Understanding the impact of the SARS-COV-2 pandemic on hospitalized patients with substance use disorder

Background The SARS-COV-2 pandemic rapidly shifted dynamics around hospitalization for many communities. This study aimed to evaluate how the pandemic altered the experience of healthcare, acute illness, and care transitions among hospitalized patients with substance use disorder (SUD). Methods We performed a qualitative study at an academic medical center in Portland, Oregon, in Spring 2020. We conducted semi-structured interviews, and conducted a thematic analysis, using an inductive approach, at a semantic level. Results We enrolled 27 participants, and identified four main themes: 1) shuttered community resources threatened patients’ basic survival adaptations; 2) changes in outpatient care increased reliance on hospitals as safety nets; 3) hospital policy changes made staying in the hospital harder than usual; and, 4) care transitions out of the hospital were highly uncertain. Discussion Hospitalized adults with SUD were further marginalized during the SARS-COV-2 pandemic. Systems must address the needs of marginalized patients in future disruptive events.

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Who’s in charge? Results from a qualitative study of caregiver perspectives on the care transition process

European Journal for Person Centered Healthcare ◽

10.5750/ejpch.v6i1.1399 ◽

2018 ◽

Vol 6 (1) ◽

pp. 50 ◽

Cited By ~ 2

Author(s):

Benjamin Shirley ◽

Nathaniel Erskine ◽

David D McManus ◽

Catarina I Kiefe ◽

Milena Anatchkova ◽

...

Keyword(s):

Medical Center ◽

Academic Medical Center ◽

Care Transitions ◽

Transition Process ◽

Care Transition ◽

Valuable Insight ◽

Structured Interviews ◽

Medical Provider ◽

Factors Affecting ◽

Health Insurance Status

Background: Care transitions are a topic of increasing interest as researchers and clinicians focus their effects on patient outcomes. Engaging caregivers, who play important roles in care transitions, may yield valuable insight into how care transition processes can be improved. Methods: We conducted semi-structured interviews, focusing on caregivers’ experiences with and perceptions of care transitions, with 11 eligible caregivers whose loved ones had recently experienced an unplanned admission to a single academic medical center. Our research team analyzed the transcripts to identify key themes.Results: Caregivers detailed multiple factors affecting care transitions, including both in-hospital and external elements. Identifying the medical provider in charge of care emerged as a common difficulty. Other areas of interest included receiving discharge information, length of stay, health insurance status, the presence of social support, access to transportation and educational level, among others. Caregivers’ views on the quality of various in-hospital aspects of their own care transition experiences varied.Conclusions: Caregivers re-affirmed the complexity of the care transition process by identifying myriad factors that influence their quality. Taking steps to address these factors may help hospitals to empower and engage caregivers, as well as to improve care transitions overall and better manage the health of their patients.

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2101. Impact of “Code Sepsis” on Antimicrobial Utilization at an Academic Medical Center

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.1781 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S710-S710

Author(s):

Minji Kang ◽

Francesca J Torriani ◽

Rebecca Sell ◽

Shira Abeles

Keyword(s):

Organ Dysfunction ◽

Early Recognition ◽

Medical Center ◽

Academic Medical Center ◽

Hospitalized Patients ◽

Antibiotic Administration ◽

Academic Medical ◽

Sepsis Bundle ◽

The Impact ◽

Infectious Source

Abstract Background Balancing antimicrobial stewardship with sepsis management is a challenge. At our academic medical center, a “Code Sepsis” was implemented as a nursing driven initiative to improve early recognition and management of sepsis. Per protocol, Code Sepsis is activated in patients who meet two or more systemic inflammatory response syndrome (SIRS) criteria due to a suspected infection to allow for early implementation of the sepsis bundle, which includes laboratory testing, fluid resuscitation, and antibiotic administration (Figure 1). We analyzed the impact that Code Sepsis had on antimicrobial use among hospitalized patients over a six month period. Methods We reviewed the electronic medical records of hospitalized patients with Code Sepsis activation between January 1, 2018 and June 30, 2018 to determine whether antibiotics were “escalated” or “not escalated.” Among patients who had antibiotic escalation, escalation was classified as “indicated” or “not indicated” (Figure 2). A logistic regression model was used to identify characteristics, SIRS or organ dysfunction criteria predictive of indicated antimicrobial escalation. Results Code Sepsis was activated in 529 patients with antibiotics escalated in 247 (47%) and not escalated in 282 (53%) (Table 1). Among patients whose antibiotics were escalated, 64% (152) had an indication. In 36% (89), escalation was not indicated as Code Sepsis was due to a suspected noninfectious source, known infectious source already on appropriate antimicrobials, or a suspected infectious source in which diagnostic results had already shown the absence of the infection (Figure 2). Odds of indicated antibiotic escalation increased with the number of SIRS and organ dysfunction criteria (Table 2). Conclusion In our efforts to improve sepsis outcomes, we focused on early recognition (Code Sepsis) and intervention (sepsis bundle). However, our Code Sepsis inadvertently led to antibiotic overutilization. By refocusing Code Sepsis on early recognition of severe sepsis and septic shock, we hope to optimize resource utilization and improve patient outcomes. Disclosures All authors: No reported disclosures.

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Relationship between dental loss and health outcomes among hospitalized patients with and without diabetes

Journal of Investigative Medicine ◽

10.1136/jim-2018-000842 ◽

2018 ◽

Vol 67 (3) ◽

pp. 669-673

Author(s):

Kenneth Izuora ◽

Ammar Yousif ◽

Gayle Allenback ◽

Civon Gewelber ◽

Michael Neubauer

Keyword(s):

Diabetes Mellitus ◽

Heart Disease ◽

Health Outcomes ◽

Medical Center ◽

Dental Health ◽

Academic Medical Center ◽

Hospitalized Patients ◽

Academic Medical ◽

Patients With Diabetes ◽

The Impact

There is mixed evidence regarding the impact of poor dental health on cardiovascular disease and other health outcomes. Our objective was to determine the outcomes associated with poor dental health among hospitalized patients with and without diabetes mellitus (DM) at our institution. We enrolled a consecutive sample of adult patients admitted to an academic medical center. We gathered demographic, health and dental information, reviewed their medical records and then examined their teeth. We analyzed data using SPSS V.24. There was a high prevalence of dental loss among all hospitalized patients. Older age (p<0.001), smoking (p=0.034), having DM (p=0.001) and lower frequency of teeth brushing (p<0.001) were predictors of having a lower number of healthy teeth. Among DM and non-DM patients, fewer remaining healthy teeth was associated with presence of heart disease (p=0.025 and 0.003, respectively). Patients with diabetes mellitus (DM) had a higher prevalence of stroke (p=0.006) while patients without DM had a higher number of discharge medications (p=0.001) associated with having fewer number of healthy teeth. There was no correlation between number of healthy teeth and the length or frequency of hospitalization. Patients with DM are more likely to have fewer number of healthy teeth compared with non-DM patients. Fewer number of healthy teeth was associated with higher prevalence of heart disease in both DM and non-DM patients and with more discharge medications in non-DM patients.

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Tracking Substance Use Complications: A Collaborative Analysis of Public Health and Academic Medical Center Records on Drug Use-Associated Infective Endocarditis

The Journal of Infectious Diseases ◽

10.1093/infdis/jiaa160 ◽

2020 ◽

Vol 222 (Supplement_5) ◽

pp. S437-S441

Author(s):

David de Gijsel ◽

Martha DesBiens ◽

Elizabeth A Talbot ◽

David J Laflamme ◽

Stephen Conn ◽

...

Keyword(s):

Public Health ◽

Substance Use ◽

Chart Review ◽

Medical Center ◽

Academic Medical Center ◽

Discharge Diagnosis ◽

Composite Measure ◽

Academic Medical ◽

Diagnosis Coding ◽

The Impact

Abstract Background Healthcare systems and public health agencies use different methods to measure the impact of substance use (SU) on population health. We studied the ability of systems to accurately capture data on drug use-associated infective endocarditis (DUA-IE). Methods We conducted a retrospective analysis of patients with IE discharge diagnosis from an academic medical center, 2011–2017, comparing data from hospital Electronic Health Record (EHR) to State Uniform Hospital Discharge Data Set (UHDDS). To identify SU we developed a composite measure. Results EHR identified 472 IE discharges (430 of these were captured in UHDDS); 406 (86.0%) were correctly coded based on chart review. IE discharges increased from 57 to 92 (62%) from 2012 to 2017. Hospitalizations for the subset of DUA-IE identified by any measure of SU increased from 10 to 54 (440%). Discharge diagnosis coding identified 128 (60.7%) of total DUA-IE hospitalizations. The composite measure identified an additional 65 (30.8%) DUA-IE hospitalizations and chart review an additional 18 (8.5%). Conclusions The failure of discharge diagnosis coding to identify DUA-IE in 40% of hospitalizations demonstrates the need for better systems to capture the impact of SU. Collaborative data sharing could help improve surveillance responsiveness to address an emerging public health crises.

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391. Small Towns, Big Cities: Rural and Urban Disparities Among Hospitalized Patients with COVID-19

Open Forum Infectious Diseases ◽

10.1093/ofid/ofab466.592 ◽

2021 ◽

Vol 8 (Supplement_1) ◽

pp. S297-S298

Author(s):

Caroline Hamilton ◽

Deepak Nag Ayyala ◽

David Walsh ◽

Christian-Jevon Bramwell ◽

Christopher Walker ◽

...

Keyword(s):

Length Of Stay ◽

Census Data ◽

Medical Center ◽

Academic Medical Center ◽

Hospitalized Patients ◽

Hospital Length Of Stay ◽

Level Of Care ◽

P Value ◽

Rural And Urban ◽

The Impact

Abstract Background More than half of all hospitals in the U.S. are rural hospitals. Frequently understaffed and resource limited, community hospitals serve a population that tends to be older and have less access to care with increased poverty and medical co-morbidities. There is a lack of data surrounding the impact of COVID-19 among rural minority communities. This study seeks to determine rural and urban disparities among hospitalized individuals with COVID-19. Methods This is a descriptive, retrospective analysis of the first 155 adult patients admitted to a tertiary hospital with a positive COVID-19 nasopharyngeal PCR test. Augusta University Medical Center serves the surrounding rural and urban counties of the Central Savannah River Area. Rural and urban categories were determined using patient address and county census data. Demographics, comorbidities, admission data and 30-day outcomes were evaluated. Results Of the patients studied, 62 (40%) were from a rural county and 93 (60%) were from an urban county. No difference was found when comparing the number of comorbidities of rural vs urban individuals; however, African Americans had significantly more comorbidities compared to other races (p-value 0.02). In a three-way comparison, race was not found to be significantly different among admission levels of care. Rural patients were more likely to require an escalation in the level of care within 24 hours of admission (p-value 0.02). Of the patients that were discharged or expired at day 30, there were no differences in total hospital length of stay or ICU length of stay between the rural and urban populations. Baseline Characteristics of Hospitalized Patients with COVID-19 Day 30 Outcomes and Characteristics Level of Care at Time of Admission Conclusion This study suggests that patients in rural communities may be more critically ill or are at a higher risk of early decompensation at time of hospitalization compared to patients from urban communities. Nevertheless, both populations had similar lengths of stay and outcomes. Considering this data is from an academic medical center with a large referral area and standardized inpatient COVID-19 management, these findings may prompt further investigations into other disparate outcomes. Disclosures All Authors: No reported disclosures

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Alcohol Hand Rub Significantly Reduces Overall Bacterial Bioburden on Stethoscopes in a Real-World Clinical Setting

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.620 ◽

2020 ◽

Vol 41 (S1) ◽

pp. s114-s115

Author(s):

Alexandra Johnson ◽

Bobby Warren ◽

Deverick John Anderson ◽

Melissa Johnson ◽

Isabella Gamez ◽

...

Keyword(s):

Real World ◽

Medical Center ◽

Academic Medical Center ◽

Randomized Study ◽

Healthcare Providers ◽

Clinical Workflow ◽

Provider Type ◽

Academic Medical ◽

Rn Students ◽

The Impact

Background: Stethoscopes are a known vector for microbial transmission; however, common strategies used to clean stethoscopes pose certain barriers that prevent routine cleaning after every use. We aimed to determine whether using readily available alcohol-based hand rub (ABHR) would effectively reduce bacterial bioburden on stethoscopes in a real-world setting. Methods: We performed a randomized study on inpatient wards of an academic medical center to assess the impact of using ABHR (AlcareExtra; ethyl alcohol, 80%) on the bacterial bioburden of stethoscopes. Stethoscopes were obtained from healthcare providers after routine use during an inpatient examination and were randomized to control (no intervention) or ABHR disinfection (2 pumps applied to tubing and bell or diaphragm by study personnel, then allowed to dry). Cultures of the tubing and bell or diaphragm were obtained with premoistened cellulose sponges. Sponges were combined with 1% Tween20-PBS and mixed in the Seward Stomacher. The homogenate was centrifuged and all but ~5 mL of the supernatant was discarded. Samples were plated on sheep’s blood agar and selective media for clinically important pathogens (CIPs) including S. aureus, Enterococcus spp, and gram-negative bacteria (GNB). CFU count was determined by counting the number of colonies on each plate and using dilution calculations to calculate the CFU of the original ~5 mL homogenate. Results: In total, 80 stethoscopes (40 disinfection, 40 control) were sampled from 46 physicians (MDs) and MD students (57.5%), 13 advanced practice providers (16.3%), and 21 nurses (RNs) and RN students (26.3%). The median CFU count was ~30-fold lower in the disinfection arm compared to control (106 [IQR, 50–381] vs 3,320 [986–4,834]; P < .0001). The effect was consistent across provider type, frequency of recent usual stethoscope cleaning, age, and status of pet ownership (Fig. 1). Overall, 26 of 80 (33%) of stethoscopes harbored CIP. The presence of CIP was lower but not significantly different for stethoscopes that underwent disinfection versus controls: S. aureus (25% vs 32.5%), Enterococcus (2.5% vs 10%), and GNB (2.5% vs 5%). Conclusions: Stethoscopes may serve as vectors for clean hands to become recontaminated immediately prior to performing patient care activities. Using ABHR to clean stethoscopes after every use is a practical and effective strategy to reduce overall bacterial contamination that can be easily incorporated into clinical workflow. Larger studies are needed to determine the efficacy of ABHR at removing CIP from stethoscopes as stethoscopes in both arms were frequently contaminated with CIP. Prior cleaning of stethoscopes on the study day did not seem to impact contamination rates, suggesting the impact of alcohol foam disinfection is short-lived and may need to be repeated frequently (ie, after each use).Funding: NoneDisclosures: NoneDisclosures: NoneFunding: None

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Communications and Screening for 2019 Novel Coronavirus at a Tertiary-Care Medical Center

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.578 ◽

2020 ◽

Vol 41 (S1) ◽

pp. s84-s84

Author(s):

Lorinda Sheeler ◽

Mary Kukla ◽

Oluchi Abosi ◽

Holly Meacham ◽

Stephanie Holley ◽

...

Keyword(s):

Screening Tool ◽

Medical Center ◽

Academic Medical Center ◽

Tertiary Care ◽

The United States ◽

World Health ◽

Communication Campaign ◽

Electronic Screening ◽

Novel Coronavirus ◽

The Impact

Background: In December of 2019, the World Health Organization reported a novel coronavirus (severe acute respiratory coronavirus virus 2 [SARS-CoV-2)]) causing severe respiratory illness originating in Wuhan, China. Since then, an increasing number of cases and the confirmation of human-to-human transmission has led to the need to develop a communication campaign at our institution. We describe the impact of the communication campaign on the number of calls received and describe patterns of calls during the early stages of our response to this emerging infection. Methods: The University of Iowa Hospitals & Clinics is an 811-bed academic medical center with >200 outpatient clinics. In response to the coronavirus disease 2019 (COVID-19) outbreak, we launched a communications campaign on January 17, 2020. Initial communications included email updates to staff and a dedicated COVID-19 webpage with up-to-date information. Subsequently, we developed an electronic screening tool to guide a risk assessment during patient check in. The screening tool identifies travel to China in the past 14 days and the presence of symptoms defined as fever >37.7°C plus cough or difficulty breathing. The screening tool was activated on January 24, 2020. In addition, university staff contacted each student whose primary residence record included Hubei Province, China. Students were provided with medical contact information, signs and symptoms to monitor for, and a thermometer. Results: During the first 5 days of the campaign, 3 calls were related to COVID-19. The number of calls increased to 18 in the 5 days following the implementation of the electronic screening tool. Of the 21 calls received to date, 8 calls (38%) were generated due to the electronic travel screen, 4 calls (19%) were due to a positive coronavirus result in a multiplex respiratory panel, 4 calls (19%) were related to provider assessment only (without an electronic screening trigger), and 2 calls (10%) sought additional information following the viewing of the web-based communication campaign. Moreover, 3 calls (14%) were for people without travel history but with respiratory symptoms and contact with a person with recent travel to China. Among those reporting symptoms after travel to China, mean time since arrival to the United States was 2.7 days (range, 0–11 days). Conclusion: The COVID-19 outbreak is evolving, and providing up to date information is challenging. Implementing an electronic screening tool helped providers assess patients and direct questions to infection prevention professionals. Analyzing the types of calls received helped tailor messaging to frontline staff.Funding: NoneDisclosures: None

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154. Antibiotic Use During Three Separate Waves of the COVID-19 Pandemic at a Large Academic Medical Center in Detroit, MI

Open Forum Infectious Diseases ◽

10.1093/ofid/ofab466.356 ◽

2021 ◽

Vol 8 (Supplement_1) ◽

pp. S188-S189

Author(s):

Deepika Sivakumar ◽

Shelbye R Herbin ◽

Raymond Yost ◽

Marco R Scipione

Keyword(s):

Retrospective Review ◽

Bacterial Pneumonia ◽

Medical Center ◽

Academic Medical Center ◽

Antibiotic Use ◽

Percent Change ◽

Academic Medical ◽

Days Of Therapy ◽

Time Periods ◽

The Impact

Abstract Background Inpatient antibiotic use early on in the COVID-19 pandemic may have increased due to the inability to distinguish between bacterial and COVID-19 pneumonia. The purpose of this study was to determine the impact of COVID-19 on antimicrobial usage during three separate waves of the COVID-19 pandemic. Methods We conducted a retrospective review of patients admitted to Detroit Medical Center between 3/10/19 to 4/24/21. Median days of therapy per 1000 adjusted patient days (DOT/1000 pt days) was evaluated for all administered antibiotics included in our pneumonia guidelines during 4 separate time periods: pre-COVID (3/3/19-4/27/19); 1st wave (3/8/20-5/2/20); 2nd wave (12/6/21-1/30/21); and 3rd wave (3/7/21-4/24/21). Antibiotics included in our pneumonia guidelines include: amoxicillin, azithromycin, aztreonam, ceftriaxone, cefepime, ciprofloxacin, doxycycline, linezolid, meropenem, moxifloxacin, piperacillin-tazobactam, tobramycin, and vancomycin. The percent change in antibiotic use between the separate time periods was also evaluated. Results An increase in antibiotics was seen during the 1st wave compared to the pre-COVID period (2639 [IQR 2339-3439] DOT/1000 pt days vs. 2432 [IQR 2291-2499] DOT/1000 pt days, p=0.08). This corresponded to an increase of 8.5% during the 1st wave. This increase did not persist during the 2nd and 3rd waves of the pandemic, and the use decreased by 8% and 16%, respectively, compared to the pre-COVID period. There was an increased use of ceftriaxone (+6.5%, p=0.23), doxycycline (+46%, p=0.13), linezolid (+61%, p=0.014), cefepime (+50%, p=0.001), and meropenem (+29%, p=0.25) during the 1st wave compared to the pre-COVID period. Linezolid (+39%, p=0.013), cefepime (+47%, p=0.08) and tobramycin (+47%, p=0.05) use remained high during the 3rd wave compared to the pre-COVID period, but the use was lower when compared to the 1st and 2nd waves. Figure 1. Antibiotic Use 01/2019 to 04/2019 Conclusion Antibiotics used to treat bacterial pneumonia during the 1st wave of the pandemic increased and there was a shift to broader spectrum agents during that period. The increased use was not sustained during the 2nd and 3rd waves of the pandemic, possibly due to the increased awareness of the differences between patients who present with COVID-19 pneumonia and bacterial pneumonia. Disclosures All Authors: No reported disclosures

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The Impact of Delayed Symptomatic Treatment Implementation in the Intensive Care Unit

Healthcare ◽

10.3390/healthcare10010035 ◽

2021 ◽

Vol 10 (1) ◽

pp. 35

Author(s):

Lesley Meng ◽

Krzysztof Laudanski ◽

Mariana Restrepo ◽

Ann Huffenberger ◽

Christian Terwiesch

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Medical Center ◽

Academic Medical Center ◽

Symptomatic Treatment ◽

Medication Administration ◽

Average Delay ◽

Treatment Implementation ◽

Medication Delivery ◽

The Impact

We estimated the harm related to medication delivery delays across 12,474 medication administration instances in an intensive care unit using retrospective data in a large urban academic medical center between 2012 and 2015. We leveraged an instrumental variables (IV) approach that addresses unobserved confounds in this setting. We focused on nurse shift changes as disruptors of timely medication (vasodilators, antipyretics, and bronchodilators) delivery to estimate the impact of delay. The average delay around a nurse shift change was 60.8 min (p < 0.001) for antipyretics, 39.5 min (p < 0.001) for bronchodilators, and 57.1 min (p < 0.001) for vasodilators. This delay can increase the odds of developing a fever by 32.94%, tachypnea by 79.5%, and hypertension by 134%, respectively. Compared to estimates generated by a naïve regression approach, our IV estimates tend to be higher, suggesting the existence of a bias from providers prioritizing more critical patients.

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Patient Involvement in Anesthesia Decision-making: A Qualitative Study of Knee Arthroplasty

Anesthesiology ◽

10.1097/aln.0000000000003795 ◽

2021 ◽

Author(s):

Veena Graff ◽

Justin T. Clapp ◽

Sarah J. Heins ◽

Jamison J. Chung ◽

Madhavi Muralidharan ◽

...

Keyword(s):

Decision Making ◽

Qualitative Study ◽

Shared Decision Making ◽

Knee Arthroplasty ◽

Patient Involvement ◽

Medical Center ◽

Academic Medical Center ◽

Shared Decision ◽

Structured Interviews ◽

Primary Knee Arthroplasty

Background Calls to better involve patients in decisions about anesthesia—e.g., through shared decision-making—are intensifying. However, several features of anesthesia consultation make it unclear how patients should participate in decisions. Evaluating the feasibility and desirability of carrying out shared decision-making in anesthesia requires better understanding of preoperative conversations. The objective of this qualitative study was to characterize how preoperative consultations for primary knee arthroplasty arrived at decisions about primary anesthesia. Methods This focused ethnography was performed at a U.S. academic medical center. The authors audio-recorded consultations of 36 primary knee arthroplasty patients with eight anesthesiologists. Patients and anesthesiologists also participated in semi-structured interviews. Consultation and interview transcripts were coded in an iterative process to develop an explanation of how anesthesiologists and patients made decisions about primary anesthesia. Results The authors found variation across accounts of anesthesiologists and patients as to whether the consultation was a collaborative decision-making scenario or simply meant to inform patients. Consultations displayed a number of decision-making patterns, from the anesthesiologist not disclosing options to the anesthesiologist strictly adhering to a position of equipoise; however, most consultations fell between these poles, with the anesthesiologist presenting options, recommending one, and persuading hesitant patients to accept it. Anesthesiologists made patients feel more comfortable with their proposed approach through extensive comparisons to more familiar experiences. Conclusions Anesthesia consultations are multifaceted encounters that serve several functions. In some cases, the involvement of patients in determining the anesthetic approach might not be the most important of these functions. Broad consideration should be given to both the applicability and feasibility of shared decision-making in anesthesia consultation. The potential benefits of interventions designed to enhance patient involvement in decision-making should be weighed against their potential to pull anesthesiologists’ attention away from important humanistic aspects of communication such as decreasing patients’ anxiety. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

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