initial coronavirus disease 2019 pandemic, Northwell Health rapidly expanded to greater than 1,000 ICU beds. The surge in patients required redeployment of noncritical care providers to the ICU bedside. The Tele-ICU program expanded from covering 176 beds pre pandemic to assisting with care for patients in approximately 450 beds via deployment of Wi-Fi-enabled mobile telehealth carts to the newly formed ICUs.Patients:Critically ill coronavirus disease 2019 patients hospitalized at Northwell Health, NY, at any point from March 2020 to June 2020.Interventions:To offset the shortage of critical care physicians, Northwell Health established a collaboration with the Tele-ICU program of Providence, St. Joseph Health in the state of Washington, which enabled the critical care physicians of Providence, St. Joseph Health to participate in virtual rounding on critically ill coronavirus disease 2019 patients at Northwell Health.Main Results:We developed an innovative hybrid model that allowed for virtual rounding on an additional 40–60 patients per day by a remote critical care physician at Providence, St. Joseph Health. This was accomplished in approximately 3 weeks and provided remote care to complex patients.Conclusions:Our findings demonstrate the proof of concept of establishing a network of connected Tele-ICU programs as a rapidly scalable and sustainable paradigm for the provision of support from critical care physicians for noncritical care teams at the bedside.

How long should we run the code? Survival analysis based on location and duration of cardiopulmonary resuscitation (CPR) after in-hospital cardiac arrest

ABSTRACT Background: The duration of cardiopulmonary resuscitation (CPR) significantly affects long-term survival in patients with in-hospital cardiac arrests (IHCA). In this study, we questioned the long-term clinical benefits of extending CPR beyond twenty minutes for patients with in-hospital cardiac arrest. Additionally, we aimed to compare the outcomes of CPR at different locations of a large tertiary care community hospital. Methods: This study was a retrospective chart review of 169 patients with IHCA recorded between 1 January 2016, and 31 December 2018, at a large volume tertiary care community hospital. Results: Of the 169 patients suffering from cardiac arrest during hospitalization, 44.4% arrested in the intensive care unit (ICU) and 55.6% in a non-critical care setting. Return of spontaneous circulation (ROSC) was achieved in 60% of ICU and 70.2% of non-ICU patients. While only 20% of ICU patients survived the cardiac arrest, the overall survival for non-ICU patients was 31.9%. Despite the significant difference in percentage survival, survival difference did not reach statistical significance (p = 0.082) due to the small sample size. Overall survival was 26.6%. An initial shockable rhythm was associated with improved survival compared to a non-shockable rhythm (41% vs. 22.5%, p = 0.022). In patients who had cardiac arrest for less than 20 minutes, 60.9% of patients achieved ROSC, compared to 37.9% who arrested for more than 20 minutes. Survival to hospital discharge was significantly lower for patients who had cardiac arrest for more than 20 minutes, compared to patients who were arrested for less than 20 minutes (3.1% vs. 41.3%, p = <0.0001). For patients who had a cardiac arrest for more than 30 minutes, ROSC was achieved in only 14.8% of patients. None of these patients survived to be discharged from the hospital (p = <0.0001). The mean age for the patients in this study was 70 years. 52.6% of subjects were male, and 47.4% were females. Older age was not related to shorter duration of CPR (Pearson correlation: 0.030, P = 0.69). Conclusion: Survival was significantly lower when CPR was unsuccessful for twenty minutes, and there is no survival benefit of extending CRP for more than 30 minutes. Lowest survival after a cardiac arrest on the general medical floor, compared to telemetry and ICU, may be related to delay in recognizing cardiac arrest and barriers in implementing standardized advanced cardiac life support (ACLS) protocol.

Discontinuing β-lactam treatment after 3 days for patients with community-acquired pneumonia in non-critical care wards (PTC): a double-blind, randomised, placebo-controlled, non-inferiority trial

Shortening the duration of antibiotic therapy for patients admitted to hospital with community-acquired pneumonia should help reduce antibiotic consumption and thus bacterial resistance, adverse events, and related costs. We aimed to assess the need for an additional 5-day course of β-lactam therapy among patients with community-acquired pneumonia who were stable after 3 days of treatment. We did this double-blind, randomised, placebo-controlled, non-inferiority trial (the Pneumonia Short Treatment [PTC]) in 16 centres in France. Adult patients (aged ≥18 years) admitted to hospital with moderately severe community-acquired pneumonia (defined as patients admitted to a non-critical care unit) and who met prespecified clinical stability criteria after 3 days of treatment with β-lactam therapy were randomly assigned (1:1) to receive β-lactam therapy (oral amoxicillin 1 g plus clavulanate 125 mg three times a day) or matched placebo for 5 extra days. Randomisation was done using a web-based system with permuted blocks with random sizes and stratified by randomisation site and Pneumonia Severity Index score. Participants, clinicians, and study staff were masked to treatment allocation. The primary outcome was cure 15 days after first antibiotic intake, defined by apyrexia (temperature ≤37·8°C), resolution or improvement of respiratory symptoms, and no additional antibiotic treatment for any cause. A non-inferiority margin of 10 percentage points was chosen. The primary outcome was assessed in all patients who were randomly assigned and received any treatment (intention-to-treat [ITT] population) and in all patients who received their assigned treatment (per-protocol population). Safety was assessed in the ITT population. This study is registered with ClinicalTrials.gov, NCT01963442, and is now complete. Between Dec 19, 2013, and Feb 1, 2018, 706 patients were assessed for eligibility, and after 3 days of β-lactam treatment, 310 eligible patients were randomly assigned to receive either placebo (n=157) or β-lactam treatment (n=153). Seven patients withdrew consent before taking any study drug, five in the placebo group and two in the β-lactam group. In the ITT population, median age was 73·0 years (IQR 57·0-84·0) and 123 (41%) of 303 participants were female. In the ITT analysis, cure at day 15 occurred in 117 (77%) of 152 participants in the placebo group and 102 (68%) of 151 participants in the β-lactam group (between-group difference of 9·42%, 95% CI -0·38 to 20·04), indicating non-inferiority. In the per-protocol analysis, 113 (78%) of 145 participants in the placebo treatment group and 100 (68%) of 146 participants in the β-lactam treatment group were cured at day 15 (difference of 9·44% [95% CI -0·15 to 20·34]), indicating non-inferiority. Incidence of adverse events was similar between the treatment groups (22 [14%] of 152 in the placebo group and 29 [19%] of 151 in the β-lactam group). The most common adverse events were digestive disorders, reported in 17 (11%) of 152 patients in the placebo group and 28 (19%) of 151 patients in the β-lactam group. By day 30, three (2%) patients had died in the placebo group (one due to bacteraemia due to Staphylococcus aureus, one due to cardiogenic shock after acute pulmonary oedema, and one due to heart failure associated with acute renal failure) and two (1%) in the β-lactam group (due to pneumonia recurrence and possible acute pulmonary oedema). Among patients admitted to hospital with community-acquired pneumonia who met clinical stability criteria, discontinuing β-lactam treatment after 3 days was non-inferior to 8 days of treatment. These findings could allow substantial reduction of antibiotic consumption. French Ministry of Health.

Review of mechanical ventilation for the non-critical care trained practitioner. Part 2

Review of mechanical ventilation for the non-critical care trained practitioner. Part 2