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Background: Healthcare services are increasingly shifting from inpatient to outpatient settings. Outpatient settings such as emergency departments (EDs), oncology clinics, dialysis clinics, and day surgery often involve invasive procedures with the risk of acquiring healthcare-associated infections (HAIs). As a leading cause of HAI, Clostridioides difficile infection (CDI) in outpatient settings has not been sufficiently described in Canada. The Canadian Nosocomial Infection Surveillance Program (CNISP) aims to describe the epidemiology, molecular characterization, and antimicrobial susceptibility of outpatient CDI across Canada. Methods: Epidemiologic data were collected from patients diagnosed with CDI from a network of 47 adult and pediatric CNISP hospitals. Patients presenting to an outpatient setting such as the ED or outpatient clinics were considered as outpatient CDI. Cases were considered HAIs if the patient had had a healthcare intervention within the previous 4 weeks, and they were considered community-associated if there was no history of hospitalization within the previous 12 weeks. Clostridioides difficile isolates were submitted to the National Microbiology Laboratory for testing during an annual 2-month targeted surveillance period. National and regional rates of CDI were stratified by outpatient location. Results: Between January 1, 2015, and June 30, 2019, 2,691 cases of outpatient-CDI were reported, and 348 isolates were available for testing. Most cases (1,475 of 2,691, 54.8%) were identified in outpatient clinics, and 72.8% (1,960 of 2,691) were classified as community associated. CDI cases per 100,000 ED visits were highest in 2015, at 10.3, and decreased to 8.1 in 2018. Rates from outpatient clinics decreased from 3.5 in 2016 to 2.7 in 2018 (Fig. 1). Regionally, CDI rates in the ED declined in Central Canada and increased in the West after 2016. Rates in outpatient clinics were >2 times higher in the West compared to other regions. RT027 associated with NAP1 was most common among ED patients (26 of 195, 13.3%), whereas RT106 associated with NAP11 was predominant in outpatient clinics (22 of 189, 11.6%). Overall, 10.4% of isolates were resistant to moxifloxacin, 0.5% were resistant to rifampin, and 24.2% were resistant to clindamycin. No resistance was observed for metronidazole, vancomycin, or tigecycline. Compared to CNISP inpatient CDI data, outpatients with CDI were younger (51.8 ± 23.3 vs 64.2 ± 21.6; P < .001), included more females (56.4% vs 50.9%; P < .001), and were more often treated with metronidazole (63.0% vs 56.1%; P < .001). Conclusions: For the first time, CDI cases identified in outpatient settings were characterized in a Canadian context. Outpatient CDI rates are decreasing overall, but they vary by region. Predominant ribotypes vary based on outpatient location. Outpatients with CDI are younger and are more likely female than inpatients with CDI.
Disclosures: Susy Hota reports contract research for Finch Therapeutics.
Children with congenital heart disease (CHD) have complex unique post-operative care needs. Limited data assess parents’ hospital discharge preparedness and education quality following cardiac surgery. The goals were to identify knowledge gaps in discharge preparedness after congenital heart surgery and to assess the acceptability of an educational mobile application to improve discharge preparedness.
Telephonic interviews with parents of children with two-ventricle physiology who underwent cardiac surgery 5–7 days post-discharge and in-person interviews with clinicians were conducted. We collected parent and clinician demographics, parent health literacy information and patient clinical data. We analysed interview transcripts using summative content analysis.
We interviewed 26 parents and 6 clinicians. Twenty-two of the 26 (85%) parents felt ready for discharge; 4 of the 6 (67%) clinicians did not feel most parents were ready for discharge. Fifteen of the 26 parents (58%) reported receiving the majority of discharge teaching on the day of discharge. Eight parents did not feel like all of their questions were answered. Most parents (14/26, 54%) preferred visual educational learning aids and could accurately describe important aspects of care. Most parents (23/26, 88%) and all 6 clinicians felt a mobile application for post-operative care education would be helpful.
Most parents received education on the day of discharge and could describe the information they received prior to discharge, although there were some preparedness gaps identified after discharge. Clinicians and parents varied in their perceptions of the readiness for discharge. Most responses suggest that a mobile application for discharge education may be helpful for transition to home.
In response to advancing clinical practice guidelines regarding concussion management, service members, like athletes, complete a baseline assessment prior to participating in high-risk activities. While several studies have established test stability in athletes, no investigation to date has examined the stability of baseline assessment scores in military cadets. The objective of this study was to assess the test–retest reliability of a baseline concussion test battery in cadets at U.S. Service Academies.
All cadets participating in the Concussion Assessment, Research, and Education (CARE) Consortium investigation completed a standard baseline battery that included memory, balance, symptom, and neurocognitive assessments. Annual baseline testing was completed during the first 3 years of the study. A two-way mixed-model analysis of variance (intraclass correlation coefficent (ICC)3,1) and Kappa statistics were used to assess the stability of the metrics at 1-year and 2-year time intervals.
ICC values for the 1-year test interval ranged from 0.28 to 0.67 and from 0.15 to 0.57 for the 2-year interval. Kappa values ranged from 0.16 to 0.21 for the 1-year interval and from 0.29 to 0.31 for the 2-year test interval. Across all measures, the observed effects were small, ranging from 0.01 to 0.44.
This investigation noted less than optimal reliability for the most common concussion baseline assessments. While none of the assessments met or exceeded the accepted clinical threshold, the effect sizes were relatively small suggesting an overlap in performance from year-to-year. As such, baseline assessments beyond the initial evaluation in cadets are not essential but could aid concussion diagnosis.
Research using single-word paradigms has established that forced language switching incurs processing costs for some bilinguals, yet, less research has addressed this phenomenon at the utterance level or considered real-world applications. The current study examined the impacts of forced language switching on spoken output and stress using a simulated virtual meeting. Twenty Spanish–English heritage bilinguals responded to general work-oriented questions in monolingual English (control) or language-switching (experimental) conditions. Responses were analyzed for mean length of utterance (MLU) and type-token-ratio (TTR). Multilevel modeling revealed an interaction effect of Condition (control vs. experimental) and question order on MLU, such that participants in the experimental condition produced significantly shorter utterances by the end of the task. Participants also had significantly lower lexical variation (TTR) overall in the experimental than the control condition. A 2 × 2 ANOVA revealed a significant effect of Condition and an interaction of Task (pre- vs. posttask) and Condition, such that participants in the control condition reported significantly lower stress after the activity. Results demonstrated the impact of a forced switching condition on production at the utterance level. Findings have implications for theory and scenarios in which heritage bilinguals are asked to use multiple languages in the workplace.
We compared methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infections (BSIs) captured by culture-based surveillance and MRSA septicemia hospitalizations captured by administrative coding using statewide hospital discharge data in Connecticut from 2010 to 2018. Observed discrepancies between identification methods suggest administrative coding is inappropriate for assessing trends in MRSA BSIs.
In the UK, mental illness is a major source of disease burden costing in the region of £105 billion pounds. mHealth is a novel and emerging field in psychiatric and psychological care for the treatment of mental health difficulties such as psychosis.
To develop an intelligent real-time therapy (iRTT) mobile intervention (TechCare) which assesses participant's symptoms in real-time and responds with a personalised self-help based psychological intervention, with the aim of reducing participant's symptoms. The system will utilise intelligence at two levels:
– intelligently increasing the frequency of assessment notifications if low mood/paranoia is detected;
– an intelligent machine learning algorithm which provides interventions in real-time and also provides recommendations on the most popular selected interventions.
The aim of the current project is to develop a mobile phone intervention for people with psychosis, and to conduct a feasibility study of the TechCare App.
The study consists of both qualitative and quantitative components. The study will be run across three strands:
– qualitative work;
– test run and intervention refinement;
– feasibility trial.
Preliminary analysis of qualitative data from Strand 2 (test run and intervention refinement) in-depth interviews with service users (n = 2) and focus group with health professionals (n = 1), highlighted main themes around security of the device, multimedia and the acceptability of psychological interventions being delivered via the TechCare App.
Research in this area can be potentially helpful in addressing the demand on mental health services globally, particularly improving access to psychological interventions.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
Antimicrobial use in the surgical setting is common and frequently inappropriate. Understanding the behavioral context of antimicrobial use is a critical step to developing stewardship programs.
In this study, we employed qualitative methodologies to describe the phenomenon of antimicrobial use in 2 surgical units: orthopedic surgery and cardiothoracic surgery.
This study was conducted at a public, quaternary, university-affiliated hospital.
Healthcare professionals from the 2 surgical unit teams participated in the study.
We used focused ethnographic and face-to-face semi-structured interviews to observe antimicrobial decision-making behaviors across the patient’s journey from the preadmission clinic to the operating room to the postoperative ward.
We identified 4 key themes influencing decision making in the surgical setting. Compartmentalized communication (theme 1) was observed with demarcated roles and defined pathways for communication (theme 2). Antimicrobial decisions in the operating room were driven by the most senior members of the team. These decisions, however, were delegated to more junior members of staff in the ward and clinic environment (theme 3). Throughout the patient’s journey, communication with the patient about antimicrobial use was limited (theme 4).
Approaches to decision making in surgery are highly structured. Although this structure appears to facilitate smooth flow of responsibility, more junior members of the staff may be disempowered. In addition, opportunities for shared decision making with patients were limited. Antimicrobial stewardship programs need to recognize the hierarchal structure as well as opportunities to engage the patient in shared decision making.
The mechanism through which developmental programming of offspring overweight/obesity following in utero exposure to maternal overweight/obesity operates is unknown but may operate through biologic pathways involving offspring anthropometry at birth. Thus, we sought to examine to what extent the association between in utero exposure to maternal overweight/obesity and childhood overweight/obesity is mediated by birth anthropometry. Analyses were conducted on a retrospective cohort with data obtained from one hospital system. A natural effects model framework was used to estimate the natural direct effect and natural indirect effect of birth anthropometry (weight, length, head circumference, ponderal index, and small-for-gestational age [SGA] or large-for-gestational age [LGA]) for the association between pre-pregnancy maternal body mass index (BMI) category (overweight/obese vs normal weight) and offspring overweight/obesity in childhood. Models were adjusted for maternal and child socio-demographics. Three thousand nine hundred and fifty mother–child dyads were included in analyses (1467 [57.8%] of mothers and 913 [34.4%] of children were overweight/obese). Results suggest that a small percentage of the effect of maternal pre-pregnancy BMI overweight/obesity on offspring overweight/obesity operated through offspring anthropometry at birth (weight: 15.5%, length: 5.2%, head circumference: 8.5%, ponderal index: 2.2%, SGA: 2.9%, and LGA: 4.2%). There was a small increase in the percentage mediated when gestational diabetes or hypertensive disorders were added to the models. Our study suggests that some measures of birth anthropometry mediate the association between maternal pre-pregnancy overweight/obesity and offspring overweight/obesity in childhood and that the size of this mediated effect is small.
Intellectual disability and autism spectrum disorder (ASD) influence the interactions of a person with their environment and generate economic and socioeconomic costs for the person, their family and society.
To estimate costs of lost workforce participation due to informal caring for people with intellectual disability or autism spectrum disorders by estimating lost income to individuals, lost taxation payments to federal government and increased welfare payments.
We used a microsimulation model based on the Australian Bureau of Statistics' Surveys of Disability, Ageing and Carers (population surveys of people aged 15–64), and projected costs of caring from 2015 in 5-year intervals to 2030.
The model estimated that informal carers of people with intellectual disability and/or ASD in Australia had aggregated lost income of AU$310 million, lost taxation of AU$100 million and increased welfare payments of AU$204 million in 2015. These are projected to increase to AU$432 million, AU$129 million and AU$254 million for income, taxation, and welfare respectively by 2030. The income gap of carers for people with intellectual disability and/or ASD is estimated to increase by 2030, meaning more financial stress for carers.
Informal carers of people with intellectual disability and/or ASD experience significant loss of income, leading to increased welfare payments and reduced taxation revenue for governments; these are all projected to increase. Strategic policies supporting informal carers wishing to return to work could improve the financial and psychological impact of having a family member with intellectual disability and/or ASD.
In this cohort of Escherichia coli and Klebsiella spp hospital-onset bacteremia, isolated fluoroquinolone resistance had a larger relative impact on mortality than other phenotypic resistance patterns. This finding may support stewardship efforts targeting unnecessary fluoroquinolone use and increased attention from infection prevention and control departments.
Introduction: While boarding of patients in the emergency department (ED) has been well documented and is carefully monitored, the time spent in emergency beds by patients waiting for Adult Protection (AP) placement is often relatively unnoticed, as they are not flagged as ‘admitted’. These patients have no emergency needs, yet consume considerable ED resources, often in excess of patients requiring emergency care. Staff familiarity with this issue may also bias them to premature diagnostic closure of patients as ‘placement problems’, risking misdiagnosis of active medical conditions. An observational study to retrospectively quantify the time spent in the ED by patients referred to AP services for urgent placement from the ED. Methods: A three-year audit of ED social work records of patients referred for AP. Results: For the period of October 1 2015-September 30, 2018, the ED social work service kept records of patients referred for AP from the ED. During this period, a total of 142 patients were referred to AP (40, 50, and 52 in each year respectively). There was an increase of 10 patients between 2015/16 and 2016/17 and two patients from 2016/17 to 2017/18. The overall length of stay for this subset of ED patients during this three-year period was alarmingly high, with an average length of stay of four days per patient (range 2.7 hours-18.5 days) compared to an average of all patients of 4.9 hours and admitted patients of 13.6 hours. Conclusion: Patients in the ED who are referred to AP services consume considerable ED resources, often requiring complete medical work-up, capacity assessments and close monitoring by multiple emergency personnel. This has been reported to cause considerable stress and friction between staff and consulting services. Furthermore, these patients are poorly served in a hectic, brightly lit, and noisy environment. The impact is often not fully appreciated due to ineffective capture by patient tracking systems.
Background: Older adults in the emergency department (ED) take an increasingly larger portion of resources, have increased length of stay and a higher likelihood of adverse outcomes. In many cases bad planning, multiple vague handovers, and lack of coordinated care exacerbate this problem. With the impending onset of our aging population this is a situation that can be expected to compound in complexity in the years to come. Aim Statement: We describe daily interdisciplinary review of ED patients over the age of 75 years (or otherwise identified as a challenging discharge) to discuss barriers and facilitators to discharge/disposition. We will use data to identify the impact of this particular population to ED flow. Measures & Design: This initiative developed from our participation in the Acute Care of the Elderly (ACE) Collaborative and applies Plan/Do/Study/Act (PDSA) cycles and run reports to compare: length of stay; Identification of Seniors at Risk (ISAR) screening tool; ED census, admission/discharge rates, bounce back rates, consulting services, and interdisciplinary participation. Evaluation/Results: The average daily census of our ED between the months of July-October of 2018 was over 211 patients/day, of which over 12% were patients 75 years and older. We conducted over 70 huddles, reviewing an average of 11 patients per day. The average length of stay for patients at the time of the huddle was 19 hours, significantly higher than the general emergency population. Next day admission and discharge rates were comparable, 44.8% and 43.1% respectively with the additional patients remaining in the ED with no disposition. Internal medicine was consulted on 30% of all huddle patients and 38.4% subsequently admitted. Thirty day bounce back rates for huddle patients discharged home was 29.3%. Around 60% of patients 75 and older were screened with the ISAR and 55.7% of these were positive (2 or more questions). Discussion/Impact: Older patients consume a disproportionate amount of ED resources. Daily interdisciplinary ‘geriatric huddles’ improved communication between members of the ED team and with consulting services. The huddles enhanced awareness of the unique demands that older adults place on the flow of the ED, and identified opportunities to enhance patient flow.
Introduction: Influenza is a preventable infectious disease that causes a yearly burden to Canada. While an influenza vaccine is available free of charge in most provinces, uptake is below target rates. 15% of Canadians who did not get the influenza vaccine reported that they “didn't get around to it”; this presents an opportunity to combine the task of influenza prevention with the logistical issue of another health system challenge: escalating emergency department (ED) wait times. At the Queen Elizabeth II Health Sciences Centre (QEII) in Halifax, NS, average wait time is 4.6 hours. Offering the influenza vaccine during this time could increase convenient access to health services, and ultimately, improve vaccination rates. Methods: This observational, cross-sectional design study is currently in progress. It aims to gauge public interest, health care provider (HCP) support, perceived barriers and perceived facilitators to influenza vaccine availability at the QEII ED. Data is being collected via short, anonymous, close-ended questionnaires over a 7-week period, set to end Dec 14, 2018. Client participants are a convenience sample of low-acuity (Canadian Triage and Acuity Scale score 4/5), adult clients who use the QEII ED during the study period, anticipated n = 150. Client questionnaires are completed, with the help of a research assistant, on an iPad that inputs data directly into a secure online data collection tool. The HCP group is a convenience sample of nurses, physicians and paramedics currently working in the QEII ED, anticipated n = 80. Questionnaires are available to HCPs either on paper outside the staff lounge, or online. Data is being collected via short, anonymous, close-ended questionnaires over a 7-week period, set to end Dec 14, 2018. Client participants are a convenience sample of low-acuity (Canadian Triage and Acuity Scale score 4/5), adult clients who use the QEII ED during the study period, anticipated n = 150. Client questionnaires are completed, with the help of a research assistant, on an iPad that inputs data directly into a secure online data collection tool. The HCP group is a convenience sample of nurses, physicians and paramedics currently working in the QEII ED, anticipated n = 80. Questionnaires are available to HCPs either on paper outside the staff lounge, or online. Results: Following completion of data collection, descriptive statistics, such as the frequency of support for ED influenza vaccination and the proportion of unvaccinated clients willing to receive the vaccine if available in the ED, will be calculated using IBM SPSS Statistics 25. This will provide meaningful data that can be used by the QEII to inform future program planning (i.e. should the influenza vaccine be made available in the ED). Conclusion: An ED vaccination program could add value to the hours clients spend waiting to be seen, and make ED care more cohesive. It is essential that clients and ED staff are approached prior to any new initiative; this study is one way we can lay the necessary groundwork for a public health program that would utilize patient “wait time” more effectively.
This study utilizes a dynamic programming decision model, considering an intertemporal nitrogen carryover function, combined with both linear stochastic and deterministic plateau response functions to evaluate optimal nitrogen fertilizer decision rules and net present values (NPVs) in Texas High Plains cotton production. Nitrogen recommendations and NPVs are influenced by response function choice and nitrogen-to-cotton price ratios. Results indicate the stochastic plateau function better describes the data; the optimum nitrogen recommendation is to apply approximately 40 lb. of nitrogen for each bale of cotton production when considering nitrogen carryover information.
Official counts of deaths attributed to disasters are often under-reported, thus adversely affecting public health messaging designed to prevent further mortality. During the Oklahoma (USA) May 2013 tornadoes, Oklahoma State Health Department Division of Vital Records (VR; Oklahoma City, Oklahoma USA) piloted a flagging procedure to track tornado-attributed deaths within its Electronic Death Registration System (EDRS). To determine if the EDRS was capturing all tornado-attributed deaths, the Centers for Disease Control and Prevention (CDC; Atlanta, Georgia USA) evaluated three event fatality markers (EFM), which are used to collate information about deaths for immediate response and retrospective research efforts.
Oklahoma identified 48 tornado-attributed deaths through a retrospective review of hospital morbidity and mortality records. The Centers for Disease Control and Prevention (CDC; Atlanta, Georgia USA) analyzed the sensitivity, timeliness, and validity for three EFMs, which included: (1) a tornado-specific flag on the death record; (2) a tornado-related term in the death certificate; and (3) X37, the International Classification of Diseases, 10th Revision (ICD-10) code in the death record for Victim of a Cataclysmic Storm, which includes tornadoes.
The flag was the most sensitive EFM (89.6%; 43/48), followed by the tornado term (75.0%; 36/48), and the X37 code (56.2%; 27/48). The most-timely EFM was the flag, which took 2.0 median days to report (range 0-10 days), followed by the tornado term (median 3.5 days; range 1-21), and the X37 code (median >10 days; range 2-122). Over one-half (52.1%; 25/48) of the tornado-attributed deaths were missing at least one EFM. Twenty-six percent (11/43) of flagged records had no tornado term, and 44.1% (19/43) had no X37 code. Eleven percent (4/36) of records with a tornado term did not have a flag.
The tornado-specific flag was the most sensitive and timely EFM. Using the flag to collate death records and identify additional deaths without the tornado term and X37 code may improve immediate response and retrospective investigations. Moreover, each of the EFMs can serve as quality controls for the others to maximize capture of all disaster-attributed deaths from vital statistics records in the EDRS.
Issa AN, Baker K, Pate D, Law R, Bayleyegn T, Noe RS. Evaluation of Oklahoma’s Electronic Death Registration System and event fatality markers for disaster-related mortality surveillance – Oklahoma USA, May 2013. Prehosp Disaster Med. 2019;34(2):125–131