Reduction in Health Care Facility Onset Catheter-Associated Urinary Tract Infections: A Resident-Led Quality Improvement Initiative

Background. Hospital-acquired catheter-associated urinary tract infection (CAUTI) was estimated to cause 19,700 cases in 2020 across the United States per the Centers for Disease Control and Prevention (CDC). While this is a 25% decrease in reported incidence rates since 2015, ad-hoc changes in care practices and limitations of surveillance definitions brought on by the giant burden of COVID-19 on the healthcare system possibly resulted in underreporting of CAUTIs. In a 290-bed tertiary, community hospital in the Detroit metropolitan area, there was a 200% increase CAUTIs from 2020 (5 CAUTIs) to 2021(16 CAUTIs). A multidisciplinary, resident-led team was assembled to reduce hospital-acquired CAUTIs. Methods. A multi-pronged quality improvement initiative was conducted from January 1, 2021, through March 31, 2022. CAUTIs were identified and reviewed via electronic health records using predefined criteria related to CDC surveillance definitions, urinary catheter insertion indications, laboratory data, and antibiotic use. Plan-Do-Study-Act (PDSA) Cycle model was used to guide the initiative. Thus far one PDSA cycle has been completed. The initial intervention bundle was designed by the multidisciplinary team and led by internal medicine and transitional year residents. The intervention bundle included 1. Provider (including physician and RN) education, 2. Design and implementation of an appropriate urinary catheter practice algorithm, and 3. Expert review of positive urine cultures and CAUTI cases. Results. Baseline data collected from January to December 2021 showed 16 CAUTIs. Post-implementation of the intervention bundle from January to March 2022 resulted in a 75% reduction in CAUTI incidence (1 CAUTI flagged). Conclusion. A targeted intervention bundle improved CAUTI incidence by reducing inappropriate urinary catheter insertion and prolonged removal. Ongoing local initiatives focused on hospital-acquired infections, such as this one, are paramount to the persistent optimization of infection prevention despite national trends.

Utilization of procalcitonin to guide antibiotic discontinuation in respiratory tract infections in a community hospital

Background: Antibiotic overuse leading to increasing antibiotic resistance has been a growing concern. Patients presenting with acute respiratory tract infections (RTI) are often started empirically on antibiotics and continued for days, unless confirmatory results are reported by microbiological testing. Procalcitonin is a serum inflammatory marker that increases in bacterial infections and is utilized as an adjunct to help differentiate viral versus bacterial pneumonia. Procalcitonin-guided management is associated with significantly lower antibiotic exposure and mortality. No studies exist in literature that assess the appropriate utilization of negative procalcitonin test for antibiotic discontinuation. This study assesses utilization of a negative PCT (<0.25 ng/ml) to guide antibiotic discontinuation in patients with pneumonia in a community hospital. Methods:Retrospective observational study including adult patients admitted to our community hospital in 1 year (July 2019-June 2020) with diagnosis of community acquired pneumonia and started on empiric antibiotic therapy and had procalcitonin levels checked. Our hypothesis was that PCT is not being appropriately used for discontinuation of antibiotics and that rate of discontinuation of antibiotics will be less despite a negative PCT. Statistical analysis was performed using XLSTAT. Categorical variables were represented by frequencies and proportions and compared using Chi-square and z test for two proportions. Results: 516 charts were reviewed. After excluding missing data, 176 patients were included. 100 patients had negative PCT. Antibiotics were discontinued in 16% of patients with negative PCT, compared to 58% (p<0.0001), in whom antibiotics were continued without any other indication (including UTI, severe COPD exacerbation, COVID pneumonia) despite a negative PCT. The difference between the percentage of antibiotic discontinuation in our PCT guided treatment sample (9%, n=16/176) was also found to be statistically significant (p< 0.001) compared to percentage of antibiotic discontinuation in population using data from a meta-analysis of 7 RCTs (42%, n=698/1658).1 Conclusion:Previous studies have shown that procalcitonin guided treatment aids in decreasing antibiotic exposure. In lower respiratory tract infections, clinicians order PCT test to aid in differentiating viral versus bacterial etiology and ultimately help guide antibiotic therapy. Our data analysis reveals that despite negative PCT, thus indicating a likely viral etiology, clinicians are not consistently making changes to empiric antibiotic use. This study addresses need for further recommendations from antibiotic stewardship programs regarding procalcitonin-guided antibiotic use and prevent unnecessary ordering of PCT test.

Covid-19 prognosis in patients with underlying ckd and kidney related complications

Introduction: In December 2019, a novel RNA virus causing COVID-19, a respiratory illness that can lead to diffuse alveolar damage and respiratory failure, was reported. The virus facilitates host cell entry through angiotensin-converting enzyme-2 (ACE2) receptor which is present in many organs including kidneys. Kidney injury, including acute kidney injury (AKI), proteinuria and hematuria, has been a reported in COVID-19 patients. The extent of renal involvement has not been extensively correlated with prognosis and outcomes in COVID-19 patients. Methods: Retrospective chart review including patients aged 18 years and older, admitted to a community hospital from March 15, 2020 to April 15, 2020, testing positive for COVID-19. Patient characteristics on admission were collected which included presence of AKI, hematuria, proteinuria and underlying CKD stage, if any. Outcomes included intubation rate, ICU admission, length of stay and inpatient-mortality. Continuous variables were compared using independent t-test. Chi-square test was used to test relationships between categorical variables. Results: A total of 212 charts were studied. After removing missing data, 186 patients were included. 22.6% (n=42) had moderate-severe underlying CKD (stage 3 or more). 38.7% (n=72) of total patients had AKI on presentation. Urinalysis was not done in 51 patients, so of the rest 135 patients, 55.6% (n=75) had hematuria and 52.6% (n=71) had proteinuria on admission. Inpatient mortality was found to be significantly higher in patients with underlying moderate-severe CKD compared to those who did not (52.4% vs 31.3%, p=0.012). Patients with hematuria on admission had significantly higher rates of intubation (37.3% vs 20%, p=0.028) and ICU admissions (44% vs 26.7%, p=0.037) compared to those who did not have hematuria on admission. Length of stay was also significantly higher in patients who had hematuria on admission compared to those who did not (10±8 vs 7±6 days, p=0.042). AKI and proteinuria on admission resulted in no significant difference in intubation, ICU admission, length of stay, or inpatient mortality. No significant difference in length of stay, intubation, and ICU admission was found in patients with underlying mod-severe CKD compared to those who didn't. Conclusion: Early renal involvement and underlying CKD worsen the prognosis of COVID-19 pneumonia and result in higher mortality outcomes. Such patients, especially those with findings of hematuria on admission, need closer monitoring. Furthermore, many COVID-19 patients receive steroids and anticoagulants as part of treatment regimen which will need to be further evaluated as these therapies may contribute to further damage of the kidneys.

CLINICAL CHARACTERISTICS AND OUTCOMES OF PATIENTS WITH COVID-19 IN A COMMUNITY HOSPITAL IN MICHIGAN

SESSION TITLE: Disaster Medicine Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: In December 2019, a viral pneumonia associated with a new coronavirus SARS COV-2 emerged in Wuhan, China and quickly spread throughout the world causing high mortality rates. As of May 30th,2020, coronavirus disease 2019 (COVID-19) has been confirmed in 56,884 people in Michigan, with case fatality rate of 10%. Since very little is known regarding patients with COVID-19 disease, we aim to describe the clinical characteristics and outcomes of patients hospitalized in a Michigan community hospital. METHODS: A single centre, retrospective chart review of 163 hospitalized patients with confirmed cases of COVID-19 at a community hospital from March 15 to April 10, 2020. Cases were confirmed by real-time polymerase chain reaction testing of nasopharyngeal samples. Epidemiological, demographic, laboratory and overall outcomes were obtained from electronic medical record. Data collected was then analysed using SPSS software. RESULTS: A total of 163 patients were reviewed and included in the study. Median age of patient with confirmed SARS-COV2 infection was 70 years (mean 68, range, 30-101), of which 52.8% were female, 60.7% white and 33.7% African American. The most common comorbidities were hypertension (112, 68.7%), obesity (79, 48.6%), and hyperlipidemia (54, 33.1%). Patients presented with shortness of breath (109, 66.9%), cough (107, 65.6%) and fever (99, 60.7%). Gastrointestinal symptoms were found in 81 (49.6%) of patients with the most common symptom being diarrhea in 44 (27%) patients. There were 66 (40.5%) patients with fever >100.4F on admission. Multilobe infiltrates were found in chest x-ray of 115 (70.6%) patients. Within one-month, overall mortality was noted to be 29.5%. Mean length of stay of non-intensive care unit (ICU) patients was 6.46 days (range 1-19) when compared 15.5 days (range 3-46) for ICU patients. During hospitalization, 55 patients (33.7%) (median age 68 years, 54.5% female, 60.1% white) were treated in the ICU of which 43(78.2%) required mechanical ventilation and 28 (50.9%) died. For patients requiring mechanical ventilation, 27 (62.8%) died and 16 (37.2%) were discharged alive. CONCLUSIONS: This study provides insight into presenting characteristics, demographics and overall outcome of patients hospitalized with COVID-19 in a Michigan community hospital. CLINICAL IMPLICATIONS: In medical emergencies like the COVID pandemic, it is important to analyze patient demographics in order to help identify the population most at risk. Knowledge of the most vulnerable population not only allows us to come up with strategies to help control the spread of disease but also helps us risk stratify the patients for better resource allocation. It is crucial to learn from an outbreak like this so we can be better prepared for the future. DISCLOSURES: No relevant relationships by Verisha Khanam, source=Web Response No relevant relationships by Sarwan Kumar, source=Web Response No relevant relationships by vesna tegeltija, source=Web Response No relevant relationships by Jurgena Tusha, source=Web Response

SEQUENTIAL ORGAN FAILURE ASSESSMENT SCORE IN PATIENTS INFECTED WITH SARS COV-2

SESSION TITLE: Lessons from the ICU: What have We Learned about the Management of COVID-19 SESSION TYPE: Original Investigations PRESENTED ON: October 18-21, 2020 PURPOSE: Throughout the years, several scoring systems have been established to measure disease severity in efforts to predict patient mortality and help guide management. In patients with sepsis, organ failure has been proven to worsen outcome, therefore utility of scores such as Sequential Organ Failure Assessment (SOFA) has helped determine the severity of disease and predict mortality. Patients infected with SARS COV-2 were observed to have varying disease progression with multiorgan involvement. Through this study, we intend to investigate the use of the SOFA score in predicting mortality in critically ill patients who tested positive for SARS COV-2. The aim of this study is to determine if the SOFA score is a strong predictor of mortality in critical care patients admitted with SARS-COV2 infection. METHODS: A single centered, retrospective chart review of 54 patients admitted to the intensive care unit (ICU) for COVID-19 infection from March 15th to April 10th 2020 was conducted. A comprehensive review of laboratory values on the day of ICU admission was done to calculate SOFA score. Total length of stay and overall patient outcome was also recorded. The collected data was statistically analyzed using the statistical software Statistical Package for the Social Sciences (SPSS). RESULTS: The results reveal that the average SOFA score of patients who tested positive for SARS COV2 was 6.31 ± 2.73. The average score of patients who survived was 4.73 ± 1.88 and the average SOFA score of the patients who died during the hospital stay was 7.78 ± 2.58. Overall, the mortality rate of patients admitted to the ICU was 51.85%, 46% of them were male and 54% female. The average length of hospital stay was calculated to be 14.5 days for those who died and 16.4 for those who survived. Logistic regression analysis was done (OR=0.56, 95% CI 0.41-0.77, p < 0.05) which was indicative of an increase in mortality by 0.56 times with every 1 point increase in SOFA score. CONCLUSIONS: COVID-19 is a new disease process and has led to many questions regarding appropriate management and treatment plans which remain unanswered. This study focused on determining whether the SOFA score is a valuable tool in predicting mortality of critically ill patients who tested positive for SARS COV2. We found that there was an increase in mortality by 0.56 times for every 1 point increase in SOFA score. High variance in clinical presentation and rapid progression of the disease made risk stratification of these patients challenging. Labs as well as clinical presentation changed significantly within the span of a day, therefore daily assessment using the SOFA score would be a better indicator of disease progression. Limitations of this study include small sample size and the novelty of the disease and its clinical progression. CLINICAL IMPLICATIONS: SOFA score on admission was not a good predictor of mortality in patients with COVID-19. DISCLOSURES: No relevant relationships by Laith Al-janabi, source=Web Response No relevant relationships by Verisha Khanam, source=Web Response No relevant relationships by Sarwan Kumar, source=Web Response No relevant relationships by DANYAL TAHERI ABKOUH, source=Web Response No relevant relationships by vesna tegeltija, source=Web Response No relevant relationships by Jurgena Tusha, source=Web Response

THE MULBSTA SCORE: PREDICTING RISK OF MORTALITY AND DISEASE SEVERITY IN PATIENTS WITH COVID-19 PNEUMONIA

SESSION TITLE: Respiratory Infections: What have We Learned About COVID-19 and New Trial Data for Management of Aspergilloma SESSION TYPE: Original Investigations PRESENTED ON: October 18-21, 2020 PURPOSE: An influx of SARS-COV2 infection has led to several unanswered questions, one such question raised was how to risk stratify these patients in order to better direct further management. The MuLBSTA score recently developed by Guo L. et al. in Shanghai, China is designed to predict 90-day mortality in patients with viral pneumonia. Since very little is known regarding patients with SARS COV-2 infection and COVID-19 disease, we aim to explore the applicability of MuLBSTA score in predicting disease severity and risk of mortality in these patients. METHODS: A single centre, retrospective chart review of one-hundred and sixty-three hospitalized patients with COVID-19 pneumonia at a community hospital in Michigan from March 15 to April 10, 2020. Several clinical characteristics were reviewed, six risk factors were incorporated into the MulBSTA score which included: multilobe infiltrate, absolute lymphocyte count ≤0.8 x 109/L, bacterial coinfection, smoking history, history of hypertension and age ≥ 60 years. The calculated score was then compared to the primary outcome of mortality and secondary outcomes which included length of stay and ventilator support. Data collected was then analysed using SPSS, validity of the data was analyzed using regression analysis and receiver operating characteristic curve. RESULTS: A total of 163 patients were manually reviewed, of which there was an overall mortality rate of 29.4%, an ICU mortality rate of 50.9% and ventilator associated mortality of 62.8%. The MuLBSTA score was applied to each patient manually at time of hospitalization. There was a mean MuLBSTA score of 8.67 (4.066) for patients who survived and a mean MuLBSTA score of 13.6 (1.87) for patients who died. There was a significant positive correlation of the MuLBSTA score with mortality (OR = 1.37, 95% CI 1.23-1.53, p =.0001). The area under the receiver operating characteristic (ROC) curve of MuLBSTA for predicting in-hospital mortality at time of admission was 0.813(SE 0.037). A positive correlation was also found with ventilator support (OR= 1.30, 95% CI 1.17-1.44, p=.0001) and length of stay (r (161) =.35, p=.0001). CONCLUSIONS: Analysis of data indicated that in patients with COVID-19 pneumonia, the MuLBSTA score successfully stratified hospitalized patients based on severity and accurately predicted overall outcome. CLINICAL IMPLICATIONS: This score correlated significantly with mortality, ventilator support and length of stay, which may be used to provide guidance to screen patients and make further clinical decisions. Further studies are required to validate this study in larger patient cohorts. DISCLOSURES: No relevant relationships by Verisha Khanam, source=Web Response No relevant relationships by Sarwan Kumar, source=Web Response No relevant relationships by vesna tegeltija, source=Web Response No relevant relationships by Jurgena Tusha, source=Web Response