Prevalence and Outcomes of Multi-Drug Resistant Blood Stream Infections Among Nursing Home Residents Admitted to an Acute Care Hospital.

OBJECTIVE: The prevalence of multi-drug resistant organism (MDRO) colonization in nursing home residents has been well documented, but little is known about the impact of MDRO bloodstream infections (BSIs). The aim of this study was to assess the prevalence, cost, and outcomes of MDRO-BSI vs. non-MDRO-BSI among nursing home residents. DESIGN: Retrospective cohort study. SETTING: 960 bed tertiary academic medical center. PATIENTS: Persons ≥18 years old admitted to an acute care tertiary hospital from Skilled Nursing Facilities with a diagnosis of sepsis between 2015 and 2018. INTERVENTIONS: Retrospective analysis of prevalence and outcomes. MEASUREMENTS AND MAIN RESULTS: Among patients admitted to the study hospital with a diagnosis of sepsis during the study period, 7% were from nursing homes. The prevalence of MDRO-BSI was 47%. We identified 54 (50%) gram positive BSIs, 48 (45%) gram negative BSI and 5 (5%) fungal BSI. Thirty-one (57%) of the gram-positive infections and 14 (30%) of the gram-negative infections were with MDROs. The prevalence of BSI organisms were Staphylococcus aureus in 24%, Escherichia coli in 14%, Proteus mirabilis in 13%, Staphylococcus epidermidis in 8%, Enterococcus faecalis in 7%, and Klebsiella pneumoniae in 6%. We found that intensive care unit length of stay (7 days vs 5 days, P = .009), direct cost ($13,639 vs $9,922, P = .027), and total cost ($23,752 vs $17,900 P = .032) were significantly higher in patients with MDRO-BSI vs. non-MDRO-BSI. Patients with MDRO-BSI were twice as likely to receive inappropriate empiric antiinfective therapy (31% vs 16%, P = .006) and were more likely to die (49.1% vs 29.6%, P = .049). CONCLUSION: Nursing home residents have a high prevalence of MDRO-BSI, which is associated with higher risk of receiving inappropriate initial anti-infective therapy, higher cost, higher ICU LOS, and higher mortality. Our research adds new information about the prevalence of fungemia in this population.

The influence of empowered work environments on the psychological experiences of nursing assistants during COVID-19: a qualitative study.

BACKGROUND: Nursing Assistants (NA) who feel empowered tend to perform their duties better, have higher morale and job satisfaction, and are less likely to leave their jobs. Organizational empowerment practices in hospitals likely shape the psychological experiences of empowerment among these personnel; however, little is known about this relationship. OBJECTIVE: We used qualitative inquiry to explore the relationship between organizational empowerment structural components and feelings of psychological empowerment among hospital frontline workers during a public health emergency. METHODS: Kanter's Theory of Structural Empowerment and Spreitzer's Psychological Empowerment in the Workplace Framework were applied to identify the conceptual influences of organizational practices on psychological experiences of empowerment. In-depth interviews were conducted with a convenience sample of NAs, caring for hospitalized COVID-19 patients. Directed content analysis was performed to generate a data matrix consisting of the psychological experiences of meaning, competence, self-determination, and impact embedded under the organizational structural components of information, resources, support, and opportunity. RESULTS: Thirteen NAs (mean age = 42 years, 92% female) completed interviews. Information, or lack thereof, provided to the NAs influenced feelings of fear, preparation, and autonomy. Resources (e.g., protocols, equipment, and person-power) made it easier to cope with overwhelming emotions, affected the NAs' abilities to do their jobs, and when limited, drove NAs to take on new roles. NAs noted that support was mostly provided by nurses and made the NAs feel appreciated, desiring to contribute more. While NAs felt they could consult leadership when needed, several felt leadership showed little appreciation for their roles and contributions. Similar to support, the opportunity to take care of COVID-19 patients yielded a diverse array of emotions, exposed advances and gaps in NA preparation, and challenged NAs to autonomously develop new care practices and processes. CONCLUSION: Management and empowerment of healthcare workers are critical to hospital performance and success. We found many ways in which the NAs' psychological experiences of empowerment were shaped by the healthcare system's empowerment-related structural conditions during a public health emergency. To further develop an empowered and committed critical workforce, hospitals must acknowledge the organizational practice influence on the psychological experiences of empowerment among NAs.

The outcomes of nurse practitioner (NP)-Provided home visits: A systematic review.

BACKGROUND: With the shortage of primary care providers to provide home-based care to the growing number of homebound older adults in the U.S. Nurse Practitioners (NPs) are increasingly utilized to meet the growing demand for home-based care and are now the largest type of primary care providers delivering home-visits. PURPOSE: The purpose of this study was to systematically examine the current state of the evidence on health and healthcare utilization outcomes associated with NP-home visits. METHOD: Five Databases (PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature and the Cochrane Library) were systematically searched to identify studies examining NP-home visits. The search focused on English language studies that were published before April 2019 and sought to describe the outcomes associated with NP-home visits. We included experimental and observational studies.  Quality appraisal was performed with the Kmet, Lee & Cook tool, and results summarized qualitatively. The impact of NP-home visits on clinical (functional status, quality of life [QOL]), and healthcare utilization (hospitalization, Emergency department(ED) visits) outcomes was evaluated. RESULTS/DISCUSSION: A total of 566 citations were identified; 7 met eligibility criteria and were included in the review. The most commonly reported outcomes were emergency department (ED) visits and readmissions. Given the limited number of articles generated by our search and wide variation in intervention and outcomes measures. NP-home visits were associated with reductions in ED visits in 2 out of 3 studies and with reduction in readmissions in 2 out of 4 studies. CONCLUSION: Published studies evaluating the outcomes associated with NP-home visits are limited and of mixed quality. Limitations include small sample size, and variation in duration and frequency of NP-home visits. Future studies should investigate the independent effect of NP-home visits on the health outcomes of older adults using large and nationally representative data with more rigorous study design.

Antimicrobial Stewardship Interventions to Optimize Treatment of Infections in Nursing Home Residents: A Systematic Review and Meta-Analysis.

Effects of antibiotic stewardship program (ASP) interventions to optimize antibiotic use for infections in nursing home (NH) residents remain unclear. The aim of this systematic review and meta-analysis was to assess ASPs in NHs and their effects on antibiotic use, multi-drug-resistant organisms, antibiotic prescribing practices, and resident mortality. Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we conducted a systematic review and meta-analysis using five databases (1988-2020). Nineteen articles were included, 10 met the criteria for quantitative synthesis. Inappropriate antibiotic use decreased following ASP intervention in eight studies with a pooled decrease of 13.8% (95% confidence interval [CI]: [4.7, 23.0]; Cochran's Q = 166,837.8, p < .001, I2 = 99.9%) across studies. Decrease in inappropriate antibiotic use was highest in studies that examined antibiotic use for urinary tract infection (UTI). Education and antibiotic stewardship algorithms for UTI were the most effective interventions. Evidence surrounding ASPs in NH is weak, with recommendations suited for UTIs.

Primary drivers and psychological manifestations of stress in frontline healthcare workforce during the initial COVID-19 outbreak in the United States.

OBJECTIVE: The purpose of this study was to understand the physical and psychological impact of high stress clinical environments and contributory factors of burnout in multidisciplinary healthcare workforce during the initial outbreak of COVID-19. METHOD: In-person qualitative interviews informed by an adaptation of Karasek's Job Demand-control model were conducted with a convenience sample of healthcare workforce from March to April 2020. RESULTS: Themes emerging from interviews coalesced around three main areas: fear of uncertainty, physical and psychological manifestations of stress, and resilience building. Shifting information, a lack of PPE, and fear of infecting others prompted worry for those working with Covid-infected patients. Participants reported that stress manifested more psychologically than physically. Individualized stress mitigation efforts, social media and organizational transparency were reported by healthcare workers to be effective against rising stressors. CONCLUSION: COVID-19 has presented healthcare workforce with unprecedented challenges in their work environment. With attention to understanding stressors and supporting clinicians during healthcare emergencies, more research is necessary in order to effectively promote healthcare workforce well-being.

The Lived Experience of Being Diagnosed With COVID-19 Among Black Patients: A Qualitative Study.

Diagnosis and hospitalization for COVID-19 are disproportionately higher among black persons. The purpose of this study was to explore the lived experience of being diagnosed with COVID-19 among black patients. Semistructured one-on-one interviews with black patients diagnosed with COVID-19 were conducted. Data were analyzed using conventional content analysis and a directed content approach. Fifteen patients participated and 3 themes were identified: Panic amidst a COVID-19 diagnosis, Feeling the repercussion of the diagnosis, and Personal assessment of risks within one's individual environment. Fear of dying, inadequate health benefits, financial issues, and worries about spreading the virus to loved ones were acknowledged by the patients as critical areas of concerns. Majority of the patients looked to God as the ultimate way of surviving COVID-19. However, none of the patients reported receiving support for spiritual needs from health care providers. This is the first study to investigate the lived experience of being diagnosed with COVID-19 among black patients. Our results highlight several factors that put this group at increased risk for COVID-19 and where additional strategies are needed to address these inadequacies. Integrating public health interventions to reduce socioeconomic barriers and integrating spirituality into clinical care could improve patient care delivery.

The powder keg: Lessons learned about clinical staff preparedness during the early phase of the COVID-19 pandemic.

BACKGROUND: Little is known about clinical staff's perspectives on preparedness for a pandemic. The purpose of this study was to obtain various clinical staff perspectives about preparedness to meet the demands for care during the early phase of the SARS-CoV-2 (COVID-19) pandemic. METHODS: We conducted a qualitative study using semistructured in-person interviews from March 2020 to April 2020 at a large tertiary academic urban hospital center. Interview guides were informed by the Resilience Framework for Public Health Emergency Preparedness and analyzed using a directed content analysis approach. RESULTS: Fifty-five clinical staff participated in the study. Three themes emerged from the data (1) Risk assessment and planning: "The powder keg," (2) Innovative evolution of roles and responsibilities, and (3) Pandemic response and capacity. In the early phases of the pandemic, participants reported varying levels of risks for dying. However, most participants adapted to practice changes and became innovative in their roles over time. Hierarchies were less relevant during care delivery, whereas team collaboration became crucial in managing workforce capacity. DISCUSSION: As the pandemic progressed, staff preparedness evolved through a trial-and-error approach. CONCLUSIONS: The pandemic is evolving as is clinical staff preparedness to meet the demands of a pandemic. In order to get a grasp on the crisis, clinical staff relied on each other and resorted to new workarounds.

Nursing perspectives on care delivery during the early stages of the covid-19 pandemic: A qualitative study.

BACKGROUND: Research examining RNs' experiences during the COVID-19 pandemic is lacking, thus inhibiting efforts to optimize nursing care delivery and patient outcomes during the current pandemic and future public health emergencies. OBJECTIVE: To explore the experience of being a registered nurse caring for patients with COVID-19 at an urban academic medical center during the early stages of the pandemic. DESIGN: Qualitative descriptive study, guided by Donabedian's Quality Framework for Evaluation of Healthcare Delivery which focuses on structures, processes, and outcomes of care delivery. SETTING: Urban academic medical center in the northeast United States. PARTICIPANTS: Registered nurses cared for or caring for patients with COVID-19, age ≥18 years old, and English-speaking. METHODS: Participants were recruited for individual in-person semi-structured interviews. Interviews occurred during March and April 2020 and were recorded and transcribed. Transcripts were analyzed by two researchers using emergent qualitative content analysis to identify themes. RESULTS: Twenty-one registered nurses participated in the study. Three themes emerged from the data, included one relevant to structures and two relevant to processes of care during the pandemic. Registered nurses perceived the clinical context as highly dynamic, but quickly adapted to pandemic-related care delivery. They felt a "sense of duty" to care for patients with COVID-19, despite being fearful of acquiring or spreading infection. Compared to clinical colleagues, registered nurses reported increased patient exposure and performed tasks previously assigned to other clinical team members. CONCLUSION: Roles and nursing practice processes evolved to meet the demand for care despite challenges. Registered nurses require adequate protection for their frontline role which may consist of increased patient exposure compared to clinical colleagues, emotional support, and clear clinical guidance. A deeper understanding of how a public health emergency, such as the COVID-19 pandemic, affects nursing practice can guide future efforts to optimize healthcare structures, nursing care processes, and patient outcomes. Our study can inform strategies for providing registered nurses with adequate communication, protection, and resources during the COVID-19 pandemic and future similar public health emergencies.

Risk of subsequent health care-associated infection among patients with a bloodstream infection present on hospital admission.

BACKGROUND: The risks and outcomes of acquiring a health care-associated infection (HAI) among patients with a bloodstream infection present on hospital admission (BSI-POA) have not been well described. The objective of this study was to examine the incidence of and risk factors for developing a subsequent HAI and to compare length of stay and mortality between patients with a BSI-POA who develop an HAI and those who do not. METHODS: This was a retrospective cohort study of patients aged ≥18 years discharged with a BSI-POA from 3 hospitals in New York City between 2006 and 2014. RESULTS: There were 761 HAIs among the 11,436 patients with a BSI-POA. Incidence rates were: catheter-associated urinary tract infections, 5.03 infections per 1,000 catheter days; pneumonia, 2.7% among BSI-POA patients; surgical site infections, 9.2% among BSI-POA patients. Length of stay was longer among patients who developed an HAI (mean ± SD, 35.0 ± 29.8 vs 12.4 ± 11.9, P < .001). Mortality was higher in patients who developed an HAI (23.9% vs 11.6%, P < .001). CONCLUSIONS: Risk factors for those who developed an HAI differed by infection type. Overall, HAI was associated with longer hospitalization, and pneumonia was associated with increased mortality.

Prevalence and risk factors for bloodstream infection present on hospital admission.

BACKGROUND: Bloodstream infection present on hospital admission (BSI-POA) is a major cause of morbidity and mortality. The purpose of this study was to measure prevalence and describe the risk factors of patients with BSI-POA and to determine the prevalence of resistance in isolates by admission source. METHODS: We conducted a retrospective cohort study of patients discharged from three hospitals in New York City between 2006 and 2014. BSI-POA was defined as BSI diagnosed within 48 h of hospitalisation. RESULTS: The prevalence for BSI-POA was 5307/315,010 discharges (1.7%). The odds of being admitted with BSI-POA were greatest among patients admitted with renal failure, chronic dermatitis, malignancies and prior hospitalisation. Odds ratios and 95% confidence intervals (CI) were 2.72 (95% CI = 2.56-2.88), 2.15 (95% CI = 1.97-2.34), 1.76 (95% CI = 1.64-1.88) and 1.59 (95% CI = 1.50-1.69), respectively. The largest proportion of BSI-POA presented with Staphylococcus aureus (48.4%), followed by Enterococcus faecalis/faecium (20.3%), Klebsiella pneumoniae (16.2%), Streptococcus pneumoniae (8.7%), Pseudomonas aeruginosa (4.2%) and Acinetobacter baumannii (2.2%). Overall, 44% of those admitted from nursing homes presented with antibiotic resistant strains versus 34% from other hospitals and 31% from private homes (P = 0.002). CONCLUSION: Understanding the risk factors of patients who present to the hospital with BSI could enable timely interventions and better patient outcomes.

Prevalence of multidrug-resistant gram-negative bacteria among nursing home residents: A systematic review and meta-analysis.

BACKGROUND: Multidrug-resistant gram-negative bacteria (MDR-GNB) are associated with an increasing proportion of infections among nursing home (NH) residents. The objective of this systematic review and meta-analysis was to critically review evidence of the prevalence of MDR-GNB among NH residents. METHODS: Following Meta-Analysis of Observational Studies in Epidemiology guidelines, a systematic review of literature for the years 2005-2016 using multiple databases was conducted. Study quality, appraised by 2 reviewers, used Downs and Black risk of bias criteria. Studies reporting prevalence of MDR-GNB colonization were pooled using a random effects meta-analysis model. Heterogeneity was assessed using Cochran Q and I2 statistics. RESULTS: Of 327 articles, 12 met the criteria for review; of these, 8 met the criteria for meta-analysis. Escherichia coli accounted for the largest proportion of isolates. Reported MDR-GNB colonization prevalence ranged from 11.2%-59.1%. Pooled prevalence for MDR-GNB colonization, representing data from 2,720 NH residents, was 27% (95% confidence interval, 15.2%-44.1%) with heterogeneity (Q = 405.6; P = .01; I2 = 98.3). Two studies reported MDR-GNB infection rates of 10.9% and 62.7%. CONCLUSION: Our findings suggest a high prevalence of MDR-GNB colonization among NH residents, emphasizing the need to enhance policies for infection control and prevention (ICP) in NHs.