Tertiary Care Referral Hospital Research Articles

Developing a multidisciplinary HCV direct-acting antivirals utilization management and assessment program

BackgroundThe introduction of direct-acting antivirals (DAAs) for the treatment of hepatitis C virus (HCV) infections has revolutionized outcomes for patients with HCV. Cost-effective use of these antivirals in addition to ensuring patient adherence is of paramount importance. ObjectivesThe goal of this article is to describe the processes by which a tertiary care, multisite institution managed the complexities involved in administering DAA treatment and managing the increased cost of therapy. Specifically, the objectives of this article are to describe the development of a multidisciplinary HCV management program and the role of pharmacists in this program, including formulary management strategies and monitoring of DAAs use in our institution, development of guidelines, electronic prescribing protocols and order sets, and specific outcomes based on a concurrent medication use evaluation. Practice descriptionKing Faisal Specialist Hospital and Research Centre is a tertiary care referral hospital. As a tertiary referral hospital, it offers primary and highly specialized inpatient and outpatient medical care. The process of selecting and developing institutional HCV management program is described. Practice innovationThis article provides key details regarding how a multidisciplinary HCV program using DAAs can be implemented successfully at a tertiary care facility. Key facets of our innovation include establishing formulary guidelines, setting up eligibility criteria for patients, and establishing an HCV taskforce and multidisciplinary HCV program clinic. EvaluationMedication use evaluations were regularly conducted to monitor sustained virologic response rates, adherence to guidelines, adverse reactions, and drug interactions. Methods: Formulary guidelines, setting up an eligibility criterion for patients, and an HCV taskforce and multidisciplinary HCV program clinic were established. ResultsThe involvement of pharmacists in a multidisciplinary HCV program in outpatient settings resulted in improved formulary decision making, reduction of costs, and improvement of adherence to institutional guidelines. Practice implicationsThe role of a pharmacist in the management of patients with HCV with DAAs is important. Pharmacists play an integral part in medication management and overall reduction in health care expenditure. Many disease management programs can be complemented with pharmacists to improve patient care and reduce cost. ConclusionHCV treatment is challenging, and a multidisciplinary approach to treat HCV is critical. It is a rapidly evolving field; therefore, it requires dynamic formulary management and collaborative practice approaches to monitor pharmacotherapy carefully and efficiently. Clinical pharmacists play a pivotal role within the multidisciplinary team by providing support to both patients and health care providers with regard to the treatment of HCV.

Triage guideline for immunocompromised children with fever in an emergency centre in Ethiopia.

Fever in children with neutropenia often portends life-threatening bacteremia that may be ameliorated with early recognition and the rapid administration of antimicrobial therapy. Studies demonstrating this effect have been done in resource-endowed countries, but not in resource-limited settings. We attempted to decrease the time to antibiotics in patients with fever and neutropenia presenting to a paediatric emergency centre at a tertiary care referral hospital in Ethiopia. In 3 phases we performed baseline data collection, instituted triaging and treatment guidelines, and provided antibiotics. We tracked a variety of outcomes, most importantly time from arrival to initiation of antibiotics. While this time was reduced during the guideline institution phase of our intervention, time reductions were inconsistent and not sustained. This was likely due to competing clinical priorities among providers caring for a high volume of ill children. While in the U.S., fever and neutropenia is easy to prioritise within the paediatric emergency centre, future quality improvement measures in this setting may have a greater benefit on critical presentations such as shock or respiratory failure. Alternative strategies geared towards general efficiency improvement and teamwork, rather than focusing on one patient group may be a higher yield approach for improving care in this paediatric emergency centre.

Preparedness and guidelines for neurosurgery in the COVID-19 era: Indian perspective from a tertiary care referral hospital.

The COVID-19 pandemic has severely impacted healthcare systems globally. The need of the hour is the development of effective strategies for protecting the lives of healthcare providers (HCPs) and judicious triage for optimal utilization of human and hospital resources. During this pandemic, neurosurgery, like other specialties, must transform, innovate, and adopt new guidelines and safety protocols for reducing the risk of cross-infection of HCPs without compromising patient care. In this article, the authors discuss the current neurosurgical practice guidelines at a high-volume tertiary care referral hospital in India and compare them with international guidelines and global consensus for neurosurgery practice in the COVID-19 era. Additionally, the authors highlight some of the modifications incorporated into their clinical practice, including those for stratification of neurosurgical cases, patient triaging based on COVID-19 testing, optimal manpower management, infrastructure reorganization, evolving modules for resident training, and innovations in operating guidelines. The authors recommend the use of their blueprint for stratification of neurosurgical cases, including their protocol for algorithmic patient triage and management and their template for manpower allocation to COVID-19 duty, as a replicable model for efficient healthcare delivery.

Surgical candidacy and treatment initiation among women with cervical cancer at public referral hospitals in Kampala, Uganda: a descriptive cohort study

ObjectivesThis study aimed to report the proportion of women with a new diagnosis of cervical cancer recommended for curative hysterectomy as well as associated factors. We also report recommended treatments...

Long-term results of laparoscopic Roux-en-Y gastric bypass for morbid obesity: 105 patients with minimum follow-up of 15 years.

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is the second most frequently performed bariatric procedure worldwide; however, long-term results are not frequently reported. To evaluate the outcomes of LRYGB on weight loss and co-morbidities in a single center 15 years after the operation. Tertiary-care referral hospital. From February 2000 to December 2003, 105 patients (86 women; mean age 39.9 ± 17.4; mean body mass index [BMI] 47.2 ± 6.4 kg/m2; 78 with BMI < 50 kg/m2 and 27 with BMI ≥ 50 kg/m2) underwent LRYGB. Retrospective analyses of a prospectively maintained database were carried out to evaluate weight loss; resolution of co-morbidities, including type 2 diabetes mellitus (T2D), hypertension (HTN), and dyslipidemia; complications; and nutritional status. The follow-up rate at 15 years was 87.6%. Mean excess weight loss was 58.6 ± 27%, with 74.1% of patients achieving a total weight loss ≥ 20%. According to the Biron etal. criteria, an inadequate outcome was found in 11/21 (52.4%) of patients with an initial BMI ≥ 50 kg/m2 versus 21/64 (32.8%) of patients with a preoperative BMI < 50 kg/m2 (P = .001). Both groups experienced gradual weight regain (WR); specifically, 34.1% of patients regained more than 15% of their lowest postoperative weight. The rates of reoperations due to early and late surgical complications were 3.8% and 9.5%, respectively. T2D was resolved in 50% of patients, HTN in 61.1%, and dyslipidemia in 58.3%. Iron deficiency anemia (53%) was the most common postoperative nutritional finding. LRYGB provides satisfactory weight loss and resolution of co-morbidities up to 15 years. WR was a common finding. A significant proportion of patients with a preoperative BMI ≥ 50 kg/m2 did not achieve a favorable weight loss outcome. Indications to perform LRYGB in this group of patientsshould be definitively reconsidered.

Proteinuria in Severe Hypothyroidism: A Prospective Study.

Hypothyroidism is associated with reversible decline in kidney function as measured by estimated glomerular filtration rate (eGFR). eGFR and proteinuria are the most important markers for clinical assessment of kidney function. Though hypothyroidism is associated with proteinuria in cross-sectional data, the impact of treatment on proteinuria is unknown. This study explores the effect of thyroid hormone replacement therapy on eGFR and 24-hour urine protein excretion in patients with severe primary hypothyroidism. This study was a prospective, observational cohort study in adults with severe primary hypothyroidism (serum thyrotropin [TSH] > 50 µIU/mL). Individuals with preexisting or past kidney disease, kidney or urinary tract abnormalities, calculi or surgery, diabetes mellitus, or hypertension were excluded. The participants received thyroid hormone replacement therapy. Thyroid functions, eGFR, 24-hour urine protein excretion, and biochemical parameters were measured at baseline and 3 months. This study took place at a single center, a tertiary care referral and teaching hospital. Of 44 enrolled participants, 43 completed 3 months of follow-up. At 3 months, serum TSH levels decreased and thyroxine levels increased (P < .001 for both). Significant increases in eGFR (mean difference, 18.25 ± 19.49 mL/min/1.73 m2; 95% CI, 12.25 to 24.25, P < .001) and declines in 24-hour urine protein excretion (mean difference, -68.39 ± 125.89 mg/day; 95% CI, -107.14 to -29.65, P = .001) were observed. Serum cholesterol and low-density lipoprotein levels also significantly decreased (P < .001). Thyroid hormone replacement therapy in patients with severe primary hypothyroidism improves eGFR and decreases 24-hour urine protein excretion, thereby suggesting reversible alterations.

Thyroid dysfunction in non-small cell lung cancer patients treated with epidermal growth factor receptor and anaplastic lymphoma kinase inhibitors: Results of a prospective cohort

ObjectivesEpidermal Growth Factor Receptor (EGFR) and Anaplastic Lymphoma Kinase (ALK) Tyrosine Kinase Inhibitors (TKIs) are the preferred treatment option for patients with advanced/metastatic non-small cell lung cancer (NSCLC) harboring EGFR mutations and ALK rearrangements respectively. TKIs can theoretically induce thyroid dysfunction via actions on many levels of the hypothalamic-pituitary-thyroid axis. However, there are no published studies on occurrence of thyroid dysfunction related to use of EGFR/ALK TKIs in lung cancer. The current study aimed to prospectively and comprehensively evaluate incidence of thyroid dysfunction in NSCLC patients treated with EGFR and ALK inhibitors. MethodsThis prospective observational study at a tertiary care referral hospital included histologically/cytologically proven advanced/metastatic NSCLC patients treated with EGFR and ALK inhibitors over a period of 15 months. Thyroid function tests (including anti-TPO antibody) were done at baseline and repeated every month for first three months and then every three monthly for 12 months. ResultsSix different drugs (EGFR and ALK inhibitors) were used for treatment of 50 NSCLC patients enrolled. Of these, four drugs caused thyroid dysfunction (EGFR inhibitors erlotinib, gefitinib and ALK inhibitors ceritinib, crizotinib). Thyroid dysfunction typically occurred at 1 month following start of TKI treatment. Prevalence of thyroid dysfunction was 8%. Distribution of subclinical (not requiring treatment) and overt thyroid dysfunction (requiring specific treatment) was 4% each. All patients were asymptomatic. Both patients with overt thyroid dysfunction had hypothyroidism while subclinical dysfunction was equally distributed between hypo- and hyper- thyroidism. All patients who developed thyroid dysfunction derived expected clinical benefit and none required TKI dose interruption or stoppage. ConclusionsNSCLC patients may need to be monitored for occurrence of thyroid dysfunction during treatment with EGFR and ALK TKIs.

Novel facial characteristics in congenital rubella syndrome: a study of 115 cases in a cardiac hospital of Bangladesh

ObjectiveTo establish novel facial characteristics unique to congenital rubella syndrome (CRS) as prediagnostic criteria to supplement disease diagnosis in patients with or without a history of maternal rubella infection.DesignAn analysis...

Pre-hospital care and its association with clinical outcome of snakebite victims presenting at a tertiary care referral hospital in South India.

Most snakebite victims in low- and middle-income countries continue to seek many forms of first aid therapy before reaching hospital, the commonest being the application of a tourniquet. Our study looked at a prospective cohort of 382 such patients to ascertain the association of pre-hospital care with clinical outcome, and found that 60% developed complications as compared to 36% who had no pre-hospital care (p < 0.001), with 10 fatalities in the former compared to only one in the latter. Pre-hospital care remains very common and definitely increases morbidity and mortality.

Variation in Treatment Approaches to Adolescent Midshaft Clavicle Fractures in Pediatric Versus Adult Hospitals.

The primary objective of this study was to identify differences in the treatment approach for isolated, displaced midshaft clavicle fractures in adolescent patients 15-18 years of age at adult versus pediatric hospitals. The secondary objective of this study was to identify factors associated with the surgical treatment of these fractures in this age group. Retrospective cohort study. Two adult and one pediatric tertiary care referral hospitals. Adolescent patients 15-18 years of age with isolated, displaced midshaft clavicle fractures treated at 2 adult tertiary care referral hospitals and one pediatric tertiary care referral hospital were identified. A total of 214 patients, 105 from the adult hospitals and 109 from the pediatric hospital, were included. Nonoperative versus surgical treatment of clavicle fractures. Surgical treatment. A multivariable logistic regression analysis showed that superior-inferior fracture displacement [odds ratio (OR) 1.13, 95% confidence interval (CI) 1.06-1.20], dominant upper extremity injury (OR 2.60, 95% CI 1.19-5.67), and treatment at an adult hospital (OR 5.28, 95% CI 2.28-12.2) were independently associated with the surgical treatment of adolescent displaced midshaft clavicle fractures. After controlling for relevant demographic and fracture characteristics, adolescent patients treated at adult hospitals for displaced midshaft clavicle fractures have more than 5 times the odds of surgical treatment than those treated at a pediatric hospital. Significant practice variation across institutions reflects ongoing controversy in surgical indications and underscores the need for high-quality prospective outcome studies. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Evaluation of a telethermographic system for temperature screening at a large tertiary-care referral hospital during the coronavirus disease 2019 (COVID-19) pandemic.

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Blistering Diseases in a Tertiary Care Hospital: A 10-year Audit

Introduction: Cutaneous blisters can occur in variety of conditions. They are broadly classified as immunobullous or non-immunobullous. Immunobullous blistering diseases can further classify as intraepidermal or subepidermal. Non-immunobullous blistering disease are commonly due to infections, drugs among others. Some of the blistering disease carry significant mortality and morbidity. There are only limited data on blistering diseases from Nepal, so this study will provide details on the prevalence of this rare dermatological disease from one of the tertiary care referral hospital in the country.&#x0D; Objective: To assess the clinical pattern and prevalence of various blistering diseases in a tertiary care referral hospital.&#x0D; Materials and Methods: All of the data were obtained from the admission register maintained at department of dermatology and venereology, National Academy of Medical Sciences. All the patients admitted with blistering disease from year April 2008 till March 2018 were included. The details including age, sex, type of blistering disease and length of hospital stay were recorded. &#x0D; Results: A total of 710 patients were admitted in the dermatology ward over the period of 10 years. There were a total of 193 blistering disease admitted during this period. Autoimmune blistering disease was diagnosed in 59 patients whereas 100 patients had non-immunobullous disease. The age grouped range from 4- 93 years with the mean age of 43± 19.71 years. The average number of hospital stay of all blistering diseases was 11.73±11.36 days.&#x0D; Conclusion: Blistering diseases are one of the most common conditions requiring admission in dermatology ward. Some of these diseases carry a significant morbidity and mortality. So, prompt diagnosis and treatment is of utmost importance.

The Direct and Indirect Impact of SARS-CoV-2 Infections on Neonates: A Series of 26 Cases in Bangladesh.

The impact of SARS-CoV-2 on neonates remains largely unknown in low- and middle-income countries (LMICs). We provide an epidemiologic and clinical report of SARS-CoV-2 infections in neonates hospitalized in Bangladesh. Outborn neonates admitted to Dhaka Shishu Hospital, a tertiary-care referral hospital, between 29 March and 1 July were screened for SARS-CoV-2. We reviewed clinical data, including chest radiograph and laboratory reports, and conducted SARS-CoV-2 genome sequencing. Patients were followed-up for 27-75 days. A subset of caregivers was also tested. Of 83 neonates tested, 26 were positive (median age 8 days). Most neonates were admitted with diagnosis unrelated to SARS-CoV-2: 11 presented with serious non-communicable diseases, 7 with early-onset sepsis, 5 with late-onset sepsis and 2 with pneumonia. In 3 of 5 chest radiograph, infiltrates and ground-glass or patchy opacities were noted. Two neonates developed metabolic acidosis, one developed disseminated intravascular coagulation. Most SARS-CoV-2 positive neonates were referred to government-designated COVID-19 hospitals, leading to gaps in treatment. Twenty-three neonates could be followed-up: 12 were healthy, 8 died and 3 were still seeking medical care. Of 9 caregivers tested, 8 were positive. SARS-CoV-2 may have serious adverse effects on children born in LMICs. The virus likely contributed directly to two deaths, but the remaining 6 neonates who died had serious comorbidities. Positive SARS-CoV-2 test results led to gaps in immediate clinical care for other morbidities, which likely contributed to adverse outcomes. This case series emphasizes the need to understand COVID-19 in neonates in LMICs and its indirect impacts.

Occlusal Adjustment vs Placebo for Chronic Temporomandibular Disorders. The MAP Randomized Clinical Trial

Importance: Evidence regarding effective treatments for temporomandibular joint disorders (TMDs) is limited. Objective: To determine whether occlusal adjustment may reduce the pain intensity of patients with chronic TMD. Design: The MAP study was a phase 3 randomized, participant- and assessor-blinded, placebo-controlled trial of a novel occlusal therapy for chronic TMD over the course of 6 months. It was carried out from August 4, 2014 to October 25, 2018 (last 6-month follow-up). Setting: Single referral tertiary care hospital. Therapies were performed in a University Clinic in a different city. Participants: From 924 adult patients screened diagnosed as TMD, 820 were excluded (partial tooth loss, no chronic condition, malocclusion); 27 declined to participate. Seventy-seven participants underwent randomization; all but one female participant completed the analysis. Interventions: Participants were randomly (1:1) assigned to occlusal adjustment therapy (N=39) or similar placebo (N=38) that did not remove any enamel. Main Outcome and Measure: Primary outcome (before data collection began): change in pain score (in a 0-10 points visual analogue scale) from baseline to the 3- and 6-month assessments. Because one majority of the 1-month therapy visits (carried out in a city 70 km away) were delayed nearest the 3-month visit, the actual primary outcome was the average pain intensity improvement at 6 months in respect of the baseline scores (05/05/2016 ISRCTN amendment). Clinical important difference 1.5 points. Results: The trial was stopped early for efficacy. This report includes all randomized participants in their originally assigned group: 39 to occlusal adjustment and 38 to placebo therapy. Both groups were balanced regarding baseline characteristics. As compared with the placebo, occlusal adjustment reduced jaw pain intensity (adjusted mean difference, -1.54; 95% confidence interval [CI] -.5 to -2.6; P=0.004; ANCOVA model). Conclusions and Relevance: The occlusal adjustment was effective in treating chronic TMD pain and improved limited mouth opening in comparison with the placebo over a 6-month period. The results of this trial are provisional and should not be generalized to patients with different dental conditions, or if the therapies are provided by less experienced dental professionals.

Hand Hygiene Compliance in a University Hospital in West Bank, Palestine: An Observational Study 2017–2019

Background: Worldwide, medical staff adherence to hand hygiene (HH), the most cost-effective measure to decrease healthcare-associated infections (HAIs), is ~40%–60%. The infection control program (ICP) at An-Najah National University Hospital (NNUH), a tertiary-care referral teaching hospital located in Nablus, in northern Palestine, monitors HH compliance by direct observations using the WHO observation checklist. In this descriptive study, we investigated the prevalence of HH across the institution during 2017–2019. Methods: The WHO multimodal strategy to enhance HH in healthcare settings was implemented at NNUH, a tertiary-care referral hospital, in 2017. HH compliance has been measured during routine patient care by direct observation by ICP team and anonymously by other trained observers. Results are reported on monthly basis to the administration and medical team (nurses and doctors), and corrective plans to increase the compliance are discussed. Training is reinforced with ultraviolet light and fluorescent alcohol-based hand rub. Yearly, staff are engaged in HH Day activities (Figs. 1 and 2). Leadership support is constant by securing the annual budget for the HH program and the enforcement of HH policy across the setting. Results: NNUH, using the WHO Hand Hygiene Self-Assessment Framework, is currently in the advanced level (395 of 500) compared to 2017 (intermediate level, 292 of 500). Overall, HCW HH compliance increased from 44% (range, 31%–57%) in 2017 to 53% (range, 30%–72%) in 2018 and to 61% (range, 55%–66%) through October 2019. During the 3-year study period, Nursing compliance increased from 36% to 59% and to 64%, respectively, whereas the compliance for doctors increased from 42% to 56% and 58%, respectively. Regarding the missed opportunities, before patient was the most frequent cause for missed opportunity with a rate of 60% (Fig. 3). This missed opportunity was mainly related to the misuse of gloves (mainly among nurses), which requires an ad hoc intervention. Conclusions: Implementation of the WHO HH strategy is feasible and effective in low-income countries and leads to significant improvements in compliance. Periodic training, personnel engagement, and leadership are key factors of HH improvement in our setting.Funding: NoneDisclosures: None

Screening for Multidrug-Resistant Organisms in a Tertiary-Care University Hospital in the North West Bank: A Descriptive Study

Background: The prevalence of multidrug-resistant organisms (MDROs) in acute healthcare settings is increasing worldwide. Active screening for MDROs carriers on admission permits the prompt implementation of the appropriate precautions to decrease the probability of cross transmission to other inpatients. Objective: To report the spectrum of bacterial nasal, axilla, and perianal colonization among in patients at Najah National University Hospital (NNUH) during 2018. Methods: A retrospective observational study was performed at NNUH, a tertiary-care referral university hospital in Nablus, north of Palestine, that includes medical and surgical ICUs for both adults and children from January to August 2018. Nasal, axilla, and perianal swabs were collected within the first 24 hours of admission according to hospital policy. Patients who were referred from another hospital, who were admitted to a hospital for at least 2 nights during the previous 8 months, and who are known to have an MDROs in the past were included. Swab samples were processed for isolation and identification of these multidrug-resistant strains. Transmission-based precautions were implemented if positive results were reported (ie, contact isolation) and decolonization regimens were applied according to the CDC recommendations (muporocin ointment for nasal MRSA, daily bathing with chlorhexidine 2% soap for the rest). A daily isolation list was circulated among bed managers and senior nurses and head of departments for appropriate management of beds and reallocation of patients. The antibiotic susceptibility pattern was assessed using the disc-diffusion method on Mueller–Hinton agar and a Vitek-2 system. Results: During the period of the study, 1,425 nasal swabs, 1,245 axilla swabs, and 300 perianal swabs were collected according to the inclusion criteria. Positive results were reportedin 7%, 4%, and 44% for nasal, axilla, and perianal specimens, respectively. Regarding the distribution of bacterial colonization in the nasal swab, 73% were MRSA; for the axial, 29% were Pseudomonas; and from the perianal swab, the most prevalent pathogen was ESBL (56%) (Figs. 1–3). A discrepancy between the number of nasal or axilla and perianal swabs was observed, which was mainly due to the refusal of many patients to have the sample collected by the nurse. Conclusions: Colonization of the skin and mucous membranes of inpatients with MDROs is considered a risk factor for developing future infections. Therefore, active screening for those pathogens is critical for infection prevention and control programs and patient safety in acute-care settings.Funding: NoneDisclosures: None

Efficacy of Balloon Tamponade Versus Merocel Nasal Packs in Endoscopic Sinonasal Surgery: A Randomized Controlled Study.

Although absorbable nasal packings have been abundantly used in the recent time, the conventional packings are still used in different sinonasal surgeries in the various parts of the globe due to their lower cost. To compare the effectiveness of the balloon tamponade (Rapid Rhino) with Merocel nasal pack in sinonasal diseases. This study was conducted from July 2018 to July 2019 in a tertiary care referral hospital. Rapid Rhino and Merocel were put in 30 patients and 31 patients, respectively. Pain, bleeding, and mucosal healing was evaluated and compared between two groups postoperatively. The reduction in the pain and postoperative bleeding was significant with balloon tamponade (Rapid Rhino) compared to the Merocel (p < .05). Although insignificant (p > 0.05), patients with balloon tamponade nasal packs had less crusting and synechia in the postoperative period. Balloon tamponade (Rapid Rhino) nasal pack can be a better alternative to the Merocel nasal pack in reducing postoperative pain, bleeding, and mucosal damage.

Hospital admission rates, length of stay, and in-hospital mortality for common acute care conditions in COVID-19 vs. pre-COVID-19 era

ObjectivesThe impact of COVID-19 upon acute care admission rates and patterns are unknown. We sought to determine the change in rates and types of admissions to tertiary and specialty care hospitals in the COVID-19 era compared with pre-COVID-19 era. MethodsAcute care admissions to the largest tertiary care referral hospital, designated national referral centers for cardiac, cancer and maternity hospital in the State of Qatar during March 2020 (COVID-19 era) and January 2020 and March 2019 (pre-COVID-19 era) were compared. We calculated total admissions, admissions for eight specific acute care conditions, in-hospital mortality rate, and length of stay at each hospital. ResultsA total of 18,889 hospital admissions were recorded. A sharp decline ranging from 9% to 75% was observed in overall admissions. A decline in both elective and non-elective surgeries was observed. A decline of 9%–58% was observed in admissions for acute appendicitis, acute coronary syndrome, stroke, bone fractures, cancer, and live births, whereas an increase in admissions due to respiratory tract infections was observed. Overall length of stay was shorter in the COVID-19 period possibly suggesting lesser overall disease severity, with no significant change in in-hospital mortality. Unadjusted mortality rate for Qatar showed marginal increase in the COVID-19 period. ConclusionsWe observed a sharp decline in acute care hospital admissions, with a significant decline in admissions due to seven out of eight acute care conditions. This decline was associated with a shorter length of stay but not associated with a change in in-hospital mortality rate.

Excess mortality due to pandrug-resistant Acinetobacter baumannii infections in hospitalized patients

Pandrug-resistant Acinetobacter baumannii (PDRAB) is increasingly being reported as a nosocomial pathogen worldwide, but determining its clinical impact is challenging. To assess the spectrum of excess mortality attributable to PDRAB infection in acute care settings. This four-year cohort study was conducted in a tertiary-care referral hospital in Greece to estimate excess in-hospital mortality due to PDRAB infection by comparing patients infected to those colonized with PDRAB by means of competing risks survival analysis. The study cohort comprised 91 patients (median age: 67 years; 77% men). For most patients, PDRAB was first isolated in the intensive care unit (ICU) (N= 51; 57%) or following ICU discharge (N= 26; 29%). Overall in-hospital mortality was 68% (95% confidence interval (CI): 57.5-77.5%). PDRAB-infected patients (N= 62; 68%) and PDRAB-colonized patients (N= 29; 32%) had similar baseline characteristics, but the absolute excess risk of 30-day mortality in infected patients compared to colonized patients was 34% (95% CI: 14-54%). Multivariable competing risks regression showed that PDRAB infection significantly increased the daily hazard of 30-day in-hospital death (cause-specific hazard ratio (csHR): 3.10; 95% CI: 1.33-7.21) while simultaneously decreasing the daily rate of discharge (csHR: 0.24; 95% CI: 0.08-0.74), thereby leading to longer hospitalization. Stronger effects were observed for bloodstream infections. New effective antimicrobials would be expected to prevent mortality in one of every three patients treated for PDRAB infection and reduce their length of hospitalization. However, available therapeutic options remain extremely limited and emphasis on preventing healthcare-associated transmission of PDRAB is ever more important.

Pediatric size phlebotomy tubes and transfusions in adult critically ill patients: a pilot randomized controlled trial

BackgroundTransfusion of red blood cells (RBC) is common, can have adverse effects, and is a costly and limited resource. Interventions that reduce iatrogenic blood losses could reduce transfusions. The objectives of this pilot trial were to assess the feasibility (acceptability of the intervention and suitability of eligibility criteria) and potential effectiveness of pediatric size phlebotomy tubes in adult critically ill patients.MethodsWe conducted a pilot, randomized controlled trial in the medical intensive care unit (ICU) of a university-affiliated, tertiary care referral hospital from November 2017 to September 2018. A total of 200 patients with hemoglobin of at least 7 g/dL and without bleeding were randomized to pediatric or adult size phlebotomy tubes. Stratification was according to baseline hemoglobin (7–9.49 g/dL, 9.5–11.99 g/dL, and 12 g/dL or greater). Acceptability was measured via the number of blood test recollections and the number of patients that discontinued the use of pediatric tubes. The suitability of patient eligibility criteria was determined by identifying baseline characteristics associated with RBC transfusions. Potential effectiveness was estimated from the time to RBC transfusion or to hemoglobin level below 7 g/dL.ResultsThe use of pediatric tubes was acceptable as patients experienced a low number of tests recollections (on average 1 every 57 days), and none of the participants discontinued their use. The baseline hemoglobin category was the only factor that appeared to be independently associated with RBC transfusions. A total of 6 patients (6%) in the pediatric tube group and 11 patients (11%) in the adult tube group (hazard ratio, 0.69; 95% CI, 0.25 to 1.9) received an RBC transfusion or reached hemoglobin below 7 g/dL. Almost all of these patients (16 of 17 participants) had baseline hemoglobin of 7–9.49 g/dL.ConclusionsThis pilot study suggests that pediatric phlebotomy tubes are acceptable to patients and can therefore be used in adult ICU patients. A future study should focus on patients with hemoglobin levels below 9.5 g/dL, as these patients have a high risk of transfusions. This intervention has the potential of being successful in selected patients. A definitive trial is warranted.Trial registrationClinicalTrials.gov, NCT03286465. Retrospectively registered on September 18, 2017.