A neonatal ward strengthening program improves survival for neonates treated with CPAP at district hospitals in Malawi

Introduction: From 2013-2015, a CPAP quality improvement program (QIP) was implemented to introduce and monitor CPAP usage and outcomes in the neonatal wards at all government district and central hospitals in Malawi. In 2016 the CPAP QIP was extended into healthcare facilities operated by the Christian Health Association of Malawi. Although clinical outcomes improved, ward assessments indicated that many rural sites lacked other essential equipment and a suitable space to adequately treat sick neonates, which likely limited the impact of improved respiratory care. The aim of this study was to determine if a ward strengthening program improved outcomes for neonates treated with CPAP. Methods: To address the needs identified from ward assessments, a ward strengthening program was implemented from 2017-2018 at rural hospitals in Malawi to improve the care of sick neonates. The ward strengthening program included the distribution of a bundle of equipment, supplemental training, and, in some cases, health facility renovations. Survival to discharge was compared for neonates treated with CPAP at 12 rural hospitals for one year before and for one year immediately after implementation of the ward strengthening program. Results: In the year prior to ward strengthening, 189 neonates were treated with CPAP; in the year after, 232 neonates received CPAP. The overall rate of survival for those treated with CPAP improved from 46.6% to 57.3% after ward strengthening (p=0.03). For the subset of neonates with admission weights between 1.00-2.49 kg diagnosed with respiratory distress syndrome, survival increased from 39.4% to 60.3% after ward strengthening (p=0.001). Conclusion: A ward strengthening program including the distribution of a bundle of equipment, supplemental training, and some health facility renovations, further improved survival among neonates treated with CPAP at district-level hospitals in Malawi.

133. A Review of Antimicrobial Formularies at Rural Hospitals: Stewardship Opportunities Abound

Background Management of a hospital’s antimicrobial formulary is an important aspect of antimicrobial stewardship and cost containment strategies. Ensuring that essential medications for clinical care are available and excluding therapeutic duplicates and unnecessary antimicrobials is time and resource intensive. Comparisons of antimicrobial formularies across multiple rural hospitals have not been evaluated in the literature. We hypothesized that a comprehensive formulary evaluation would reveal important opportunities for antimicrobial stewardship efforts and could help smaller hospitals optimize available medications. Methods The University of Washington Tele-Antimicrobial Stewardship Program (UW-TASP) is comprised of 68 hospitals of varying sizes, most of which are rural and critical access, in Washington, Oregon, Arizona, Idaho, and Utah. We surveyed UW-TASP participating hospitals and other networked rural hospitals in multiple Western states using REDCap, a HIPAA-compliant, electronic data management program. Respondents reported which antimicrobials are on their hospital formulary as well as basic information about hospital size and inpatient units. Data were reviewed by a panel of infectious diseases trained physicians and pharmacists at UW-TASP. Results Surveys from 49 hospitals were received; two were excluded from the data analysis (Table 1) – one submission was incomplete, and one was a large inpatient psychiatric hospital. Select antimicrobials and proportion of hospitals carrying these agents is shown in Table 2. Several antimicrobials are on the formulary at all hospitals, regardless of size. In some critical access hospitals (< 25 beds), empiric first-line bacterial meningitis and viral encephalitis coverage (Table 3) was lacking. Six hospitals (12.7%) lacked ampicillin for Listeria coverage and only one had a suitable alternative agent (meropenem). Seven hospitals (14.9%) lacked intravenous acyclovir, although three had oral valacyclovir. Formulary inclusion of agents for multi-drug resistant organisms was rare. Conclusion In critical access hospitals in the Western USA, lack of essential empiric antimicrobials may be more of a concern than inclusion of agents with unnecessarily broad spectra. Disclosures Chloe Bryson-Cahn, MD, Alaska Airlines (Other Financial or Material Support, Co-Medical Director, position is through the University of Washington)

1277. Colonization Rates for Antimicrobial-resistant Bacteria in Kenya: An Antibiotic Resistance in Communities and Hospitals (ARCH) Study

Background Characterization of antimicrobial-resistant organism (ARO) colonization is critical to understand transmission dynamics and infection risk, however data in resource-limited settings are scare. We estimated the prevalence of Enterobacterales colonization with extended-spectrum cephalosporin-resistance (ESCrE), carbapenem-resistance (CRE) and methicillin-resistant Staphylococcus aureus (MRSA) among community residents and hospitalized patients in rural (Siaya County) and urban (Kibera) Kenya. Methods Community-dwelling adults and children were enrolled via cluster randomized sampling. Inpatients of all ages were enrolled by simple random sampling. Stool/rectal and nasal swabs were collected and screened for ESCrE, CRE and MRSA, respectively, using HardyChrom™ media. Vitek2® was used for isolate confirmation and antibiotic susceptibility testing. Fisher’s exact tests were used to compare prevalence of AROs. Results The prevalence of ESCrE was higher for the urban hospital (69.8%, 263/377) compared to rural hospitals (62.7%, 298/475, P=0.04); a similar pattern was evident for CRE (16.7%, 63/377 and 6.5%, 31/475, respectively, P< 0.01). The prevalence of MRSA was 3.2% for both urban and rural hospitals (P=0.99). For adults, the prevalence of ESCrE was higher in Kibera households (51.4%, 346/673) compared to Siaya (44.6%, 283/634, P=0.02) while the prevalence of both CRE and MRSA was < 3% for both areas and did not differ significantly (CRE, P=0.13, MRSA, P=0.14). There was no significant difference between urban and rural children for ESCrE (47.7%, 74/155 and 53.4%, 135/253, P=0.31); both CRE and MRSA were rarely detected (< 2%) with no difference across settings (CRE, P=1.0, MRSA, P=0.42). Among Enterobacteriaceae recovered, Escherichia coli and Klebsiella spp. predominated. Conclusion Colonization with AROs were widespread in households and hospitals in urban and rural areas. Hospitals with elevated prevalence of highly transmissible AROs should consider whether implementation of colonization screening can be incorporated as part of their infection prevention and control programs. Risk factors for ARO colonization should be elucidated to identify novel prevention strategies. Disclosures All Authors: No reported disclosures

Discrete-Event Simulation to Model the Thrombolysis Process for Acute Ischemic Stroke Patients at Urban and Rural Hospitals

Background: Effective treatment with tissue plasminogen activator (tPA) critically relies on rapid treatment. Door-to-needle time (DNT) is a key measure of hospital efficiency linked to patient outcomes. Numerous changes can reduce DNT, but they are difficult to trial and implement. Discrete-event simulation (DES) provides a way to model and determine the impact of process improvements.Methods: A conceptual framework was developed to illustrate the thrombolysis process; allowing for treatment processes to be replicated using a DES model developed in ARENA. Activity time duration distributions from three sites (one urban and two rural) were used. Five scenarios, three process changes, and two reductions in activity durations, were simulated and tested. Scenarios were tested individually and in combinations. The primary outcome measure is median DNT. The study goal is to determine the largest improvement in DNT at each site.Results: Administration of tPA in the imaging area resulted in the largest median DNT reduction for Site 1 and Site 2 for individual test scenarios (12.6%, 95% CI 12.4–12.8%, and 8.2%, 95% CI 7.5–9.0%, respectively). Ensuring that patients arriving via emergency medical services (EMS) remain on the EMS stretcher to imaging resulted in the largest median DNT improvement for Site 3 (9.2%, 95% CI 7.9–10.5%). Reducing both the treatment decision time and tPA preparation time by 35% resulted in a 11.0% (95% CI 10.0–12.0%) maximum reduction in median DNT. The lowest median and 90th percentile DNTs were achieved by combining all test scenarios, with a maximum reduction of 26.7% (95% CI 24.5–28.9%) and 17.1% (95% CI 12.5–21.7%), respectively.Conclusions: The detailed conceptual framework clarifies the intra-hospital logistics of the thrombolysis process. The most significant median DNT improvement at rural hospitals resulted from ensuring patients arriving via EMS remain on the EMS stretcher to imaging, while urban sites benefit more from administering tPA in the imaging area. Reducing the durations of activities on the critical path will provide further DNT improvements. Significant DNT improvements are achievable in urban and rural settings by combining process changes with reducing activity durations.