Evaluation of Hospital Antimicrobial Stewardship Programs: Implementation, Process, Impact, and Outcomes, Review of Systematic Reviews.

Antimicrobial Stewardship Programs (ASP) were introduced in healthcare as a public health priority to promote appropriate prescribing of antimicrobials, to reduce adverse events related to antimicrobials, as well as to control the escalating challenges of antimicrobial resistance. To deliver aimed outcome objectives, ASPs involve multiple connected implementation process measures. A systematic review was conducted to evaluate both concepts of ASPs. Guided by PRISMA frames, published systematic reviews (SR) focusing on ASPs restricted to secondary and tertiary healthcare were evaluated over the past 10 years involving all age groups. Out of 265 identified SR studies, 63 met the inclusion criteria. The majority were conducted in Europe and North America, with limited studies from other regions. In the reviewed studies, all age groups were examined, although they were conducted mainly on adults when compared to children and infants. Both process and outcomes measures of ASPs were examined equally and simultaneously through 25 different concepts, dominated by efficacy, antimicrobial resistance, and economic impact, while information technology as well as role of pharmacy and behavioral factors were equally examined. The main broad conclusions from the review were that, across the globe, ASPs demonstrated effectiveness, proved efficacy, and confirmed efficiency, while focused evaluation advocated that developed countries should target medium- and small-sized hospitals while developing countries should continue rolling ASPs across healthcare facilities. Additionally, the future of ASPs should focus on embracing evolving information technology to bridge the gaps in knowledge, skills, and attitude, as well as to enhance appropriate decision making.

Association between depression, happiness, and sleep duration: data from the UAE healthy future pilot study.

BACKGROUND: The United Arab Emirates Healthy Future Study (UAEHFS) is one of the first large prospective cohort studies and one of the few studies in the region which examines causes and risk factors for chronic diseases among the nationals of the United Arab Emirates (UAE). The aim of this study is to investigate the eight-item Patient Health Questionnaire (PHQ-8) as a screening instrument for depression among the UAEHFS pilot participants. METHODS: The UAEHFS pilot data were analyzed to examine the relationship between the PHQ-8 and possible confounding factors, such as self-reported happiness, and self-reported sleep duration (hours) after adjusting for age, body mass index (BMI), and gender. RESULTS: Out of 517 participants who met the inclusion criteria, 487 (94.2%) participants filled out the questionnaire and were included in the statistical analysis using 100 multiple imputations. 231 (44.7%) were included in the primary statistical analysis after omitting the missing values. Participants' median age was 32.0 years (Interquartile Range: 24.0, 39.0). In total, 22 (9.5%) of the participant reported depression. Females have shown significantly higher odds of reporting depression than males with an odds ratio = 3.2 (95% CI:1.17, 8.88), and there were approximately 5-fold higher odds of reporting depression for unhappy than for happy individuals. For one interquartile-range increase in age and BMI, the odds ratio of reporting depression was 0.34 (95% CI: 0.1, 1.0) and 1.8 (95% CI: 0.97, 3.32) respectively. CONCLUSION: Females are more likely to report depression compared to males. Increasing age may decrease the risk of reporting depression. Unhappy individuals have approximately 5-fold higher odds of reporting depression compared to happy individuals. A higher BMI was associated with a higher risk of reporting depression. In a sensitivity analysis, individuals who reported less than 6 h of sleep per 24 h were more likely to report depression than those who reported 7 h of sleep.

Robotic Coronary Revascularization is Feasible and Safe: 10-year Single-Center Experience.

Objective: The purpose of this study is to investigate the outcomes of patients undergoing robotic surgical coronary revascularization whether total endoscopic coronary artery bypass (TECAB) or robotic-assisted minimally invasive direct coronary artery bypass (RA-MIDCAB) in our center. Methods: This is a retrospective single-center study. It was conducted in the heart hospital at Hamad Medical Corporation, Qatar. We retrospectively studied all cases that had single grafts, left internal mammary artery (LIMA) to left anterior descending (LAD) coronary artery through a minimally invasive approach, either TECAB grafting or RA-MIDCAB grafting operations between February 2009 and December 2020. Both procedures were performed with the assistance of the da Vinci robotic system. In TECAB, the robotic system was used to harvest LIMA and perform the anastomosis with LAD. Whereas in RA-MIDCAB, LIMA was harvested by the robotic system but the anastomosis of LIMA to LAD was performed under direct vision through a small anterior thoracotomy incision. Seventy-one patients' files from the medical records department were reviewed. Preoperative data included age, gender, ethnicity, body mass index (BMI), cardiac risk factors, Euro score, presentation, and the results of the cardiac investigations. The intraoperative data were the type of procedure, operative time, and whether the procedure was completed as planned or converted to thoracotomy or sternotomy. The postoperative data included the length of hospital stay, postoperative complications, 3-month clinic follow-up, and the need for repeat coronary angiography or revascularization. Results: We found that our patients' ages ranged from 31 to 70 years. The majority were males, with 64 (90.14%) patients. Thirty-one (44.93%) patients were found to have a BMI of 25-29.9 Kg/m2. Forty-seven (66.2%) patients were hypertensive and 37 (52.11%) were diabetic. Dyslipidemia was reported in 35 (50%) patients. TECAB was the primary procedure in 47 (66.2%) patients and the rest underwent RA-MIDCAB. Only 7 (10.14%) patients underwent a planned hybrid procedure. The procedure was completed as planned in 52 (73.2%) patients. The mean operative time was 355.9 ± 95.79 min. Fourteen (19.72%) TECAB procedures were converted to MIDCAB, whereas 5 (7.04%) required sternotomy. Thirteen (18.3%) patients were extubated on the table, 47 (66%) patients were extubated in <24 h, and 7 (9.8%) patients were extubated after 24 h of the procedure. Forty-two (59%) patients stayed only 24 h in ICU and 24 (33.8%) spent more than 24 h. Blood transfusion was required in 8 (11.2%) patients. Only 2 (2.8%) patients experienced bleeding after the surgery. Postoperative infection was observed in 3 (4.29%) patients. No new cerebrovascular accident was detected among the patients after the procedure. Median postoperative hospital stay was 5 days, interquartile range 2, range (2-39). During the 3-month postoperative follow-up, we found that three unplanned coronary angiographies were required for repeat intervention, one of them for LIMA-LAD anastomosis. No redo surgery was performed. Thirty-day mortality was reported in two patients only. Conclusion: From our experience over more than 10 years in robotic cardiac surgery in Qatar, we believe that robotic coronary revascularization is safe and feasible in selected patients mainly with single vessel coronary artery disease but should be performed in specialized centers and by robotic-trained surgeons.

The Effect of Ivabradine on Hospitalization of Heart Failure Patients: A Retrospective Cohort Study.

BACKGROUND: Ivabradine is recommended in heart failure (HF) patients to reduce cardiovascular death and hospitalization due to worsening of HF symptoms. AIMS AND OBJECTIVES: To study the effect of Ivabradine in addition to guideline-directed medical therapy (GDMT) in a group of HF patients with HR more than 70 bpm, HF with reduced ejection fraction (HFrEF) left ventricular ejection fraction (LVEF ≤ 40%), and New York Heart Association class II-IV. METHODS: The study was conducted at Heart Hospital, Hamad Medical Corporation, Qatar. HF patients with age > 18 years, LVEF ≤40%, on GDMT, and HR of ≥70 bpm were included. The study population was divided into two groups: ivabradine group and non-ivabradine group. The primary outcomes were risk, number and length of hospitalizations due to worsening HF, and cardiovascular mortality. The secondary outcome was all-cause mortality. Baseline characteristics were collected at enrollment. Study outcomes were compared in the two groups by applying Chi-square and Fisher's exact tests. Logistic regression model was applied to assess both hospitalizations and cardiovascular mortality. RESULTS: A total of 111 patients were studied, 37 (33.94%) ivabradine group and 74 (66.67%) non-ivabradine group. Risk of hospitalization was lower in Ivabradine group compared to non-Ivabradine group (odds ratio: 0.43, 95% confidence interval [CI]: 0.16-1.015, P = 0.094). Average length of hospitalization in ivabradine and non-ivabradine groups was 12.54 and 8.91 days, respectively (incidence rate ratio [IRR]: 1.63, 95% CI: 0.79-3.38, P = 0.187). Compared to non-ivabradine, ivabradine patients had lower number of hospitalizations (IRR: 1.13, 95% CI: 0.61-2.11, P = 0.694). Death rate in both ivabradine and non-ivabradine groups was 3. CONCLUSIONS: Ivabradine along with GDMT reduces the risk of hospitalization due to worsening HF symptoms. Ivabradine had no significant effect on cardiovascular mortality and all-cause mortality. HFrEF non-Arabs patients have lower risk, number and length of hospitalization, and mortality compared to Arabs.

Bundle approach used to achieve zero central line-associated bloodstream infections in an adult coronary intensive care unit.

BACKGROUND: Central venous catheterisation is commonly used in critical patients in intensive care units (ICU). It may cause complications and attribute to increase mortality and morbidity. At coronary ICU (CICU) of cardiac hospital, central line-associated bloodstream infection (CLABSI) rate was 2.82/1000 central line days in 2015 and 3.11/1000 central line days in 2016. Working in collaboration with Institute for Healthcare Improvement (IHI), we implemented evidence-based practices in the form of bundles in with the aim of eliminating CLABSI in CICU. METHODS: In collaboration with IHI, we worked on this initiative as multidisciplinary team and tested several changes. CLABSI prevention bundles were tested and implemented, single kit for line insertion, simulation-based training for line insertions, standardised and real-time bundle monitoring by direct observations are key interventions tested. We used model for improvement and changes were tested using small Plan-Do-Study-Act cycles. Surveillance methods and CLABSI definition used according to National Healthcare Safety Network. RESULTS: The CLABSI rate per 1000 patient-days dropped from 3.1 per 1000 device-days to 0.4 per 1000 device-days. We achieved 757 days free of CLABSI in the unit till December 2018 when a single case happened. After that we achieved 602 free days till July 2020 and still counting. CONCLUSIONS: Implementation of evidence-based CLABSI prevention bundle and process monitoring by direct observation led to significant and subsequently sustained improvement in reducing CLABSI rate in adult CICU.

A quality improvement programme to reduce hospital-acquired pressure injuries.

BACKGROUND: At Heart Hospital in Doha, Qatar (HH), 127 pressure injuries (PI) were identified in 2014, corresponding to an incidence of 6.1/1000 patient-days in first 4 months of 2014. Hospital-acquired pressure injury (HAPI) is one of the most common preventable complications of hospitalisation. HAPI significantly increases healthcare costs, including use of resources (dressings, support surfaces, nursing care time and medications). They also have a significant impact on patients in terms of pain, worsened quality of life, psychological trauma and increased length of stay. Working with the Institute for Healthcare Improvement (IHI), we implemented evidence-based practices in all In patient Units at HH with the aim of reducing the number of HAPIs by 60% within 2 years. METHODS: In collaboration with IHI, our multidisciplinary clinical and risk assessment teams tested several changes and implemented a successful programme. The Surface, Skin inspection, Keep moving, Incontinence and Nutrition bundle was implemented. Signs, turning clocks and PI incidence 'calendars' were used in the units as reminders. Attention was paid to endotracheal tube ties in order to address device-related pressure injuries. Counts of HAPI (incidence) and number of PIs per 100 patients surveyed (prevalence) were prominently displayed. Changes were tested using the Plan-Do-Study-Act methodology. Statistical analysis using the independent t-test was applied to detect the significance of any difference in the incidence of HAPI before and after implementation of the changes. RESULTS: The incidence of HAPI dropped from 6.1/1000 patient-days to 1.1/1000 patient-days, an 83.5% reduction. The prevalence, based on quarterly survey fell from 9.7/100 patients surveyed to 2.0/100 patients surveyed, a 73.4% decline. CONCLUSIONS: The interventions proved to be successful, reducing the incidence of PI by >80%. The outcomes were sustained over a 4-year period.

The Impact of SARS-CoV-2 on ST-Elevation Myocardial Infarction Volume, Time to Presentation, and Door-to-Balloon Time: A Report from a High-Volume Statewide Primary Percutaneous Intervention Program.

BACKGROUND: The novel severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) outbreak has affected ST-elevation myocardial infarction (STEMI) care worldwide. Reports from China, Europa, and North America showed a significant decline in STEMI volume with a simultaneous increase in time from symptoms to hospital presentation. AIM: The aim of the study was to study the effect of the SARS-CoV-2 outbreak on primary percutaneous coronary intervention (PPCI) volume performed for STEMI, symptom onset to hospital presentation time (symptom-to-door [S2D]), and door-to-balloon time (D2B) at the main nationwide PPCI center in Qatar. METHODS: A retrospective evaluation of prospectively collected quality improvement cardiac catheterization data in Qatar was performed. PPCI volume and S2D and D2B time during the outbreak from March 9, 2020, to May 14, 2020, were compared with that of the same period from the prior year and the period immediately preceding the outbreak. RESULTS: Since the SARS-CoV-2 outbreak in Qatar, 137 PPCI procedures were performed. There was a 40% reduction in the volume of PPCI when compared with the period immediately preceding the outbreak and 16% reduction in volume when compared with that of the same period in 2019. The median S2D time was 115 min (interquartile range [IQR: 124]), which was not statistically different from that of the preceding period or the same period in 2019. D2B time during the outbreak increased by an average of 7 min when compared with that of the same period preceding the outbreak (median: 47 min [IQR: 28] during the outbreak vs. median: 40 min [IQR: 21] during the preceding period, P = 0.016). CONCLUSION: In a statewide PPCI program in Qatar, we observed a mild reduction in PPCI cases during the SARS-CoV-2 outbreak (16% when compared with the same period in 2019), with a modest increase in D2B time. PPCI can be performed effectively during the SARS-CoV-2 outbreak at very high-volume centers with the adoption of strict infection control measures. With proper training and monitoring, both target D2B and hospital staff safety can be achieved.