Quasi-experimental Cohort Study Research Articles

1085. Impact of a Novel Infectious Diseases Pharmacy Service on Medication-Related Errors and Linkage to Care in Inpatients Living with Human Immunodeficiency Virus

BackgroundComplexity of antiretroviral therapy (ART) for human immunodeficiency virus (HIV) and lack of experience with treatment regimens by providers may lead to medication-related errors (MRE). Consequences of MRE may include loss of virologic suppression, development of ART resistance, HIV transmission, and increased morbidity and mortality. The purpose of this study was to compare ART-related MRE and linkage to care through consultation with Infectious Diseases (ID) providers as a result of ID-pharmacist review.MethodsAn ID pharmacist-led intervention incorporating prospective review of electronic medical records of adult patients admitted with an ICD-10 code for HIV was implemented. Patients not on ART were triaged for linkage to care with ID consultation, and those on ART received profile review to assess for and correct MRE. We then conducted an IRB-approved, quasi-experimental cohort study comparing adult patients living with HIV who were admitted between February 2017 to June 2017 (pre-intervention) and October 2018 to March 2019 (post-intervention). Patients on ART for indications other than the treatment of HIV were excluded. Rates of ART-related MRE and frequency of ID consultation with linkage to care were compared before and after our intervention.ResultsA total of 200 patients were included, with 100 patients in each of the intervention periods. The institutional stewardship program intervened to correct one error in the pre-intervention period, whereas 119 interventions were made in the post-intervention period with an acceptance rate of 97%. The proportion of patients who experienced an MRE decreased from 70% to 25% (absolute risk reduction 45%, P < 0.01). The total number of errors also decreased between intervention periods (102 vs. 36, P < 0.01). A description of ID pharmacist intervention type is provided in Figure 1. To link patients into care or clarify an ART regimen, the number of ID consults significantly increased from 19% to 39% (P < 0.01) as a result of the ID pharmacist-led initiative.ConclusionFocused ID pharmacy review of patients admitted with HIV and inpatient ART prescription as part of an antimicrobial stewardship program was successful in reducing ART-related MRE and increasing ID consultation to promote linkage to care. Disclosures All authors: No reported disclosures.

End-of-Life Care, Palliative Care Consultation, and Palliative Care Referral in the Emergency Department: A Systematic Review

ContextThere is growing interest in providing palliative care (PC) in the emergency department (ED), but relatively little is known about the efficacy of ED-based PC interventions. A 2016 systematic review on this topic found no evidence that ED-based PC interventions affect patient outcomes or health care utilization, but new research has emerged since the publication of that review. ObjectivesThis systematic review provides a concise summary of current literature addressing the impact of ED-based PC interventions on patient-reported or family reported outcomes, health care utilization, and survival. MethodsWe searched PubMed, Embase, Web of Science, Scopus, and the Cumulative Index to Nursing and Allied Health Literature from inception until September 1, 2018 and reviewed references. Eligible articles evaluated the effects of PC interventions in the ED on patient-reported or family reported outcomes, health care utilization, or survival. ResultsWe screened 3091 abstracts and 98 full-text articles with 13 articles selected for final inclusion. Two articles reported the results of a single randomized controlled trial, whereas the remaining 11 studies were descriptive or quasi-experimental cohort studies. More than half of the included articles were published after the previous systematic review on this topic. Populations studied included older adults, patients with advanced malignancy, and ED patients screening positive for unmet PC needs. Most interventions involved referral to hospice or PC or PC provided directly in the ED. Compared with usual care, ED-PC interventions improved quality of life, although this improvement was not observed when comparing ED-PC to inpatient PC. ED-PC interventions expedited PC consultation; most studies reported a concomitant reduction in hospital length of stay and increase in hospice utilization, but some data were conflicting. Short-term mortality rates were high across all studies, but ED-PC interventions did not decrease survival time compared with usual care. ConclusionExisting data support that PC in the ED is feasible, may improve quality of life, and does not appear to affect survival.

Effectiveness of computer-assisted virtual planning, cutting guides and pre-engineered plates on outcomes in mandible fibular free flap reconstructions: a systematic review protocol.

The objective of this review is to synthesize the best available evidence on the outcomes of mandibular fibular free flap (MFFF) reconstructions using computer-assisted techniques versus traditional freehand techniques. Fibular free flaps are the most commonly used free flap for mandible reconstruction and are considered best practice for mandible reconstructions following resection of head and neck cancers. There are several reported advantages of computer-assisted MFFF reconstructions, including increased accuracy, decreased operation time, decreased ischemia time, decreased overall cost and improved patient outcomes. It is important to assess the advantages and potential harms of these techniques in a systematic review. Eligible studies will consider patients of all ages undergoing MFFF reconstruction. Studies will compare computer-assisted techniques to traditional freehand techniques for the primary outcomes of flap failure, patient-reported outcomes and bony resection margin status. Studies published in English from 2008 will be included. Experimental, quasi-experimental, prospective and retrospective cohort, case-control and analytical cross-sectional studies will be considered. MEDLINE, Embase, Scopus and the Cochrane Central Register of Controlled Trials will be searched. Gray literature sources will include Google Scholar and the World Health Organization International Clinical Trials Registry Platform. Two independent reviewers will screen titles and abstracts, assess full-text papers against the inclusion criteria, evaluate methodological quality using standardized critical appraisal instruments and extract data using a customized form. If possible, data will be pooled for statistical meta-analysis, and a Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Summary of Findings will be presented.

Shared Reading Practices and Early Literacy Promotion in the First Year of Life.

To describe infant home reading trajectories and environments in the first year and to assess whether receiving books starting in the newborn period, compared with starting at 6 months, alters these trajectories. Two study groups were enrolled in a quasi-experimental sequential cohort study; both groups received shared reading counseling starting in the newborn period and completed surveys throughout the first year. The Standard group received books starting at 6 months, whereas the Early Books group received books starting at 2 weeks. Reading trajectories were assessed both overall and between the study groups. At the 2-week visit, less than half of families in each group had started shared reading with their infant, which rose to >97% by 12 months. Approximately two-thirds of families owned >10 children's books at 2 weeks, which increased to >80% at 12 months. Incorporating shared reading into bedtime routines also increased during the first year. Early versus standard book distribution did not alter these trajectories. Over the first year of life, families almost universally initiated shared reading and increased the number of books in the home. Reading habits established during this time were maintained in both groups. Literacy promotion beginning at the earliest well-child visits may help establish routines that will persist throughout childhood.

Influencing nursing students\u2019 perceptions of community care with curriculum-redesign; a quasi-experimental cohort study

BackgroundThe shift in healthcare to extramural leads to more patients with complex health problems receiving nursing care at home. However, the interest of baccalaureate nursing students for community nursing is moderate, which contributes to widespread labour-market shortages. This study investigates the effect of a more ‘community-care-oriented’ curriculum on nursing students’ perceptions of community care.MethodsA quasi-experimental quantitative survey study with a historic control group (n = 477; study cohorts graduating in 2015, 2016, and 2017; response rate 90%) and an intervention group (n = 170; graduating in 2018; response rate 93%) was performed in nursing students of a University of Applied Sciences in a large city in the Netherlands. The intervention group underwent a new curriculum containing extended elements of community care. The primary outcome was assessed with the Scale on Community Care Perceptions (SCOPE). The control and intervention group were compared on demographics, placement preferences and perceptions with a chi-square or T-test. Multiple regression was used to investigate the effect of the curriculum-redesign on nursing students’ perceptions of community care.ResultsThe comparison between the control and intervention group on students’ perceptions of community care shows no significant differences (mean 6.18 vs 6.21 [range 1–10], respectively), nor does the curriculum-redesign have a positive effect on students’ perceptions F (1,635) = .021, p = .884, R2 = < .001. The comparison on placement preferences also shows no significant differences and confirms the hospital’s popularity (72.7% vs 76.5%, respectively) while community care is less often preferred (9.2% vs 8.2%, respectively). The demographics ‘working in community care’ and ‘belonging to a church/religious group’ appear to be significant predictors of more positive perceptions of community care.ConclusionsGraduating students who experienced a more ‘community-care-oriented’ curriculum did not more often prefer community care placement, nor did their perceptions of community care change. Apparently, four years of education and placement experiences have only little impact and students’ perceptions are relatively static. It would be worth a try to conduct a large-scale approach in combination with a carefully thought out strategy, based on and tying in with the language and culture of younger people.

The influence of mathematics self-efficacy on numeracy performance in first-year nursing students: A quasi-experimental study.

To examine the factors that influence nursing students' mathematics self-efficacy, the effect of numeracy instruction on self-efficacy, and the association between self-efficacy and numeracy test performance. Medication administration errors, including administering incorrect dosages or infusion rates, can result in serious harm to patients. Hence, it is essential that nursing students are adequately prepared with the necessary numeracy skills during their nursing program. This quasi-experimental cohort study used a pre- and post-test survey design. The study complied with the STROBE checklist for cohort research. In total, n = 715 undergraduate first year nursing students participated in the study from June to October 2017 at a single multi-campus university in the Western Sydney region of Australia. Data were collected at three time-points: (a) baseline, including assessing pre-instruction mathematics self-efficacy (NSE-Math scale); (b) 6-week follow-up; including assessing post-instruction mathematics self-efficacy; and (c) numeracy test performance was collected at 7-week follow-up. At baseline, those with high NSE-Math scale scores were more likely to be male and have at least high school advanced mathematics level education. Following structured numeracy instruction, NSE-Math scale scores increased significantly, and those who obtained a satisfactory grade in their numeracy assessment were more likely to have high NSE-Math scale scores and high academic performance in the previous semester. The study shows that structured numeracy instruction improved mathematics self-efficacy, which in turn influenced numeracy test performance. Using a structured medication numeracy pedagogical approach, to teach skills in nursing undergraduate programs, provides students with the foundations to improve mathematics self-efficacy and to be successful and safe with medication numeracy calculations and administration in clinical practice.

Maternity waiting homes as a cost-effective intervention in rural Liberia.

To analyze the cost-effectiveness of maternity waiting homes (MWHs) in rural Liberia by examining the cost per life saved and economic effect of MWHs on maternal mortality. A cost-effectiveness analysis was used to evaluate costs and economic effect of MWHs on maternal mortality in rural Liberia to guide future resource allocation. A secondary data analysis was performed based on a prior quasi-experimental cohort study of 10 rural primary healthcare facilities, five with a MWH and five without a MWH, that took place from October 30, 2010 to February 28, 2015. Calculations signified a low cost per year of life saved at MWHs in a rural district in Liberia. Total population-adjusted number of women's lives saved over 3years was 6.25. While initial costs were considerable, over a period of 10 or more years MWHs could be a cost-effective and affordable strategy to reduce maternal mortality rates in Liberia. Discussion of the scaling up of MWH interventions for improving maternal outcomes in Liberia and other low- and middle-income countries is justified. Findings can be used to advocate for policy changes to increase the apportionment of resources for building more MWHs in low resource settings.

Impact of a vaccination promotion intervention using motivational interview techniques on long-term vaccine coverage: the PromoVac strategy

ABSTRACTBackground: Delayed vaccinations at 2, 4, and 6 months are associated with a higher probability of delayed age-appropriate vaccination during childhood. This study aimed to assess the effectiveness of an information session on immunization during infancy.Methods: An individual educational information session with motivational interview techniques for immunization of infants was conducted (experimental group) or not conducted (control group) during postpartum stay in a quasi-experimental cohort study. Immunization data were collected from the Eastern Townships Public Health registry at 3, 5, 7, 13, 19, and 24 months of age. Logistic regressions with repeated measures were performed to assess the intervention’s impact. Relative risks (RR) were estimated. A multivariate model was obtained adjusted for confounding factors.Results: The experimental and control groups included 1140 and 1249 families, respectively. In per protocol analysis, a significant increase in VC of 3.2, 4.9, 7.3, 6.7, 10.6, and 5.1% was observed at 3, 5, 7, 13, 19, and 24 months. Children from experimental group had 9% more chance at a complete vaccination status between 3 and 24 months compared to children from control group (RR (95% CI): 1.09 (1.05-1.13), p < .001). Children with complete vaccination status at 3 months were more likely to have a complete vaccination status at 24 months (82.3 vs. 48.1%, RR (95% CI): 2.72 (2.28-3.24), p < .001). After adjustment, the estimated RR of the intervention’s impact was 1.05 (1.02-1.07), p < .001.Conclusions: An educational information session about immunization based on motivational interview techniques conducted during postpartum hospitalization could improve immunization during infancy.

PP34 Costs Of Healthcare-Associated Infections In Latin America

IntroductionHealthcare-associated infections (HAI) are among the most common preventable health adverse event, associated with significant burden globally. Limited data on HAI costs in lower and middle-income countries is available. The aim of this study is to assess the cost, additional length-of-stay (LOS) and extra-mortality of HAI in the Latin American and Caribbean (LAC) Region.MethodsWe searched Medline/PubMed, Embase, Web of Science, Lilacs, Cochrane, National Health Service Economic Evaluation Database, Centre for Reviews and Dissemination, EconLit, and gray literature published in any language without restriction of date till July 2017. We included observational studies addressing the outcomes of interest, in which hospitalized patients with HAI are compared to those without HAI. The following study designs were included: quasi-experimental, controlled before-after, prospective and retrospective comparative cohort, case-control, and cross-sectional studies. We considered the following HAI-sites: surgical site infections (SSI), catheter-associated urinary-tract infections (CA-UTI), ventilator-associated pneumonia (VAP), and central line-associated bloodstream infection (CLA-BSI), as well as cross-infection (CI). Screening of citations, data extraction, and risk of bias assessment were conducted in duplicate by independent reviewers, according to the study protocol registered on PROSPERO. Reported costs were converted to USD considering official exchange rates.ResultsWe identified 4,339 citations. After removing duplicates, a total of 3,029 citations were screened for eligibility. A total of 87 studies from 17 countries were included. The majority (27.4 percent) reported on VAP, followed by CLA-BSI (21.2 percent), SSI (16.4 percent), and CA-UTI (14.4 percent). Most studies (46.7 percent) reported on incremental LOS, with an average of 14.8 days (range 0.9-49 days). Costs were reported by 25 percent of studies, with average incremental costs of USD 3,460 (range 49-12,155). Average extra-mortality of 15.6 percent (range -2.8-45.2 percent) was reported by 12.6 percent of studies.ConclusionsAvailable evidence from the LAC Region reports significant economic burden of HAI. This information will be useful for cost-effectiveness analysis of interventions aimed at reducing HAI economic and health burden.

Comparing Youth-Friendly Health Services to the Standard of Care Through "Girl Power-Malawi": A Quasi-Experimental Cohort Study.

Adolescent girls and young women (AGYW) face challenges to seeking HIV and sexual and reproductive health services in sub-Saharan Africa. Integrated approaches designed for AGYW may facilitate service uptake, but rigorous evaluation is needed. Four comparable public-sector health centers were selected in Malawi and randomly assigned to a service delivery model. One offered "standard of care" (SOC), consisting of vertical HIV testing, family planning, and sexually transmitted infection management in adult-oriented spaces, by providers without extra training. Three offered youth-friendly health services (YFHS), consisting of the same SOC services in integrated youth-dedicated spaces and staffed by youth-friendly peers and providers. In each health center, AGYW aged 15-24 years were enrolled and followed over 12 months to determine use of HIV testing, condoms, and hormonal contraception. The SOC and YFHS models were compared using adjusted risk differences and incidence rate ratios. In 2016, 1000 AGYW enrolled (N = 250/health center). Median age was 19 years (interquartile range = 17-21 years). Compared with AGYW in the SOC, those in the YFHS models were 23% [confidence interval (CI): 16% to 29%)] more likely to receive HIV testing, 57% (CI: 51% to 63%) more likely to receive condoms, and 39% (CI: 34% to 45%) more likely to receive hormonal contraception. Compared with AGYW in the SOC, AGYW in the YFHS models accessed HIV testing 2.4 (CI: 1.9 to 2.9) times more, condoms 7.9 (CI: 6.0 to 10.5) times more, and hormonal contraception 6.0 (CI: 4.2 to 8.7) times more. A YFHS model led to higher health service use. Implementation science is needed to guide scale-up.

Status epilepticus alert reduces time to administration of second-line antiseizure medications.

Status epilepticus (SE) is a neurologic emergency with high morbidity and mortality. Delays in SE treatment are common in clinical practice and can be associated with poorer outcomes. Our goal was to determine whether the implementation of an SE alert protocol improves time to administration of a second-line antiseizure medication (ASM) in hospitalized adults. We developed and implemented an inpatient SE alert system. A quasiexperimental cohort study was performed. We analyzed all patients aged 18-85 years who were managed at the University of Kentucky Medical Center using the SE alert protocol between March 2015 and June 2017 (n = 19). Controls were the first 20 consecutive patients treated for SE over the same time period, but who were managed with usual care (i.e., without SE alert protocol). Time to administration of a second-line ASM was shorter with the use of the SE alert system (22.21 ± 3.44 minutes) compared to usual care (58.30 ± 6.72 minutes; p < 0.0001). Implementation of an SE alert system led to a marked improvement in time to administration of a second-line ASM. This study provides Class III evidence that for adult inpatients treated for SE, implementation of an SE alert protocol reduces time to administration of second-line ASM.

Implementación de un programa de uso racional de antibióticos en cuidado intensivo: ¿se pueden mejorar los resultados?

IntroductionThe misuse of antibiotics has been associated with adverse outcomes in critically ill patients. It is possible that the implementation of a rational antibiotic use program and clinical management protocols for infections in the Intensive Care Unit (ICU) could improve outcomes.. ObjectiveTo determine if the implementation of a rational use of antibiotics program is associated with positive outcomes in the ICU. MethodsAn ambispective quasi-experimental cohort-study was carried out in 2 phases of 3 months each, separated by a period of education, between July 2016 and January 2017 in an ICU of a tertiary care centre. ResultsThe study included 78 patients, of whom 93% were diagnosed with septic shock at ICU admission. E. coli related infections were identified in 29.4% of cases, followed by Klebsiella pneumoniae in 8.5%. The rational treatment rate was higher in phase 2 compared to that of phase 1 (71% vs 65%), and the difference was statistically significant (P=.015). The ICU stay was shorter in phase 2 (4.2 vs 6.7, P=.04), and days on mechanical ventilation days were also reduced (5.7 vs 2.0, P=.03). ConclusionsThe rational use of antibiotics program implementation in critically ill patients is related with ICU stay and mechanical ventilation day reduction but not with lower mortality rates. We recommend the implementation of a multidisciplinary rational antibiotic use program in our country led by the intensivists to improve clinical outcomes in critical patients.

Comparing youth-friendly health services to the standard of care through "girl Power-Malawi": A quasi-experimental cohort study

Comparing youth-friendly health services to the standard of care through "girl Power-Malawi": A quasi-experimental cohort study

Do Prophylactic Foam Dressings Reduce Heel Pressure Injuries?

The purpose of this evidence-based report card is to examine the evidence and provide recommendations related to the effectiveness of prophylactic foam dressings in reducing heel pressure injuries. Do prophylactic foam dressings applied to the heel reduce heel pressure injuries for patients in the acute care setting? A search of the literature was performed by a trained university librarian that resulted in 56 articles that examined pressure injury, prevention, and prophylactic dressings. A systematic approach was used to review titles, abstracts, and text, yielding 13 studies that met inclusion criteria. Strength of the evidence was rated based on the methodology from Essential Evidence Plus: Levels of Evidence and Oxford Center for Evidence-Based Medicine. Thirteen studies were identified that met inclusion criteria; 1 was a randomized controlled trial, 2 were systematic reviews, 3 quasi-experimental cohort studies, 1 quality improvement study, 1 case series, 1 scoping review, 1 consensus panel, and 3 bench studies. All of the studies identified suggest that the use of prophylactic foam dressings reduces the development of pressure injuries on the heel when used in conjunction with a pressure injury prevention program. The strength of the evidence for the identified studies was level 1 (4 level A, 4 level B, and 5 level C). The use of prophylactic multilayer foam dressings applied to the heels, in conjunction with an evidence-based pressure injury prevention program, is recommended for prevention of pressure injuries on the heel (SORT level 1).

Comparing four service delivery models for adolescent girls and young women through the ‘Girl Power’ study: protocol for a multisite quasi-experimental cohort study

IntroductionIn sub-Saharan Africa, adolescent girls and young women (AGYW) face a range of sexual and reproductive health (SRH) challenges. Clinical, behavioural and structural interventions have each reduced these risks and...

Clinical and Antibiotic Management of Urinary Tract Infections Pre- and Postimplementation of the CLINITEK AUWi System From Siemens to Screen Out Negative Urine Samples Submitted for Culture: A Retrospective Cohort Study.

To compare patterns of inpatient and outpatient antibiotic use between patients who awaited urine culture results and patients whose urine specimens had been submitted for culture and were screened using the CLINITEK AUWi System. This quasi-experimental retrospective cohort study included patient records with a urine specimen and hospital admission from 1 month before to 1 month after implementation of the system. We compared data from the pre- and postimplementation groups using the χ2 test or Fisher exact test. A similar proportion of patients in the pre- and postimplementation groups were prescribed antibiotics (71.2% vs 80.0%; P = .45); the postimplementation group had a significantly shorter length of stay in hours (median, 226 vs 123; P = .005). The median inpatient antibiotic treatment duration was lower for those in the postimplementation group; however, the duration of outpatient antibiotic treatment was longer. Our findings suggest that screening specimens using the CLINITEK AUWi System may reduce the excess administration of antibiotics.

Combination therapy vs. monotherapy for Gram-negative bloodstream infection: matching by predicted prognosis

The utility of empirical combination antimicrobial therapy for Gram-negative bloodstream infection (BSI) remains unclear. This retrospective, quasi-experimental matched cohort study examined the impact of empirical combination therapy on mortality in patients with Gram-negative BSI. Hospitalized adults with Gram-negative BSI from 1 January 2010 to 31 December 2013 at Palmetto Health Hospitals in Columbia, SC, USA were identified. Patients receiving combination therapy or beta-lactam monotherapy were matched 1:1 based on age, sex and Bloodstream Infection Mortality Risk Score (BSIMRS). Multivariate Cox proportional hazards regression with propensity score adjustment was used to examine overall 28–day mortality and within predefined BSIMRS categories (<5 and ≥5). A total of 380 patients receiving combination therapy or monotherapy for Gram-negative BSI were included in the study. Median age was 66 years and 204 (54%) were female. Overall, 28-day mortality in patients who received combination therapy and monotherapy was 13% and 15%, respectively (P = 0.51). After stratification by BSIMRS, mortality in both combination therapy and monotherapy groups was 1.1% in patients with BSIMRS <5 (P = 0.98) and 27% and 32%, respectively, in patients with BSIMRS ≥5 (P = 0.47). After adjusting for propensity to receive combination therapy, risk of mortality was not significantly different for combination therapy compared to monotherapy (hazard ratio [HR] 0.90, 95% confidence interval [CI] 0.51–1.60). This finding persisted for both subgroups of BSIMRS <5 (HR 0.96, 95% CI 0.04–24.28) and BSIMRS ≥5 (HR 0.83, 95% CI 0.46–1.48). There is no survival benefit from empirical combination therapy over monotherapy in patients with Gram-negative BSI, regardless of predicted prognosis at initial presentation.

A systematic review of the effect of reproductive intention screening in primary care settings on reproductive health outcomes.

PurposeNo recommendations exist for routine reproductive intention screening in primary care. The objective of this systematic review is to assess the effect of reproductive intention screening in primary care on reproductive health outcomes (PROSPERO CRD42015019726).MethodsWe performed a systematic search in Ovid Medline, PubMed, CINAHL, Embase, CDR/DARE databases, Web of Science, ISRCTN registry, Clinicaltrials.gov and Cochrane Library. Studies published in English between 2000 and 2017 and whose population was patients of reproductive age (15–49) were included. Studies without a comparison group were excluded. Two independent reviewers assessed eligibility, study quality and abstracted data.ResultsOf 24 780 titles and/or abstracts reviewed, nine studies met inclusion criteria: four randomized controlled trials (RCTs) and five observational studies. Two RCTs and one quasi-experimental cohort study showed a statistically significant increase in knowledge related to healthier pregnancy, such as the benefits of folic acid supplementation, and increased risk profiles for those with chronic conditions. Among studies measuring contraceptive use, only one cohort study showed any increase while the RCT and retrospective cohort did not show a statistically significant effect. Neither of the two RCTs that assessed the provision of contraception by primary care providers for those not desiring pregnancy found increased access to contraception, although one found increased documentation of contraception in electronic medical records. Acceptability of reproductive intention screening was measured in seven studies, and participant satisfaction was high in all seven studies.ConclusionsMore research is needed to determine whether routine inclusion of reproductive intention screening in primary care is warranted.

Cumulative Effect of an Antimicrobial Stewardship and Rapid Diagnostic Testing Bundle on Early Streamlining of Antimicrobial Therapy in Gram-Negative Bloodstream Infections.

The use of rapid diagnostic tests (RDTs) enhances antimicrobial stewardship program (ASP) interventions in optimization of antimicrobial therapy. This quasi-experimental cohort study evaluated the combined impact of an ASP/RDT bundle on the appropriateness of empirical antimicrobial therapy (EAT) and time to de-escalation of broad-spectrum antimicrobial agents (BSAA) in Gram-negative bloodstream infections (GNBSI). The ASP/RDT bundle consisted of system-wide GNBSI treatment guidelines, prospective stewardship monitoring, and sequential introduction of two RDTs, matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) and the FilmArray blood culture identification (BCID) panel. The preintervention period was January 2010 through December 2013, and the postintervention period followed from January 2014 through June 2015. The postintervention period was conducted in two phases; phase 1 followed the introduction of MALDI-TOF MS, and phase 2 followed the introduction of the FilmArray BCID panel. The interventions resulted in significantly improved appropriateness of EAT (95% versus 91%; P = 0.02). Significant reductions in median time to de-escalation from combination antimicrobial therapy (2.8 versus 1.5 days), antipseudomonal beta-lactams (4.0 versus 2.5 days), and carbapenems (4.0 versus 2.5 days) were observed in the postintervention compared to the preintervention period (P < 0.001 for all). The reduction in median time to de-escalation from combination therapy (1.0 versus 2.0 days; P = 0.03) and antipseudomonal beta-lactams (2.2 versus 2.7 days; P = 0.04) was further augmented during phase 2 compared to phase 1 of the postintervention period. Implementation of an antimicrobial stewardship program and RDT intervention bundle in a multihospital health care system is associated with improved appropriateness of EAT for GNBSI and decreased utilization of BSAA through early de-escalation.

Impact of inpatient Care in Emergency Department on outcomes: a quasi-experimental cohort study

BackgroundHospitals around the world are faced with the issue of boarders in emergency department (ED), patients marked for admission but with no available inpatient bed. Boarder status is known to be associated with delayed inpatient care and suboptimal outcomes. A new care delivery system was developed in our institution where boarders received full inpatient care from a designated medical team, acute medical team (AMT), while still residing at ED. The current study examines the impact of this AMT intervention on patient outcomes.MethodsWe conducted a retrospective quasi-experimental cohort study to analyze outcomes between the AMT intervention and conventional care in a 1250-bed acute care tertiary academic hospital in Singapore. Study participants included patients who received care from the AMT, a matched cohort of patients admitted directly to inpatient wards (non-AMT) and a sample of patients prior to the intervention (pre-AMT group). Primary outcomes were length of hospital stay (LOS), early discharges (within 24 h) and bed placement. Secondary outcomes included unplanned readmissions within 3 months, and patient’s bill size. χ2- and Mann-Whitney U tests were used to test for differences between the cohorts on dichotomous and continuous variables respectively.ResultsThe sample comprised of 2279 patients (1092 in AMT, 1027 in non-AMT, and 160 in pre-AMT groups). Higher rates of early discharge (without significant differences in the readmission rates) and shorter LOS were noted for the AMT patients. They were also more likely to be admitted into a ward allocated to their discipline and had lower bill size compared to non AMT patients.ConclusionsThe AMT intervention improved patient outcomes and resource utilization. This model was noted to be sustainable and provides a potential solution for hospitals’ ED boarders who face a gap in inpatient care during their crucial first few hours of admissions while waiting for an inpatient bed.