ABSTRACT
Purpose/Objectives: The AHRQ Safety Program for Improving Antibiotic Use aimed to improve antibiotic use by engaging clinicians and staff to incorporate antibiotic stewardship principles into practice culture, communication, and decision making. We report on changes in visits and antibiotic prescribing among participating pediatric primary and urgent care ambulatory practices during the COVID-19 pandemic. Design/Methods: The Safety Program used webinars, audio presentations, educational tools, and office hours to engage clinician champions and staff leaders to: (a) establish antibiotic stewardship programs, (b) address attitudes and culture that pose challenges to judicious antibiotic prescribing, and (c) incorporate best practices for the management of common infections into their workflow using the Four Moments of Antibiotic Decision Making framework. Monthly data on total visits (in-person and virtual), acute respiratory infection (ARI) visits, and antibiotic prescribing were collected from all participating practices during the pre-intervention period (September 2019-November 2019) and during the Safety Program (December 2019-November 2020). Data from the beginning to the end of the Safety Program were compared using linear mixed models to account for random effects of participating sites and repeated measurements of outcomes within practices over time. Results: The 63 participating pediatric practices included 23 general pediatric clinics (37%) and 40 pediatric urgent care clinics (63%). 60 practices submitted complete data for analysis, including 1,040,810 visits. Visits/practice-month declined March-April 2020 but exceeded baseline by Safety Program end (Figure 1). Total antibiotic prescribing declined by 16 prescriptions/100 visits (95% CI: -18 to -14) from November 2019 and November 2020. ARI visits/practice-month similarly declined March-June 2020 after widespread recognition of the COVID-19 epidemic, and remained below baseline by Safety Program end (Figure 2). ARIrelated antibiotic prescriptions decreased by 16 prescriptions/100 ARI visits (95% CI: -20 to -12) from November 2019 to November 2020. Among antibiotic classes, the greatest change was in penicillins. Prescriptions for penicillins was reduced by 11 prescriptions/100 ARI visits (95% CI: -14 to -8). Conclusion/Discussion: During the COVID-19 pandemic, while visit rates gradually normalized, a national ambulatory Antibiotic Stewardship program was associated with declines in overall and ARI-related antibiotic prescribing.
ABSTRACT
Background: Home Health (HH) agencies are in a unique position to identify and address patient safety risks during the COVID-19 pandemic. National pandemic-related guidance has primarily focused on hospital or institutional settings. HH agencies need guidance that address patient safety during hospital-to-HH care transitions in the COVID-19 era. Objectives: Elicit novel threats to patient safety during care transitions and identify emerging HH agency best practices in two geographic areas impacted differently by the pandemic. Methods: Qualitative study using semi-structured interviews of HH staff and front-line providers (nurses, rehab therapists) at two agencies (Baltimore, MD and New York City, NY). Interviews were audio-recorded and transcribed verbatim. At least two researchers independently coded each transcript using a content analysis approach. We used ATLAS.ti to facilitate data analysis. Results: 34 participants (25 staff and 9 front-line providers) at the two sites were interviewed. Novel safety threats to care transition safety included lack of Personal Protective Equipment (PPE) access, increased acuity of patients, less patient/caregiver training prior to hospital discharge, staffing shortages, and lack of reimbursement for telehealth visits. Best practices included collaboration between healthcare institutions, implementation of COVID-19 messaging, increased frequency of staff meetings, screening of patients' medical information, and PPE strategic allocation. Participants reported feeling that more attention was needed to value the essential nature of these services. Conclusions: We identified novel threats to older adults' safety in care transitions during the pandemic, and best practices for how HH agencies and providers adapted to these threats. Study findings will guide the development and dissemination for HH agencies by improving care for older adults during hospital-to-home care transitions.
ABSTRACT
Background: Louis-Dietz syndrome (LDS) Type 3 is a rare disorder caused by an autosomal-dominant mutation in SMAD-3, altering the TGF-β pathway. LDS Type 3 typically manifests as aortic aneurysms and early-onset osteoarthritis, however other dermatologic, cardiovascular, and skeletal abnormalities have been reported. Case: A 51-year-old woman was referred to the cardiology clinic for episodes of palpitations, syncope, chest pain, and shortness of breath during the COVID-19 pandemic. She had a history of congestive heart failure, cardiomyopathy, patent foramen ovale, atrial septal aneurysm, pre-COVID myocarditis, mitral valve prolapse, mitral regurgitation, and pericarditis. She also has a pertinent medical history of hypermobile Ehlers-Danlos syndrome (hEDS) and systemic lupus erythematosus (SLE). Her family and social history were remarkable for a daughter with SLE. Cardiopulmonary and general physical exams were remarkable for hypermobility. Evaluation with an ECG and Holter monitor showed normal sinus rhythm with unifocal premature ventricular contractions (PVCs) that correlated with her symptoms. Decision-making: The patient was initially managed un-successfully with beta and calcium channel blockers. Cardiac ablation was subsequently performed on a left ventricular septal focus with remote magnetic navigation using the Niobe system from Stereotaxis inc. (due to its low risk for cardiac perforation). At 6 months follow up, the patient exhibited an increase in left ventricular ejection fraction from 40-50% to 55-60%, fewer symptoms, and fewer PVCs. She was later diagnosed with a right internal carotid artery aneurysm that prompted genetic testing that was positive for LDS Type 3. Conclusion: This patient’s unique combination of illnesses required a multidisciplinary team for management. The Stereotaxis robotic system safely and successfully treated the patient’s PVCs and resulted in improvement of left ventricular function. Due to previous reports of arrhythmias associated with these connective tissue disorders, additional studies are necessary to understand the role of the SMAD-3 mutation, EDS, and SLE in contributing to arrhythmogenicity.
ABSTRACT
Background. The AHRQ Safety Program for Improving Antibiotic Use aimed to improve antibiotic use by engaging clinicians and staff to incorporate antibiotic stewardship (AS) into practice culture, communication, and decision making. We report on changes in visits and antibiotic prescribing in AHRQ Safety Program ambulatory practices during the COVID-19 pandemic. Methods. The Safety Program used webinars, audio presentations, educational tools, and office hours to engage clinician champions and staff leaders to: (a) address attitudes and culture that pose challenges to judicious antibiotic prescribing and (b) incorporate best practices for the management of common infections into their workflow using the Four Moments of Antibiotic Decision Making framework. Total visits (in-person and virtual), acute respiratory infection (ARI) visits, and antibiotic prescribing data were collected. Using linear mixed models to account for random effects of participating practices and repeated measurements of outcomes within practices over time, data from the pre-intervention period (September-November 2019) and the Ambulatory Care Safety Program (December 2019-November 2020) were compared. Results. Of 467 practices enrolled, 389 (83%) completed the program, including 162 primary care practices (42%;23 [6%] pediatric), 160 urgent care practices (41%;40 [10%] pediatric), and 49 federally-supported practices (13%). 292 practices submitted complete data for analysis, including 6,590,485 visits. Visits/practice-month declined March-May 2020 but gradually returned to baseline by program end (Figure 1). Total antibiotic prescribing declined by 9 prescriptions/100 visits (95% CI: -10 to -8). ARI visits/practice-month declined significantly in March-May 2020, then increased but remained below baseline by program end (Figure 2). ARI-related antibiotic prescriptions decreased by 15/100 ARI visits by program end (95% CI: -17 to -12). The greatest reduction was in penicillin class prescriptions with a reduction of 7/100 ARI visits by program end (95% CI: -9 to -6). Conclusion. During the COVID-19 pandemic, a national ambulatory AS program was associated with declines in overall and ARI-related antibiotic prescribing.
ABSTRACT
People with intellectual and/or developmental disabilities (IDD) are at greater risk for contracting the coronavirus disease 2019 (COVID-19) caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) virus and experiencing more severe outcomes that people without IDD. Many people with IDD live and work in congregate settings, which provide an ideal environment for rapid spread and outbreaks. Although sources such as the World Health Organization and the US Centers for Disease Control and Prevention have issued guidelines to inform responses to COVID-19 in communities globally and in the United States, few address the specific needs of people with IDD. In this paper, authors evaluate generally available guidelines and adapt them to the needs of people with IDD, with recommendations on application to congregate settings including group homes.