2020 Pennsylvania Patient Safety Reporting: Updated Acute Care Reporting Rates

In our recent article summarizing 2020 data from acute care facilities in Pennsylvania, reporting rates and fall rates were provided for Q1 and Q2 2020 based on the latest data we had available at the time of publication. Given that 2020 was an unpredictable year in healthcare, any forecasting of rates for Q3 and Q4 2020 would have been unreliable. Therefore, this data snapshot serves to complete reporting rates for 2020 now that all hospital patient days and surgical encounters data from 2020 have been made available for rate calculations.

11. Electronic Surveillance Criteria for Non-Ventilator HAP: Empiric testing and Chart Review at Veterans Affairs Facilities

Background Surveillance of Non-Ventilator Hospital-Acquired Pneumonia (NV-HAP) is limited by the ambiguity in diagnosing pneumonia. We implemented electronic surveillance criteria for NV-HAP across the VA healthcare system and tested for reliability, validity and meaning of the electronic criteria vs manual chart review. Methods We defined NV-HAP surveillance criteria as oxygen deterioration concurrent with fever or abnormal WBC count, ≥3 days of antibiotics, and orders for chest imaging. We applied these criteria to EHR data from all patients hospitalized ≥3 days at all VA acute care facilities from 1/1/2015-12/31/2020 and calculated NV-HAP incidence and inpatient mortality. Clinician reviewers used a consensus review guide to independently review and adjudicate 47 cases meeting NV-HAP surveillance criteria for 1) clinical deterioration, 2) CDC-NHSN pneumonia criteria, 3) treating clinicians’ assessment, and 4) reviewer’s diagnosis. All reviewers subsequently adjudicated all cases and conducted an error analysis to identify sources of discordance. Results Among 2.3M hospitalizations, 14,023 met NV-HAP surveillance criteria (0.6 per 100 admissions). Inpatient mortality was 26% (vs 2% for non-flagged hospitalizations). Among 47 hospitalizations flagged by surveillance criteria, 45 (97%) had a confirmed clinical deterioration, (the other 2 were immediate post-operative cases), 20 (43%) met CDC-NHSN pneumonia criteria, 21 (47%) had possible pneumonia per treating clinicians, and 25 (53%) had possible or probable NV-HAP per reviewers. Agreement among the 3 reviewers before adjudication was 51% (Fleiss’ κ 0.43) for CDC-NHSN and 58% (Fleiss’ κ 0.33) for NV-HAP. The most common source of discordance between reviewers was chest imaging classification (15/19 discordant cases). Conclusion NV-HAP electronic surveillance criteria demonstrated high precision for identifying clinical deterioration and moderate concordance with CDC-NHSN pneumonia criteria or reviewer diagnosis. Agreement between electronic surveillance criteria vs manual chart review was low but similar to agreement amongst manual reviewers applying NHSN criteria. Electronic surveillance may provide greater consistency than human review while facilitating wide-scale automated surveillance. Disclosures Chanu Rhee, MD, MPH, UpToDate (Other Financial or Material Support, Chapter Author) Michael Klompas, MD, MPH, UpToDate (Other Financial or Material Support, Chapter Author)

40. Impact of an Antimicrobial Intake Process within a Post-acute Medical System

Background Implementation of antimicrobial stewardship programs (ASPs) within long-term acute care facilities (LTACs) is challenging due to limited resources and missing patient data from transferring facilities. In October 2018, an ASP was established within a 43-hopital system consisting of LTACs and rehabilitation hospitals. Despite the presence of a restricted antimicrobial policy, increased utilization was observed for five restricted antimicrobials. The system ASP committee implemented a multipronged approach to optimize utilization of these five agents. Investigators sought to assess the impact of an antimicrobial intake process on antimicrobial consumption. Methods This was a retrospective analysis within a 43-hospital system of LTACs and rehabilitation hospitals, comparing use of five restricted antibiotics before (Jul19-Jun20) and after (Jul20-Apr21) implementation of a data-collection and system review process. An antibiotic intake form and process for review for five restricted antibiotics (ceftaroline, ceftazidime/avibactam, ceftolozane/tazobactam, fidaxomicin, meropenem/vaborbactam) was approved at the system ASP committee. The intake form consisted of a restricted antibiotic form, cultures and susceptibilities, physician notes, and other pertinent data. Any orders for the five antibiotics required completion of an intake form and submission to system ASP members for review and recommendations. Antibiotic consumption was measured in cost per acute patient day (cost/pd) using a 2-sided t-test. Results Post-implementation, the five restricted antibiotics comprised 29.1% of the total antibiotic expenditure for the healthcare system compared to 35.6% pre-implementation. Ten months after program implementation, the total antibiotic cost/PD decreased 29.45% [(&12.02 ± 2.29) vs. (&8.48 ± 1.45); p=0.0003]. The cost/PD of the five restricted antibiotics decreased 42.52% [(&4.28 ± 1.09) vs. (&2.46 ± 0.99) ; p=0.0005]. Conclusion Implementation of an antimicrobial intake process within a post-acute medical system resulted in a significant reduction in antibiotic consumption for five targeted antibiotics as well as overall antibiotic expenditure. Disclosures All Authors: No reported disclosures

170. Antimicrobial Use Before and During COVID-19 – Data from 108 VA Facilities

Background Increased antibiotic prescribing rates during the early phases of the COVID-19 pandemic have been widely reported. We previously reported that while both antibiotic days of therapy (DOT) and total days present (DP) declined in the first 5 months of 2020 at Veterans Affairs (VA) acute care facilities nationwide relative to the comparable period in 2019, antibiotic DOT per 1000 DP increased by 11.3%, largely reversing declines in VA antimicrobial utilization from 2015 – 2019. We now evaluate whether these changes in antibiotic use persisted throughout the COVID-19 pandemic. Methods Data on antibacterial use, patient days present, and COVID-19 care for acute inpatient care units in 108 VA level 1 and 2 facilities were extracted through the VA Informatics and Computing Infrastructure; level 3 facilities which provide limited acute inpatient services were excluded. DOT per 1000 DP were calculated and stratified by CDC-defined antibiotic classes. Results From 1/2020 to 2/2021, care for 34,096 COVID-19 patients accounted for 13% of all acute inpatient days of care in the VA. Following the onset of COVID-19 pandemic, monthly total acute care antibiotic use increased from 533 DOT/1000 DP in 1/2020 to a peak of 583 DOT/1000 DP in 4/2020; during that month COVID-19 patients accounted for 13% of all DP (Figure). In subsequent months, total antibiotic use declined such that for the full year the change of antibiotic use from 2019 to 2020 (a decrease of 18 DOT/1000 DP) was similar to the rate of decline from 2015 to 2019 (mean decrease of 13 DOT/1000 DP; Table). The decreased DOT/1000 DP from 5/2020 to 2/2021 occurred even as the percentage of all DP due to COVID-19 peaked at 14 - 24% from 11/2020 to 2/2021. Conclusion Although rates of antibiotic use increased within the VA during the early phases of the COVID-19 pandemic, rates subsequently decreased to below previous baseline levels even as the proportion of COVID-19 DP spiked between 11/2020 and 02/2021. Although the degree to which the initial increase in antibiotic use is attributable to concerns of bacterial superinfection versus changes in case-mix (e.g., decreased elective admission) remains to be assessed, these data support the continued effectiveness of antimicrobial stewardship programs in the VA. Disclosures Matthew B. Goetz, MD, Nothing to disclose

221. Evaluation of Rates of Culture Positive Blood Stream Pathogens Prior to and During the SARS-CoV-2 Pandemic: A Multicenter Evaluation

Background Bacterial co-infections or super-infections are well-characterized complications of viral infections, further increasing morbidity and mortality of global viral pandemics. We evaluated trends in the incidence of culture positive gram-negative (GN), gram-positive (GP), and fungal/yeast pathogens from a blood source in hospitalized patients at US hospitals before and during the SARS-CoV-2 pandemic. Table: Incidence and rate of blood pathogens in the pre and post SARS-CoV-2 period. Gray indicates significantly lower rate compared to pre-pandemic time period, black indicates significantly higher rates compared to pre-pandemic. Methods: This was a multi-center, retrospective cohort analysis of all hospitalized patients from 267 US acute care facilities with >1-day inpatient admission between 7/1/19-5/19/21 (BD Insights Research Database [Becton, Dickinson and Company, Franklin Lakes, NJ]). SARS-CoV-2 infection was identified by a positive PCR during or ≤7 days prior to hospitalization. All admissions with a non-contaminant culture positive GN, GP, and fungal/yeast pathogen from a blood source were evaluated prior to and during the SARS-CoV-2 pandemic as rates per 1,000 admissions (p< .05 for significance). Results There were 2,001,793 admissions in the pre-SARS-CoV-2 period (7/2019-2/2020) and 2,875,219 admissions during the SARS-CoV-2 pandemic. Incidence of GN/GP blood stream pathogens was significantly higher prior to the SARS-CoV-2 pandemic than during the pandemic. Higher rates of blood stream pathogens occurred in those who were tested for SARS-CoV-2, but all non-tested patients had significantly lower rates than pre-pandemic. Rates of Candida spp., Enterococcus spp., Serratia marcescens, and Enterobacter cloacae were higher in SARS-CoV-2 positive patients compared to pre-pandemic patients. Compared to the prior pandemic period, the incidence of B. fragilis, Streptococcus, Enterococcus and Candida were higher among those tested for SARS-CoV-2 but were negative. Conclusion In general, rates of positive blood cultures for bacterial pathogens were either lower or similar during the SARS-CoV-2 period compared to the pre-SARS-CoV-2 pandemic period. The patients that were tested for SARS-CoV-2 but were positive who had higher rates of infection than prior may indicate the similarity in viral and bacterial clinical presentation. Further evaluation of higher rates of Enterococcus and Candida in the pandemic period are warranted. Disclosures Laura A. Puzniak, PhD, Merck & Co., Inc. (Employee) Karri A. Bauer, PharmD, Merck & Co., Inc. (Employee, Shareholder) Kalvin Yu, MD, BD (Employee) Pamela Moise, PharmD, Merck (Employee) Vikas Gupta, PharmD, BCPS, Becton, Dickinson and Company (Employee, Shareholder)

1261. Antimicrobial Susceptibilities of Carbapenem-Resistant Klebsiella pneumoniae (CRKP) Isolates from a Multi-state Network of Long-term Acute Care Hospitals (LTACHs)

Background CRKP infection is common among LTACH patients. However, CRKP antimicrobial susceptibility testing (AST) with newer antibiotics has not been described in this population. In this study, we performed AST on CRKP in LTACHs. Methods CRKP clinical cultures were collected from 21 Kindred Healthcare LTACHs (12 southern California, 6 Texas, 2 Florida, 1 Kentucky) from 8/1/14-7/25/15. AST was performed using a custom SensititreTM broth microdilution panel (ThermoFisher Scientific, Waltham, MA). 2021 Clinical & Laboratory Standards Institute interpretive criteria were used for all agents except plazomicin (PLZ), for which US Food and Drug Administration breakpoints were used. Results 459 CRKP clinical isolates were collected, including 254 (55.5%) respiratory, 155 (33.8%) urine, 39 (8.5%) blood, and 10 (2.2%) wound cultures. Most (419, 91.0%) were from southern California. 151 (32.9%) were colistin-resistant. 42 (9.2%) isolates were non-susceptible to meropenem-vaborbactam (MVB), 16 (8.9%) to imipenem-relebactam (IPR), 4 (0.9%) to ceftazidime-avibactam (CZA), and 3 (0.7%) to PLZ. Cross-resistance patterns are shown in Table 1. Among southern California facilities, there was significant inter-facility variation in MVB non-susceptibility (Pearson’s chi-squared test, p=0.005) but not in CZA, IPR, or PLZ non-susceptibility. Table 1. Cross-resistance to antimicrobials among carbapenem-resistant Klebsiella pneumoniae isolates from 21 Kindred long-term acute care facilities, August 1, 2014 – July 25, 2015 (N=459). Number of isolates and column percentages reported. 2021 Clinical & Laboratory Standards Institute interpretive criteria are used for all agents except for PLZ, for which US Food and Drug Administration breakpoints are used. Abbreviations: CST = colistin. CZA = ceftazidime-avibactam. I = intermediate. IPR = imipenem-relebactam. MIC = minimum inhibitory concentration. MVB = meropenem-vaborbactam. PLZ = plazomicin. R = resistant. S = susceptible. Conclusion In this sample of CRKP isolates from LTACHs in 2014-2015, nearly 10% of isolates were non-susceptible to MVB or IPR, respectively, despite neither agent being commercially available at the time. In contrast, there was a low prevalence of non-susceptibility to CZA, which received initial US Food and Drug Association approval in 2/2015, and PLZ, which was not commercially available during the study period. Cross-resistance between CZA and carbapenem/beta-lactamase combination antibiotics was uncommon. Future studies should evaluate CRKP susceptibilities to new agents in post-marketing cohorts and identify risk factors for resistance. Disclosures Jennifer Han, MD, MSCE, GlaxoSmithKline (Employee, Shareholder) Ebbing Lautenbach, MD, MPH, MSCE, Merck (Other Financial or Material Support, Member of Data and Safety Monitoring Board (DSMB))

Non-contact heart rate variability monitoring using Doppler radars located beneath bed mattress: a case report

Background Heart rate variability (HRV) has been investigated previously in autonomic nervous system-related clinical settings. In these settings, HRV is determined by the time-series heartbeat peak-to-peak intervals using electrocardiography (ECG). To reduce patient discomfort, we designed a Doppler radar-based autonomic nervous activity monitoring system (ANMS) that allows cardiopulmonary monitoring without using ECG electrodes or spirometry monitoring. Case summary Using our non-contact ANMS, we observed a bedridden 80-year-old female patient with terminal phase sepsis developed the daytime Cheyne-Stokes respiration (CSR) associated with the attenuation of the low frequency (LF) and high frequency (HF) of HRV components 20 days prior to her death. The patient developed a marked linear decrease in the LF and the HF of HRV components for over 3 days in a row. Furthermore, after the decrease both the LF and the HF showed low and linear values. Around the intersection of the two lines, the decreasing LF and HF lines and the constant LF and HF lines, the ANMS automatically detected the daytime CSR pathogenesis. The attenuation rate of HF (1340 ms2/day) was higher than that of LF (956 ms2/day). Heart rate increased by ∼10 b.p.m. during these 3 days. Discussion We detected CSR-associated LF and HF attenuation in a patient with terminal phase sepsis using our ANMS. The proposed system without lead appears promising for future applications in clinical settings, such as remote cardiac monitoring of patients with heart failure at home or in long-term acute care facilities.

Projecting COVID-19 isolation bed requirements for people experiencing homelessness

As COVID-19 spreads across the United States, people experiencing homelessness (PEH) are among the most vulnerable to the virus. To mitigate transmission, municipal governments are procuring isolation facilities for PEH to utilize following possible exposure to the virus. Here we describe the framework for anticipating isolation bed demand in PEH communities that we developed to support public health planning in Austin, Texas during March 2020. Using a mathematical model of COVID-19 transmission, we projected that, under no social distancing orders, a maximum of 299 (95% Confidence Interval: 223, 321) PEH may require isolation rooms in the same week. Based on these analyses, Austin Public Health finalized a lease agreement for 205 isolation rooms on March 27th 2020. As of October 7th 2020, a maximum of 130 rooms have been used on a single day, and a total of 602 PEH have used the facility. As a general rule of thumb, we expect the peak proportion of the PEH population that will require isolation to be roughly triple the projected peak daily incidence in the city. This framework can guide the provisioning of COVID-19 isolation and post-acute care facilities for high risk communities throughout the United States.