Small Community Hospital Research Articles

Impact of Pharmacist Intervention on Inappropriate Continuations of Antipsychotics upon ICU Discharge.

Background: Transitions of care (TOC) are important to best practices as they are at times prone to medication errors. The intensive care unit (ICU) is an essential location needing effective TOC due to many reasons, but an important one being that certain medications are only indicated there. One example is antipsychotics used for agitation, delirium, and sedation. Objective: To design, implement, and analyze the benefit of a pharmacist intervention on inappropriate antipsychotic continuation from the ICU to another point in care at a small community hospital. Secondary outcomes include patients discharged from the hospital on antipsychotics inappropriately and accepted pharmacist interventions. Methods: This standard of care, prospective with historical control study included adult patients who were ordered a formulary antipsychotic for delirium, agitation, or sedation during their ICU-level of care admission at SSM Health: St. Clare Hospital- Fenton. Results: There were 33 patients in the historical period and 24 in the intervention period. Those in the intervention period were less likely to have a continuation of antipsychotics beyond 72 hours compared to patients in the historical period (16.7% vs 57.6%, P = 0.002). In addition, patients in the intervention period were less likely to have continuation of antipsychotics when discharged to home (12.5% vs 36.4%, P = 0.04). Conclusions: A pharmacist-driven intervention led to a significant decrease in patients continuing antipsychotics upon ICU discharge. This decrease was seen at both 72hours from patients leaving the ICU and at hospital discharge.

Abstract P302: Impact of Publication of Hypertension Guidelines on Inappropriate Use of Intravenous (IV) Antihypertensive Medications for Hypertensive Urgencies (HU)

Background: Hypertensive urgencies are common in hospitalized patients. In late 2017 and 2018, the publication of major U.S and European hypertension guidelines included specific recommendations against the use of IV antihypertensive medications for the management of severe acute BP elevations in the absence of acute target organ damage (HU). Aim: To study the impact of the publication of guidelines on local utilization of IV medications for HU. Methods and Results: We analyzed 224,265 non-ICU, non-obstetric, non-pediatric hospital admissions to 5 U.S. hospitals (total 2,681 beds) in a medium-sized U.S. healthcare system between January 2016 and March 2020. These included one large academic medical center with two campuses (Hosp A), one medium sized teaching community hospital (Hosp B), one small teaching community hospital (Hosp C), and two small non-teaching hospitals (Hosp D and E). Among all admitted patients, 22,929 (10.2%) developed HU (SBP>180 or DBP >110 mmHg sustained for at least 1 hour without evidence of acute target organ damage). A total of 2,914 HU patients (12.7%) received at least 1 intravenous medication within 6 hours of acute BP elevation, most commonly hydralazine (N 1473, 50.5%], labetalol (N 749, 25.7%) or metoprolol (N 632, 21.7%). The fraction of patients receiving IV antihypertensives decreased during the five years of the study across the five hospitals, but the absolute change was small (2016=13.7%, 2017=12.8%, 2018=12.5%, 2019=11.4%, 2020=11.7%, P value for overall change = 0.003). The Figure displays temporal trends for each hospital. There was significant heterogeneity across hospitals (P<0.0001). Trends were not related to teaching (vs. nonteaching) status of each hospital. Conclusion: In a medium sized U.S. hospital system, the publication of guidelines recommending against IV antihypertensive use in HU was temporally associated with very modest reductions in IV medication use in HU. Process improvement initiatives are needed to optimize guideline-congruent practice.

Medium-term follow up of active surveillance for early prostate cancer at a non-academic institution.

To report oncological outcomes of active surveillance (AS) at a single non-academic institution adopting the standardised Prostate Cancer Research International Active Surveillance (PRIAS) protocol. Competing risk analyses estimated the incidence of overall mortality, metastases, conversion to treatment, and grade reclassification. The incidence of reclassification and adverse pathological findings at radical prostatectomy were compared between patients fulfilling all PRIAS inclusion criteria vs those not fulfilling at least one. We analysed 341 men with Grade Group 1 prostate cancer (PCa) followed on AS between 2010 and 2022. There were no PCa deaths, two patients developed distant metastases and were alive at the end of the study period. The 10-year cumulative incidence of metastases was 1.9% (95% confidence interval [CI] 0.33-6.4%). A total of 111 men were reclassified, and 127 underwent definitive treatment. Men not fulfilling at least one PRIAS inclusion criteria (n = 43) had a higher incidence of reclassification (subdistribution hazards ratio 1.73, 95% CI 1.07-2.81; P = 0.03), but similar rates of adverse pathological findings at radical prostatectomy. Metastases in men on AS at a non-academic institution are as rare as those reported in established international cohorts. Men followed without stringent inclusion criteria should be counselled about the higher incidence of reclassification and reassured they can expect rates of adverse pathological findings comparable to those fulfilling all criteria. Therefore, AS should be proposed to all men with low-grade PCa regardless of whether they are followed at academic institutions or smaller community hospitals.

A retrospective analysis of the social determinants of health affecting stroke outcomes in a small hospital situated in a health professional shortage area (HPSA).

Where someone lives is a major determinant of population health. In the United States, people who live in Health Professional Shortage Areas are considered medically underserved and have a higher propensity for conditions such as stroke, hypertension, and diabetes. Our goal was to better understand the diverse needs of patients presenting to the Crouse Hospital emergency department with stroke symptoms. Crouse Hospital is a small community hospital located in a shortage area serving both urban and rural populations in and around Syracuse, New York. Despite its small size, Crouse Hospital quickly became a major comprehensive stroke center in Central New York. With this study we assessed the social factors affecting the stroke patient population in the community and compared these characteristics between those living in served and underserved areas. Informed by the social determinants of health framework, we analyzed 1731 incidents of stroke that occurred between January 2019 and January 2021, and observed that the circumstances associated with stroke varied by service category and race, with White patients and those from served areas having better stroke outcomes compared to those residing in underserved areas and those that were not White. Our analyses help us to understand the underlying factors influencing the observed disparities and allow us to move forward by implementing informed community-based interventions to decrease stroke incidence and improve post-stroke care. Using our example other small hospitals can enact similar strategies to address the social determinants affecting their patients to improve stroke outcomes in their region.

Impact of tele-antimicrobial stewardship at two small community hospitals in partnership with an academic medical center: two years of experience.

To analyze the impact of a fully remote tele-antimicrobial stewardship program (TASP) at two small community hospitals in partnership with an academic medical center. Retrospective survey from August 1, 2020, to July 31, 2022. A TASP, co-led by an infectious diseases (ID) physician and ID pharmacist, was implemented at M Health Fairview (MHF) Northland, a 21-bed hospital, and at MHF Lakes, a 49-bed hospital. The ID physician and ID pharmacist are located at the University of Minnesota Medical Center. Antimicrobial stewardship interventions were tracked monthly. Restricted antimicrobial days of therapy per 1000 patient days (DOT/1000 PD) were also tracked monthly and two years pre and postimplementation data were compared. All annual antimicrobial expenditures were followed. For the first two TASP years, a total of 789 antimicrobial interventions were made with 85.6% being accepted. Restricted antimicrobial use trended down from 142.93 to 113.97 DOT/1000 PD at MHF Northland. A smaller decrease from 106.31 to 103.12 DOT/1000 PD was seen at MHF Lakes. Annual antimicrobial costs per total patient days decreased. MHF Northland hospital's annual antimicrobial expenditures per total patient days fell from $18.89 in 2019 (preimplementation) to $6.64. MHF Lakes followed a similar trend, decreasing from $11.20 to $5.36. A fully remote TASP in partnership with an academic medical center for two small community hospitals resulted in high rates of accepted interventions sustained over two years. Restricted antimicrobial use and antimicrobial costs trended down.

Investigating the Impact of Mindfulness Meditation on Stress Reduction and Self-Compassion of Nursing Health Care Professionals in a Small Community Hospital in the Midwest

Coronavirus-19 exacerbated daily stressors for nurses due to long hours, understaffing, and potential burnout in health care personnel. There is evidence that nurses who participate in mindfulness activities may experience significant changes related to stress, anxiety, and mood; however, more quantitative research studies are needed to investigate and substantiate the impact of mindfulness-based interventions. This intervention investigated the impact of a 4-week mindfulness meditation on perceived stress and self-compassion. Thirty-two participants were enrolled at the beginning of the study and 26 completed the intervention (intervention group, n = 17; control group, n = 9). A 2-tailed Mann-Whitney U sample rank-sum test was used to explore differences between groups on the 2 outcome variables—Perceived Stress Scale (PSS) and the Self-Compassion Scale (SC). Postintervention assessments were conducted, and statistically significant differences were found between the intervention and control groups for 2 constructs. The intervention group was more likely to “feel confident handling problems” (PSS#4) versus the control group (median = 11.76, 16.78, respectively; P = .020; α = .05); and the intervention group tended to “take a more balanced view of life situations” (SC#3) than the control group (median = 12.50, 15.39, respectively; P =.047; α = .05). Other constructs from the PSS and the SC were not statistically different. In conclusion, this study found observable improvements in the raw data and statistically significant differences for the intervention group; however, more research is warranted.

Implementation of multifaceted diagnostic stewardship for Clostridioides difficile infection during the COVID-19 pandemic at a small Japanese hospital.

Clostridioides difficile infection (CDI) is a common, healthcare-associated infection. However, in Japan, testing for CDI is infrequent, suggesting that its incidence may be underestimated. This study aimed to examine the implementation of a multifaceted, diagnostic stewardship (DS) for CDI in a small Japanese hospital during the coronavirus 2019 pandemic. Before-after study. A small Japanese community hospital. Healthcare workers including physicians, nurses, and pharmacists. A multifaceted intervention including (1) the addition of CD testing criteria to the hospital guidelines; (2) provision of a tutorial on CD testing to physicians, nurses, and pharmacists; (3) assessment by clinical pharmacists and nurses of the need for CD testing in patients with nosocomial diarrhea and issuance of recommendations for CD testing to physicians; (4) reporting of data on the CD testing rate and CDI incidence in the study center. The CD testing rate increased before the pandemic (+0.16/10,000 patient-days (PD); P = .28), decreased significantly during the pandemic (-0.79/10,000 PD; P = .02), and then increased significantly immediately after the implementation of the intervention (+29.6/10,000 PD; P < .01). Similarly, the CDI incidence increased significantly before the pandemic (+0.26/10,000 PD; P = .02) and decreased significantly during the pandemic (-0.49/10,000 PD; P = .01). Implementation of the intervention resulted in an immediate and significant increase in the CDI incidence (+6.2/10,000 PD; P < .01). Multifaceted DS involving multidisciplinary specialists was effective in improving CD testing, suggesting that appropriate testing can contribute to diagnosing CDI accurately.

The Covid-19 pandemic as a driver towards integrated health care-learning from the experiences of UK community hospitals

Introduction: Many changes occurred in the UK National Health Service (NHS) during the COVID-19 pandemic-some positive and some negative. We were interested in how the pandemic drove integration of health care in small community hospitals in the UK.&#x0D; Method: Appreciative inquiry was used to understand staff perspectives of how community hospitals responded. A total of 20 organisations participated, representing 168 (34%) of community hospitals in the UK. Qualitative interviews were conducted, with a total of 85 staff members, using an online video platform. Community representation was featured through the membership of our project board and advisory group which includes Hospital Leagues of Friends. 30 case studies were developed from these interviews.&#x0D; Results: From our case studies we examine 4 types of integrated care: Multi-Disciplinary Team Working, Community Hospital and Primary Care, Community Hospital and Acute Care, Community Hospital and Local Community. In the interviews staff gave accounts of improved collaborations and partnerships across the local health and care system, and the consequent impact on patients, families, staff and the community. Many staff said that in many cases teamworking and partnerships were already established, so the trust was there to build on even closer joint working.&#x0D; Case studies demonstrating enhanced integration of health care at the micro, meso and macro level are described. Examples of micro changes were small but significant local improvements which impacted positively on the patient experience. Examples of meso changes were those that were across a community hospital or hospitals, with partnerships and joint working supporting improved services. We focus particularly on the macro level, where system-wide changes were implemented to embed innovations and integrated working. &#x0D; We pay particular reference to factors that are known to be associated with successful integration as shown in a recently published systematic review, namely: organisational culture, workforce management, inter-organisational collaboration, leadership ability of staff, economic factors and political factors.&#x0D; Discussion: We discuss the learning from the case studies that in order to make the most of our community hospitals we need to be: making decisions locally, benefiting from excellent leadership, recognising community hospitals as community assets and looking after our staff. In particular locally devolved decision-making appropriate to local context was viewed as a critical success factor in swiftly making changes and improvements for the benefit of patients and families, and also for staff. Where this was supported by strong leadership, staff reported successful quality improvements. We continue to work with staff in online discussion groups in our Community Hospital Q Community Special Interest Group to build on this learning and share widely across the community hospital network.&#x0D; Conclusion: This study shows how the pandemic accelerated integrated care between staff, services and systems, and the improved recognition of the vital role of community hospitals as community services in the local health and care system.&#x0D; &#x0D; &#x0D;

157. Implementation of multidisciplinary diagnostic stewardship for Clostridioides difficile infection during the COVID-19 pandemic at a small Japanese hospital

Abstract Background Clostridioides difficile infection (CDI) is a common, healthcare-associated infection. However, its incidence has reportedly declined in the United States owing to the COVID-19 pandemic. On the other hand in Japan, testing for CDI has been infrequent, suggesting that this disease may be underdiagnosed. The present study examined the implementation of multifaceted, diagnostic stewardship for CDI in a small Japanese hospital during the pandemic. Methods The following interventions were introduced at Tama-Nambu Chiiki Hospital, a small community hospital in Tokyo: 1) criteria for CDI testing were added to the hospital's guidelines; 2) clinical pharmacists and nurses assessed the need for CDI testing in patients with nosocomial diarrhea and made recommendations for CDI testing to physicians; 3) a tutorial on CDI testing was given to physicians, nurses, and pharmacists; 4) data on the density of CDI testing and the CDI incidence in the hospital were provided to healthcare workers every three months. The outcomes were CDI testing frequency and the CDI incidence per 10,000 patient days. Segmented regression in interrupted time-series analysis (ITSA) was performed before the pandemic (2018/04-2020/03), after the pandemic (2020/04-2022/03), and after the intervention (2022/04-2023/03). Results The frequency of CDI testing tended to increase before the pandemic (+0.16/10,000 PD, P=0.28) but decreased significantly after the pandemic (-0.79/10,000 PD, P=0.02), then increased significantly immediately after the intervention (+29.6/10,000 PD, P&amp;lt; 0.01). Similarly, the incidence of CDI increased significantly before the pandemic (+0.23/10,000PD, P=0.02) but decreased significantly after the pandemic (-0.45/10,000PD, P=0.01). Implementation of the intervention resulted in an immediate, significant increase in the CDI incidence (+6.8/10,000PD, P&amp;lt; 0.01). Conclusion Multifaceted, diagnostic stewardship involving multiple specialists was effective in improving CDI testing, suggesting that appropriate testing can contribute to the accurate diagnosis of CDI. Disclosures All Authors: No reported disclosures

2882. Impact of a Tele-Antimicrobial Stewardship Program at Two Small Community Hospitals in Partnership with an Academic Medical Center: 2 Years of Experience

Abstract Background Community and rural hospitals often lack resources for infectious diseases (ID) specialists. Tele-antimicrobial stewardship programs (TASPs) have emerged as a method for health systems to meet regulatory requirements. We analyzed the impact of a fully remote TASP at two small community hospitals in partnership with an academic medical center over a two-year period. Methods A TASP, co-led by an ID physician and ID pharmacist, was implemented at a 21-bed hospital in Princeton, MN, and 49-bed hospital in Wyoming, MN, in August 2020. Figure 1 outlines daily TASP workflows in which the ID physician and ID pharmacist were located at an academic medical center. Frequently encountered restricted antimicrobial agents included vancomycin (intravenous and enteral), piperacillin-tazobactam, cefepime, meropenem, ertapenem, micafungin, and remdesivir. Antimicrobial stewardship interventions were tracked monthly. Restricted antimicrobial days of therapy per 1000 patient days (DOT/1000 PD) mean averages two years pre- and post-implementation were compared. Annual antimicrobial expenditures were followed. Results For the first two TASP years (8/1/2020 to 7/31/2022), a total of 789 antimicrobial interventions were made with 85.6% being accepted. Each site boasted similar TASP intervention acceptance rates, 85% for the Princeton hospital and 86% for Wyoming (Figure 2 and Table 1). Restricted antimicrobial use trended down from 141.97 to 113.97 DOT/1000 PD at Princeton. A smaller decrease from 106.3 to 103.12 DOT/1000 PD was seen at Wyoming. Annual antimicrobial costs per total patient days also decreased (Figure 3). Princeton hospital’s annual antimicrobial expenditures per total patient days fell from $18.89 in 2019 (pre-implementation) to $6.64. Wyoming showed a reduction in antimicrobial costs per total patient days by decreasing from $11.20 to $5.36. Conclusion A fully remote TASP in partnership with an academic medical center for two small community hospitals resulted in a rapid increase in the rates of accepted interventions. These high rates were sustained over two years. Restricted antimicrobial use and antimicrobial costs trended down. Consistent communication with tele-hospital physicians and pharmacists helped establish trusting relationships. Disclosures All Authors: No reported disclosures

2249. Piperacillin-tazobactam-targeted provider education to improve utilization in a small community hospital

Abstract Background Piperacillin-tazobactam is a broad-spectrum antibiotic commonly used for the treatment of Pseudomonas aeruginosa and other susceptible Gram negative and anaerobic infections. Piperacillin-tazobactam utilization is markedly elevated in our institution compared with regional and national rates.Thus, interventions to promote optimal use of this antibiotic to reduce utilization rates and negative consequences are needed. Methods Healthcare providers were provided with guidelines on piperacillin-tazobactam alternative treatments for various infections. Guideline handouts were disseminated and complemented by in-person presentations and one-on-one case discussions, as needed. Data on piperacillin-tazobactam utilization was gathered using BD Medmined’s medication analytics. Results Total antibiotic utilization at our institution is higher compared to national and regional rates. In the 2nd quarter (Q2) of 2021, piperacillin-tazobactam utilization was 44% and 26% above national and regional comparative rates, respectively. In Q2 2022, piperacillin-tazobactam was 59% and 45% higher, respectively. Immediately post-initiation of intervention (Q3 2022), utilization rates dropped to 34% and 22%, respectively and utilization dropped further in the succeeding quarters attaining comparable rates to national and regional comparator hospitals. Conclusion Providing healthcare providers with antibiotic-targeted education on alternative treatments can significantly reduce the utilization of piperacillin-tazobactam. Further studies are warranted to evaluate the long-term impact of this intervention on antibiotic stewardship in small community hospitals. Disclosures Cirle A. Warren, MD, Ser-109 Coactuate: Advisor/Consultant|Ser-109 Coactuate: Honoraria

1213. Application of Short Course Criteria for Community-Acquired Pneumonia (CAP) Among Patients Admitted Within a 17-community Hospital Telehealth Antimicrobial Stewardship Program (Tele-ASP)

Abstract Background A recent randomized controlled trial by Dinh et al. found three days of antibiotics was appropriate for certain community-acquired pneumonia (CAP) patients, but the real-world applicability of this study remains to be evaluated. In February 2022, a telehealth antimicrobial stewardship program (Tele-ASP) intervention was implemented across 17 small community hospitals to identify patients meeting clinical stability criteria used by Dinh et al. for short course therapy (3 days). An alert was implemented to notify the infectious diseases telehealth (Tele-ID) pharmacist of patients on room air for whom an antibiotic was ordered for pneumonia. Methods This IRB-approved study aimed to evaluate feasibility and impact of the intervention. Patients with severe or complicated CAP, known immunosuppression, or who were transferred were excluded. The primary outcome was total antibiotic duration. Secondary outcomes included whether the total duration was greater than 5 and 7 days and total IV antibiotic duration. Continuous antibiotic duration endpoints were assessed using Mann Whitney U and Fisher's Exact tests were used for categorical endpoints. Results Of 480 patients screened, only 148 (31%) patients met early clinical stability criteria. The primary reason for not meeting criteria was requirement of supplemental oxygen on Day 3 or greater on antibiotics (n=145). This proportion is far lower than previous studies, including that by Dinh et al., which found 60-70% patients met stability criteria. Of the 90 patients included, 27 patients had a Tele-ID review. Patients with an intervention were less likely to receive &amp;gt; 5 days of antibiotics (59% vs 73%) and &amp;gt; 7 days of antibiotics (19% vs. 32%), although these differences were not statistically significant. Conclusion This study relied on accuracy of oxygen charting, which may partly explain relatively lower proportion of patients meeting strict clinical stability criteria and likely limits feasibility of a scalable intervention. A pragmatically modified approach for this Tele-ASP intervention (i.e. allowance for no more than 1 unmet criterion) is an important area for further exploration and could improve the feasibility of a scalable telehealth intervention. Disclosures All Authors: No reported disclosures

The Impact of Antimicrobial Stewardship in Treating Patients with Escherichia coli Bacteremia in a Small Single Center Community Hospital.

Purpose: There are many challenges that pharmacist led antimicrobial stewardship programs can encounter including lack of resources, costs, and inaccurate antimicrobial susceptibility testing (AST) results. The COVID-19 pandemic has led to increased resistance especially with gram negative infections. At a small single center community hospital, gram negative infections, particularly Escherichia coli infections, predominately occur. Therefore, this study aims to address gram negative bacteremia burden and its impact on antimicrobial stewardship efforts for combatting Escherichia coli and ESBL organisms with such barriers during the pandemic. Methods: In a retrospective cohort study, patients ≥ 18 years of age from a small community hospital were reviewed. Patients were excluded if their blood cultures were not positive for Escherichia coli and if antibiotics were not initiated during hospital stay. The primary endpoint was to determine the length of hospital stay. Critical secondary endpoints include antibiotic de-escalations, duration of antibiotics, time to definitive antibiotic therapy, serum procalcitonin levels, blood culture availabilities, MIC breakpoints, co-infection of COVID-19, and Clostridioides difficile occurrences. Results: Out of 74 patients with gram negative bacteremia, 41 patients specifically had Escherichia coli bacteremia. The primary endpoint results showed that patients with Escherichia coli bacteremia that stayed in the ICU had a length of stay of 13.6 days. Patients with Escherichia coli bacteremia in the Non-ICU setting has a length of stay of 7.3 days, and patients with ESBL bacteremia in the Non-ICU setting had a length of stay of 6.8 days. Conclusions: Despite the various challenges that antimicrobial stewardship programs (ASP) face in a single center small community hospital, the ASP at this small community hospital utilizes various policies and tools to increase appropriate antibiotic use and decrease hospital length of stay in patients with Escherichia coli bacteremia.

An Interdisciplinary Videoconference to Improve Transitions of Care and Reduce Readmission, Cost, and Post-Acute Length of Stay in a Teaching and Community Hospital

ObjectivesCoordination of care across health care settings is needed to ensure safe patient transfers. We examined the effects of the ECHO-Care Transitions program (ECHO-CT) on readmissions, skilled nursing facility (SNF) length of stay (LOS), and costs. DesignThis is a prospective cohort study evaluating the ECHO-CT program. The intervention consisted of weekly 90-minute teleconferences between hospital and SNF-based teams to discuss the care of recently discharged patients. Setting and ParticipantsThe intervention occurred at one small community hospital and 7 affiliated SNFs and 1 large teaching hospital and 11 associated SNFs between March 23, 2019, and February 25, 2021. A total of 882 patients received the intervention. MethodsWe selected 13 hospitals and 172 SNFs as controls. Specific hospital-SNF pairings within the intervention and control groups are referred to as hospital-SNF dyads. Using Medicare claims data for more than 10,000 patients with transfers between these hospital-SNF dyads, we performed multivariable regression to evaluate differences in 30-day rehospitalization rates, SNF lengths of stay, and SNF costs between patients discharged to intervention and control hospital-SNF dyads. We split the post period into pre-COVID and COVID periods and ran models separately for the small community and large teaching hospitals. ResultsThere was no significant difference-in-differences among intervention compared to control facilities during either post-acute care period for any of the outcomes. Conclusions and ImplicationsAlthough video-communication of care plans between hospitalists and post-acute care clinicians makes good clinical sense, our analysis was unable to detect significant reductions in rehospitalizations, SNF lengths of stay, or SNF Medicare costs. Disruption of the usual processes of care by the COVID pandemic may have played a role in the null findings.

Scale development to measure the patient perception of patient-centered care of dentists in primary care settings of Thailand: a measurement invariance test

BackgroundPatient-centered care is essential for providing quality services thoroughly at the primary care level, but it is unclear and lacks measurement. This study aimed to develop a reliable and valid instrument to measure patient perception of patient-centered care in primary dental care in Thailand and test the measurement invariance between large and small community hospitals.MethodsThe initial set of 45 items for the patient perception of Patient-Centered Care of Dentist Scale (PCCDS-P version) was developed using a mixed-method approach, which included a literature review, a content validity test, cognitive interviews, and a pre-test. A multistage sampling strategy was used to recruit dental patients or their parents or caregivers from community hospitals across Thailand. Validity was examined through exploratory factor analysis (EFA) and confirmatory factor analysis (CFA). Reliability was assessed using Cronbach's alpha coefficient and the intraclass correlation coefficient. Furthermore, a multi-group analysis was conducted to compare the responses of patients from large and small community hospitals.ResultsThree hundred thirty-six and One thousand one hundred sixty-seven samples were randomized for EFA and CFA, respectively. The final PCCDS-P version consists of 7 factors with satisfactory reliability and validity and is composed of 42 items: dentist-patient relationship, disease-illness, integrated care, communication, shared information and decision-making, holistic, and empathy and anxiety management. The CFA showed the model fit was consistent with the entire sample. The metric invariance analysis showed that the factor loadings were invariant across patient groups. Overall, Cronbach's alpha coefficient and intraclass correlation coefficient were satisfactory.ConclusionsThe newly developed PCCDS-P version is composed of seven domains with 42 items with good reliability and validity, and it indicated measurement invariance across patients in large and small community hospitals.

The Burden of COVID-19 Mortality Due to Referrals From Skilled Nursing Facilities in a Small Community Hospital.

Amidst the COVID-19 pandemic, nursing home residents have seen a significant increase in hospitalizations. However, there is a lack of published data on the healthcare provided to these individuals in community hospitals. This knowledge gap hinders our understanding and evaluation of the quality and outcomes of care received by nursing home residents when they are hospitalized for COVID-19 or other medical conditions. Furthermore, insufficient data is used to compare the clinical outcomes of COVID-19-related admissions from nursing facilities between small community hospitals and tertiary care facilities. It is essential to conduct further research to identify potential disparities, which may indicate an unequal burden of nursing facility referrals to less-resourced hospitals. We examined the characteristics of COVID-19-related deaths in a community hospital during the first surge of COVID-19and calculated the proportion of patients who expired and were transferred from nearby nursing facilities. We performed a retrospective review of all cases of COVID-19 admitted to a 160-bed community hospital in Connecticut from January 1, 2020, to August 1, 2020. One hundred seventy-seven patients with COVID-19 who were admitted to our hospital were included in this study. Seventy patients (70/177, 39.54%) were transferred fromnearby nursing facilities. The primary objective of this study was to examine the clinical characteristics of COVID-19-related deaths in our community hospital during the first surge of COVID-19. We also calculated the proportion of patients who expired and were transferred from nearby nursing facilities. Although the mortality rate in our community hospital was 15.23% (27/177), the majority of those who died were from nursing facilities (85.18%, 23/27). In contrast, mortality among the patients admitted from the community was 3.7% (4/107). The patients transferred from a nursing facility had 12.6 times higher odds of 30-day inpatient mortality or referral to hospice (95% CI, 4.1-38.5; p<0.001). The majority of COVID-19 deaths in our community hospital were due to nursing facility referrals. We hypothesize that this high mortality may reflect healthcare inequality due to the unequal burden of nursing facility referrals to less-resourced hospitals.

Refrigerated human mesenchymal stromal cells as an alternative to cryostorage for use in clinical investigation.

Mesenchymal stromal cells (MSCs) and other therapeutic cells show efficacy for cardiac damage, neurological disease, chronic lung disease, pediatric graft versus host disease, and several inflammatory conditions. Based on their anti-inflammatory and immune-modulatory activities, responsiveness, and secretion of beneficial factors, cellular therapeutics may provide benefits in acute and chronic traumatic injury. However, the use of live cells presents logistical challenges, especially for military trauma. MSCs are generally shipped and stored frozen but require sterile handling before infusion. This requires skilled personnel and equipment not readily available in a forward medical treatment facility or even a small community hospital. Commercial human bone marrow- and adipose-derived MSCs from multiple donors were cultured under standard conditions, harvested and stored at 4°C in solution for up to 21 days. Cell viability, ATP content, apoptosis, proliferation capability, immunomodulation activity, and responsiveness were assessed after different amounts of time. Human MSCs can be stored at 4°C in MSC culture medium for 14 days while maintaining a reasonable level of viability and function. Both viability and function are reduced when MSCs are stored in crystalloid solutions. This approach makes it feasible to prepare cellular therapeutic agents in a laboratory or commercial facility and ship them under refrigerated conditions. Once they reach their destination, they can be stored at 4°C under conditions similar to blood products. Cells prepared and stored this way could also be used directly with minimal handling, making them more practical for both civilian and military trauma.

Trends of Opioid Usage in Surgical Patients in a Small Community Hospital: Analysis of Patient Data Between 2017 and 2021.

Purpose: The purpose of our study was to quantify and analyze the annual opioid usage in surgical patients at Wood County Hospital (WCH) between 2017 and 2021. Methods: In this retrospective study, patient data between 2017 and 2021 was analyzed to determine the oral morphine milligram equivalent (MME) of opioids used in surgical patients at WCH. Annual MME prescribed per admission was compared each year using one-way ANOVA followed by Tukey post hoc test. Similarly, the annual use of intravenous (IV) acetaminophen for surgical patients per admission was also calculated and analyzed using the one-way ANOVA followed by Tukey post hoc test. Results: Compared to the year 2017 (42.0 ± 3.6), a statistically significant decrease in opioid usage per surgical admission (mean±SEM of MME) was observed during the years 2018 (32.6 ± 1.4; P = .04), 2019 (30.4 ± 1.2; P = .01), and 2021 (30.8 ± 1.9; P = .01). An analysis of individual opioid use revealed a trend toward lower fentanyl and hydromorphone usage each year since 2017. A significant decrease in the annual morphine usage (mean±SEM of MME) for surgical patients was observed during both 2020 (14.4 ± 0.9; P = .05) and 2021 (14.0 ± 0.7; P = .05) compared to the year 2017 (22.1 ± 2.4). Finally, compared to the year 2017, a statistically significant decrease (P < .05) in the annual use of oxycodone (MME) and IV acetaminophen (mg) for pain management in surgical patients was observed from 2018 to 2021. Conclusion: Our analysis reveals a significant decrease in opioid usage per surgical admission at WCH over 2017 to 2021 indicating a positive impact of the various opioid stewardship measures implemented at the hospital.

Effect of tele-COVID rounds and a tele-stewardship intervention on antibiotic use in COVID-19 patients admitted to 17 small community hospitals.

Antibiotic stewardship interventions are urgently needed to reduce antibiotic overuse in hospitalized COVID-19 patients, particularly in small community hospitals (SCHs), who often lack access to infectious diseases (ID) and stewardship resources. We implemented multidisciplinary tele-COVID rounds plus tele-antibiotic stewardship surveillance in 17 SCHs to standardize COVID management and evaluate concurrent antibiotics for discontinuation. Antibiotic use was compared in the 4 months preintervention versus 10 months postintervention. Interrupted time-series analysis demonstrated an immediate decrease in antibiotic use by 339 days of therapy/1000 COVID-19 patient days (p < .001), and an estimated 5258 antibiotic days avoided during the postintervention period. Thirty-day mortality was not significantly different, and a significant reduction in transfers was observed following the intervention (23.3% vs. 7.8%, p < .001). A novel tele-ID and tele-stewardship intervention significantly decreased antibiotic use and transfers among COVID-19 patients at 17 SCHs, demonstrating that telehealth is a feasible way to provide ID expertise in community and rural settings.

Improving Sepsis Compliance With Human Factors Interventions in a Community Hospital Emergency Room

Background: Adherence to best practices for sepsis management at a small community hospital was below system, state, and national benchmarks and affected vital indicators, including mortality. This study aimed to improve sepsis best practice compliance by implementing human factors–influenced interventions. Methods: The Plan-Do-Study-Act quality improvement methodology was used for this project. Baseline metrics included sepsis bundle compliance following CMS (Centers for Medicare &amp; Medicaid Services) core measure standards, hospital morality, sepsis triage screening, and physician order set use. Interventions: Several human factors workflows and tools were used to boost early identification with screening opportunities and enhance staff awareness of sepsis indicators. Results: With the interventions, the hospital’s compliance with sepsis best practice treatment improved by a 23 percentage-point increase from baseline. Sepsis triage screening also increased and remained consistent after project interventions. Conclusions: With the project, using human factors tools enhanced staff engagement and increased sepsis awareness. Engagement increased sepsis identification and screening in a small community hospital setting.