Evaluation of low acuity patients discharged from a virtual emergency department at a major urban academic health sciences centre in Toronto, Canada.

Objective In response to the COVID-19 pandemic, Sunnybrook Health Sciences Centre launched the first virtual emergency department (VED) in Toronto, Ontario. The objective of this pilot project was to leverage linked administrative data to describe the healthcare utilization of VED patients compared to matched patients who attended an ED in person. Approach Evaluation of the VED program was supported by the ICES Applied Health Research Question Program, which is funded by the Ontario Ministry of Health to answer questions directly related to Ontario healthcare policy, planning, or practice. VED visit records from December 2020 to May 2021 were linked with Ontario administrative data. VED patients with low acuity complaints were matched 1:1 with in-person ED comparators according to visit date, presenting complaint, and a propensity score that incorporated age, sex, comorbidities, and other important potential confounders. The primary outcomes were healthcare utilization within 7 days and all-cause mortality within 30 days. Results Of the 609 eligible patients discharged from the VED, 600 (98.5%) were successfully matched to a comparator. Mean (SD) age was 43.0 (21.1) and 64.1% were female. In-person ED revisits and hospitalizations were similar for VED and comparator patients at 72 hours (ED: 12.1% vs. 11.3%; Δ 0.8%, 95%: -2.8, 4.5%; hospitalization:  1.2% vs. 1.5%; Δ 0.3%, 95%: -0.7, 1.4%,) and 7 days (ED: 16.1% vs. 14.4%; Δ 1.7, 95%: -2.4, 5.7%; hospitalization: 1.7% vs. 1.8%; Δ 0.2%, 95%: -0.1, 1.4%) following the index visit. The number of patients visiting a primary care provider within 7 days was also similar between groups (36.7% vs. 32.4%; Δ 4.3, 95%: -1.1, 9.8%). No patients died within 30 days. Conclusion/Implications VED patients and their matched comparators had similar healthcare utilization in the 7 days following their index ED visit. Methodology from this study will inform a province-wide evaluation of VED programs across Ontario

Risk factors for adverse outcomes in women with high-risk pregnancy and their neonates, Haiti

Objectives. To determine the prevalence of maternal death, stillbirth and low birthweight in women with (pre-) eclampsia and complicated pregnancies or deliveries in Centre de Références des Urgences Obstétricales, an obstetric emergency hospital in Port-au-Prince, Haiti, and to identify the main risk factors for these adverse pregnancy outcomes. Methods. We conducted a retrospective cohort study of pregnant women admitted to Centre de Référence des Urgences Obstétricales between 2013 and 2018 using hospital records. Risk factors investigated were age group, type of pregnancy (singleton, multiple), type of delivery and use of antenatal care services. Results. A total of 31 509 women and 24 983 deliveries were included in the analysis. Among these, 204 (0.6%) maternal deaths (648 per 100 000 women giving birth), 1962 (7.9%) stillbirths and 11 008 (44.1%) low birthweight neonates were identified. Of all admissions, 10 991 (34.9%) were women with (pre-)eclampsia. Caesarean section significantly increased the risk of maternal death in the women with a complicated pregnancy and women with (pre-)eclampsia, but reduced the risk of stillbirth in such women. Not attending antenatal care was associated with a significantly higher risk of stillbirth (odds ratio (OR) 4.82; 95% confidence interval (CI) 3.55–6.55) and low birthweight (OR 1.40; 95% CI 1.05–1.86) for women with complicated pregnancies. Conclusion. To prevent and treat pregnancy complications as early as possible, antenatal care attendance is crucial. Improving the quality of and access to antenatal care services and providing it free to all pregnant women in Haiti is recommended

Rectal screening displays high negative predictive value for bloodstream infections with (ESBL-producing) gram negative bacteria in neonates with suspected sepsis in a low-resource setting neonatal care unit.

Objectives We analysed the concordance of rectal swab isolates and blood culture for Gram-negative bacteria (GNB) isolates in neonates with a suspicion of neonatal sepsis admitted to a neonatal care unit in Haiti. Methods We matched pairs of blood and rectal samples taken on the date of suspected sepsis onset in the same neonate. We calculated the proportion of rectal isolates in concordance with the blood isolates by species and genus. We calculated the negative predictive value (NPV) for GNB and extended-spectrum β-lactamase (ESBL)-producing GNB for all rectal and blood isolate pairs in neonates with suspected sepsis. Results We identified 238 blood and rectal samples pairs, with 238 blood isolate results and 309 rectal isolate results. The overall concordance in genus and species between blood and rectal isolates was 22.3% [95% confidence interval (CI) 17.4–28.0%] and 20.6% (95% CI 16.0–26.2%), respectively. The highest concordance between blood and rectal isolates was observed for samples with no bacterial growth (65%), followed byKlebsiella pneumoniae (18%) and Klebsiella oxytoca (12%). The NPV of detecting GNB bacterial isolates in rectal samples compared with those in blood samples was 81.6% and the NPV for ESBL-positive GNB was 92.6%. Conclusions The NPV of rectal swab GNB isolates was high in all patient groups and was even higher for ESBL-positive GNB. Clinicians can use the results from rectal swabs when taken simultaneously with blood samples during outbreaks to inform the (de-)escalation of antibiotic therapy in those neonates that have an ongoing sepsis profile

Virtual care use prior to emergency department admissions during a stable COVID-19 period in Ontario, Canada.

BackgroundThe increased use of telemedicine to provide virtual outpatient visits during the pandemic has led to concerns about potential increased emergency department (ED) admissions and outpatient service use prior to such admissions. We examined the frequency of virtual visits use prior to ED admissions and characterized the patients with prior virtual visit use and the physicians who provided these outpatient visits.MethodsWe conducted a retrospective, population-based, cross-sectional analysis using linked health administrative data in Ontario, Canada to identify patients who had an ED admission between July 1 and September 30, 2021 and patients with an ED admissions during the same period in 2019. We grouped patients based on their use of outpatient services in the 7 days prior to admission and reported their sociodemographic characteristics and healthcare utilization.ResultsThere were 1,080,334 ED admissions in 2021 vs. 1,113,230 in 2019. In 2021, 74% of these admissions had no prior outpatient visits (virtual or in-person) within 7 days of admission, compared to 75% in 2019. Only 3% of ED admissions had both virtual and in-person visits in the 7 days prior to ED admission. Patients with prior virtual care use were more likely to be hospitalized than those without any outpatient care (13% vs 7.7.%).InterpretationThe net amount of ED admissions and outpatient care prior to admission remained the same over a period of the COVID-19 pandemic when cases were relatively stable. Virtual care seemed to be able to appropriately triage patients to the ED and virtual visits replaced in-person visits ahead of ED admissions, as opposed to being additive

Rectal screening displays high negative predictive value for bloodstream infection with (ESBL-producing) Gram-negative bacteria in neonates with suspected sepsis in a low-resource setting neonatal care unit

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Virtual care use prior to emergency department admissions during a stable COVID-19 period in Ontario, Canada

Background The increased use of telemedicine to provide virtual outpatient visits during the pandemic has led to concerns about potential increased emergency department (ED) admissions and outpatient service use prior to such admissions. We examined the frequency of virtual visits use prior to ED admissions and characterized the patients with prior virtual visit use and the physicians who provided these outpatient visits. Methods We conducted a retrospective, population-based, cross-sectional analysis using linked health administrative data in Ontario, Canada to identify patients who had an ED admission between July 1 and September 30, 2021 and patients with an ED admissions during the same period in 2019. We grouped patients based on their use of outpatient services in the 7 days prior to admission and reported their sociodemographic characteristics and healthcare utilization. Results There were 1,080,334 ED admissions in 2021 vs. 1,113,230 in 2019. In 2021, 74% of these admissions had no prior outpatient visits (virtual or in-person) within 7 days of admission, compared to 75% in 2019. Only 3% of ED admissions had both virtual and in-person visits in the 7 days prior to ED admission. Patients with prior virtual care use were more likely to be hospitalized than those without any outpatient care (13% vs 7.7.%). Interpretation The net amount of ED admissions and outpatient care prior to admission remained the same over a period of the COVID-19 pandemic when cases were relatively stable. Virtual care seemed to be able to appropriately triage patients to the ED and virtual visits replaced in-person visits ahead of ED admissions, as opposed to being additive.</p

Evidence of transmission of Clostridium difficile in asymptomatic patients following admission screening in a tertiary care hospital.

BackgroundClostridium difficile (CD) is the leading cause of infectious health-care associated diarrhea. However, little is known regarding CD carriage and transmission amongst asymptomatic colonizers. We evaluated carriage, characterized strains and examined epidemiologic linkages in asymptomatic colonized CD patients.MethodsRectal swabs from asymptomatic patients admitted to the general medicine ward from April 1-June 30 2012 were collected. PCR-confirmed CD colonies were ribotyped and characterized by Modified-Multi Locus Variable Number Tandem Repeat Analysis (MMLVA).Results1549-swabs were collected from 474-patients. Overall, 50/474(10.6%) were CD PCR-positive, 24/50 were colonized at admission, while 26/50 were first identified > = 72 hours after admission. Amongst the 50 CD PCR-positive patients, 90% were asymptomatically colonized and 80% of individuals carried toxigenic CD-strains, including ribotype-027 (5/45:11%). MMLVA revealed five-clusters involving 15-patients harboring toxigenic (4/5) and non-toxigenic CD strains (1/5). In two clusters, patients were CD positive on admission while in the other three clusters involving 10 patients, we observed CD transmission from asymptomatically colonized patients to 8 previously CD-negative patients.ConclusionsWe identified increasing rates of colonization during admission to medical wards. MMLVA typing effectively discriminated between strains and suggests that 20% of patients with CD colonization acquired their strain(s) from asymptomatically colonized individuals in hospital

Emergence of Carbapenemase-Producing Enterobacteriaceae, South-Central Ontario, Canada

We analyzed population-based surveillance data from the Toronto Invasive Bacterial Diseases Network to describe carbapenemase-producing Enterobacteriaceae (CPE) infections during 2007–2015 in south-central Ontario, Canada. We reviewed patients’ medical records and travel histories, analyzed microbiologic and clinical characteristics of CPE infections, and calculated incidence. Among 291 cases identified, New Delhi metallo-β-lactamase was the predominant carbapenemase (51%). The proportion of CPE-positive patients with prior admission to a hospital in Canada who had not received healthcare abroad or traveled to high-risk areas was 13% for patients with oxacillinase-48, 24% for patients with New Delhi metallo-β-lactamase, 55% for patients with Klebsiella pneumoniae carbapenemase, and 67% for patients with Verona integron-encoded metallo-β-lactamase. Incidence of CPE infection increased, reaching 0.33 cases/100,000 population in 2015. For a substantial proportion of patients, no healthcare abroad or high-risk travel could be established, suggesting CPE acquisition in Canada. Policy and practice changes are needed to mitigate nosocomial CPE transmission in hospitals in Canada