Non-intensive Care Unit Research Articles

Rapid Intensive Care Unit Onboarding in Response to a Pandemic.

Background:In the wake of the coronavirus disease 2019 (COVID-19) pandemic, hospital resources have been stretched to their limits. We introduced an innovative course to rapidly on-board a group of non-intensive care unit (ICU) nurse practitioners as they begin to practice working in a critical care setting.Objective:To assess whether a brief educational course could improve non-ICU practitioners’ knowledge and comfort in practicing in an intensive care setting.Methods:We implemented a multi-strategy blended 12-week curriculum composed of bedside teaching, asynchronous online learning and simulation. The course content was a product of data collected from a targeted needs assessment. The cognitive learning objectives were taught through the online modules. Four simulation sessions were used to teach procedural skills. Bedside teaching simultaneously occurred from critical care faculty during daily rounds. We assessed learning through a pre and post knowledge multiple choice question (MCQ) test. Faculty assessed learners by direct observation and review of clinical documentation. We evaluated learner reaction and comfort in critical practice by comparing pre and post surveys.Results:All 7 NPs were satisfied with the course and found the format to work well with their clinical schedules. The course also improved their self-reported comfort in managing critically ill patients in a medical ICU. There was an increase in the mean group score from the pre-to the post-course MCQ (60% vs 73%).Conclusions:The COVID-19 Critical Care Course (CCCC) for NPs was implemented in our ICU to better prepare for an anticipated second surge. It focused on delivering practical knowledge and skills as learners cared for critically ill COVID-19 patients. In a short period of time, it engaged participants in active learning and allowed them to feel more confident in applying their education.

Thromboembolic Rates Are Similar Between Intensive Care Unit and Nonintensive Care Unit Hospitalized Patients With Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2): A Retrospective Cohort Study.

High rates of thromboembolic events have been described in intensive care unit (ICU) patients. Data regarding thromboembolic events in all hospitalized patients has been less frequently reported, raising concerns that thromboembolic events in non-ICU may be underrecognized. In addition, optimal anticoagulation type and dose is still unsettled at this time. This is a retrospective cohort study of 159 hospitalized patients with coronavirus disease 2019 (COVID-19) pneumonia during a 9-month period to determine an association between the frequency of thromboembolic rates and hospitalized patients with COVID-19. Secondary outcomes sought to investigate association of thromboembolic events with relation to place of admission, risk factors, anticoagulation, mortality, hospital length of stay, and discharge disposition. Among the cohort of 159 hospitalized patients who met criteria, 16 (10%) were diagnosed with a thromboembolic event. There were a total of 18 thromboembolic events with 12 venous and 6 arterial. Admission to the ICU was not associated with a higher frequency of thromboembolic events compared with non-ICU patients (37.5% vs 62.5%), p = .71. Patients with a thromboembolic event had a significantly higher mortality compared with those with no thromboembolic event (37.5% vs 13.3%), p = .012. Patients hospitalized with COVID-19 have increased rates of thromboembolic events, both venous and arterial, which contribute to a significant increase in mortality. However, the frequency of thromboembolism in patients admitted to the ICU was similar to events in non-ICU patients. We hope to increase awareness of the increased risk of hypercoagulability in all hospitalized patients with COVID-19 including non-ICU patients.

Evaluation of non-intensive care unit acquired sepsis and septic shock patients in intensive care unit outcomes

Evaluation of non-intensive care unit acquired sepsis and septic shock patients in intensive care unit outcomes

66. Impact of a Pharmacist-Driven Azithromycin De-escalation Protocol for Community-Acquired Pneumonia

BackgroundCeftriaxone and azithromycin are common empiric antibiotics for community-acquired pneumonia (CAP). Despite low suspicion for atypical infection, azithromycin is often continued for a full course. Negative laboratory data for atypical bacteria may assist with azithromycin de-escalation. Thus, a pharmacist-driven azithromycin de-escalation protocol was implemented for immunocompetent, non-intensive care unit (ICU) patients treated for CAP. The primary outcome was to compare azithromycin duration before and after protocol implementation. Secondary outcomes included hospital length of stay (LOS) and all-cause 30-day readmission.MethodsThis was a single-center, quasi-experimental study of hospitalized, non-ICU patients treated with azithromycin and a beta-lactam for CAP. The pre- and post-intervention cohorts were from 07/01/2018–04/30/2019 and 07/01/2019–04/30/2020, respectively. Patients were included if they were ≥18 years old, diagnosed with CAP, and had a negative Legionella pneumophila urinary antigen and negative nasopharyngeal swab PCR for Mycoplasma pneumoniae and Chlamydia pneumoniae. Patients were excluded if they were immunocompromised, admitted to an ICU, prescribed azithromycin for an alternative indication, or had evidence of atypical bacteria.ResultsAfter exclusion criteria were applied, 90 and 100 patients were included in the pre- and post-intervention cohorts, respectively. Demographic and clinical characteristics were mostly similar between cohorts. This initiative was associated with a statistically significant decrease in azithromycin duration (2 days (IQR 1–2.75) vs. 5 days (IQR 3–6), p < 0.001) and hospital LOS (3 days (IQR 2–5) vs. 5 days (IQR 3–8.25), p < 0.001). No statistically significant difference was observed for all-cause 30-day readmission (14 days (15.6%) vs 13 days (13.0%), p=0.614).ConclusionImplementation of a pharmacist-driven azithromycin de-escalation protocol for CAP was associated with reduced azithromycin duration and hospital LOS, but not all-cause 30-day readmission.Disclosures Jeffrey Steele, PharMD, Paratek Pharmaceuticals (Advisor or Review Panel member) Wesley D. Kufel, PharmD, Melinta (Research Grant or Support)Merck (Research Grant or Support)Theratechnologies, Inc. (Advisor or Review Panel member)

138. Focused Outpatient Antibiograms: Time for Widespread Implementation?

BackgroundSignificant antimicrobial use occurs in outpatient settings, making this an important area for expanding stewardship. Data show over 260 million annual prescriptions in the U.S. Family practitioners prescribed the most antibiotic courses (24%)1. Urinary Tract Infections (UTI) comprise one of the most common indications for antibiotics. In this study, antibiogram data were compiled for urinary isolates of E coli collected from all outpatients as well as Family Medicine-specific (FM) clinics in an academic medical center in Eastern NC. The objective is to identify susceptibility variations for E. coli from urine isolates specific to combined outpatient and academic FM clinics compared to composite non-intensive care unit (ICU) data. Also, assess impact of providers’ knowledge/access to a focused antibiogram on choice of empiric therapy.MethodsData were electronically obtained from the microbiology laboratory at Vidant Health (VH), a large regional system serving over 1.4 million people from 29 counties in Eastern NC. All urine cultures with E. coli from 9/2018 - 9/2019 were included. Two focused antibiograms were then developed via MedMind.A pre and post intervention survey was conducted with FM practitioners, including residents. Intervention was defined as a brief talk to educate providers about variations identified via focused antibiograms. Survey results were compared to assess for intent to change practice.ResultsPre-survey data are noted in Figure 1. Post-survey changes are described in Figure 2 noting that 100% of respondents now felt a need to have access to focused antibiogram data.There were 1107 E coli urinary isolates for all outpatients and 104 for FM clinics only. Figure 3 highlights key differences in antibiogram data, especially enhanced susceptibilities for common antibiotics in FM-specific clinics when compared to composite institutional data.Pre-Intervention Survey Post-Intervention Survey Comparison of Antibiogram ConclusionComposite hospital antibiograms may not be optimal for determining empiric UTI treatment in the community and antibiotic selections thought to be suboptimal in an institution may be effective in outpatient settings. Thus, antibiograms developed specifically for outpatient clinics, especially in academic centers, have potential to greatly enhance appropriate care.Disclosures Paul P. Cook, MD, Contrafect (Grant/Research Support, Scientific Research Study Investigator)Gilead (Grant/Research Support, Scientific Research Study Investigator)Leonard-Meron (Grant/Research Support, Scientific Research Study Investigator)Lilly (Grant/Research Support, Scientific Research Study Investigator)

Prognostic value of labs ordered on patients hospitalized with COVID-19

ABSTRACT Background: Hospitalists at our institution have taken on most non-intensive care unit (ICU) coronavirus disease 2019 (COVID-19) care. Based on sparse research, our institution developed a protocol for ordering labs for this patient population, including routine admission labs in addition to eight COVID-19-specific daily labs. The study goal is to determine if COVID-19-specific admission labs have any prognostic value beyond that provided by routine admission labs and vitals, and costs of labs with no prognostic value. Methods: We retrospectively reviewed adult patients admitted with COVID-19 from 3/2020 to 7/2020. Outcomes were mortality, ICU stay, and length of hospitalization. Multivariable logistic and linear regression were used to determine if COVID-19-specific admission labs have any prognostic value beyond that provided by vitals and routine admission labs. COVID-19-specific labs were d-Dimer, fibrinogen, ferritin, LDH, CK, pro-BNP, troponin, and CRP. Multivariable models included all routine admission labs and vitals. COVID-19-specific admission labs were included in the multivariable models if the p-value was <0.05 in the univariable analysis. Results: 331 patients met study criteria, inpatient mortality was 13.0%, 52.4% of patients required ICU stays and the average length of hospitalization was 8.9 days. COVID-19-specific labs showed no additional prognostic value for mortality. CRP, LDH, and d-Dimer provided additional prognostic information for ICU stay. CRP≥100 mg/dL and LDH≥900 U/L were associated with increased length of hospitalization. Conclusion: Only 3 of 8 admission COVID-19-specific labs recommended by our institution’s protocol had additional prognostic value beyond that provided by routine labs and vitals. The total cost of non-prognostic COVID-19-specific labs during the study period was $75,874.

Implementing daily chlorhexidine gluconate (CHG) bathing in VA settings: The human factors engineering to prevent resistant organisms (HERO) project

Daily use of chlorhexidine gluconate (CHG) has been shown to reduce risk of healthcare-associated infections. We aimed to assess moving CHG bathing into routine practice using a human factors approach. We evaluated implementation in non-intensive care unit (ICU) settings in the Veterans Health Administration. Our multiple case study approach included non-ICU units from 4 Veterans Health Administration settings. Guided by the Systems Engineering Initiative for Patient Safety, we conducted focus groups and interviews to capture barriers and facilitators to daily CHG bathing. We measured compliance using observations and skin CHG concentrations. Barriers to daily CHG include time, concern of increasing antibiotic resistance, workflow and product concerns. Facilitators include engagement of champions and unit shared responsibility. We found shortfalls in patient education, hand hygiene and CHG use on tubes and drains. CHG skin concentration levels were highest among patients from spinal cord injury units. These units applied antiseptic using 2% CHG impregnated wipes vs 4% CHG solution/soap. Non-ICUs implementing CHG bathing must consider human factors and work system barriers to ensure uptake and sustained practice change. Well-planned rollouts and a unit culture promoting shared responsibility are key to compliance with daily CHG bathing. Successful implementation requires attention to staff education and measurement of compliance.

How do routine laboratory tests change in coronavirus disease 2019?

How the routine laboratory tests change in terms of coronavirus disease 2019 (COVID-19) was retrospectively analyzed in a large group of patients. Biochemical, hematological and inflammatory variables of a totaly 555 (n = 532 in non-intensive care unit (non-ICU), n = 23 in ICU) patients diagnosed with COVID-19 were analyzed accessing them through the laboratory information system. White blood cell (WBC), neutrophil (NEU), platelet large cell ratio, neutrophil to lymphocyte ratio (NLR), derived NLR (d-NLR), aspartate aminotransferase, urea, creatine kinase (CK) myocardial band (CK-MB), procalcitonin (PCT) values were high whereas lymphocyte (LYM), eosinophil, red blood cells (RBC), hemoglobin, lymphocyte to monocyte ratio, estimated glomerular filtration rate values were low in the ICU group when compared with non-ICU. WBC, NEU, red cell distribution width, alanine transaminase, creatinine, urea, CK-MB, CK, direct bilirubin, lactate dehydrogenase, glucose, C-reactive protein, erythrocyte sedimentation rate, ferritin, D-dimer, PCT and international normalized ratio values increased while RBC, hemoglobin, hematocrit, mean corpuscular volume and total bilirubin values decreased in a significant proportion of patients in both groups based on the normal reference ranges. LYM count was found to be low in a significant number of patients (57.5%) especially in the ICU group and as an important risk factor and diagnostic parameter on admission to ICU (OR: 125, AUC: 0.74). Routine laboratory tests provide important information in terms of both diagnosis and severity of COVID-19. Lymphopenia is a condition that should be monitored which indicates the severity of the disease.

On a Controlled Se(Is)(Ih)(Iicu)AR Epidemic Model with Output Controllability Issues to Satisfy Hospital Constraints on Hospitalized Patients

An epidemic model, the so-called SE(Is)(Ih)(Iicu)AR epidemic model, is proposed which splits the infectious subpopulation of the classical SEIR (Susceptible-Exposed-Infectious-Recovered) model into four subpopulations, namely asymptomatic infectious and three categories of symptomatic infectious, namely slight infectious, non-intensive care infectious, and intensive care hospitalized infectious. The exposed subpopulation has four different transitions to each one of the four kinds of infectious subpopulations governed under eventually different proportionality parameters. The performed research relies on the problem of satisfying prescribed hospitalization constraints related to the number of patients via control interventions. There are four potential available controls which can be manipulated, namely the vaccination of the susceptible individuals, the treatment of the non-intensive care unit hospitalized patients, the treatment of the hospitalized patients at the intensive care unit, and the transmission rate which can be eventually updated via public interventions such as isolation of the infectious, rules of groups meetings, use of face masks, decrees of partial or total quarantines, and others. The patients staying at the non-intensive care unit and those staying at the intensive care unit are eventually, but not necessarily, managed as two different hospitalized subpopulations. The controls are designed based on output controllability issues in the sense that the levels of hospital admissions are constrained via prescribed maximum levels and the measurable outputs are defined by the hospitalized patients either under a joint consideration of the sum of both subpopulations or separately. In this second case, it is possible to target any of the two hospitalized subpopulations only or both of them considered as two different components of the output. Different algorithms are given to design the controls which guarantee, if possible, that the prescribed hospitalization constraints hold. If this were not possible, because the levels of serious infection are too high according to the hospital availability means, then the constraints are revised and modified accordingly so that the amended ones could be satisfied by a set of controls. The algorithms are tested through numerically worked examples under disease parameterizations of COVID-19.

Systematic duplex ultrasound screening in conventional units for COVID-19 patients with follow-up of 5 days

ObjectiveCOVID-19 patients may develop coagulopathy, which is associated with poor prognosis and high risk of thrombosis. The main objective of this work was to evaluate the prevalence of deep venous thrombosis of lower limbs (DVT) through ultrasonography in patients infected with COVID-19 admitted to conventional units at our hospital with 5 days of monitoring. The secondary objective was to determine if D-dimer levels, body mass index, and C-reactive protein were associated with DVT. MethodsA total of 72 patients, with a mean age of 65 ± 12.3 years, infected with COVID-19 were admitted to three conventional units at our institution; 28 patients were women. A COVID-19 diagnosis was made by a transcriptase polymerase chain reaction by means of nasopharyngeal swab or by chest computer tomography without iodine contrast media. Demographics, comorbidities, and laboratory parameters were collected. A preventive anticoagulation treatment was established on admission with low-molecular-weight heparin. A complete venous duplex ultrasound (DU) test of lower limbs was performed on day (D) 0 and D5. A pulmonary computer tomography angiogram with iodine contrast media was required when pulmonary embolism was suspected. ResultsOn D0, the DU showed acute DVT in seven patients (9.75%). A pulmonary computer tomography angiogram was performed in 12 patients (16.65%), 3 (25%) of whom had an acute pulmonary embolism. On D0, acute DVT was not significantly associated with C-reactive protein (mean 101 ± 98.6 in the group without DVT vs 67.6 ± 58.4 mg/L, P = .43) or body mass index (27.7 ± 5.04 vs 28.1 ± 2.65 kg/m2, P = .54). However, we found a significant association between acute DVT and D-dimer levels (1536 ± 2347 vs 9652 ± 10,205 ng/mL, P < .01). Among the patients included on D0, only 32 had a DU on D5. Forty of them (55.55%) were not examined for the following reasons: 7 (9.7%) were previously diagnosed with venous thromboembolism on D0 and therefore were excluded on D5, 8 (11%) were transferred to the intensive care unit, 10 (14%) were discharged from the hospital, 5 (7%) died, and 10 (13.9%) were excluded because of technical issues. On D5, five (15.6%) patients had acute DVT in addition to those found on D0; three were distal and two proximal despite preventive anticoagulation with low-molecular-weight heparin. ConclusionsHospitalized non-intensive care unit patients with COVID-19 pneumonia have a high frequency of venous thrombotic events justifying screening with DU.

Holistic care model of time-sharing management for severe and critical COVID-19 patients.

The rapid global outbreak of coronavirus disease 2019 (COVID-19) and the surge of infected patients have led to the verge of exhaustion of critical care medicine resources worldwide, especially with regard to critical care staff. A holistic care model on time-sharing management for severe and critical COVID-19 patients is proposed, which includes formulation of individualized care objectives and plans, identification of care tasks in each shift and making detailed checklist, and management of quality of care. This study was conducted in the COVID-19 treatment center of Harbin, Heilongjiang Province. The data collected from the treatment center were recorded and analyzed. From the results we can deduce that it is especially suitable for non-intensive care unit (non-ICU) nurses to adapt care management mode of ICU as soon as possible and ensure the quality and efficiency of care during the epidemic. The holistic care model on time-sharing management for severe and critical cases with COVID-19 proposed based on our daily work experiences can assist in improving the quality and efficiency of care, thus reducing the mortality rate of patients in ICU.

Abstract 13704: Simulation-based Uptraining Improves Provider Comfort in the Management of Critically Ill Patients With Covid-19

Introduction: The COVID-19 surge at our institution required deployment of large numbers of non-intensive care unit (ICU) physicians and advanced practice providers to assist in the management of the critically ill. A 3-hour “uptraining” simulation session was offered to these providers that focused on various aspects of ICU care. Hypothesis: We hypothesized that following a 3-hour simulation session, providers would feel more comfortable in managing critically-ill patients with COVID-19. Methods: One hundred and seventy-five providers underwent a 3-hour simulation-based session focused on management of shock, acute respiratory distress syndrome, and critical care ultrasound. All participants were sent surveys to assess their comfort with various aspects of ICU care following return to their usual work environments. Results: One hundred and eight providers of 175 (62%) completed the surveys. Cardiology fellows and faculty accounted for 36% of the responders, acute care nurse practitioners (NPs) accounted for 16%, while other NPs, residents, and fellows accounted for the remainder. Prior to simulation training, 31% regularly managed patients in the ICU and 28% occasionally managed ICU patients. Following training, 71% of participants were deployed to a COVID-19 ICU as part of their workflow. Overall, 104/108 responders (96%) felt training either significantly or somewhat improved their knowledge in the management of ICU patients. Ninety-four participants (91%) felt training impacted their care of critically ill patients with COVID-19. Table 1 is a display of specific ICU skillsets taught in the session and if the participants felt better equipped to utilize what was covered post deployment. Conclusions: Simulation-based training improved provider comfort in the management of critically ill patients with COVID-19. Table 1: Participants response to “if they felt better equipped to utilize ICU skills following simulation training”

Abstract 13939: Optimizing Telemetry Usage in Non-intensive Care Unit Patients Based on American Heart Association Guidelines: A Quality Improvement Initiative

Introduction: The overuse of hospital resources is a pervasive issue. Out of the $3.5 trillion, the United States spent on health care in 2017, 30 % was considered excess cost in complications and ancillary orders. Even with established guidelines and revisions over the past few years, overzealous use of telemetry is rampant. Methods: The study included observation and admitted patients in September and October of 2018 and 2019. Patients in 2018 constituted baseline cohort (BC) and patients in 2019 were intervention cohort (IC). Both observation and inpatient admissions were analyzed separately. In August 2019, a series of presentations regarding AHA telemetry guidelines and group training for the use of telemetry monitor and software was undertaken. A template was used to document telemetry which consisted of reason for telemetry and day of telemetry in daily progress notes. Daily report of telemetry was shared on secured messaging group for residents. A comparison was made between the cohorts. Results: 516 patients were included in the study, 335 observation patients and 181 admitted patients. The number of patients on telemetry in combined IC (2019 patients) reduced by 31 % (34.32 % in observation group &amp; 24.86 % in admission group). Taking an average of $ 272 per patient on telemetry (based on hospital billing data), the burden of cost reduced by $ 43,520 in the two months of 2019. “To rule out ACS” and “monitor for arrythmias” were the most common reason for telemetry use in observation and admitted inpatients in both cohorts. There was an increase of 14.59 % patients exceeding 48 hours on telemetry in inpatient admissions of IC. Telemetry triggers in notes (reasoning and justification) increased from 4.04 % to 37.08 %. All changes in IC occurred without any adverse outcome. The comparison is shown in Figure 1. Conclusions: Strict adherence to AHA guidelines improves the quality of care and is an effective means to reduce cost for hospitals without significant adverse events.

Association between discontinuation of benzodiazepine receptor agonists and post-operative delirium among inpatients with liaison intervention: A retrospective cohort study

BackgroundSeveral studies have investigated the association between benzodiazepine receptor agonist (BZDRA) use during the perioperative period and an elevated incidence of delirium. However, no study has focused on the time course of BZDRA use, including continuation, discontinuation, initiation, and no use. This study aimed to examine the influence of the time course of BZDRA use on post-operative delirium. MethodsThis retrospective cohort study was conducted by reviewing medical records. We included patients who were scheduled for surgery under general anesthesia and had been referred to a liaison psychiatrist for pre-operative psychiatric assessment. The patients were classified into four groups based on the pre- and post-operative time course of oral BZDRA use, as follows: continuation, discontinuation, initiation, and no use (never used). The primary outcome was the prevalence of post-operative delirium in non-intensive care unit settings. We also performed stratified analyses according to age, the presence of cognitive impairment, the presence of delirium history, and antipsychotic drug use on admission. ResultsAmong 250 patients, 78 (31%) developed post-operative delirium. The Discontinuation group had a higher rate of delirium (49%, 24/49) than the other groups (Continuation [14%, 4/29]; Initiation [38%, 3/8], Never used [29%, 47/164], p = 0.008). ConclusionsAbrupt discontinuation of BZDRAs during the perioperative period may be a risk factor for post-operative delirium and should therefore be avoided.

Nutritional therapy for patients with coronavirus disease 2019 (COVID-19): Practical protocol from a single center highly affected by an outbreak of the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.

ObjectivesCoronavirus disease 2019 (COVID-19) carries a high risk for malnutrition owing to the state of debilitation that results from acute respiratory failure symptoms. The aim of this study was to provide an approach to reduce the risk for malnutrition and improve patients’ clinical outcomes.MethodsShort age-adjusted Nutritional Risk Screening was performed with 94 non-intensive care unit (ICU) patients admitted to the Giovanni Borea Civil Hospital in Sanremo. Forty-nine patients in the ICU were considered at risk for malnutrition without screening and were fed with enteral nutrition plus supplemental parenteral nutrition. In the non-ICU setting, patients underwent a personalized nutritional protocol, considering their conditions, which consisted of a high-protein and high-calorie pureed diet, oral nutritional supplements, and/or artificial nutrition or other personalized nutritional path.ResultsThe nutritional treatment was well tolerated by the patients. Of the non-ICU patients, 19.1% died. They were mainly women, with higher body mass indices and older in age. Of the patients in the ICU, 53.1% died. Of the 94 non-ICU patients, 72 scored positive on at least one nutritional risk screening item (excluding age). Of the 94 non-ICU patients, 68 were >70 y of age. Non-ICU patients whose energy and protein needs were not met were older (P = 0.01) and had a higher death rate than patients whose needs were met (P < 0.001).ConclusionsThis protocol should not be considered as a guideline; rather, it is intended to report the clinical experience of a nutrition team in an Italian reference center for the treatment of patients with COVID-19. Nutritional strategies should be implemented to prevent worsening of clinical outcomes.

Impact of SARS-Cov-2 Pandemic and Strategies for Resumption of Activities: A Report from Eight Paediatric Hospitals from the ECHO Network

Background: The Severe Acute Respiratory Syndrome CoronaVirus type 2 (SARS-CoV-2) pandemic impacted the organization of paediatric hospitals. The aims of this study were to evaluate the preparedness for the pandemic among a European network of children’s hospitals and to explore the strategies used to restart paediatric health care services.Methods: A cross‐sectional, web‐based survey was distributed in May 2020 to the 13 children’s tertiary care hospitals belonging to the European Children’s Hospitals Organization, covering the preparedness to the pandemic and the strategies for reopening.Findings: Responses were obtained from eight hospitals (62%). Significant reductions were observed in accesses to the emergency departments (41·7%), outpatient visits (35·7%), intensive and non-intensive care unit inpatient admissions (16·4% and 13%, respectively) between February 1 and April 30, 2020 as compared with the same period of 2019. Overall, 93 children with SARS CoV-2 infection were admitted to inpatient wards. All the hospitals created a multidisciplinary planning committee that developed written SARS-CoV-2 infection preparedness plans for the evaluation, diagnosis and management of confirmed or suspected infected patients. Routine activities were re-scheduled or cancelled. Four hospitals shared their own staff with adult units, two designated bed spaces for adults and only one admitted adults to inpatient wards. The three main components of the strategic planning process for the resumption of clinical activities were testing, source control, and reorganization of spaces and flows of patients. Telemedicine and telehealth services were used before the SARS-CoV-2 pandemic by three hospitals and by all the hospitals during it.Interpretation: The present study provides for the first time a perspective on preparedness to SARS-CoV-2 pandemic among eight large European children’s hospitals, on the impact of the pandemic on the hospital activities and on the strategies adopted to restart the paediatric health care services.Funding Statement: No source of funding to disclose. Declaration of Interests: The authors declare no competing interests.Ethics Approval Statement: Ethical approval was not required for this service evaluation study because individual patient data was not collected.

Identifying opportunities for antimicrobial stewardship through a point prevalence survey in an Indian tertiary-care teaching hospital

ObjectivesUnregulated and inappropriate use of antimicrobial agents has been a major driver of antimicrobial resistance with a dangerous impact on health issues in developing nations. We report an audit of antimicrobial use patterns in a tertiary-care teaching hospital in order to identify opportunities for antimicrobial stewardship. MethodsA point prevalence survey was conducted to study the use of ten selected antibiotics in various adult inpatient facilities. Patient characteristics as well as indications and patterns of antibiotic prescription were recorded. ResultsA total of 188 patients received any one of the survey antibiotics, accounting for 43% of patients admitted under the study specialties. Of the 188 patients, 59% were admitted in non-intensive care unit settings. The median (interquartile range) duration of hospitalisation during the survey was 8 (4.75) days. Intra-abdominal infections (75; 40%) and respiratory infections (41; 22%) were the most common reasons for admission. Empirical antibiotic use was observed in 66% of patients. Antimicrobial use without any microbiological test was evidenced in 32 patients (17%). Significant differences were noted between medical and surgical specialties in choice of antibiotic, dosage and utilisation of microbiological tests. ConclusionsHigh empirical antibiotic use, poor transition from empirical to rational use, and underutilisation of microbiological tests were noted. The choice of antibiotics differed among specialties. Inappropriate dosing was greater in surgical specialties, especially with aminoglycosides. Adherence to local antibiotic policy, optimal dosing and audit of reserved antibiotic use can be useful approaches to strengthen antimicrobial stewardship programmes.

Impact of a pharmacist‐driven azithromycin de‐escalation initiative for community‐acquired pneumonia

AbstractBackgroundCommunity‐acquired pneumonia (CAP) is a commonly encountered infection and cause of hospitalization. Discontinuation of atypical antibiotic coverage when atypical bacteria are the unlikely cause of CAP represents a potential antimicrobial stewardship opportunity.Study ObjectiveTo compare azithromycin duration, hospital length of stay (LOS), 30‐day all‐cause or pneumonia readmission, and in‐hospital mortality before and after implementation of a pharmacist‐driven azithromycin de‐escalation initiative in the setting of negative laboratory data for atypical bacteria in immunocompetent, nonintensive care unit (non‐ICU) patients treated for CAP.DesignSingle‐center, quasi‐experimental study.SettingA 472‐bed academic medical center in Syracuse, NY.PatientsPatients were included if they were ≥18 years old, diagnosed with CAP, and had a negative Legionella pneumophila urinary antigen and negative Biofire FilmArray Respiratory Panel for Mycoplasma pneumoniae and Chlamydia pneumoniae. Patients were excluded if they were immunocompromised, admitted to an ICU during hospitalization, prescribed azithromycin for an alternate indication, or had evidence of atypical bacteria.Measurements and Main ResultsA total of 983 patients received an azithromycin‐containing regimen for CAP during the study period with 458 and 525 patients in preintervention and postintervention cohorts, respectively. After exclusion criteria were applied, 90 and 100 patients were included in the preintervention and postintervention cohorts, respectively. Demographic and clinical characteristics were mostly similar between cohorts. A statistically significant reduction in azithromycin duration (2 days [interquartile range (IQR) 1‐2.75] vs 5 days [IQR 3‐6], P &lt; .001) and hospital LOS (3 days [IQR 2‐5] vs 5 days [IQR 3‐8.25], P &lt; .001) were observed in the postintervention cohort compared with the preintervention cohort. No statistically significant difference was identified for 30‐day all‐cause 30‐day readmission (15.6% vs 13.0%, P = .614), 30‐day readmission secondary to pneumonia (4.44% vs 2.0%, P = .926), or in‐hospital mortality (1.1% vs 1.0%, P = 1.000) between cohorts.ConclusionImplementation of a pharmacist‐driven azithromycin de‐escalation initiative for immunocompetent, non‐ICU patients with CAP was associated with a decrease in azithromycin duration and hospital LOS without increasing 30‐day all‐cause or pneumonia readmission, or in‐hospital mortality.

Clinical characteristics of non-intensive care unit COVID-19 patients in Saudi Arabia: A descriptive cross-sectional study

IntroductionThe ongoing pandemic of the coronavirus disease 2019 (COVID-19) is a global health concern. It has affected more than 5 million patients worldwide and resulted in an alarming number of deaths globally. While clinical characteristics have been reported elsewhere, data from our region is scarce. We investigated the clinical characteristics of mild to moderate cases of COVID-19 in Saudi Arabia. MethodsThis is a descriptive, cross-sectional study. Data of 401 confirmed COVID-19 patients were collected from 22 April 2020 to 21 May 2020 at five tertiary care hospitals in Riyadh, Saudi Arabia. The patients were divided into four groups according to age, Group 1: 0–<18 years, Group 2: 18–<50 years, Group 3: 50–60 years, and Group 4: >60 years; and their clinical symptoms were compared. ResultsThe median (IQR) age in years was 10.5 (1.5−16) in group I, 34 (29−41) in group II, 53 (51−56) in group III, and 66 (61−76) in group IV. Most patients were male (80%, n = 322) and of Arabian or Asian descent. The median length of stay in the hospital was 10 (8–17) days (range 3–42 days). The most common symptoms were cough (53.6%), fever (36.2%), fatigue (26.4%), dyspnea (21.9%), and sore throat (21.9%). Hypertension was the most common underlying comorbidity (14.7%), followed by obesity (11.5%), and diabetes (10%). Hypertensive patients were less likely to present with shortness of breath, cough, sputum, diarrhea, and fever. ConclusionThere was no significant difference in the symptoms among different age groups and comorbidities were mostly seen in the older age group. Interestingly, hypertensive patients were found to have milder symptoms and a shorter length of stay. Further larger collaborative national studies are required to effectively understand clinical characteristics in our part of the world to efficiently manage and control the spread of SARS-CoV-2.

Safety and Pharmacokinetics of Recombinant Human Plasma Gelsolin in Patients Hospitalized for Nonsevere Community-Acquired Pneumonia

There remains an unmet need to address the substantial morbidity and mortality associated with severe community-acquired pneumonia (sCAP). Recombinant human plasma gelsolin (rhu-pGSN) improves disease outcomes in diverse animal models of infectious and noninfectious inflammation. This blinded dose-escalation safety study involved non-intensive care unit (ICU) patients admitted for mild CAP and randomized 3:1 to receive adjunctive rhu-pGSN or placebo intravenously. Thirty-three subjects were treated: 8 in the single-dose phase and 25 in the multidose phase. For the single-dose phase, rhu-pGSN at 6 mg/kg of body weight was administered once. For the multidose phase, a daily rhu-pGSN dose of 6, 12, or 24 mg/kg was given on 3 consecutive days. Adverse events (AEs) were generally mild in both treatment groups irrespective of dose. The only serious AE (SAE) in the single-dose phase was a non-drug-related pneumonia in a rhu-pGSN recipient who died after institution of comfort care. One single-dose placebo recipient had a drug-related AE (maculo-papular rash). In the multidose phase, there were 2 SAEs in 1 placebo recipient, including a fatal pulmonary embolism. In the 18 rhu-pGSN recipients in the multidose phase, there were no serious or drug-related AEs, and nausea and increased blood pressure were each reported in 2 patients. The median rhu-pGSN half-life exceeded 17 h with all dosing regimens, and supraphysiologic levels were maintained throughout the 24-h dosing interval in the 2 highest dosing arms. Rhu-pGSN was well tolerated overall in CAP patients admitted to non-ICU beds, justifying a larger proof-of-concept trial in an ICU population admitted with sCAP. (This study has been registered at ClinicalTrials.gov under identifier NCT03466073.).