Ward Census Research Articles

SG-APSIC1123: Diagnostic and infection prevention and control (IPC) performance of rapid polymerase chain reaction (PCR) compared to conventional culture PCR methods for detecting carbapenemase-producing organisms (CPOs)

Objectives: In this study, we compared the performance of a rapid polymerase chain reaction (PCR) method in detecting carbapenemase-producing organisms (CPOs) and its impact on infection prevention and control (IPC) measures compared with a culture PCR method. Methods: All patients requiring CPO screening were included. Rectal swabs were collected with double rayon swabs (Copan 139C). They were simultaneously analyzed for the presence of CPOs using rapid PCR assay (Xpert Carba-R assay, Cepheid, Sunnyvale, CA) and a culture–PCR method (ChromID CARBA-SMART, bioMerieux, Marcy-l’Etoile, France). For CARBA-SMART, only colored colonies (ie, Enterobacterales) were evaluated for CPOs according to the prevailing institutional protocol. We tracked time to CPO detection. Using CPO positivity from either the rapid PCR or the culture PCR method as the gold standard, we calculated the sensitivity and specificity of both tests. We calculated the number of epidemiologically linked contacts generated when the first test results were known. We prospectively followed the ward census to identify the putative additional number of contacts generated by the later known result. Contacts were patients who shared the same ward (with overlapping time) as the CPO patients. Results: Between April 2019 and June 2020, culture PCR method detected CPOs in 316 (1.3%) of 24,514 samples (blaOXA48, N = 211; blaNDM, N = 51; blaIMI, N = 21; blaIMP, N = 10; blaKPC, N = 9; mixed genotypes, N = 14). The rapid PCR test detected CPOs in 605(2.5%) of 24,514 samples (blaOXA48, N = 266; blaNDM, N = 161; blaIMP, N = 99; blaVIM, N = 29; blaKPC, N = 15; mixed genotypes, N = 35). The sensitivity of direct PCR and culture PCR methods were 94.2% (95% CI, 92.1%–95.8%) and 43.5% (95% CI, 39.6%–47.4%), respectively. Both tests had 100% specificity. The median times to detection for the rapid PCR and culture PCR methods were 3–4 hours and 4 days, respectively. Compared with rapid PCR, the culture PCR method generated additional 7,415 contacts when it also tested positive for CPOs and an additional 23,135 contacts when it tested negative for CPOs. Conclusions: In our study, the rapid PCR test was more sensitive, identified CPO faster, and generated fewer epidemiologically linked contacts than the culture PCR method.

Association of Unit Census with Delays in Antimicrobial Initiation among Ward Patients with Hospital-acquired Sepsis.

Rationale: Patients with hospital-acquired sepsis (HAS) experience higher mortality and delayed care compared with those with community-acquired sepsis. Capacity strain, the extent to which demand for hospital resources exceeds availability, thus impacting patient care, is a possible mechanism underlying antimicrobial delays for HAS but has not been studied. Objectives: Assess the association of ward census with the timing of antimicrobial initiation among ward patients with HAS. Methods: This retrospective cohort study included adult patients hospitalized at five acute care hospitals between July 2017 and December 2019 who developed ward-onset HAS, distinguished from community-acquired sepsis by onset after 48 hours of hospitalization. The primary exposure was ward census, measured as the number of patients present in each ward at each hour, standardized by quarter and year. The primary outcome was time from sepsis onset to antimicrobial initiation. We used quantile regression to assess the association between ward census at sepsis onset and time to antimicrobial initiation among patients with HAS defined by Centers for Disease Control and Prevention Adult Sepsis Event criteria. We adjusted for hospital, year, quarter, age, sex, race, ethnicity, severity of illness, admission diagnosis, and service type. Results: A total of 1,672 hospitalizations included at least one ward-onset HAS episode. Median time to antimicrobial initiation after HAS onset was 4.1 hours (interquartile range, 0.4-22.3). Marginal adjusted time to antimicrobial initiation ranged from 3.6 hours (95% confidence interval [CI], 2.4-4.8 h) to 6.8 hours (95% CI, 5.3-8.4 h) at census levels 2 standard deviations (SDs) below and above the ward-specific mean, respectively. Each 1-SD increase in ward census at sepsis onset, representing a median of 2.4 patients, was associated with an increase in time to antimicrobial initiation of 0.80 hours (95% CI, 0.32-1.29 h). In sensitivity analyses, results were consistent across severity of illness and electronic health record-based sepsis definitions. Conclusions: Time to antimicrobial initiation increased with increasing census among ward patients with HAS. These findings suggest that delays in care for HAS may be related to ward capacity strain as measured by census. Additional work is needed to validate these findings and identify potential mechanisms operating through clinician behavior and care delivery processes.

Intussusception among children less than 2 years of age: Findings from pre-vaccine introduction surveillance in Pakistan

BackgroundRotavirus vaccination introduction in routine immunization is under consideration in Pakistan. Data on the baseline epidemiology of intussusception will inform surveillance strategies for intussusception after rotavirus vaccine introduction in Pakistan. We describe the epidemiology of intussusception-associated hospitalizations among children <2years of age in Karachi, Pakistan. MethodsWe conducted a retrospective chart review for July 01, 2012 through June 30, 2015 at the National Institute of Child Health (NICH) and Aga Khan University Hospital (AKUH) Karachi. At AKUH, the International Classification of Disease, ninth revision, code 560.0 for intussusception was used to retrieve intussusception case records. At NICH, daily Operation Theater, Emergency Room, and surgical daycare log sheets and surgical ward census sheets were used to identify cases. Records of children who fulfilled eligibility criteria and the Brighton Collaboration level one case definition of intussusception were selected for data analysis. We used structured case report forms to extract data for the descriptive analysis. ResultsWe identified 158 cases of confirmed intussusception; 30 cases (19%) were from AKUH. More than half (53%) of the cases occurred in children aged 6–12months, followed by 35% among those aged <6months. Two-thirds (106/158) of the cases were male. The most common presenting complaints were vomiting and bloody stool. At NICH, almost all (93%) were managed surgically, while at AKUH, ∼57% of the cases were managed with enemas. Three deaths occurred, all from NICH. Cases occurred without any seasonality. At NICH, 4% (128/3618) of surgical admissions among children aged <2years were attributed to intussusception, while that for AKUH was 2% (30/1702). ConclusionIn this chart review, intussusception predominantly affected children 0–6months of age and occurred more commonly in males. This information on the baseline epidemiology of intussusception will inform post-vaccine introduction adverse event monitoring related to intussusception in Pakistan.

Relationship between ICU bed availability, ICU readmission, and cardiac arrest in the general wards.

The decision to admit a patient to the ICU is complex, reflecting patient factors and available resources. Previous work has shown that ICU census does not impact mortality of patients admitted to the ICU. However, the effect of ICU bed availability on patients outside the ICU is unknown. We sought to determine the association between ICU bed availability, ICU readmissions, and ward cardiac arrests. In this observational study using data collected between 2009 and 2011, rates of ICU readmission and ward cardiac arrest were determined per 12-hour shift. The relationship between these rates and the number of available ICU beds at the start of each shift (accounting for census and nursing capacity) was investigated. Grouped logistic regression was used to adjust for potential confounders. Five specialized adult ICUs comprising 63 adult ICU beds in an academic medical center. Any patient admitted to a non-ICU inpatient unit was counted in the ward census and considered at risk for ward cardiac arrest. Patients discharged from an ICU were considered at risk for ICU readmission. None. Data were available for 2,086 of 2,190 shifts. The odds of ICU readmission increased with each decrease in the overall number of available ICU beds (odds ratio = 1.06; 95% CI, 1.00-1.12; p = 0.03), with a similar but not statistically significant association demonstrated in ward cardiac arrest rate (odds ratio = 1.06; 95% CI, 0.98-1.14; p = 0.16). In subgroup analysis, the odds of ward cardiac arrest increased with each decrease in the number of medical ICU beds available (odds ratio = 1.26; 95% CI, 1.06-1.49; p = 0.01). Reduced ICU bed availability is associated with increased rates of ICU readmission and ward cardiac arrest. This suggests that systemic factors are associated with patient outcomes, and flexible critical care resources may be needed when demand is high.

Objective Factors Associated with Physicians’ and Nurses’ Perceptions of Intensive Care Unit Capacity Strain

Time-varying demand for critical care may strain the capacities of intensive care units (ICUs) to provide optimal care. Intensivists and ICU nurses may be the best judges of the strain on their ICU. Yet, it is not clear what ICU and hospital factors contribute to this perceived sense of strain among ICU providers. To identify measureable ICU and hospital factors associated with perceived strain by intensivists and ICU nurses. During a 6-month prospective cohort study, we surveyed nurses and physicians responsible for bed management regarding the ability of a 24-bed medical ICU (MICU) to provide optimal critical care. We simultaneously assessed time-varying ICU-level factors, including patient census, number of admissions, average patient acuity, number of interhospital transfer requests, and censuses of other hospital units. To identify factors associated with strain, we used an algorithm for covariate selection in regression models that selects variables that contribute sufficiently to model prediction to justify their inclusion. Of 254 surveys, 226 (89%) were completed by 18 charge nurses and 17 physicians. On a scale of 1 to 10 (where a higher score indicated more strain), the median perceived strain score among nurses was 6 (interquartile range, 3-7) and among physicians was 5 (interquartile range, 3-7), with moderate correlation within days (interclass correlation coefficient, 0.45; 95% confidence interval: 0.30, 0.60). Average patient acuity, MICU census, number of MICU admissions, and general ward census were included in the most efficient model of strain perceived by nurses. Only MICU census was strongly associated with strain perceived by physicians. A model containing commonly available metrics of ICU census, average patient acuity, and the proportion of new admissions has validity as a model of ICU nurses' perceived ICU capacity strain. However, only ICU census was associated with increased perceived capacity strain by physicians, highlighting the need for involvement of multiple stakeholder groups to improve our understanding of ICU capacity strain.

807 – The relationship between ward occupancy level and staff-to-patient ratio and incidents of aggressive behavior on an acute psychiatric inpatient unit in iran

Objective Violence in psychiatric wards is common, and it is on the rise. This study examined the relationship between ward occupancy level and staff-to-patient ratio and incidents of aggressive behavior, both physical and verbal, on an acute inpatient unit in Iran. Methods Logistic regression was used to analyze data collected from the ward's log of adverse incidents and the ward census over a 12-month period. A physical incident was defined as an unwelcome physical contact or willful damage to property. Incidents of self-harm were excluded. Verbal aggression was any threat of physical or sexual harm. Results Among 381 admissions during the study period, 58 incidents were recorded--25 incidents of verbal aggression and 33 incidents of physical violence. Logistic regression demonstrated that the occupancy level was positively associated with the occurrence of any type of violent incident. The average occupancy level when an incident occurred was 77 percent, compared with 69 percent when no incidents occurred. The average occupancy level was significantly higher when verbal incidents occurred (80 percent) than when physical incidents occurred (70 percent). No association was found between violence and staff-to-patient ratio. Incidents were significantly more likely to occur during the afternoon shifts (3 p.m. to 11 p.m.). Conclusions Crowding was found to be significantly associated with aggressive incidents, and in particular with verbal aggression.

Ward crowding and incidents of violence on an acute psychiatric inpatient unit.

Violence in psychiatric wards is common, and it is on the rise. This study examined the relationship between ward occupancy level and staff-to-patient ratio and incidents of aggressive behavior, both physical and verbal, on an acute inpatient unit in rural New Zealand. Logistic regression was used to analyze data collected from the ward's log of adverse incidents and the ward census over a 12-month period. A physical incident was defined as an unwelcome physical contact or willful damage to property. Incidents of self-harm were excluded. Verbal aggression was any threat of physical or sexual harm. Among 381 admissions during the study period, 58 incidents were recorded--25 incidents of verbal aggression and 33 incidents of physical violence. Logistic regression demonstrated that the occupancy level was positively associated with the occurrence of any type of violent incident. The average occupancy level when an incident occurred was 77 percent, compared with 69 percent when no incidents occurred. The average occupancy level was significantly higher when verbal incidents occurred (80 percent) than when physical incidents occurred (70 percent). No association was found between violence and staff-to-patient ratio. Incidents were significantly more likely to occur during the afternoon shifts (3 p.m. to 11 p.m.). Crowding was found to be significantly associated with aggressive incidents, and in particular with verbal aggression.

Variations in seclusion and restraint practices by hospital location.

Data from a survey of seclusion and restraint practices in New York state hospitals were analyzed to determine if they differed by hospital location. The study included 19 hospitals--five in New York City, four in New York City suburbs, three in large towns, and seven in small towns. Overall, New York City and large-town hospitals had the highest rates of seclusion and restraint, but analysis by age group showed that New York City had the lowest rate for patients under age 35, who constituted the majority of patients who were secluded or restrained, and large towns had the highest rate. Compared with suburban and small-town hospitals, city and large-town hospitals used seclusion more often than restraint and had a higher ward census and a lower-staff patient ratio. In all groups males and blacks were overrepresented compared with the hospital population. The authors believe clarification of regional variations in assaultive behavior is important for treatment and system planning.

Pastoral counseling seminars for rural clergymen.

dresses, often without panties or bras. They used only spoons for eating, and meat and bread were not placed on individual plates because residents grabbed food from one another. Twenty residents had to be restrained to be fed, and were fed as a group. Seventy-four residents were almost continuously in restraint or seclusion of some kind. Nine months after the program was introduced, the ward census had been reduced to 126 as a result of tile transfer of 17 women to other units. Subdivision of living space had in effect increased the number of dayrooms and dormitories from two to five. All residents wore shoes of some type, either oxfords or tennis shoes, and only 35 wore custodial clothing. Fifty-five residents could use a complete set of silverware, including knives, forks, and spoons, and all foods were placed on the plates of all except two residents. Only one resident was restrained during feeding, and that was for training purposes. Almost all residents were completely toilet-trained. Restraints were used on occasion for 29 residents, primarily as part of a behavior-modification program; no one was kept in restraints or seclusion continuously. Some residents who had been placed on individual behavior-modification programs had responded so well that they were no longer considered problem cases. Similar results have been obtained in the men’s unit, which houses 86 residents between the ages of 17 and 50 in two dayrooms and three dormitories. The activity program on that unit has been expanded to include work assignments such as making beds, cleaning floors, and helping in the dining room, in addition to the wide variety of recreational activities. Trips off the grounds have been regularly scheduled, and residents have attended Detroit Tiger baseball games, go-cart races, movies at local theaters, and wrestling matches in nearby Saginaw, as well as visiting a zoo and a fire house. Despite the success of our program, we are convinced that we have made only a beginning, and that even more can be accomplisiled when and if we can provide greater numbers of activities and further reduce congestion. Our aim, simply, is to fulfill our belief that the most severely and profoundly retarded can live normally if their environment provides the opportunity. It is our hope that in tile future humane and normal environments will become the rule rather than the exception for all mentally retarded individuals.

Ward atmosphere and outcome of treatment of acute schizophrenia

The purpose of this study was to examine the relationship among various dimensions of ward atmosphere in twelve wards of four hospitals ( N = 202), and the short-term outcome of schizophrenic patients treated with either phenothiazines or placebo. The detailed rationale and description of the quantified measures of ward atmosphere is the subject of an earlier paper. 15 The wards were divided into ‘high’ and ‘low’ groups along each ward atmosphere dimension for analysis of the association of dimensions of ward atmosphere with treatment outcome. Hypotheses were formulated and tested that patients will improve more if assigned to wards: 1. (1) whose other patients are less disturbed; 2. (2) whose patients are less aggressive; 3. (3) where the other patients are less alone; 4. (4) where the patients not alone form larger rather than smaller social clusters; 5. (5) where there is more staff-patient contact; 6. (6) where patients are given more adults status; 7. (7) where the ward census is smaller; 8. (8) where the number of patients/staff member is smaller. Although the study hospitals did not have an explicit policy regarding transfer of patients from ward to ward on the basis of improvement, they tended to assign new patients to different wards according to initial severity of illness. The effect of ward atmosphere on short-term symptom reduction depended on the kind of symptom in question. The greatest number of effects were found on ‘paranoid’ symptoms, while the least number of effects were found on symptoms of ‘withdrawal’. Symptoms which could not be classified as ‘paranoid’ or ‘withdrawal’ held an intermediate position. The results generally conformed to the hypotheses concerning the association of good treatment outcome with wards with low disturbed behavior, low aggressive behavior, low aloneness, high cluster-size and high staff-patient contact (called patient behavior variables). However, the results were diametrically opposed to the hypotheses, at a statistically significant level, for the ward atmosphere dimensions adult status, ward census, and number of patients/staff member. The latter have been termed hospital policy dimensions. The interpretation is offered that the patient behavior dimensions of ward atmosphere are a part of far more powerful social forces affecting clinical course than are the hospital policy dimensions.

Carotid bruits in 1,000 normal subjects.

Since Hunt,1in 1914, called attention to the importance of carotid insufficiency there has been increasing interest in the clinical identification of carotid artery narrowing or occlusion. Arteriography,2,3ophthalmodynamometry,4contralateral carotid compression,5,6and palpation of the carotid arteries in the neck7and pharynx8have all been recommended as diagnostic measures. The simplicity of carotid artery auscultation commends it as a means of detecting narrowing of the homo- or contralateral lumen, since bruits have been identified in patients with carotid insufficiency.9 However, children have been reported to have cranial bruits which are of no pathological significance,10and attention has been called to the innocence of supraclavicular bruits in adults.11The possibility has also been raised that abdominal bruits in adults may not signify vascular disease.12 Accordingly, it seemed appropriate to determine the incidence of carotid artery bruits in persons without neurological disease. Methods One thousand patients were randomly selected from a group of presumed normal individuals from the clinic and ward census