Non-critical Care Units Research Articles

Nonlinear association of nurse staffing and readmissions uncovered in machine learning analysis.

Several studies of nurse staffing and patient outcomes found a curvilinear or U-shaped relationship, with benefits from additional nurse staffing diminishing or reversing at high staffing levels. This study examined potential diminishing returns to nurse staffing and the existence of a "tipping point" or the level of staffing after which higher nurse staffing no longer improves and may worsen readmissions. The Readiness Evaluation And Discharge Interventions (READI) study database of over 130,000 adult (18+) inpatient discharges from 62 medical, surgical, and medical-surgical (noncritical care) units from 31 United States (US) hospitals during October 2014-March 2017. Observational cross-sectional study using a fully nonparametric random forest machine learning method. Primary exposure was nurse hours per patient day (HPPD) broken down by registered nurses (nonovertime and overtime) and nonlicensed nursing personnel. The outcome was 30-day all-cause same-hospital readmission. Partial dependence plots were used to visualize the pattern of predicted patient readmission risk along a range of unit staffing levels, holding all other patient characteristics and hospital and unit structural variables constant. Secondary analysis of the READI data. Missing values were imputed using the missing forest algorithm in R. Partial dependence plots were U-shaped, showing the readmission risk first declining and then rising with additional nurse staffing. The tipping points were at 6.95 and 0.21 HPPD for registered nurse staffing (nonovertime and overtime, respectively) and 2.91 HPPD of nonlicensed nursing personnel. The U-shaped association was consistent with diminishing returns to nurse staffing suggesting that incremental gains in readmission reduction from additional nurse staffing taper off and could reverse at high staffing levels. If confirmed in future causal analyses across multiple outcomes, accompanying investments in infrastructure and human resources may be needed to maximize nursing performance outcomes at higher levels of nurse staffing.

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

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.

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.

Influence of COVID-19 Pandemic on Health-care Workers’ Hand Hygiene Practice at a Private Academic Hospital in Johannesburg, South Africa: A Quantitative and Qualitative Longitudinal Study

ABSTRACT Background: Hand hygiene (HH) is a cornerstone infection prevention measure and is crucial in the fight against the COVID-19 pandemic. Improving and monitoring of HH compliance in a hospital setting is a complex challenge given the behavioural component associated with it. We aimed to assess the impact of the COVID-19 pandemic on HH compliance using both quantifiable hand product usage and observational data. Methods: Using the hospital's HH usage monitoring system, the quantity of different HH products per nursing unit, expressed as millilitres (mL) per patient bed day (PBD), was analysed longitudinally during the course of the pandemic. Observational HH compliance data was drawn from the hospital audit system for comparison. Results: Across all units, there was a significant increase in HH product usage coinciding with the onset of the pandemic (53 mL/PBD to 111 mL/PBD, in non-critical care units (non-CCU's); 127 mL/PBD to 217 mL/PBD, in CCU's). This increase was largely attributable to an increase in alcohol-based hand rub usage. Discordance with observed compliance rates was noted. Conclusion: An unprecedented increase in HH product usage in a hospital setting was seen to coincide with the onset of the COVID-19 pandemic. No specific HH campaign was introduced, and the improved usage compliance appears to be driven primarily by health-care workers’ own behavioural change.

Environmental screening of multi drug resistant organisms in high touch area of critical and non critical units in tertiary care hospital

Patient’s environment in Health care settings responsible for causing variety of infections to patients and to the healthcare professions. Many of them are MDRO which may get transmitted as hospitals acquired infections that increases the chances of mortality and morbidity. These study was undertaken to isolate and identify aerobic bacteria with their resistance pattern in high touch areas of critical and non-critical care units of tertiary care hospital in absence of defined outbreaks.The cross sectional analytical study was carried out in the Microbiology Department, after obtaining the Institutional Ethics Committee clearance with waiver of consent during a period of two months. A total 100 samples from nine surface locations of critical and non critical care units of tertiary care hospital were included in this study. All tubes were vortexed and 0.5 μl of the peptone water was inoculated immediately on Blood Agar and MacConkey Agar for semi-quantitative estimation of the organisms.The environmental screening for MDROs from high touch areas was carried out in the 650 bedded tertiary care hospital.. A total of 34/126 (26.98%) samples from various areas had the growth of microorganisms where Staphylococcus aureus predominated. 24.60% showed S. aureus growth while 2.38% were E.coli. A total of 47.05% strains were isolated from the critical care areas all of which were S. aureus whereas 52.94% strains were from the non-critical areas. This study established to isolate and identify aerobic bacteria with their resistance pattern in high touch areas of critical and non critical care units of tertiary care hospital in absence of defined outbreak. These creates awareness regarding emerging of MDROs in hospital settings and also leads to improve in imperfect techniques of hand hygiene practices as well as inadequate surface disinfection practices especially in high touch areas.This study established the presence of aerobic bacteria with their resistance pattern in high touch areas of critical and non critical care units of tertiary care hospital in absence of defined outbreak. This will help creates awareness regarding emerging of MDROs in hospital settings and also leads to improve in imperfect techniques of hand hygiene practices as well as inadequate surface disinfection practices especially in high touch areas.

Beverage ethanol exposures among infants reported to United States poison control centers

Background Case studies and small series have demonstrated that beverage ethanol may pose a serious poisoning hazard to infants. Intoxicated infants may not present with the classic signs or symptoms of ethanol poisoning. The objective of this study was to describe the epidemiology of beverage ethanol exposures among infants reported to the United States poison control centers. Methods Data from the National Poison Data System were retrospectively analyzed for infants <12 months of age who were exposed to beverage ethanol from 2009–2018. Results Over the 10-year study period, 1,818 infant exposures to beverage ethanol were reported. Most exposures were single substance (95.2%), and the most common route of exposure was ingestion (n = 1,738). Infants 9–11 months were the most commonly exposed age group subset (45.3%). The annual number and rate of alcoholic beverage exposure increased by 37.5% and 42.9%, respectively, from 2009 to 2018. Of the 563 infants evaluated at a healthcare facility, 38% of exposures were hospitalized. Infants 0–5 months of age had higher odds of being admitted to a non-critical (OR: 2.35, 95% CI: 1.41–3.92) or critical care unit (OR: 2.39; 95% CI: 1.50–3.79) compared to infants 6–11 months of age. Infants 0–5 months of age were more likely to (OR: 4.65; 95% CI: 3.18–6.79) experience a serious outcome compared to infants ages 6–11 months. Five fatalities in infants <6 months old were documented. An in-depth case review identified improper storage and subsequent formula preparation with beverage ethanol as a common exposure mechanism. Conclusions Beverage ethanol exposures among infants are associated with hospitalization, serious clinical effects, and mortality. Infants may present with atypical signs and symptoms of intoxication, requiring a high index of suspicion. Opportunities exist to reduce exposures by addressing improper storage of beverage alcohols.

COVID-19 in Older Adults: A Series of 76 Patients Aged 85 Years and Older with COVID-19.

BACKGROUNDClinical presentation and risk factors of death in COVID‐19 in oldest adults have not been well characterized.OBJECTIVESTo describe clinical features and outcome of COVID‐19 in patients older than 85 years and study risk factors for mortality.DESIGNProspective cohort.PARTICIPANTS AND SETTINGPatients aged 85 years and older, admitted in noncritical care units at the University Hospital Lariboisière Fernand‐Widal (Paris, France) for confirmed severe acute respiratory syndrome coronavirus 2 infection were included and followed up for 21 days.MEASUREMENTSClinical and laboratory findings were collected. Cox survival analysis was performed to explore factors associated with death.RESULTSFrom March 14 to April 11, 2020, 76 patients (median age = 90 (86–92) years; women = 55.3%) were admitted for confirmed COVID‐19. Of the patients, 64.5% presented with three or more comorbidities. Most common symptoms were asthenia (76.3%), fever (75.0%) and confusion and delirium (71.1%). An initial fall was reported in 25.0% of cases, and digestive symptoms were reported in 22.4% of cases. COVID‐19 was severe in 51.3% of cases, moderate in 32.9%, and mild in 15.8%. Complications included acute respiratory syndrome (28.9%), cardiac decompensation (14.5%), and hypotensive shock (9.0%). Fatality at 21 days was 28.9%, after a median course of disease of 13 (8–17) days. Males were overrepresented in nonsurvivors (68.2%). In survivors, median length of stay was 12 (9–19.5) days. Independent predictive factors of death were C‐reactive protein level at admission and lymphocyte count at nadir.CONCLUSIONSpecific clinical features, multiorgan injury, and high case fatality rate are observed in older adults with COVID‐19. However, rapid diagnosis, appropriate care, and monitoring seem to improve prognosis.

Survey of antibiotic and antifungal prescribing in patients with suspected and confirmed COVID-19 in Scottish hospitals

Concern regarding bacterial co-infection complicating SARS-CoV-2 has created a challenge for antimicrobial stewardship. Following introduction of national antibiotic recommendations for suspected bacterial respiratory tract infection complicating COVID-19, a point prevalence survey of prescribing was conducted across acute hospitals in Scotland. Patients in designated COVID-19 units were included and demographic, clinical and antimicrobial data were collected from 15 hospitals on a single day between 20th and 30th April 2020. Comparisons were made between SARS-CoV-2 positive and negative patients and patients on non-critical care and critical care units. Factors associated with antibiotic prescribing in SARS-CoV-2 positive patients were examined using Univariable and multivariable regression analyses. There were 820 patients were included, 64.8% were SARS-CoV-2 positive and 14.9% were managed in critical care, and 22.1% of SARS-CoV-2 infections were considered probable or definite nosocomial infections. On the survey day, antibiotic prevalence was 45.0% and 73.9% were prescribed for suspected respiratory tract infection. Amoxicillin, doxycycline and co-amoxiclav accounted for over half of all antibiotics in non-critical care wards and meropenem, piperacillin-tazobactam and co-amoxiclav accounted for approximately half prescribed in critical care. Of all SARS-CoV-2 patients, 38.3% were prescribed antibiotics. In a multivariable logistic regression analysis, COPD/chronic lung disease and CRP ≥ 100 mg/l were associated with higher odds and probable or confirmed nosocomial COVID-19, diabetes and management on an elderly care ward had lower odds of an antibiotic prescription. Systemic antifungals were prescribed in 9.8% of critical care patients and commenced a median of 18 days after critical care admission. A relatively low prevalence of antibiotic prescribing in SARS-CoV-2 hospitalised patients and low proportion of broad spectrum antibiotics in non-critical care settings was observed potentially reflecting national antimicrobial stewardship initiatives. Broad spectrum antibiotic and antifungal prescribing in critical care units was observed indicating the importance of infection prevention and control and stewardship initiatives in this setting. The Scottish Antibiotic Prescribing Group is funded by Scottish Government.

Patient characteristics and admitting vital signs associated with coronavirus disease 2019 (COVID-19)-related mortality among patients admitted with noncritical illness.

To determine risk factors for mortality among COVID-19 patients admitted to a system of community hospitals in the United States. Retrospective analysis of patient data collected from the routine care of COVID-19 patients. System of >180 acute-care facilities in the United States. All admitted patients with positive identification of COVID-19 and a documented discharge as of May 12, 2020. Determination of demographic characteristics, vital signs at admission, patient comorbidities and recorded discharge disposition in this population to construct a logistic regression estimating the odds of mortality, particular for those patients characterized as not being critically ill at admission. In total, 6,180 COVID-19+ patients were identified as of May 12, 2020. Most COVID-19+ patients (4,808, 77.8%) were admitted directly to a medical-surgical unit with no documented critical care or mechanical ventilation within 8 hours of admission. After adjusting for demographic characteristics, comorbidities, and vital signs at admission in this subgroup, the largest driver of the odds of mortality was patient age (OR, 1.07; 95% CI, 1.06-1.08; P < .001). Decreased oxygen saturation at admission was associated with increased odds of mortality (OR, 1.09; 95% CI, 1.06-1.12; P < .001) as was diabetes (OR, 1.57; 95% CI, 1.21-2.03; P < .001). The identification of factors observable at admission that are associated with mortality in COVID-19 patients who are initially admitted to non-critical care units may help care providers, hospital epidemiologists, and hospital safety experts better plan for the care of these patients.

Epidemiology of Bacterial Contamination of Inert Hospital Surfaces and Equipment in Critical and Non-critical Care Units: A Brazilian Study

Aims: The hospital environment is an important reservoir of microorganisms, including multidrug-resistant pathogens, which can cause in-patient contamination and healthcare-related infections. The objective of this study was to describe the epidemiology of bacterial contamination (contaminated sites, pathogen species and their antimicrobial susceptibility, and identifying of multidrug-resistant microorganisms - MDR) of inert hospital surfaces and medical equipment in two public hospitals in Northern Brazil.&#x0D; Methods: This was a cross-sectional study with 243 samples (n = 208, from Hospital A; and n = 35, from Hospital B) collected by friction with humidified swabs from inert surfaces and equipment. Sequentially the samples were cultivated and bacterial species were identified by culture-based methods and tested for their susceptibility through agar diffusion assay according to the Clinical and Laboratory Standards Institute (CLSI).&#x0D; Results: Most inert surfaces and equipment analyzed presented bacterial contamination (95.5%). Staphylococcus aureus was the main pathogen of clinical significance detected both in Hospital A (61.8%) and B (68.6%). Hospital A showed higher rates of isolated MDR bacteria than Hospital B, especially in the Adult Intensive Care Unit, which included methicillin-resistant Staphylococcus aureus (MRSA) (52.7%), Enterobacteria resistant to 4th generation cephalosporins (19.4%), and multidrug-resistant Pseudomonas aeruginosa (2.8%).&#x0D; Conclusion: The failures in the control of bacterial contamination of inert surfaces and equipment in the two hospitals analyzed reinforce the need for a revised protocol for cleaning and disinfection of the inert surfaces and equipment, and for regulation of antibiotic dispensing, mainly in the AICU of Hospital A, which was found to be a reservoir of MDR pathogens.

1230-P: Advantages of Network-Based Blood Glucose Team Management on Hyperglycemic Patients in Noncritical Units

Purpose: To provide a new system of in-hospital blood glucose team management combining with network blood glucose monitoring system, and analyze the effect on hyperglycemic patients’ blood glucose control lived in non-critical care units. Methods: Hyperglycemic patients admitted to non-critical care units were divided into two groups. They were intervened actively by the hospital’s blood glucose management team and routine consultation group, respectively. A better method with shorter hospital stay and inpatient diabetes cost could be selected by comparing the two blood glucose management methods. Results: Compared to routine consultation group, the team management group had higher detection rate of hyperglycemia (18.49% vs16.17%, P&amp;lt;0.01) and glycosylated hemoglobin (51.53% vs. 30.97%, P&amp;lt;0.01), lower incidence rate of hyperglycemia (59.24% vs. 61.59%, P&amp;lt;0.01), severe hyperglycemia (3.56% vs. 5.19%, P&amp;lt;0.01) and clinically significant hypoglycemia (0.26% vs. 0.35%, P&amp;lt;0.05). Simultaneously, blood glucose drift (mmol/L) (2.50 (1.83, 3.25) vs. 2.76 (2.01, 3.57), P&amp;lt;0.01), blood glucose coefficient of variation (%) (28.86 (22.70, 34.83) vs. 29.80 (23.47, 36.13), P&amp;lt;0.01), maximum blood glucose fluctuation (mmol/L) (9.30 (6.20, 13.10) vs. 10.10 (7.00, 14.40), P&amp;lt;0.01), nosocomial infection (5.42% vs. 8.05%, P&amp;lt;0.05), hospitalization days (7 (3, 12) vs. 8 (4, 14), P &amp;lt; 0.01) and hospitalization expenses (10,000 yuan) (1.62 (1.01, 3.35) vs. 1.89 (1.29, 4.47), P &amp;lt; 0.01) of patients were managed by team management group all decreased. Conclusion: In-hospital blood glucose team management combined network blood glucose monitoring system effectively improved the blood glucose control and fluctuation level of patients, who admitted to non-critical care units, thereby reducing hospital stay and inpatient hyperglycemia cost. Disclosure Y. Zhu: None. M. Yang: None. H. Zhou: None. W. Xia: None. P. Li: None. Y. Yang: None.

Effect of informatization-based blood glucose team management on the control of hyperglycaemia in noncritical care units.

PurposeTo provide a new system of in-hospital blood glucose team management combined with a network blood glucose monitoring system and analyse the effect on hyperglycaemic participants’ blood glucose control in noncritical care units.MethodsHyperglycaemic participants in noncritical care units were divided into two groups. They underwent active intervention by the hospital’s blood glucose management team or the routine consultation group. The better method, based on a shorter length of stay (LOS) and lower hospital cost, could be selected by comparing the two blood glucose management strategies.ResultsCompared with the routine consultation group, the team management group had a higher detection rate of hyperglycaemia (18.49% vs 16.17%, P<0.01) and glycosylated haemoglobin (51.53% vs 30.97%, P<0.01) and a lower incidence rate of hyperglycaemia (59.24% vs 61.59%, P<0.01), severe hyperglycaemia (3.56% vs 5.19%, P<0.01) and clinically significant hypoglycaemia (0.26% vs 0.35%, P<0.05). Simultaneously, blood glucose drift (mmol/L) (2.50 (1.83, 3.25) vs 2.76 (2.01, 3.57), P<0.01), blood glucose coefficient of variation (%) (28.86 (22.70, 34.83) vs 29.80 (23.47, 36.13), P<0.01), maximum blood glucose fluctuation (mmol/L) (9.30 (6.20, 13.10) vs 10.10 (7.00, 14.40), P<0.01) and nosocomial infection (5.42% vs 8.05%, P<0.05) were all lower among participants in the team management group. In addition, the LOS (P<0.001) and hospital costs (P<0.001) of participants were lower in the team management group.ConclusionIn-hospital blood glucose team management combined with a network blood glucose monitoring system effectively improved the blood glucose control and fluctuation levels of participants who were admitted to noncritical care units, thereby reducing LOS and hospital cost.

Chlorhexidine Bathing to Prevent Central Line–Associated Bloodstream Infections in Hematology Units: A Prospective, Controlled Cohort Study

Chlorhexidine (CHG) bathing decreases the incidence of bloodstream infections in intensive care units, but its effect has been understudied in patients with hematological malignancies in noncritical care units. Adults with hematological malignancies hospitalized for cytotoxic chemotherapy in noncritical care units were offered daily 2% CHG bathing. We compared outcomes of patients who chose CHG bathing (CHG group) with outcomes of those who did not choose CHG bathing (usual-care group). The primary outcome was gram-positive cocci-related, skin flora-related, or central line-associated bloodstream infection. The negative control outcome was gut-origin bacteremia. The CHG group (n = 485) had a crude incidence rate of the primary outcome that was 60% lower than the rate for the usual-care group (n = 408; 3.4 vs 8.4 per 1000 patient-days, P = .02) but had a similar crude incidence rate of the negative control outcome (4.5 vs 3.2 per 1000 patient-days; P = .10). In multivariable analyses, CHG bathing was associated with a 60% decrease in the primary outcome (adjusted hazard ratio [HR], 0.4; P < .001). In contrast, CHG bathing had no effect on the negative control outcome (adjusted HR, 1.1; P = .781). CHG bathing was well tolerated by participants in the CHG group. CHG bathing could be a highly effective approach for preventing gram-positive cocci-related, skin flora-related, or central line-associated bacteremia in patients with hematological malignancies who are hospitalized for cytotoxic chemotherapy in noncritical care units.

Lacosamide: a Study of Exposures Reported to US Poison Centers over a 9-Year Period.

Lacosamide (Vimpat®) is an anticonvulsant used to treat partial-onset seizures. Little is known about the characteristics and outcomes of patients exposed to lacosamide. To characterize lacosamide exposures reported to US poison centers with regard to patient demographics, clinical effects, and outcomes. This retrospective observational study queried the National Poison Data System (NPDS) for single substance lacosamide exposures from January 2008 to December 2016. Variables of interest included age, gender, medical outcome, management site, level of healthcare facility, reason for exposure, and clinical effects. Lacosamide exposures were identified in 1124 patients, ranging from ages 2months to 99years. Six hundred and twenty-two patients (55.3%) were female. Nine hundred and seventy-six patients (86.8%) had minimal or no toxic effects. Life-threatening exposures numbered 30 cases (2.7%). There was one death. Five hundred and forty-eight patients (48.8%) did not require healthcare management while 537 (47.7%) were either referred to or already at a hospital. Among those treated at a healthcare facility, 269 (50.1%) did not require admission. Thirty-three patients (6.1%) were admitted to a psychiatric facility, 68 (12.7%) to a non-critical care unit, and 93 (17.3%) to a critical care unit. Six hundred and thirty-two exposures (56.2%) were due to therapeutic error. Suicide attempts numbered 168 (14.9%). Neurologic, gastrointestinal, and cardiovascular symptoms were commonly encountered. Lacosamide exposures infrequently cause death or disability; however, a considerable proportion of the study population required intensive care. Exposed patients with symptoms require healthcare evaluation.

Management of Glucose Control in Noncritically Ill, Hospitalized Patients Receiving Parenteral and/or Enteral Nutrition: A Systematic Review.

Hyperglycemia is a common occurrence in hospitalized patients receiving parenteral and/or enteral nutrition. Although there are several approaches to manage hyperglycemia, there is no consensus on the best practice. We systematically searched PubMed, Embase, Cochrane Central, and ClinicalTrials.gov to identify records (published or registered between April 1999 and April 2019) investigating strategies to manage glucose control in adults receiving parenteral and/or enteral nutrition whilst hospitalized in noncritical care units. A total of 15 completed studies comprising 1170 patients were identified, of which 11 were clinical trials and four observational studies. Diabetes management strategies entailed adaptations of nutritional regimens in four studies, while the remainder assessed different insulin regimens and administration routes. Diabetes-specific nutritional regimens that reduced glycemic excursions, as well as algorithm-driven insulin delivery approaches that allowed for flexible glucose-responsive insulin dosing, were both effective in improving glycemic control. However, the assessed studies were, in general, of limited quality, and we see a clear need for future rigorous studies to establish standards of care for patients with hyperglycemia receiving nutrition support.