Step-down Unit Research Articles

Registered nurses’ experience of care for adult patients with a temporary tracheostomy at general hospital wards. A phenomenological-hermeneutic explorative study

BackgroundCaring for adult patients with a temporary tracheostomy in general wards can be challenging and complex. Little research has explored registered nurses’ experiences with caring for these groups of patients. ObjectivesThis study sought to interpret and describe registered nurses’ lived experiences of caring for adult patients with a tracheostomy in general wards. Research design/methodologySix registered nurses were interviewed in this study. The interviews were analysed to gain comprehensive knowledge about caring for adult patients with a temporary tracheostomy. The interviews were transcribed, analysed, and interpreted by using Gadameŕs philosophical hermeneutics and Kvale and Brinkmann’s three steps of understanding. SettingThree different wards medical, surgical, and neurological of a teaching hospital in Norway. FindingsThree themes emerged from data analysis. These included experiencing clinically challenging patients, a lack of clinical support from the intensive care nurses, and a lack of professional confidence. ConclusionThis study highlighted the challenges surrounding the care of an adult patient with a tracheostomy in the general wards. Identifying these challenges would lead to further improvement in registered nurses’ experiences and, in turn, in the quality of competent care for adult patients with a tracheostomy in the general ward. Implications for Clinical PracticeUnderstanding the registered nurses’ experiences will assist the head nurses in planning and providing relevant information and education to provide safe and holistic patient care. Adequate support from intensive care unit nurses and professional development are required to ensure high-quality care. This study recommends that healthcare managers focus on establishing step-down units to improve patient outcomes, especially for high-risk patients and to increase the competencies of registered nurses in caring for adult patients with a tracheostomy as a whole person.

LBA01-07 MULTI-DISCIPLINARY DEVELOPMENT AND IMPLEMENTATION OF A TRIAL OF VOID ALGORITHM TO REDUCE INDWELLING URETHRAL CATHETER USE

You have accessJournal of UrologyCME1 Apr 2023LBA01-07 MULTI-DISCIPLINARY DEVELOPMENT AND IMPLEMENTATION OF A TRIAL OF VOID ALGORITHM TO REDUCE INDWELLING URETHRAL CATHETER USE David Han, Lovie Amolo, Hersy Contreras, Maureen Lowers Roach, Bridgette Bennett, Maria Sofia Luga, Shelly-Anne Layne, Coraima Rihan Veliz, Subhash Krishnamoorthy, David Weiner, Christopher Anderson, and Gina Badalato David HanDavid Han More articles by this author , Lovie AmoloLovie Amolo More articles by this author , Hersy ContrerasHersy Contreras More articles by this author , Maureen Lowers RoachMaureen Lowers Roach More articles by this author , Bridgette BennettBridgette Bennett More articles by this author , Maria Sofia LugaMaria Sofia Luga More articles by this author , Shelly-Anne LayneShelly-Anne Layne More articles by this author , Coraima Rihan VelizCoraima Rihan Veliz More articles by this author , Subhash KrishnamoorthySubhash Krishnamoorthy More articles by this author , David WeinerDavid Weiner More articles by this author , Christopher AndersonChristopher Anderson More articles by this author , and Gina BadalatoGina Badalato More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003360.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Prolonged indwelling catheter use is a risk factor for catheter-associated urinary tract infections (CAUTIs). To reduce catheter use among post-operative patients, we sought to create and implement a novel algorithm to standardize the removal of indwelling Foley catheters. METHODS: We partnered with nursing leadership and the General Surgery Department to develop an evidence-based trial of void algorithm for a surgical Step-Down Unit at an urban teaching hospital [Figure 1A]. Our cohort included post-operative patients treated with intraabdominal, thoracic, vascular, and gynecologic surgeries; patients having urologic surgeries with an imperative indication for a long-term indwelling urethral catheter were excluded from the algorithm but included in analysis. The primary outcome was mean cumulative indwelling urethral catheter days (ex. if 2 patients had catheters for 3 and 7 days, then cumulative catheter days would be 10). We also measured mean total patient days (as a surrogate for patient volume), mean daily number of patients with catheters, and the number of CAUTIs, which are all nationally reported outcomes from the Centers for Disease Control and Prevention. Another surgical unit where the algorithm was not implemented was used as a natural control. We analyzed changes in relevant outcomes 90 days before and after algorithm implementation. RESULTS: The mean number of hospitalized patient days before and after algorithm introduction did not differ on the Step-Down Unit (32.2 vs. 32.0, p=0.60). After implementation, mean cumulative catheter days decreased (14.8 vs. 9.9, p<0.01), as did mean daily number of patients with catheters (3.7 vs. 3.1, p=0.02). Measures of catheter use variation also decreased [Figure 1B]. There was one CAUTI before and after algorithm implementation, the latter deemed potentially associated with algorithm non-adherence on root cause analysis. Measures of catheter use in the surgical floor control group did not differ for any outcome (p>0.05) over the same time-period. CONCLUSIONS: A multi-disciplinary approach to standardize catheter care with an evidence-based trial of void algorithm is feasible and effective in reducing catheter use. Further expansion of this pilot is needed to establish an impact on the associated rate of CAUTI. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1178 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information David Han More articles by this author Lovie Amolo More articles by this author Hersy Contreras More articles by this author Maureen Lowers Roach More articles by this author Bridgette Bennett More articles by this author Maria Sofia Luga More articles by this author Shelly-Anne Layne More articles by this author Coraima Rihan Veliz More articles by this author Subhash Krishnamoorthy More articles by this author David Weiner More articles by this author Christopher Anderson More articles by this author Gina Badalato More articles by this author Expand All Advertisement PDF downloadLoading ...

Assessment of Duration of Feeding, Spillage, Weight Changes, Days to Reach Full Oral Feeds, Full Breastfeed, and Length of Hospitalization Among Preterm Neonates

Background Preterm neonates are not able to breastfeed due to immature sucking swallow reflexes and are kept on an alternative method of feeding until they are able to do so. The time to reach full oral feeds and breastfeed, the duration of feeding, and spillage are important parameters that need to be observed so that a baseline value can be provided, which can help healthcare professionals see the progression and appropriateness of feeding preterm neonates. Objective To assess the duration of feeding, spillage, weight changes, days to reach full oral feeds, full breastfeed, and length of hospitalization among preterm neonates. Material and Methods A descriptive study was carried out on 106 preterm neonates in the step-down unit of the NICU, PGIMER, Chandigarh. The variables under study were duration of feeding, spillage, weight changes, days to reach full oral feeds, days to reach full breastfeed, and length of hospitalization. The tools for data collection used were a socio-demographic profile along with a clinical profile of neonates, a neonatal assessment, and an observation sheet to record spillage and duration of feeding. The methods of data collection used were observation and biophysiological methods. Weight was assessed by the infant weighing scale present in the unit (in grams) and to measure spillage, a bib was used, and its pre- and post-feeding weight was measured on a diaper weighing machine. The values are expressed in grams. The data were collected from July 2021 to November 2021. The data are analyzed using the SPSS version 23.0. Results The results showed that neonates took an average of mean ± SD (range) 15.0 ± 3.12 (10−26) min to complete one feeding session, and spillage was around 1.37± 0.3 (0.8−2.3) g. The transition time to full oral feeds was 8.01 ± 7.21 (1–44) days, and the average time to reach full breastfeed was 26.7 ± 12.1 (5−56) days. Conclusion The present study has provided valuable data on duration of feeding and spillage that serves as a guide for the amount of milk that can be added to the prescribed feed. The information is also helpful in educating the parents to be patient while feeding the baby and wait for at least 3 weeks to 2 months to reach full breastfeed. Gestational age at birth and birth weight affect (negative correlation) the time to reach full oral feeds, breastfeed, and length of hospital stays ( p &lt; .05).

Blueprints for well-being: Modeling the way through Human-Centered Leadership and Pathway to Excellence.

Blueprints for well-being: Modeling the way through Human-Centered Leadership and Pathway to Excellence.

Implementation of a Streamlined Care Pathway to Reduce Cost and Length of Stay for Patients Undergoing Endoscopic Transsphenoidal Pituitary Surgery.

We implemented a streamlined care pathway for patients undergoing endoscopic transsphenoidal (TSA) pituitary surgery. Select patients are recovered in the postanesthesia care unit and transferred to a step-down unit for intermediate neurologic care (INCU), with clinicians trained to manage cerebrospinal fluid leak, diabetes insipidus (DI), and other complications. We evaluated all TSA surgeries performed at 1 academic medical center from 7th January, 2017 to 30th March, 2020, collecting patient factors, tumor characteristics, cost variables, and outcomes. The INCU pathway was implemented on 7th January 2018. Pathway patients were compared with nonpathway patients across the study period. Outcomes were assessed using multivariate regression, adjusting for patient and surgical characteristics, including intraoperative cerebrospinal fluid leak, postoperative DI, and tumor dimensions. One hundred eighty-seven patients were identified. Seventy-nine were on the INCU pathway. Mean age was 53.5years. Most patients were male (66%), privately insured (62%), and white (66%). Mean total cost of admission was $27,276. Mean length of stay (LOS) was 3.97days. Use of the INCU pathway was associated with total cost reduction of $6376.33 (P < 0.001, 95% confidence interval [CI]: $3698.21-$9054.45) and LOS reduction by 1.27days (P= 0.008, 95% CI: 0.33-2.20). In-hospital costswere reduced across all domains, including $1964.87 invariable direct labor costs (P < 0.001, 95% CI: $1142.08-$2787.64) and $1206.52 in variable direct supply costs (P < 0.001, 95% CI: $762.54-$1650.51). Pathway patients were discharged earlier despite a higher rate of postoperative DI (25% vs. 11%, P= 0.011), with fewer readmissions (0% vs. 6%, P= 0.021). A streamlined care pathway following TSA surgery can reduce in-hospital costs and LOS without compromising patient outcomes.

Interdisciplinary assessment of tracheostomy care knowledge: An opportunity for quality improvement

PurposeA 2013 AAOHNS consensus statement called for reduced variation in tracheostomy care. Multidisciplinary approaches and standardized protocols have been shown to improve tracheostomy outcomes. This study aims to identify inconsistencies in knowledge in order to design standardized education targeting these areas to improve quality of care. Materials and methodsAn online, multiple-choice tracheostomy care knowledge assessment was administered to nurses and respiratory therapists in ICUs, stepdown units, and regular nursing floors, as well as residents in otolaryngology, general surgery, and thoracic surgery. The survey was administered and data were recorded using the Select Survey online platform. Results173 nurses, respiratory therapists, and residents participated in this study. Over 75 % of respondents identified correct answers to questions addressing basic tracheostomy care, such as suctioning and humidification. Significant variation was observed in identification and management of tracheostomy emergencies, and appropriate use of speaking valves. Only 47 % of all respondents identified all potential signs of tracheostomy tube displacement. Respiratory therapists with over 20 years of experience (p = 0.001), were more likely to answer correctly than those with less. Nurses were less likely than respiratory therapists to have received standardized tracheostomy education (p = 0.006) and were less likely than others to choose the appropriate scenario for speaking valve use (p = 0.042), highlighting the need for interdisciplinary education. ConclusionsAn interdisciplinary assessment of tracheostomy care knowledge demonstrates variation, especially in identification and management of tracheostomy emergencies and appropriate use of speaking valves. Design of a standardized educational program targeting these areas is underway.

1358 USING THE SUPPORTIVE AND PALLIATIVE CARE INDICATORS TOOL (SPICT) TO PRIORITISE FRAIL INPATIENTS FOR ANTICIPATORY CARE PLANNING

Abstract Introduction Patients with frailty who have emergency admissions are at risk of mortality and may benefit from Anticipatory Care Planning (ACP). Appropriate identification, to target limited resource in an in-patient environment can be challenging. We conducted a prospective study on a cohort of frail in-patients with a hospital admission of ≥ 72 hours duration. We aimed to evaluate the effectiveness of the SPICT tool alongside CFS as a predictor of mortality to improve our targeting of patients for ACP. Method On a single day a SPICT form was completed prospectively for each inpatient on 3 hospital inpatient wards (Complex Frailty Unit, General/Orthopaedic Rehabilitation, Step-Down Unit). Patients were deemed SPICT positive if they scored on ≥ 2 General Indicators and ≥ 2 Clinical Indicators. CFS was also recorded. Electronic records of this patient cohort were followed up for 9 months. Results Of 66 inpatients, 58 (87.9%) were aged ≥ 65 years and had a CFS ≥ 4. Mode CFS value = 6 (23 patients, 39.7%). 32 (55.2%) were SPICT positive; 26 (44.8%) SPICT negative. At 3 months follow-up SPICT had Positive Predictive Value (PPV) 40.6% and Negative Predictive Value (NPV) 84.6% for mortality. At 6 months PPV = 56.3%; NPV = 80.8%. At 9 months PPV = 59.4%; NPV = 76.9%. SPICT negative patients with CFS 6 had mortality risk of 14.3% at 3, 6 and 9 months follow-up respectively. SPICT positive patients with CFS 6 had mortality risks of 50% at 3 months and 62.5% at 6 and 9 months. Conclusion SPICT is a predictor of mortality in patients with frailty during unplanned admissions to hospital of ≥ 72 hours duration. It is now used alongside CFS for all patients admitted to our Complex Frailty Unit, identifying patients most likely to benefit from inpatient ACP on discharge.

Nurses and Respiratory Therapists Lived Experience During COVID-19 Pandemic: A Qualitative Study.

Nurses and respiratory therapists working on the frontline during the pandemic surge were short-staffed and worked extended hours while adding new tasks to already demanding workloads. As the world watched news covering COVID-19's effect, nurses and respiratory therapists lived through the daily stress of treating each patient with care, dignity, and compassion. Limited studies have focused on this population, which is vital to providing care and saving lives; research is needed to understand nurses' and respiratory therapists' experiences during the COVID-19 pandemic. The study aimed to understand nurses' and respiratory therapists' experiences during the COVID-19 pandemic. A qualitative descriptive study, informed by naturalistic philosophy, was designed to obtain a detailed account of participants' experiences during the pandemic surge. A purposive sample was recruited and enrolled from the community through professional organizations and snowball sampling from December 2021 to September 2022. Data was analyzed using thematic analysis. Participants were seven registered nurses and six respiratory therapists employed full-time in an intensive care unit, step-down intensive care unit, emergency department, or medical-surgical unit; seven (53.8%) with an associate degree, and six (46.2%) with a bachelor's degree. Eight (66.7%) self-identified as White, one Asian, one non-Hispanic Black, and two Pacific Islanders. The mean age was 40, and 10 (76.9%) were female. Six primary themes emerged: (a) the work-life experience before the COVID-19 pandemic, (b) the work-life experience during the COVID-19 pandemic, (c) the personal life experience during COVID-19, (d) the coping period, (e) the professional role change, and (f) the work and personal life experiences post COVID-19 surge. The knowledge gained from this study can help improve understanding of the professional quality of life, the need for organizational and community support, and for healthcare professionals to seek help and practice self-care to prevent burnout and secondary traumatic stress.

Wide QRS Complexes Following Ablation for Reentrant Tachycardia

Scenario: A 25-year-old man was referred from a cardiology clinic for an acute exacerbation of supraventricular tachycardia (SVT) during an exercise stress echocardiogram. He has a history of dilated cardiomyopathy (50% left ventricular ejection fraction [LVEF]), wall motion abnormalities, and long QT syndrome. In the clinic before admission, an SVT event was captured during an electrocardiogram (ECG) recording and resolved with a carotid sinus massage. The patient was fully conscious during the event. A few days later, he underwent an electrophysiology (EP) study with radio frequency ablation for atrioventricular reentrant tachycardia (AVRT). He was transferred to the cardiac step-down unit after the EP procedure, and his blood pressure was 94/56 mm Hg, heart rate 87/min, respiratory rate 21/min (regular), oxygen saturation 94% via room air, and body temperature 37 °C (99 °F). The 12-lead ECG below was taken 6 hours after admission to the unit.Normal sinus rhythm, frequent premature ventricular complexes (PVCs) in a quadrigeminy pattern, prolonged QTc interval.Generally, wide QRS complexes (>120 milliseconds) represent electrical activity that originates from the ventricles. Exceptions are aberrantly conducted supraventricular beats, preexcitation associated with an accessory pathway, bundle branch block, and electrolyte imbalance. Given the AVRT diagnosis with recent ablation treatment, these PVCs may be mistaken for preexcitations associated with an accessory pathway, especially as the PVC QRSs appear slurred (ie, “pseudo” delta wave), a characteristic associated with an accessory pathway. However, some features support PVC as the cause. First, the wide QRS complexes are premature, albeit only slightly at first glance. However, if calipers are used, or even on careful visual inspection, one can appreciate that these beats are indeed premature. In this case, the P waves fall just before the PVC but should not be confused with a delta wave. Furthermore, there is a complete compensatory pause after the PVCs because the timing of the sinus node is not interrupted. In contrast, a supraventricular beat (eg, aberrancy, premature atrial complex) would typically have a P wave before the QRS complex, and one would see an incomplete pause because these beats usually enter the sinus node and reset its timing.PVCs can be monomorphic, as in this case, or polymorphic (multiple QRS morphologies). Interestingly, the morphology of the PVC can be used to determine the ventricle of origin (ie, left or right) by examining lead V1. In this example, the morphology resembles a left bundle branch block (ie, negative wide QRS complex). This pattern indicates that the ectopic impulse is moving away from lead V1 and travels toward the left ventricle (ie, deep S wave). The QRS complex is wide because the ventricular impulse travels slowly from the right ventricle, outside the normal conduction system, to the left ventricle, slowing depolarization.Premature beats, including PVCs, can trigger reentrant tachyarrhythmias when an accessory pathway is present. Although PVCs were not documented as the source of the AVRT events in this patient, they are a likely source. This patient’s history of cardiomyopathy may be contributing to the occurrence of PVCs, which may also need to be treated with ablation. Considering that this patient has a prolonged QTc and other significant risk factors (postablation, AVRT, cardiomyopathy, and reduced EF), medications that prolong the QT/QTc should be closely reviewed and adjusted if necessary to prevent torsades de pointes. This patient was discharged home and was followed up by outpatient cardiology.

Rationale, Design, and Characteristics of the VALIANT (COVID-19 in Older Adults: A Longitudinal Assessment) Cohort.

Most older adults hospitalized with COVID-19 survive their acute illness. The impact of COVID-19 hospitalization on patient-centered outcomes, including physical function, cognition, and symptoms, is not well understood. To address this knowledge gap, we collected longitudinal data about these issues from a cohort of older survivors of COVID-19 hospitalization. We undertook a prospective study of community-living persons age ≥ 60 years who were hospitalized with COVID-19 from June 2020-June 2021. A baseline interview was conducted during or up to 2 weeks after hospitalization. Follow-up interviews occurred at one, three, and six months post-discharge. Participants completed comprehensive assessments of physical and cognitive function, symptoms, and psychosocial factors. An abbreviated assessment could be performed with a proxy. Additional information was collected from the electronic health record. Among 341 participants, the mean age was 71.4 (SD 8.4) years, 51% were women, and 37% were of Black race or Hispanic ethnicity. Median length of hospitalization was 8 (IQR 6-12) days. All but 4% of participants required supplemental oxygen, and 20% required care in an intensive care unit or stepdown unit. At enrollment, nearly half (47%) reported at least one preexisting disability in physical function, 45% demonstrated cognitive impairment, and 67% were pre-frail or frail. Participants reported a mean of 9 of 14 (SD 3) COVID-19-related symptoms. At the six-month follow-up interview, more than a third of participants experienced a decline from their pre-hospitalization function, nearly 20% had cognitive impairment, and burdensome symptoms remained highly prevalent. We enrolled a diverse cohort of older adults hospitalized with COVID-19 and followed them after discharge. Functional decline was common, and there were high rates of persistent cognitive impairment and symptoms. Future analyses of these data will advance our understanding of patient-centered outcomes among older COVID-19 survivors.

981: CHANGE IN ATTITUDE FROM CENTRAL TO PERIPHERAL VASOPRESSOR ADMINISTRATION

Introduction: Cancer patients have a nearly 10-fold risk of developing sepsis and septic shock compared with patients without cancer. The Surviving Sepsis Campaign guideline recommends prioritizing treatment of low mean arterial pressure (MAP) through vasopressors given peripherally, rather than waiting for placement of a central venous catheter (CVC). Administration of vasopressors through peripheral venous catheters (PVCs) has traditionally been avoided given concerns of extravasation, limb ischemia and tissue necrosis. Studies with safety guidelines when using peripheral vasopressors have been associated with significantly lower prevalence of complications. We sought to evaluate the safety of vasopressor administration through a PVC in a high-risk group of adult oncology patients admitted to our intensive care unit (ICU) and Stepdown Unit (SDU). Methods: Using hospital and ICU databases, we retrospectively analyzed oncology patients admitted to our ICU and SDU from January to December 2021. We then identified patients admitted for septic shock using ICD-10 codes who received a vasopressor agent for > 1 hour via a PVC. Extravasation or other adverse events recorded during or immediately after the peripheral infusion of vasopressor agent were recorded. Results: A total of 1715 patients were admitted to the ICU (n=1097) and SDU (n=618) during the 1-year period. 596 (35%) patients required vasopressors (ICU 491/SDU 105). 165 (28%) of these patients did not have a CVC and received peripheral vasopressors for >1h. 51 of these 165 patients had septic shock. Mean age was 63 years. 77% had solid malignancies. No active extravasation events were noted in all patients administered vasopressors through PVCs. Conclusions: Our study of oncology patients with septic shock demonstrates that administration of vasopressors via PVCs, when given for a limited duration, under close observation, was not associated with extravasation events. Institutional protocols can assist in standardizing the practice for peripheral vasopressor administration and documentation of adverse events.

723: BEDSIDE NURSE STAFFING ON PATIENT OUTCOMES AND THROUGHPUT IN A PEDIATRIC CARDIAC INTENSIVE CARE UNIT

Introduction: Healthcare throughput is the progression of patients from admission to discharge, limited by bed occupancy and hospital capacity. This study examines Heart Center throughput, cascading effects of limited beds, transfer delays, and nursing assignments on outcomes utilizing elective surgery cancellation during the initial COVID-19 pandemic wave. Methods: Nursing assignments, patient data, and transfers were collected. Elective surgery cancellation was March-May 2020. Heart Center occupancy (Stepdown Unit and Cardiac Intensive Care Unit), transfer delays, and patient outcomes were analyzed controlling for patient factors, surgical risk, staffing, and time effects. Setting: Retrospective single-center study Patients: Heart Center admissions January 1, 2018 – December 31, 2020. Results: There were 2,589 patients, median age 5 months (6 days-4 years), 1,543 (60%) surgical, 1,046 (40%) medical. Mortality was 3.9% (n=101), median stay 5 days (3-11 days), median 1:1 nursing assignments 40% (33%-48%), median occupancy 54% (43%-65%) for Stepdown Unit and 81% (74%-85%) for Cardiac Intensive Care Unit. Every 10% increase in Stepdown Unit occupancy had a 0.5-day increase in Cardiac Intensive Care Unit stay (p=0.044), 2.1% increase 2-day readmission (p=0.023), and 2.6% mortality increase (p< 0.001). Every 10% increase in Cardiac Intensive Care Unit occupancy had 3.4% increase in surgical delay (p=0.016) and 6.5% increase in transfer delay (p=0.020). Elective surgery cancellation reduced high occupancy days (23% to 10%, p< 0.001), increased 1:1 nursing (34% to 55%, p< 0.001), decreased transfer delays (19% to 4%, p=0.008), and decreased mortality (3.7% to 1.5%, p=0.044). Conclusions: Cancelation of elective surgery was associated with increased 1:1 nursing assignments and decreased mortality. Increased Cardiac Stepdown Unit occupancy resulted in longer Cardiac Intensive Care Unit stay, and increased Cardiac Intensive Care Unit occupancy increased transfer and surgical delays. Additional studies are need to understand the interaction of staffing and outcomes.

2017. Comparison of California Acute Care Hospital Central Line-Associated Bloodstream Infection Incidence by Hospital Location Before and During the COVID-19 Pandemic

Abstract Background Central line-associated bloodstream infection (CLABSI) incidence among acute care hospitals (ACH) and in some patient care locations such as critical care (CC) units increased substantially nationwide during the COVID-19 pandemic. We compared California ACH CLABSI incidence by location before and during the pandemic to identify locations with high burden to inform targeted prevention efforts. Methods Using California ACH (n=327) CLABSI standardized infection ratio (SIR) data from the National Healthcare Safety Network, we compared incidence during the second halves of 2019 (2019H2) and 2020 (2020H2) to evaluate early pandemic changes, and during 2019 (pre-pandemic) and 2021 (pandemic) periods by hospital type, location type (e.g., CC), and patient care location (e.g., medical CC), excluding rehabilitation units. A mid-P exact test was applied to compare SIRs between study periods. Results ACH CLABSI SIR increased statewide from 2019H2 to 2020H2 by 50.8% (0.65 to 0.98) and from 2019 to 2021 by 34.3% (0.67 to 0.90). Community hospitals &amp;lt; 125 beds had the highest SIR and percentage increase in 2021 as well as 2020H2. Of 9 location types and 58 patient care locations, CC units and medical and medical-surgical CC had significantly higher SIR in both comparisons (2020H2 versus 2019H2 and 2021 versus 2019); wards and medical wards in 2020H2 only, and step-down units and adult step-down in 2021 only. Trauma CC SIR was significantly higher only in 2020H2 compared to 2019H2, while surgical CC SIR was significantly higher in 2021 compared to 2019. Respiratory CC had the highest SIR (2.99, 95%CI 2.14-4.08) in 2021, but was not significantly higher when compared to 2019 (1.06, 95%CI 0.21-3.41). Conclusion We observed an overall statewide increase in hospital CLABSI incidence, especially in CC locations, during the pandemic. Although the SIR increase relative to pre-pandemic was smaller in 2021 than in 2020H2, with some exceptions, most locations had persistently higher incidence. We will further assess associations between CLABSI incidence and antimicrobial resistance, device insertion dates, and hospital COVID-19 burden. We will use our findings to guide public health support for hospital infection prevention programs to reduce their CLABSI incidence. Disclosures All Authors: No reported disclosures.

914: SEPSIS IN THE STREAM: SEVERE LEGIONELLA AND HISTOPLASMA PNEUMONIA ACQUIRED FROM SPRING WATER

Introduction: Legionnaires’ disease (LD) and pulmonary histoplasmosis are important causes of community-acquired pneumonia (CAP). Both infections are acquired via inhalation from a myriad of reported contaminated environmental sources. Herein, we present a case of concurrent LD and pulmonary histoplasmosis ultimately linked to contaminated spring water used in a home continuous positive airway pressure (CPAP) device, highlighting the importance of source identification and proper patient education on device maintenance. Description: A 67-year-old male with obstructive sleep apnea (OSA) was admitted to our ICU for acute respiratory distress syndrome (ARDS) requiring endotracheal intubation after one week of dyspnea associated with fevers, vomiting, and diarrhea. Vital signs on arrival were significant for fever of 102.8°F, vasopressor-dependent hypotension, and refractory hypoxemia despite maximal ventilator support. Thoracic CT revealed bilateral multifocal consolidations and urine legionella antigen test was positive, confirming the diagnosis of LD. He was also diagnosed with possible pulmonary histoplasmosis after serum histoplasma antigen resulted positive. Treatment included salvage ARDS supportive measures and broad-spectrum antimicrobials, including levofloxacin and amphotericin B. His ICU course was complicated by a prolonged ventilator wean requiring tracheostomy. Upon further questioning, the patient’s family revealed he used a nearby spring as his primary water source, including in his home CPAP device. He ultimately transitioned to a step-down unit with plans for outpatient pulmonary follow-up on discharge. Discussion: Legionella pneumonia and pulmonary histoplasmosis both represent significant and potentially fatal causes of CAP. Environmental reservoirs remain the primary source of infection and may persist since investigations are often reserved for large outbreaks. Our case highlights a source of both legionella and histoplasmosis not previously reported. It demonstrates the value of taking a thorough history while recognizing non-traditional sources of both infections. It also highlights the importance of emphasizing proper device maintenance. Increased awareness of risk factors for these infections enables earlier diagnosis and treatment and ideally improves outcomes.

Multistudy Research Operations in the ICU: An Interprofessional Pandemic-Informed Approach.

Two-phase, single-center multistudy cohort. University-affiliated ICU in Hamilton, ON, Canada. Adult patients in the ICU, medical stepdown unit, or COVID-19 ward. None. An interprofessional COVID Collaborative was convened at the pandemic onset within our department, to proactively coordinate studies, help navigate multiple authentic consent encounters by different research staff, and determine which studies would be suitable for coenrollment. From March 2020 to May 2021, five non-COVID trials continued, two were paused then restarted, and five were launched. Over 15 months, 161 patients were involved in 215 trial enrollments, 110 (51.1%) of which were into a COVID treatment trial. The overall informed consent rate (proportion agreed of those eligible and approached including a priori and deferred consent models) was 83% (215/259). The informed consent rate was lower for COVID-19 trials (110/142, 77.5%) than other trials (105/117, 89.7%; p = 0.01). Patients with COVID-19 were significantly more likely to be coenrolled in two or more studies (29/77, 37.7%) compared with other patients (13/84, 15.5%; p = 0.002). Review items for each new study were collated, refined, and evolved into a modifiable checklist template to set up each study for success. The COVID Collaborative expanded to a more formal Department of Critical Care Research Operations Committee in June 2021, supporting sustainable research operations during and beyond the pandemic. Structured coordination and increased communication about research operations among diverse research stakeholders cultivated a sense of shared purpose and enhanced the integrity of clinical research operations.

Management of postoperative respiratory complication in a child with severe obstructive sleep apnoea syndrome during Covid-19

IntroductionCoronavirus disease (Covid-19) was first discovered in December 2019 with no signs of conceding to date. Many operations which are regarded as not lifesaving are postponed indefinitely owing to hospital bed shortage as well as to reduce the spread of infection among patients and staff. However, healthcare professionals are thrown down a huge challenge when deciding the timing of treatment for non-life-threatening conditions like severe paediatric obstructive sleep apnoea syndrome (OSAS) with a substantial impact on the development of very young children.AimTo outline management of postoperative respiratory complication in a child with severe obstructive sleep anoea syndrome during Covid-19.Case studyWe present a case of a major respiratory event requiring reintubation that developed post-adenotonsillectomy in a 3-year-old child with severe OSAS.Results and discussionThe child was given close monitoring for 6 h in the post-anaesthetic care unit (PACU) before he was transferred to the general paediatric ward, without PICU admission during his stay in the hospital.ConclusionsPostoperative monitoring at the step-down unit with a high nurse-to-patient ratio appears to be beneficial as it does not compromise the need for close postoperative observation, meanwhile saving costs.

The necessity for routine intensive care unit admission following elective craniotomy for epilepsy surgery: a retrospective single-center observational study.

Traditionally, patients who underwent elective craniotomy for epilepsy surgery are monitored postoperatively in an intensive care unit (ICU) overnight in order to sufficiently respond to potential early postoperative complications. In the present study, the authors investigated the frequency of early postoperative events that entailed ICU monitoring in patients who had undergone elective craniotomy for epilepsy surgery. In a second step, they aimed at identifying pre- and intraoperative risk factors for the development of unfavorable events to distinguish those patients with the need for postoperative ICU monitoring at the earliest possible stage. The authors performed a retrospective observational cohort study assessing patients with medically intractable epilepsy (n = 266) who had undergone elective craniotomy for epilepsy surgery between 2012 and 2019 at a tertiary care epilepsy center, excluding those patients who had undergone invasive diagnostic approaches and functional hemispherectomy. Postoperative complications were defined as any unfavorable postoperative surgical and/or anesthesiological event that required further ICU therapy within 48 hours following surgery. A multivariate analysis was performed to reveal preoperatively identifiable risk factors for postoperative adverse events requiring an ICU setting. Thirteen (4.9%) of 266 patients developed early postoperative adverse events that required further postoperative ICU care. The most prevalent event was a return to the operating room because of relevant postoperative intracranial hematoma (5 of 266 patients). Multivariate analysis revealed intraoperative blood loss ≥ 325 ml (OR 6.2, p = 0.012) and diabetes mellitus (OR 9.2, p = 0.029) as risk factors for unfavorable postoperative events requiring ICU therapy. The present study revealed routinely collectable risk factors that would allow the identification of patients with an elevated risk of postsurgical complications requiring a postoperative ICU stay following epilepsy surgery. These findings may offer guidance for a stepdown unit admission policy following epilepsy surgical interventions after an external validation of the results.

Transcarotid artery revascularization can safely be performed with regional anesthesia and no intensive care unit stay

ObjectiveHospital resource use is under constant review, and the extent and intensity of postoperative care requirements for vascular surgical procedures is particularly relevant in the setting of the coronavirus disease 2019 pandemic and its impact on staffed intensive care unit (ICU) beds. We sought to evaluate the feasibility of regional anesthesia (RA) and low-intensity postoperative care for patients undergoing transcarotid artery revascularization (TCAR) at our institution. MethodsAll patients undergoing TCAR at a single institution from 2018 to 2020 were reviewed. Perioperative management (anticoagulation and antiplatelet therapy, hemodynamic monitoring, neurovascular examination, nursing instructions) was standardized by use of an institutional protocol. Anesthetic modality was at the surgeon’s preference. Patients were transferred to a postanesthesia care unit for 2 hours followed by the step-down unit, to a postanesthesia care unit for 4 hours followed by the floor, or alternatively transferred to the ICU. Intravenous (IV) blood pressure medications could be administered at all environments except the floor. Recovery location and length of stay were recorded. ResultsA total of 83 patients underwent TCAR during the study period. The mean age 72 ± 9 years and 59% were male. Thirty-six percent were symptomatic. RA was used for 84% with none converted to general anesthesia (GA) intraoperatively. Postoperatively, 7 of the 83 patients (8%) included in this study were monitored in an ICU overnight (decided perioperatively), mostly for patients with prior neurological symptoms, but in 1 case for postoperative neurological event and in another owing to pulseless electrical activity arrest. Six patients required IV antihypertensives and eight required IV vasoactive support postoperatively. The mean length of ICU stay was 3.7 ± 5.1 days. The mean length of hospital stay for all patients was 2.4 ± 3.3 days. The length of stay for patients undergoing TCAR with GA was higher than those undergoing TCAR with RA (4.2 ± 4.9 days vs 1.4 ± 1.2 days, respectively; P = .066). The incidence of stroke, death, and myocardial infarction was 2.4%. There was one postoperative stroke considered to be a recrudescence of prior stroke, and one respiratory arrest fatality in a frail patient with neck hematoma both of whom were treated under GA. ConclusionsUsing perioperative care protocols, TCAR can safely be performed while avoiding both GA and an ICU stay in most patients.

Delayed Discharge From the Intensive Care Unit Is Associated With Longer Hospital Lengths of Stay

The study authors sought to determine if delayed discharge from the intensive care unit (ICU) secondary to a lack of floor beds led to longer postoperative hospital length of stay (LOS) or more hospital readmissions. A retrospective study comparing patients with delayed discharge from the ICU to patients without delayed discharge. At a cardiovascular ICU in a tertiary care university hospital. A total of 5,777 patients that were ready for discharge from the ICU after recovering from cardiac surgery. None. The authors used linear regression to measure postoperative hospital LOS and logistic regression to measure hospital readmission in patients whose transfer out of the ICU was delayed at least overnight to patients who were transferred out the same day. There were 3,903 patients transferred to the stepdown unit on the same day as the transfer order and 1,874 patients were transferred on a subsequent day. The postoperative LOS was shorter in the no delay group (9 ± 9 v 11 ± 10 days, standardized difference = 0.162), whereas the stepdown unit stay was similar (6 ± 6 v 5 ± 6 days, standardized difference = 0.076). The readmission rates were 15% in the no delay group versus 14% in the delayed discharge group (standardized difference = 0.032). After adjustment, the authors found by linear regression that delayed discharge was associated with an increase (0.72 [95% CI 0.43-1.01] days, p < 0.001) in postoperative LOS but was not associated with readmission. The study authors found that patients who had their discharge from the ICU delayed had an increased hospital LOS but a similar rate of hospital readmission.

BELZUTIFAN-INDUCED HYPERSENSITIVITY PNEUMONITIS

BELZUTIFAN-INDUCED HYPERSENSITIVITY PNEUMONITIS