Care for critically and terminally ill patients and moral distress of physicians and nurses in tertiary hospitals in South Korea: A qualitative study

Physicians and nurses working in acute care settings, such as tertiary hospitals, are involved in various stages of critical and terminal care, ranging from diagnosis of life-threatening diseases to care for the dying. It is well known that critical and terminal care causes moral distress to healthcare professionals. This study aimed to explore moral distress in critical and terminal care in acute hospital settings by analyzing the experiences of physicians and nurses from various departments. Semi-structured in-depth interviews were conducted in two tertiary hospitals in South Korea. The collected data were analyzed using grounded theory. A total of 22 physicians and nurses who had experienced moral difficulties regarding critical and terminal care were recruited via purposive maximum variation sampling, and 21 reported moral distress. The following points were what participants believed to be right for the patients: minimizing meaningless interventions during the terminal stage, letting patients know of their poor prognosis, saving lives, offering palliative care, and providing care with compassion. However, family dominance, hierarchy, the clinical culture of avoiding the discussion of death, lack of support for the surviving patients, and intensive workload challenged what the participants were pursuing and frustrated them. As a result, the participants experienced stress, lack of enthusiasm, guilt, depression, and skepticism. This study revealed that healthcare professionals working in tertiary hospitals in South Korea experienced moral distress when taking care of critically and terminally ill patients, in similar ways to the medical staff working in other settings. On the other hand, the present study uniquely identified that the aspects of saving lives and the necessity of palliative care were reported as those valued by healthcare professionals. This study contributes to the literature by adding data collected from two tertiary hospitals in South Korea.

Utility of Methicillin-Resistant Staphylococcus aureus Nares Screening in Hospitalized Children with Acute Infectious Disease Syndromes

Studies in adults support the use of a negative methicillin-resistant Staphylococcus aureus (MRSA) nares screening (MNS) to help limit empiric anti-MRSA antibiotic therapy. We aimed to evaluate the use of MNS for anti-MRSA antibiotic de-escalation in hospitalized children (<18 years). Records of patients admitted between 1 January 2015 and 31 December 2020 with a presumed infectious diagnosis who were started on anti-MRSA antibiotics, had a PCR-based MNS, and a clinical culture performed were retrospectively reviewed. A total of 95 children were included with a median age (range) of 2 (0–17) years. The top three diagnosis groups were skin and soft tissue infections (n = 38, 40%), toxin-mediated syndromes (n = 17, 17.9%), and osteoarticular infections (n = 14, 14.7%). Nasal MRSA colonization and growth of MRSA in clinical cultures was found in seven patients (7.4%) each. The specificity and the negative predictive value (NPV) of the MNS to predict a clinical MRSA infection were both 95.5%. About half (n = 55, 57.9%) had anti-MRSA antibiotics discontinued in-house. A quarter (n = 14, 25.5%) were de-escalated based on the negative MNS test alone, and another third (n = 21, 38.2%) after negative MNS test and negative culture results became available. A high NPV suggests that MNS may be useful for limiting unnecessary anti-MRSA therapy and thereby a useful antimicrobial stewardship tool for hospitalized children. Prospective studies are needed to further characterize the utility of MNS for specific infectious diagnoses.

62. Secondary Prophylaxis in Clostridioides difficile Infections: a Closer Look at Outcomes

Background Clostridioides difficile infection (CDI) is an urgent public threat and carries a 25% chance of recurrence (rCDI). Data on safety and efficacy of oral vancomycin prophylaxis (OVP) in reducing rCDI is limited. We implemented a best practice advisory (BPA) to alert the prescriber and antibiotic stewardship (ASP) team for patients with CDI in the previous 60 days being initiated on systemic antimicrobials. The alert states “Don’t use antibiotics in patients with recent CDI without convincing evidence of need. Antibiotics pose a high risk of recurrence”. ASP team would recommended OVP if antibiotics are continued. This study evaluated the impact of the BPA alert on OVP prescribing and patient outcomes. Methods IRB approved, retrospective, observational cohort study comparing patients who received OVP to no OVP. Inclusion: adults with history of laboratory confirmed CDI, ≥ 14 days post-CDI treatment completion, BPA from 3/7/19 – 3/31/20, receiving non-CDI systemic antimicrobials, and without history of bezlotoxumab infusion. Data were reported using descriptive statistics and bivariate analysis. Primary endpoint: rCDI within 2-8 weeks post-OVP completion. Secondary endpoints: vancomycin-resistant Enterococcus spp (VRE) in clinical culture post-OVP and 1-year mortality. Results 70 patients included: 32 (46%) no-OVP and 38 (54%) OVP. Baseline characteristics, previous CDI treatment, and outcomes were similar (Table 1). Index CDI was severe in the OVP group (18, 47% vs. 9, 28%). Median Charlson comorbidity index: 7 (3 – 9) no-OVP and 7 (5 – 9) OVP. OVP regimens, 125 mg by mouth: once daily 4 (10%), twice daily 22 (58%), and every 6 hours 12 (32%). Median prophylaxis duration: 10 days (6 – 13). rCDI occurred in 3 (9%) no-OVP and 2 (5%) OVP (P = 0.654). Mortality: 10 (31%) no-OVP and 16 (42%) OVP (P = 0.458). Table 1. Patient Characteristics and Endpoints Conclusion OVP was utilized in approximately half of patients who required non-CDI antibiotics. Efficacy interpretation is limited by inconsistent dosing regimens and significant comorbid illness in the cohort. Future work will focus on further optimizing the BPA and standardizing the OVP regimen. Disclosures Rachel Kenney, PharmD, Medtronic, Inc. (Other Financial or Material Support, spouse is an employee and shareholder) Susan L. Davis, PharmD, Nothing to disclose

1138. Utility of Methicillin-resistant Staphylococcus aureus Nares Screening in Hospitalized Children With Acute Infectious Disease Syndromes

Background Empirical antibiotic regimens frequently include treatment for methicillin-resistant Staphylococcus aureus (MRSA). Studies in adults with pneumonia support the use of a negative MRSA nares screening (MNS) to help de-escalate antibiotic therapy. Comparable pediatric data in the literature is scarce. We aimed to evaluate the use of MNS for antibiotic de-escalation in hospitalized children (&lt; 18 years) at a tertiary children’s hospital. Methods A retrospective chart review was conducted of pediatric inpatients (January 01, 2015 to December 31, 2020) with a presumed infectious diagnosis who had a PCR-based MNS test and a clinical culture (i.e. site of infection or blood) performed as part of their diagnostic work up. Those who were screened &gt;5 days since admission or &gt; 48 hours since start of MRSA-active antimicrobials, and those who had antibiotic treatment withdrawn after 48 hours because of negative cultures were excluded. Results A total of 101 children were included with a median age (range) of 2 years (0-17) and about half (n=57, 56.4%) were male. Top three diagnosis groups were skin and soft tissue infections (n=33, 32.7%), toxin-mediated syndromes (n=21, 20.8%), and osteoarticular infections (n=13, 12.9%). Pneumonia accounted for only six (5.9%) patients. The prevalence of nasal MRSA colonization was 6.9% (n=7). The sensitivity of the MNS test to predict a MRSA infection was 42.9% with a specificity of 95.7%. The positive predictive value (PPV) and negative predictive values (NPV) were 42.9% and 95.7%, respectively. In about half (55/95, 57.9%) of patients initiated on anti-MRSA therapy, these agents were discontinued during the admission. A quarter (n=14, 25.5%) were de-escalated based on the negative MNS test alone, and another third (n=21, 38.2%) after negative MNS test and negative culture results became available. Conclusion Pediatric providers at this institution have started to use the MNS to help limit anti-MRSA therapy. We noted a high NPV which suggests that MNS may be useful for timely de-escalation of anti-MRSA therapy and thereby a useful antimicrobial stewardship tool for hospitalized children. Prospective studies to evaluate the utility of MNS for the various infectious syndromes are warranted. Disclosures All Authors: No reported disclosures

Solutions to bridge the theory-practice gap in nursing education in the UAE: a qualitative study

Background The theoretical knowledge of nursing underpins the practice, while the practice environment determines the circumstances within which the theoretical knowledge is applied. The biggest challenge facing nursing as an academic field is the theory-practice gap, which is a universal issue in nursing. This study aimed to raise solutions to close the gap between theory and practice in nursing education through the eyes of nursing students in UAE. Methods A qualitative descriptive approach was followed; whereby 25 Emirati nursing students were interviewed. Results Two main themes are discussed in this study: ‘Clinical Culture Creation’ and ‘Curriculum Content Reformation’. The students suggested to decreased the loud and stress on their clinical educators. They also suggested creating synchronization between what is taught in classrooms and labs and what is offered in the clinical training. Moreover, some of the students expected to have more benefit if they get their clinical training in health institutions owned by their college. On the other side, many of the participants suggested to move from the integration system to the block system. Another interesting suggestion includes having the same college staff to teach the theory and the clinical. The final suggestion includes decreasing the paper work during clinical training. Conclusions This study explored the solutions to bridge the theory-practice gap in nursing education in the UAE. The study has implications for nursing education and practice within the UAE and is imperative for graduating workplace ready professional nurses within the country.

Culturally competent, safe and equitable clinical care for Ma¯ori with bipolar disorder in New Zealand: The expert critique of Ma¯ori patients and Wha¯nau

Objective: Research designed to increase knowledge about Māori with bipolar disorder is required to understand how health services support wellbeing and respond to identified levels of community need. This paper synthesises the expert critique of Māori patients with bipolar disorder and their whānau regarding the nuances of cultural competence and safety in clinical encounters with the health system. Methods: A qualitative Kaupapa Māori Research methodology was used. A total of 24 semi-structured interviews were completed with Māori patients with bipolar disorder and members of their whānau. Structural, descriptive and pattern coding was completed using an adapted cultural competence framework to organise and analyse the data. Results: Three themes were evident from participants’ critique of clinical components of the health system. Theme 1 established that the efficacy of clinical care for bipolar disorder was dependent on Māori patients and whānau having clear pathways through care, and being able to access timely, consistent care from clinically and culturally competent staff. Theme 2 identified the influence of clinical culture in bipolar disorder services, embedded into care settings, expressed by staff, affecting the safety of clinical care for Māori. Theme 3 focused on the need for bipolar disorder services to prioritise clinical work with whānau, equip staff with skills to facilitate engagement and tailor care with resources to enhance whānau as well as patient wellbeing. Conclusion: The standard of clinical care for Māori with bipolar disorder in New Zealand does not align with practice guidelines, Māori models of health or clinical frameworks designed to inform treatment and address systemic barriers to equity. Research also needs to explore the role of structural and organisational features of the health system on Māori patient and whānau experiences of care.

Towards an Open Medical School without Checkerboards during the COVID-19 Pandemic: How to Flexibly Self-Manage General Surgery Practices in Hospitals?

Background: Can we create a technological solution to flexibly self-manage undergraduate General Surgery practices within hospitals? Before the pandemic, the management of clerkships was starting to depend less on checkerboards. This study aims to explore undergraduates’ perceptions of doing rotations in teaching hospitals using different teaching styles and elicit their views regarding the options of managing practices to design a mobile app that substitutes for checkerboards. Methods: In this sequential exploratory mixed methods study, 38 semi-structured interviews at a teaching hospital were conducted. The data was used to survey 124 students doing their rotations in four teaching hospitals during the first wave of COVID-19. Results: 21 themes highlighted concerns related to the practices, the teacher involvement in the students’ education, and the students’ adaptation to clinical culture. The students reported positive perceptions concerning self-managing and organizing practices via a mobile application. However, problems emerged regarding transparency, the lack of feedback, and the need for new tools. Regarding the teaching styles, the facilitator and personal models were perceived as optimal, but the personal style had no effect on using or not using a tool. Conclusions: A mobile-learning application designed like an educational opportunities’ manager tool can probably promote self-directed learning, flexible teaching, and bidirectional assessments. However, teachers who employ a personal teaching style may not need either checkerboards or a tool. This solution supports teaching at hospitals in pandemic times without checkerboards.

Biofilm and catheter-related bloodstream infections

Careful attention to detail and adherence to procedure guidelines when inserting and managing intravascular catheters has decreased the incidence of catheter-related bloodstream infections (CRBSIs). In order to limit these, health professionals must understand the underlying microbiology. Biofilms can explain the clinical findings most often seen with CRBSIs, yet they are poorly understood within medicine. Bacteria growing on solid surfaces such as a catheter are predominantly in biofilm phenotype, with a group of genes active that allow the bacteria to be tolerant to antiseptics and antibiotics by producing a self-secreted protective matrix. It is unclear whether it is planktonic seeding or small fragments of biofilm breaking off into the bloodstream that eventually results in the acute infection. The literature identifies four routes for microbes to adhere to a catheter and start biofilm formation: catheter contact, catheter insertion, catheter management and non-catheter-related sources. Routine clinical culture methods are inadequate to fully identify microbes producing catheter biofilm and/or bloodstream infection, therefore DNA methods may be required to diagnose CRBSIs. Treatment is removal and reinsertion of the catheter in a different site when possible. However, antibiofilm strategies can be employed to try to salvage the catheter. The use of high-dose antiseptics or antibiotics for long durations inside the catheter and hub (antibiotic/antiseptic lock) can suppress biofilm enough to reduce the seeding of the blood below a level where the patient's immune system can prevent bloodstream infection.

Standardizing clinical culture specimen collection in Ethiopia: a training‐of‐trainers

Background Proper specimen collection is central to improving patient care by ensuring optimal yield of diagnostic tests, guiding appropriate management, and targeting treatment. The purpose of this article is to describe the development and implementation of a training-of-trainers educational program designed to improve clinical culture specimen collection among healthcare personnel (HCP) in Ethiopia. Methods A Clinical Specimen Collection training package was created consisting of a Trainer’s Manual, Reference Manual, Assessment Tools, Step-by-Step Instruction Guides (i.e., job aides), and Core Module PowerPoint Slides. Results A two-day course was used in training 16 master trainers and 47 facility-based trainers responsible for cascading trainings on clinical specimen collection to HCP at the pre-service, in-service, or national-levels. The Clinical Specimen Collection Package is offered online via The Ohio State University’s CANVAS online platform. Conclusions The training-of-trainers approach may be an effective model for development of enhanced specimen collection practices in low-resource countries.

Understanding Steps and Challenges to Take-home Naloxone and Buprenorphine/naloxone Implementation in Québec Emergency Rooms: Suboxed Project

BackgroundDeaths attributable to drug abuse are on the rise across Canada. It is estimated that there were more than 13,900 opioid-related deaths from January 2016 to June 2019 in the country. Emergency departments (EDs) are often on the frontline of care provided to people at risk of opioid overdose within Québec’s healthcare system. A variety of programs to implement take-home naloxone distribution and/or the provision of opioid agonist treatment for ED patients who are at risk for overdose have been created in the United States and in Europe. However, few EDs in Canada have developed protocols for the provision of take-home naloxone and/or opioid agonist treatment by ED doctors.MethodsA clinical algorithm for take home naloxone (THN) and prescription of buprenorphine/naloxone (B/N) was implemented in three EDs of Québec, Canada. This first phase of the SuboxED project required selecting clinical experts, describing the patient population, and creating partnerships with pharmacists and opioid agonist treatment clinics.Results:The clinical experts developed tools based on literature reviews and national and international guidelines. They also created educational tools and trained over 328 ED clinical staff. In addition, SuboxED ensured that a supply of take-home naloxone and B/n was available in the three ED sites for the study.ConclusionImplementing the proposed clinical algorithm for THN and prescription of B/N was challenging: drug supply and ED staff’s buy-in were among the most notable difficulties of SuboxED. Planning training sessions at three different institutions, each with its own governance structure and clinical culture, local realities and harm reduction priorities was complicated. Engaging already overworked ED teams consistently working in a gridlocked environments, revealed in itself to be a difficult endeavour.In the next phase of SuboxED, we will focus on data collection and analysis to evaluate both the implementation of the protocol through a retrospective review of electronic health records and satisfaction surveys of patients and healthcare professionals.Trial registration: none