scholarly journals COVID-19 and Ventilator-Associated Event Discordance

2021 ◽  
Vol 1 (S1) ◽  
pp. s45-s45
Author(s):  
Kelly Cawcutt ◽  
Mark Rupp ◽  
Lauren Musil
Keyword(s):  
Chart Review ◽  
Respiratory Illness ◽  
The United States ◽  
Healthcare Facilities ◽  
Mechanically Ventilated ◽  
Viral Shedding ◽  
History Of ◽  
Healthcare Acquired Infections ◽  
Hospital Acquired ◽  
Present On Admission

Background: The COVID-19 pandemic has challenged healthcare facilities since its discovery in late 2019. Notably, the subsequent COVID-19 pandemic has led to an increase in healthcare-acquired infections such as ventilator associated events (VAEs). Many hospitals in the United States perform surveillance for the NHSN for VAEs by monitoring mechanically ventilated patients for metrics that are generally considered to be objective and preventable and that lead to poor patient outcomes. The VAE definition is met in a stepwise manner. Initially, a ventilator-associated condition (VAC) is met when there an increase in ventilator requirements after a period of stability or improvement. An IVAC is then met when there is evidence of an infectious process such as leukocytosis or fever and a new antimicrobial agent is started. Finally, possible ventilator-associated pneumonia (PVAP) is met when there is evidence of microbial growth or viral detection. Since the beginning of the COVID-19 pandemic, our hospital has seen an increase in VAEs, which is, perhaps, not unexpected during a respiratory illness pandemic. However, the NSHN definitions of VAE, and PVAP in particular, do not account for the novelty and nuances of COVID-19. Methods: We performed a chart review of 144 patients who had a VAE reported to the NHSN between March 1 and December 31, 2020. Results: Of the 144 patients with a VAE reported to NHSN, 39 were SARS-CoV-2 positive. Of the 39 patients, 4 patients (10.25%) met the NHSN PVAP definition due to a positive SARS-CoV-2 PCR that was collected in the prolonged viral shedding period of their illness (< 90 days). One of the four patients also had a bacterial infection in addition to their subsequent positive COVID-19 result. All these patients were admitted to the hospital with a COVID-19 diagnosis and their initial PCR swab was performed upon admission. Conclusions: We believe that the PVAP definition was inappropriately triggered by patients who were decompensating on the ventilator due to a novel respiratory virus that was present on admission. Early in the pandemic, frequent swabbing of these patients was performed to try and understand the duration of viral shedding and to determine when it would be safe to transfer patients from isolation after prolonged hospitalization. The NSHN definition should take into consideration the prolonged viral shedding period of COVID-19 and natural history of the illness, and subsequent COVID-19 testing within 90 days of an initial positive should not require classification as a hospital-acquired PVAP.Funding: NoDisclosures: None

Abstract WP221: Predictors of Stroke in a Sample of Patients With Infective Endocarditis

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Ives A Valenzuela ◽  
Bradley Klein ◽  
Lauren Dunn ◽  
Robert Sorabella ◽  
Sang Myung Han ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Infective Endocarditis ◽  
Chart Review ◽  
Hemorrhagic Stroke ◽  
Care Center ◽  
Tertiary Care ◽  
The United States ◽  
High Morbidity ◽  
History Of ◽  
Prior Stroke

Background: Infective endocarditis (IE) affects up to 20,000 people per year in the United States. Stroke is a feared complication of IE and is associated with high morbidity and mortality. We aim to identify predictors of stroke in a large sample of patients treated at a tertiary care center. Methods: A retrospective chart review was carried out using ICD9 codes for IE and cerebrovascular events in patients admitted to the New York Presbyterian Hospital/Columbia University Medical Center from 2000 to 2015. Incident stroke was ascertained if imaging demonstrated an acute infarction during the hospital visit in which endocarditis was diagnosed using Duke’s criteria. Demographics, vascular risks and ancillary data were obtained by chart review. Generalized linear models were used to obtain the risk ratio (RR) and their 95% confidence intervals (95%CI) adjusting for age, sex, ethnicity, hypertension, diabetes, dyslipidemia, smoking, congestive heart failure (CHF), presence of cardiac vegetations, valvular abscesses, positive blood culture, and immunosuppression. Results: The sample included 727 IE subjects (mean age 61±18, range 18-101, 62% men, 62% non-white). Twelve percent of the sample were immunosuppressed. The majority of the patient had vegetations (61%) and positive blood cultures (87%, MRSA 13%) while valvular abscess were less frequent (13%). Of the 727 patients, 13% had an acute pre-surgical stroke (10% ischemic and 3% hemorrhagic). Meanwhile, of the 314 patient who underwent surgical intervention, only 0.5% had post-surgical strokes. The risk of pre-operative ischemic stroke was higher among patients with diabetes (RR 1.7, 1.1-2.8), cardiac vegetations (RR 2.8, 1.6-5.0), and history of prior stroke (RR 1.8, 1.8-2.9) while the risk of pre-surgical hemorrhagic stroke was higher among patients with history of prior stroke (RR 4.5, 1.7-11.9). Conclusions: Prior stroke was a risk factor for ischemic and hemorrhagic stroke, which suggests baseline brain vulnerability that may influence the risk of stroke in the setting of IE. Additionally, diabetes and the presence of vegetations increased the risk of ischemic stroke. Early identification of sub-populations with IE at risk of stroke may help stratify risk and test preventive interventions.

scholarly journals Comparison of comorbidities and treatment between ankylosing spondylitis and non-radiographic axial spondyloarthritis in the United States

Rheumatology ◽  
2019 ◽  
Vol 58 (11) ◽  
pp. 2025-2030 ◽  
Author(s):  
Sizheng Steven Zhao ◽  
Joerg Ermann ◽  
Chang Xu ◽  
Houchen Lyu ◽  
Sara K Tedeschi ◽  
...  
Keyword(s):  
United States ◽  
Chart Review ◽  
The United States ◽  
Cross Sectional Study ◽  
Cross Sectional ◽  
Academic Hospitals ◽  
Biologic Dmard ◽  
History Of ◽  
Icd Codes ◽  
The Mean

Abstract Objectives This study aimed to compare comorbidities and biologic DMARD (bDMARD) use between AS and non-radiographic axial SpA (nr-axSpA) patients, using a large cohort of patients from routine clinical practice in the United States. Methods We performed a cross-sectional study using electronic medical records from two academic hospitals in the United States. Data were extracted using automated searches (⩾3 ICD codes combined with text searches) and supplemented with manual chart review. Patients were categorized into AS or nr-axSpA according to classification criteria. Disease features, comorbidities (from a list of 39 chronic conditions) and history of bDMARD prescription were compared using descriptive statistics. Results Among 965 patients identified, 775 (80%) were classified as having axSpA. The cohort was predominantly male (74%) with a mean age of 52.5 years (s.d. 16.8). AS patients were significantly older (54 vs 46 years), more frequently male (77% vs 64%) and had higher serum inflammatory markers than those with nr-axSpA (median CRP 3.4 vs 2.2 mg/dl). Half of all patients had at least one comorbidity. The mean number of comorbidities was 1.5 (s.d. 2.2) and similar between AS and nr-axSpA groups. A history of bDMARD-use was seen in 55% of patients with no difference between groups. The most commonly prescribed bDMARDs were adalimumab (31%) and etanercept (29%). Ever-prescriptions of individual bDMARDs were similar between AS and nr-axSpA. Conclusion Despite age differences, nr-axSpA patients had similar comorbidity burdens as those with AS. Both groups received comparable bDMARD treatment in this United States clinic-based cohort.

Using Ventilator-Associated Pneumonia Rates as a Health Care Quality Indicator: A Contentious Concept

2017 ◽  
Vol 38 (03) ◽  
pp. 237-244 ◽  
Author(s):  
Girish Nair ◽  
Michael Niederman
Keyword(s):  
Health Care Quality ◽  
Infection Prevention ◽  
The United States ◽  
Care Quality ◽  
Ventilator Associated Pneumonia ◽  
Mechanically Ventilated ◽  
Potential Measure ◽  
Hospital Acquired ◽  
Prevention Approach

AbstractPneumonia is a leading cause of hospital-acquired infections, although reported rates of ventilator-associated pneumonia (VAP) have been declining in recent years. A multifaceted infection prevention approach, using a “ventilator bundle,” has been shown to reduce the frequency of VAP, while improving other patient outcomes. Because of difficulties in defining VAP, the Center for Medicare and Medicaid Service introduced a new streamlined ventilator-associated event (VAE) definition in 2013 for the surveillance of complications in mechanically ventilated patients. VAE measures are increasingly being measured by institutions in the United States in place of VAP rates and as a potential measure of the quality of intensive care unit (ICU) care. However, there is increased recognition that the streamlined definitions identify a different subset of patients than those identified by traditional VAP surveillance and that VAP prevention strategies may not impact all the causes of VAE. Also, VAP and VAE rates may not always reflect the quality of care in a given ICU, especially since patient factors, beyond the control of the hospital, may impact the rates of VAP and VAE. In this review, we discuss the issues related to VAP as a quality measure and the areas of uncertainty related to the new VAE definitions.

scholarly journals Hospital-Acquired COVID-19: Case Discussions of Two Patients Treated at a Level I Trauma Center

2021 ◽  
Vol 2021 ◽  
pp. 1-5
Author(s):  
Ryan M. Desrochers ◽  
Jonathan D. Gates ◽  
Daniel Ricaurte ◽  
Jane J. Keating
Keyword(s):  
Trauma Patients ◽  
Healthcare Facilities ◽  
Consulting Services ◽  
Potential Risk Factors ◽  
History Of ◽  
Case Discussions ◽  
Level I ◽  
Prolonged Hospital ◽  
Hospital Acquired ◽  
Insight Into

The community spread of COVID-19 is well known and has been rigorously studied since the onset of the pandemic; however, little is known about the risk of transmission to hospitalized patients. Many practices have been adopted by healthcare facilities to protect patients and staff by attempting to mitigate internal spread of the disease; however, these practices are highly variable among institutions, and it is difficult to identify which interventions are both practical and impactful. Our institution, for example, adopted the most rigorous infection control methods in an effort to keep patients and staff as safe as possible throughout the pandemic. This case report details the hospital courses of two trauma patients, both of whom tested negative for the COVID-19 virus multiple times prior to producing positive tests late in their hospital courses. The two patients share many common features including history of psychiatric illness, significant injuries, ICU stays, one-to-one observers, multiple consulting services, and a prolonged hospital course prior to discharge to a rehabilitation facility. Analysis of these hospital courses can help provide a better understanding of potential risk factors for acquisition of a nosocomial COVID-19 infection and insight into which measures may be most effective in preventing future occurrences. This is important to consider not only for COVID-19 but also for future novel infectious diseases.

Identifying Bleeding Risk In Medical Inpatients

Blood ◽  
2013 ◽  
Vol 122 (21) ◽  
pp. 2933-2933
Author(s):  
John P. Winters ◽  
Michael Desarno ◽  
Damon Houghton ◽  
Samuel A Merrill ◽  
Peter Callas ◽  
...  
Keyword(s):  
Risk Factors ◽  
Heart Failure ◽  
Blood Cell ◽  
Major Bleeding ◽  
Respiratory Dysfunction ◽  
Increased Risk ◽  
Medical Inpatients ◽  
History Of ◽  
Hospital Acquired ◽  
Present On Admission

Abstract Introduction Expert guidelines and regulatory agencies recommend that all medical inpatients be assessed for venous thrombosis (VT) risk and pharmacologic prophylaxis provided to at-risk patients. However, anticoagulant prophylaxis may increase the risk of major bleeding in medical inpatients and the incidence and risk factors for major bleeding are not established. Our goal was to determine the rate of hospital-acquired major bleeding in medical inpatients and whether patients at increased risk of hospital-acquired VT were also at increased risk for hospital-acquired major bleeding. Methods All cases of hospital-acquired major bleeding on medical services (cardiology, hematology/oncology, intensive care, internal medicine) were identified at Fletcher Allen Health Care (500-bed teaching hospital for the University of Vermont) between June 2009 and April 2012. Major bleeding was defined as symptomatic bleeding in a critical area (intracranial, intraspinal, intraocular, retroperitoneal and peritoneal by ICD-9 discharge codes with the present on admission flag marked as ‘no') or any bleeding that caused a fall in hemoglobin of 2g/dL within 24 hours (assessed from the laboratory database after the patient had been admitted for 24 hours) and required a red blood cell transfusion. The sensitivity and specificity of the definition was confirmed by chart review of 20 cases of hospital-acquired major bleeding and 20 non-cases. Logistic regression was used to calculate odds ratios (OR) for major bleeding for age, use of anticoagulation, and risk factors for hospital-acquired VT contained in the Medical Inpatient Thrombosis (MITH) score (Table). The MITH score was calculated for each patient using data present on admission: history of heart failure = 5 points, history of rheumatologic disease = 4 points, history of fracture in past 3 months = 3 points, history of cancer in past 12 months = 1 point, tachycardia (HR>100 at admission) = 2 points, respiratory dysfunction (SpO2<90% at admission or intubated on hospital day 1) = 1 point, white blood cell count >11 x 103/µL = 1 points, platelet count >350 x 103/µL = 1 point). Major bleeding rate was calculated for MITH score using the following cut off points: 0-1, 2-5, ≥6. Results 241 cases of major bleeding complicated 20,946 medical admissions (11.1 per 1000 admissions). The sensitivity and specificity of our definition of hospital-acquired major bleeding was 100% and 83%, respectively. Prophylactic anticoagulation ordered on admission was not associated with major bleeding (OR 1.1) but full anticoagulation on admission was associated with major bleeding (OR 1.4). Of the MITH score variables, respiratory dysfunction (OR 2.2), prior history of congestive heart failure (OR 2.2) and white cell count ≥11 x 103/µL (OR 2.0) on admission were associated with major bleeding (table 1). For MITH scores 0-1, 2-5, and ≥5, major bleeding occurred in 6, 11, and 19 per 1000 admissions, respectively. The corresponding incidence of hospital-acquired venous thrombosis for a MITH score of 0-1, 2-5, and ≥6 were 2, 7, and 14 per 1000 admissions. Hospital-acquired VT was strongly associated with major bleeding (OR 20.4; 95% CI 12.4, 33.7). Conclusion Major bleeding is a more common complication of hospital admission than VT. Risk factors and an aggregate risk score for hospital-acquired VT were associated with the risk of major bleeding. Evidence-based models which assess both bleeding and thrombosis risk are urgently needed to help risk stratify medical patients for appropriate VT prophylaxis. Disclosures: No relevant conflicts of interest to declare.

Validation Of Medical Inpatient Venous Thrombosis Risk Assessment (MITH) Score

Blood ◽  
2013 ◽  
Vol 122 (21) ◽  
pp. 2931-2931
Author(s):  
Damon E Houghton ◽  
Michael Desarno ◽  
Peter Callas ◽  
Allen B Repp ◽  
Mary Cushman ◽  
...  
Keyword(s):  
Risk Factors ◽  
Risk Assessment ◽  
Risk Factor ◽  
Venous Thrombosis ◽  
Sensitivity And Specificity ◽  
Validation Cohort ◽  
Medical Inpatients ◽  
History Of ◽  
Hospital Acquired ◽  
Present On Admission

Abstract Introduction Governmental agencies recommend risk assessment of venous thrombosis (VT) for medical inpatients at admission and provision of VT prophylaxis for moderate to high risk patients. While several risk factor models for predicting hospital-acquired VT have been proposed, none have been widely accepted and few have been prospectively validated. We sought to validate the recently published MITH VT risk assessment model in an independent cohort of medical inpatients (Zakai et al, Journal of Thrombosis and Haemostasis 2013). Methods Hospital-acquired VT and risk factors present at admission were collected from adult inpatients between June 2009 and April 2012 admitted to the medicine, medical intensive care, hematology/oncology, or cardiology services at Fletcher Allen Hospital (500 bed teaching hospital for the University of Vermont). Hospital-acquired VT was defined using VT discharge ICD-9 codes (flagged as not present on admission) and record of an imaging study that could diagnosis VT (such as duplex ultrasound, computed tomography angiography, or ventilation perfusions scan). Inpatients with VT ICD-9 codes flagged as present on admission were excluded. The sensitivity and specificity of the definition was confirmed by chart review of 30 cases of hospital-acquired VTE and 30 non-cases. Risk factors for hospital-acquired VT were captured using ICD-9 codes from the problem list, discharge codes, vital signs, and laboratory values at admission. The MITH score was calculated for each patient based on the points for each risk factor: history of heart failure = 5 pts, history of rheumatologic disease = 4 pts, history of fracture in past 3 months = 3 pts, history of cancer in past 12 months = 1 pt, tachycardia (HR>100 at admission) = 2pt, respiratory dysfunction (SpO2<90% at admission or intubated on hospital day 1) = 1 pt, white blood cell count >11 = 1 pt, platelet count >350 = 1 pt. The absolute rates of hospital-acquired VT for different cut points of the score were calculated and compared qualitatively to those previously published for the MITH score. Results There were 120 hospital-acquired VT events complicating 20,334 medical admissions (5.9 cases per 1,000 hospital admissions). The sensitivity and specificity of our definition of hospital-acquired VT was 100% and 91%, respectively. The table presents the prevalence of the MITH score at various cut-offs in cases and non-cases as well as the incidence of VT. In the derivation of the MITH score, the rate of VT per 1000 admissions for a score <1, <2, or <3 was 1.0, 1.5, and 2.1 compared with 0.7, 1.8, and 2.2 VT per 1000 admissions for the validation cohort. The incidence of VTE in the derivation of the MITH score for a score ≥1, ≥2, and ≥3 was 6.0, 8.9, and 12.4 per 1000 admissions compared with 7.9, 9.0, and 10.3 per 1000 admissions in the validation cohort. Conclusions We have validated a previously published VT risk score for hospitalized medical patients in an independent population. Determination of a patient's risk of VT at admission using readily available clinical and laboratory data could allow physicians to make informed decisions about risks and benefits of DVT prophylaxis. Further work is required to determine at what level of risk pharmacologic VT prophylaxis is warranted in this patient population. Disclosures: No relevant conflicts of interest to declare.

scholarly journals How to prevent transmission of MRSA in the open community?

2004 ◽  
Vol 9 (11) ◽  
pp. 1-2 ◽  
Author(s):  
F Vandenesch ◽  
J Etienne
Keyword(s):  
Methicillin Resistance ◽  
Past History ◽  
The United States ◽  
Hospital Acquired Infection ◽  
History Of ◽  
Mrsa Strains ◽  
Healthcare Associated ◽  
Resistance Rates ◽  
Low Prevalence ◽  
Hospital Acquired

In the past 20 to 30 years, methicillin-resistant Staphylococcus aureus (MRSA) strains have been present in hospitals and have become a major cause of hospital-acquired infection. Methicillin resistance rates of S. aureus vary considerably between countries, with a high prevalence in the United States, and southern Europe (&gt;20%) and a low prevalence in northern Europe (&lt; or =5%). Community-acquired MRSA emerged worldwide in the late 1990s. There has been great confusion in the literature between healthcare-associated MRSA infections occurring in the community in patients who are at risk of acquiring hospital MRSA (such as those with past history of hospital admission, immunocompromised status, etc.), and true CA-MRSA infections due to strains that are present in the community only.

scholarly journals Does Copper treating of commonly touched surfaces reduce healthcare acquired infections? A Systematic Review and meta-analysis

2020 ◽  
Author(s):  
Loai Albarqouni ◽  
Oyuka Byambasuren ◽  
Justin Clark ◽  
Anna Mae Scott ◽  
David Looke ◽  
...  
Keyword(s):  
Systematic Review ◽  
Meta Analysis ◽  
Clinical Importance ◽  
Potential Effect ◽  
Current Evidence ◽  
Healthcare Facilities ◽  
Healthcare Acquired Infections ◽  
Effect Of Copper ◽  
Hospital Acquired ◽  
The Impact

AbstractBackgroundHealthcare acquired infections (HAIs) cause substantial morbidity and mortality. Copper appears to have strong viricidal properties under laboratory conditions.AimWe conducted a systematic review to examine the potential effect of copper treating of commonly touched surfaces in healthcare facilities.MethodsWe included controlled trials comparing the effect of copper-treated surfaces (furniture or bed linens) in hospital rooms versus standard rooms on hospital acquired infections (HAIs). Two reviewers independently screened retrieved articles, extracted data, and assessed the risk of bias of included studies. The primary outcome was the occurrence of healthcare acquired infections.FindingsWe screened 638 records; 7 studies comprising 12362 patients were included. All of included studies were judged to be at high risk in ≥2 of the 7 domains of bias. All 7 included studies reported the effect of copper-treated surfaces HAIs. Overall, we found low quality evidence of a potential clinical importance that copper-treated hard surfaces and/or bed linens and clothes reduced healthcare acquired infections by 27% (RR 0.73; 95% CI 0.57 to 0.94).ConclusionGiven the clinical and economic costs of healthcare acquired infections, the potentially protective effect of copper-treated surfaces appears important. The current evidence is insufficient to make a strong positive recommendation. However, it would appear worthwhile and urgent to conduct larger-scale publicly funded clinical trials of the impact of copper coating.

Healers and Healthcare

2020 ◽  
pp. 18-44
Author(s):  
Jeff Levin
Keyword(s):  
United States ◽  
The United States ◽  
Early Church ◽  
Healthcare Facilities ◽  
Roman World ◽  
Greco Roman ◽  
Medical Centers ◽  
Faith Traditions ◽  
History Of

Chapter 2 narrates the history of religious healers from the time of the ancients through developments in Asia and the Greco-Roman world and in the early church. The chapter also describes the origins of hospitals as religiously sponsored institutions of care for the sick. These institutions emerged globally, across faith traditions—in the pagan world, in Christianity, in Islam, in the global East—and they remain today largely an expression of religious outreach. This can be observed in the United States, for example, in the countless religiously branded hospitals, medical centers, and healthcare facilities in most communities that go by names such as Catholic, Lutheran, Baptist, Methodist, Presbyterian, Adventist, Episcopal, Jewish, and so on.

Methicillin-resistantStaphylococcus aureusin Canada: a historical perspective and lessons learned

2010 ◽  
Vol 56 (2) ◽  
pp. 89-120 ◽  
Author(s):  
Nevio Cimolai
Keyword(s):  
The United States ◽  
Management Control ◽  
Lessons Learned ◽  
Teaching Hospitals ◽  
Medical Problems ◽  
Term Care ◽  
Dramatic Rise ◽  
History Of ◽  
Hospital Acquired ◽  
And Control

The history of methicillin-resistant Staphylococcus aureus (MRSA) in Canada has many similarities to MRSA evolution worldwide, but especially to that in the United States and United Kingdom. Reports of MRSA occurred as early as 1964, and community isolates were cited in the 1970s. Nosocomial outbreaks were becoming common by 1978 and flourished gradually thereafter. Endemic institutional MRSA became predominant in the 1990s, threatening large teaching hospitals in particular. In the last decade, both hospital-acquired and community-acquired MRSA have created major medical problems in Canada. More recently, an epidemic of Canadian community-acquired MRSA-10, has led to heightened public health concerns. Canadian contributions to MRSA science are numerous, with organized surveillance continuing to mature across the nation. A typing system for epidemic clones is now available and is being judiciously applied. Estimated costs for MRSA surveillance, treatment, and control are extraordinary, paralleling the dramatic rise in the number of MRSA isolations. Whereas surveillance continues to form an essential aspect of MRSA management, control, eradication, and overall diminution, MRSA reservoirs deserve much greater attention. Such efforts, however, must be as widely publicized in the community and in patient homes as they are in medical institutions responsible for both acute and long-term care.

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