Emergency department (ED) clinical decision-making, specifically for transfer or disposition decisions, has been challenging to characterize. The purpose of this descriptive study is to identify the work system elements that influence the ED disposition decision-making process and to identify those work system elements that vary under low and high demands. We conducted a work systems analysis of 20 contextual inquiry-based ED visit observations and 18 semi-structured interviews with ED clinicians. Results identified work system elements not previously characterized (i.e., physical environment) and revealed that a subset of elements within the ED work system vary with demand. To fully elucidate the meaning and effect of these differences, we must develop a systematic approach to eliciting the influence each work system element has on disposition decision-making process performance.

INTRODUCTION:The COVID-19 pandemic caused unprecedented operational stress on hospital-based antimicrobial stewardship programs (ASP). We utilized a systems engineering framework to characterize multi-level systems challenges to and strategies for resilient, hospital-based antimicrobial stewardship (AMS) during the COVID-19 pandemic. METHODS:Using a national data set, we identified hospitals that had significant COVID-19 burden. We conducted semi-structured interviews with pharmacists, physicians and quality leaders involved in ASPs during the pandemic at those hospitals. Interview guides were developed using the Systems Engineering Initiative for Patient Safety (SEIPS) framework. Transcribed interviews were analyzed using deductive content analysis. RESULTS:We interviewed 37 participants from 22 different healthcare systems across the country. Challenges to resilient ASP included physician employment model; limited AMS resources; staff shortages due to illness; shift in priorities; increased workload; remote work; and therapeutic momentum. Preexisting strategies to promote resilient AMS included system-wide AMS; decentralized AMS; excellent interprofessional relationships; strong culture of AMS and embracing incremental change. Real-time response strategies included ability to prioritize well; consistency with AMS work; being flexible and adopting change; intensifying infectious disease engagement; dedication to the profession; and reliance on automated tools and technology. CONCLUSION:Using a systems engineering informed qualitative approach, participants identified many modifiable challenges to AMS resiliency. Given the unfortunate reality that infectious disease pandemics and periods of operational stress are likely to occur in the future, we recommend that healthcare system leadership utilize the preexisting and real-time response strategies identified in this manuscript as a roadmap to ASP preparedness and a more proactive future response.

BACKGROUND:Cellulitis is overdiagnosed in up to 36% of emergency department (ED) cases. Teledermatology has been proposed as a solution to reduce diagnostic misclassification yet there is a paucity of data supporting this approach. OBJECTIVE:To compare cellulitis diagnostic discordance, confidence and perceived difficulty of diagnosis between emergency medicine (EM); dermatology (Derm); and infectious diseases (ID) physicians using information available during teledermatology conditions. METHODS:We conducted a secondary analysis of adult patients presenting to the ED for an acute skin complaint of the lower extremity. A consensus panel of six acute care physicians independently reviewed cases and determined cellulitis diagnosis. We then compared diagnostic discordance, confidence, and perceived difficulty between the three specialties using chi-squared tests. RESULTS:201 participants were included in this analysis. Diagnostic discordance did not vary significantly by specialty (Derm: 15.7%; EM: 12.9%; ID: 17.7%; p = 0.176). There were significant differences in the confidence of diagnosis with ID physicians being very certain 38% of the time compared to Derm, 19%, and EM, 17% (p < 0.001) and in ratings of difficulty with ID physicians rating the diagnosis as very easy in 35% of cases compared to Derm: 13%, and EM: 14% (p < 0.001). CONCLUSIONS:Under conditions that replicate teledermatology, cellulitis diagnosis did not differ by specialty. These findings suggest that diagnostic acumen is not a primary driver of ED cellulitis overdiagnosis. Future research aimed at improving cellulitis diagnosis should focus on interventions and clinical tools that target reported barriers, such as diagnostic uncertainty and access to follow-up care.

The emergency department (ED) is characterised by varied demands. Yet, processes like ED disposition decision-making have been previously conceptualised as occurring similarly regardless of demand. The goal of this study was to develop a reproducible methodological approach to operationalising configuration by identifying the factors that most strongly shape the ED disposition decision-making process under conditions of low and high demand. Using a modified Delphi approach consisting of surveys sent to ED clinicians, we identified the influence of 32 work system elements on the disposition decision-making process under varied demands. Fifty-nine percent of elements were given similar ratings under low and high demand. Variations in ratings represent meaningful differences in the ED work system structure. Understanding how the influence of ED work system elements varies across the demand continuum can support the translation of descriptive findings into prescriptive insights that can inform and prioritise future research or system design.

Background. Significant concerns have been raised regarding the overuse of antibiotics among patients hospitalized for coronavirus disease 2019 (COVID-19) and the broad impact of the pandemic on antimicrobial stewardship in acute care. We sought to compare potentially unnecessary antibiotic prescribing over time among patients admitted with symptomatic COVID-19 and non-COVID-19 viral acute respiratory tract infections (ARTIs). Methods. We conducted a repeated cross-sectional analysis of the monthly antibiotic prescribing rate from March 2020 to December 2023 for COVID-19 admissions and from January 2019 to December 2023 for other viral ARTI admissions to 803 acute care hospitals in the United States that contributed data to the Premier Healthcare Database. Our primary outcome was the receipt of >= 1 dose of an antibiotic during the first 5 days of the admission. Secondary outcomes included days and duration of antibiotic therapy. Results. This study included 513 698 COVID-19 and 106 932 non-COVID-19 viral ARTI admissions from March 2020 to December 2023. At the onset of the pandemic, >80% of patients admitted for COVID-19 received antibiotics, and antibiotic prescribing for other viral ARTIs increased to nearly 70%. Antibiotic prescribing for these viral infections declined over time, with prescribing for COVID-19 stabilizing around 35% in 2022-2023 and prescribing for other viral ARTIs returning to 2019 seasonal patterns in 2023, with average monthly prescribing around 50%. Conclusions. Despite improvements since the early part of the COVID-19 pandemic, potentially unnecessary antibiotic prescribing for inpatients with COVID-19 and non-COVID-19 viral ARTIs remains an important antibiotic stewardship target.

Abstract Background The COVID-19 pandemic was an unprecedented stress test for hospital-based antimicrobial stewardship (AMS) programs. The purpose of this study was to characterize strategies for AMS program resiliency during the COVID-19 pandemic. Methods Using a national dataset, we identified hospitals according to three criteria: 1.) significant COVID-19 burden; 2.) appropriate antibiotic prescribing patterns before the pandemic; and 3.) maintenance of appropriate antibiotic prescribing patterns during the pandemic. We conducted semi-structured interviews with pharmacists, physicians and quality leaders involved in AMS during the pandemic from identified hospitals. Interview guides were developed using the Systems Engineering Initiative for Patient Safety (SEIPS) framework. Transcribed interviews were analyzed iteratively using content analysis directed by the SEIPS model. Results We conducted 30 interviews from 19 unique high-performing health care systems across the country. We interviewed 17 pharmacists, 12 physicians and 1 infection prevention nurse. Resilient AMS strategies in place pre-pandemic included positive hospital wide AMS culture (organization); system-wide AMS programs (organization); decentralized antimicrobial stewardship (organization); strong interprofessional relationships (organization & person); infectious disease involvement (person); protocols to facilitate pharmacist autonomy (organization & tools and technology) and automated tools to facilitate AMS program activities (tools and technology). Additionally, the following strategies were implemented during the pandemic to withstand increased workload and the rapidly evolving pandemic: prioritization of highest yield stewardship interventions (organization & task); and organizational flexibility (organization). Conclusion Using a systems engineering informed qualitative approach, we characterized work system strategies to promote resiliency among AMS programs during the COVID-19 pandemic which should inform future efforts to promote AMS program resiliency during periods of health system stress. Disclosures All Authors: No reported disclosures

Objective: Skin and soft tissue infections (SSTIs) account for over 2.8 million annual emergency department (ED) visits and often result in suboptimal antibiotic therapy. The objective of this study was to evaluate a set of interventions in minimizing inappropriate prescription of antibiotics for presumed SSTIs in the ED.Design: Case vignette survey.Participants: A national sample of emergency medicine (EM) physicians.Methods: Each vignette described a clinical scenario of a presumed SSTI (cellulitis or abscess) and included a unique combination of zero to five interventions (outpatient follow-up, inappropriate antibiotic request flag, thermal imaging for cellulitis or rapid wound MRSA PCR for abscess, patient education/shared decision-making, and clinical decision support). Out of 64 possible vignettes, we asked participants to respond to eight vignettes. Following each vignette, we asked participants if they would prescribe an antibiotic in their everyday practice (yes/no). We built adjusted hierarchical logistic regression models to estimate the probability of prescribing an antibiotic for each intervention and vignette.Results: Surveys were completed by 113 EM physicians. The thermal imaging, rapid wound MRSA PCR, and patient education/shared decision-making interventions showed the largest decrease (15-20%) in antibiotic prescribing probability. Vignettes with a combination of both a diagnostic intervention (thermal imaging or rapid wound MRSA PCR) and a patient education/shared decision-making intervention had the lowest prescribing probabilities.Conclusion: We recommend future research focuses on the development and integration of novel diagnostic tools to identify true infection and incorporate shared decision-making to improve diagnosis and management of SSTIs.

BACKGROUND:Prior studies have found increases in sepsis-related mortality among patients with non-English language preference (NELP) vs. English language preference (ELP) in the inpatient setting, even after controlling for demographic, illness severity, and clinical encounter variables. It is unclear if disparities in sepsis care extend to the emergency department. OBJECTIVE:We compared time to sepsis alert and antibiotics between patients with NELP vs. ELP overall and by emergency severity index (ESI) subgroup. METHODS:In this retrospective observational cohort study, the independent variable was preferred language, and the dependent variables were time to sepsis alert (clinician-initiated vs. automatic) and antibiotics. We developed multivariable adjusted plus inverse probability of treatment weight (IPTW) Cox proportional hazard models. RESULTS:There were no overall differences in the time to sepsis alerts or time to antibiotic administration. In the ESI 2 subgroup, NELP patients had faster time to sepsis alert than ELP patients in clinician-initiated alerts (clinician-initiated: absolute difference: 17 min; covariate +IPTW: HR: 1.76, 99.44% CI 1.22, 2.54, p < 0.001). Within the ESI 3 to 5 subgroup, among patients with a clinician-initiated alert, NELP patients had slower time to sepsis alert than ELP patients (absolute difference: 17 min; covariate +IPTW: HR: 0.64, 99.44% CI 0.44, 0.94, p = 0.012). CONCLUSION:While we found no overall differences in time to sepsis alert, there were significant differences in subgroups, suggesting that language preference may be associated with triage score assignment and sepsis recognition. The lack of differences observed in time to antibiotics underscores the potential for thoughtfully designed best practice alerts to support equitable clinical practice.

Abstract Background The COVID-19 pandemic stressed antimicrobial stewardship (AMS) programs with increased workloads and lack of guidance on the treatment of COVID-19. Throughout the pandemic, COVID-19 patients have received antibiotics for this viral illness despite reported low rates of confirmed bacterial co-infections. The purpose of this study was to identify challenges to and strategies for successful antibiotic stewardship for COVID-19 inpatients. Part 1 of Table 1 Methods We utilized the Premier Healthcare Database to identify hospitals with appropriate antibiotic prescribing before and maintained during the pandemic while facing significant COVID-19 patient burden. We conducted semi-structured interviews with pharmacists, physicians, and quality leaders involved in AMS during the pandemic. Interview guides were developed according to participants’ roles using the Systems Engineering Initiative for Patient Safety (SEIPS) framework. Interviews were recorded, transcribed, and analyzed iteratively using directed content analysis guided by the SEIPS model. Part 2 of Table 1 Results We conducted 30 interviews from 19 different high-performing health care systems across the country. We interviewed 17 pharmacists, 12 physicians and 1 nurse. The main challenges participants identified included lack of knowledge and formal guidance on how to treat COVID-19, feelings of helplessness, and diagnostic uncertainty. Strong, clear leadership from hospital leaders or infectious disease groups, organizational and national guidelines and clinical experience caring for COVID-19 helped providers overcome lack of knowledge, and guidelines on how to treat COVID-19 assuaged feelings of helplessness. Diagnostic tools including host response biomarkers (e.g. procalcitonin) and chest imaging were utilized and incorporated into workflows to help overcome diagnostic uncertainty and guide antibiotic prescribing. Part 3 of Table 1 Conclusion Successful strategies for COVID-19 antibiotic stewardship included overcoming knowledge gaps with clear leadership from infectious disease teams and implementation of structured COVID-19 diagnostic and treatment guidelines. Disclosures All Authors: No reported disclosures

Background Cellulitis is misdiagnosed in 19 % to 34 % of emergency department (ED) cases resulting in excess healthcare spending and threatening patient safety. The objectives of this planned secondary analysis was to report the proportion of cellulitis misdiagnosis in the ED. Secondarily, we evaluated the potential impact of diagnostic adjuncts on misdiagnosis rates. Methods We prospectively enrolled ED patients presenting with acute lower extremity dermatologic complaints involving visible erythema (potential cellulitis). We abstracted the treating physician's diagnosis from the medical chart. Consensus diagnosis was determined by a group of six independent, multidisciplinary physicians. The treating ED physician's diagnosis was compared to the consensus panel diagnosis to identify errors. We evaluated the potential impact of two individual diagnostic adjuncts, skin surface temperature measurement and the ALT-70 score, plus a combination of both, on reducing cellulitis diagnostic errors Results The final sample included 201 patients. The diagnosis assigned by the treating physician and consensus panel was discordant in 50 of 201 cases (24.9 %). Among patients with an ED physician diagnosis of cellulitis, 35.6 % were overdiagnosed (48/135). In cases diagnosed as cellulitis, utilization of skin surface temperature, the two-level ALT-70 and the combination measure would have yielded an absolute reduction in cellulitis overdiagnosis by 8.9 %, 5.7 % and 13.0 % of cases respectively Conclusion Consistent with other reports, we observed a high rate of cellulitis overdiagnosis, highlighting the need for diagnostic support interventions. Proposed diagnostic adjuncts had an overall positive theoretical impact on overdiagnosis and should be evaluated in prospective interventional trials

Background Significant concerns have been raised regarding the overuse of antibiotics among patients hospitalized for coronavirus disease 2019 (COVID-19) and the broad impact of the pandemic on antimicrobial stewardship in acute care. We sought to compare potentially unnecessary antibiotic prescribing over time among patients admitted with symptomatic COVID-19 and non–COVID-19 viral acute respiratory tract infections (ARTIs). Methods We conducted a repeated cross-sectional analysis of the monthly antibiotic prescribing rate from March 2020 to December 2023 for COVID-19 admissions and from January 2019 to December 2023 for other viral ARTI admissions to 803 acute care hospitals in the United States that contributed data to the Premier Healthcare Database. Our primary outcome was the receipt of ≥1 dose of an antibiotic during the first 5 days of the admission. Secondary outcomes included days and duration of antibiotic therapy. Results This study included 513 698 COVID-19 and 106 932 non–COVID-19 viral ARTI admissions from March 2020 to December 2023. At the onset of the pandemic, >80% of patients admitted for COVID-19 received antibiotics, and antibiotic prescribing for other viral ARTIs increased to nearly 70%. Antibiotic prescribing for these viral infections declined over time, with prescribing for COVID-19 stabilizing around 35% in 2022–2023 and prescribing for other viral ARTIs returning to 2019 seasonal patterns in 2023, with average monthly prescribing around 50%. Conclusions Despite improvements since the early part of the COVID-19 pandemic, potentially unnecessary antibiotic prescribing for inpatients with COVID-19 and non–COVID-19 viral ARTIs remains an important antibiotic stewardship target.

We surveyed physicians and patients to create a novel Desirability of outcome ranking (DOOR) for non-severe community-acquired pneumonia (CAP). Patients generally ranked uncomfortable but non-life-threatening symptoms as less desirable, while physicians focused on traditional medical outcomes. When developing DOORs, both patient and clinician perspectives should be considered.

Importance:Patients hospitalized with nonsevere COVID-19 continue to receive community-acquired pneumonia (CAP) antibiotic treatment despite a low risk of bacterial coinfection. Unnecessary antibiotic prescribing contributes to global antibiotic resistance and also poses a threat to individual patients. Objective:To examine the association of CAP antibiotic treatment started on admission with clinical outcomes among a large sample of patients hospitalized for nonsevere COVID-19 in hospitals across the US. Design, Setting, and Participants:This retrospective cohort study used a target trial emulation design. Participants were adult, immunocompetent patients admitted to general care for COVID-19 from April 2020 to December 2023 at 1053 US-based acute-care hospitals that contribute data to the Premier Healthcare Database. Patients with nonpneumonia bacterial infections present on admission were excluded. Data were analyzed from April to October 2024. Exposure:Receipt of a CAP antibiotic regimen on the day of admission. Main Outcomes and Measures:The primary outcome was a composite measure of deterioration (vasopressor, high-flow oxygen, noninvasive ventilation, invasive mechanical ventilation, intermediate care, intensive care unit admission) and in-hospital mortality occurring on day 2 or later. The association between receipt of antibiotic therapy and the primary outcome was assessed using propensity methods while adjusting for a broad set of potential confounders, including cotreatments. Results:The cohort included 520 405 patients with COVID-19 (median [IQR] age, 66 [53-78] years; 266 186 [51.2%] male), including 92 708 Black patients (17.8%), 63 619 Hispanic patients (12.2%), and 304 649 White patients (58.5%); 279 656 patients (53.7%) had Medicare insurance. A total of 160 482 patients (30.8%) were treated with a CAP antibiotic regimen on day 1 of admission. The primary composite outcome was higher in the CAP group (20.8%) compared with the unexposed (no antibiotic) group (18.4%), but the difference did not meet the predefined criteria for clinical significance (ASD, 4.1%). Patients who received CAP antibiotics had higher odds of poor clinical outcomes (propensity matched-odds ratio [OR], 1.03 [95% CI, 1.01-1.05]; P = .003; inverse probability treatment weighted-OR, 1.03 [95% CI, 1.02-1.05]; P < .001; standardized mortality ratio weighted-OR, 1.10 [95% CI, 1.08-1.12]; P < .001). Conclusions and Relevance:In this large cohort study of patients hospitalized with nonsevere COVID-19, there was no clinically meaningful difference in outcomes with early antibiotic treatment. Given the risks associated with unnecessary antibiotic treatment, these results argue against routine antibiotic use in this population.

Objectives: The objective of this study was to use a participatory Human Factors Engineering (HFE) approach to identify key design guidelines and design requirements of a patient safety passport (PSP) to improve patient safety at care transition points along the patient journey. Methods: We conducted a work system analysis and participatory design process to integrate the needs of multiple perspectives using cognitive interviews, contextual inquiry, team-based analysis, and codesign sessions. Results: We conducted semistructured interviews (N=29) with clinicians. We also conducted 20 contextual inquiry observations of older adult patients in the emergency department (ED) followed by 20 interviews with the ED clinicians who cared for those patients. We mapped the care transition process that included transitioning to the ED, being seen in the ED, and transitioning from the ED to the next location. We identified 21 categories representing the interaction of work system barriers and facilitators to safe ED care transitions. We identified 5 design guidelines, which provide the overarching conceptual characteristics of a PSP, and 5 design requirements to guide PSP design. Conclusions: Our participatory HFE approach with a multidisciplinary design team identified key design guidelines and requirements for a PSP. Although this work was focused on the ED, a PSP is likely applicable to a range of care transition domains. Future work should seek to validate and refine PSP design requirements and guidelines across domains as part of a learning health system that can transform care transitions to be points of patient safety resilience.

Objective To describe older adult patients’ and care partners’ knowledge broker roles during emergency department (ED) visits. Background Older adult patients are vulnerable to communication and coordination challenges during an ED visit, which can be exacerbated by the time and resource constrained ED environment. Yet, as a constant throughout the patient journey, patients and care partners can act as an information conduit, or knowledge broker, between fragmented care systems to attain high-quality, safe care. Methods Participants included 14 older adult patients ([Formula: see text] 65 years old) and their care partners (e.g., spouse, adult child) who presented to the ED after having experienced a fall. Human factors researchers collected observation data from patients, care partners and clinician interactions during the patient’s ED visit. We used an inductive content analysis to determine the role of patients and care partners as knowledge brokers. Results We found that patients and care partners act as knowledge brokers by providing information about diagnostic testing, medications, the patient’s health history, and care accommodations at the disposition location. Patients and care partners filled the role of knowledge broker proactively (i.e. offer information) and reactively (i.e. are asked to provide information by clinicians or staff), within-ED work system and across work systems (e.g., between the ED and hospital), and in anticipation of future knowledge brokering. Conclusion Patients and care partners, acting as knowledge brokers, often fill gaps in communication and participate in care coordination that assists in mitigating health care fragmentation.

Scope This ESCMID guideline provides evidence-based recommendations to support a selection of appropriate antibiotic use practices for patients seen in the emergency department (ED) and guidance for their implementation.The topics addressed in this guideline are: 1) Do biomarkers or rapid pathogen tests improve antibiotic prescribing and/or clinical outcomes? 2) Does taking blood cultures in common infectious syndromes improve antibiotic prescribing and/or clinical outcomes? 3) Does watchful waiting without antibacterial therapy or with delayed antibiotic prescribing reduce antibiotic prescribing without worsening clinical outcomes in patients with specific infectious syndromes? 4) Do structured culture follow-up programs in patients discharged from the ED with cultures pending improve antibiotic prescribing? Methods An expert panel was convened by ESCMID and the guideline chair. The panel selected in consensus the four most relevant AMS topics according to pre-defined relevance criteria. For each main question for the four topics, a systematic review was performed, including randomized controlled trials and observational studies. Both clinical outcomes as well as stewardship process outcomes related to antibiotic use were deemed relevant. The literature searches were conducted between May 2021 and March 2022. In April 2022, the panel members were formally asked to suggest additional studies that were not identified in the initial searches. Data were summarized in a meta-analysis if possible or otherwise summarized narratively. The certainty of the evidence was classified according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. The guideline panel reviewed the evidence per topic critically appraising the evidence and formulated recommendations through a consensus-based process. The strength of the recommendations was classified as strong or weak. To substantiate the implementation process, implementation trials or observational studies describing facilitators/barriers for implementation were identified from the same searches and were summarized narratively. Recommendations The recommendations on the use of biomarkers and rapid pathogen diagnostic tests focus on the initiation of antibiotics in patients admitted through the ED. Their effect on the discontinuation or de-escalation of antibiotics during hospital stay was not reported, neither was their effect on hospital infection prevention and control practices. The recommendations on watchful waiting (i.e., withholding antibiotics with some form of follow-up) focus on specific infectious syndromes for which the primary care literature was also included. The recommendations on blood cultures focus on the indication in three common infectious syndromes in the ED explicitly excluding patients with sepsis or septic shock.Most recommendations are based on very-low- and low-certainty of evidence, leading to weak recommendations or, when no evidence was available, to best practice statements. Implementation of these recommendations needs to be adapted to the specific settings and circumstances of the ED. The scarcity of high-quality studies in the area of antimicrobial stewardship in the ED highlights the need for future research in this field.

Objective Oropharyngeal dysphagia (dysphagia) is highly prevalent (up to 86%) in hospitalized patients with Alzheimer disease and related dementias (ADRD). This study aims to describe the management and clinical course of dysphagia in hospitalized patients with ADRD. Design Prospective observational cohort study. Setting and Participants The study was conducted across 10 hospitals within a large health system in New York. Participants were older adults with ADRD admitted to the medicine service and diagnosed with dysphagia to liquids on speech-language pathologist (SLP) assessment and were recruited between January and June 2023. Methods Baseline characteristics (eg, dementia Functional Assessment Staging Tool [FAST]), dysphagia management (eg, prescribed diet), and clinical course (eg, dysphagia improvement, respiratory complications) were collected. Results Of patients with ADRD and dysphagia (n = 62), the average age was 86.5 and 66.1% were FAST Stage 7. On admission, 48.4% had pneumonia, 79.0% had delirium, and 69.4% were made nil per os (NPO) for aspiration risk. Of those who received SLP reassessment after diet initiation (n = 25), 76% demonstrated dysphagia improvement; 75% of patients with FAST stage 7 demonstrated improvement. Respiratory complications occurred in 21.0% of patients on the following diets: NPO, nasogastric tube feeding, dysphagia diets, and comfort feeds. In univariate analyses, hospital-acquired dehydration, no dysphagia improvement, and delirium were associated with respiratory complications. Conclusions and Implications The potential for dysphagia improvement in hospitalized patients with ADRD (even those with advanced dementia) highlights the critical need for standardizing reassessment. Further studies are needed to evaluate factors associated with respiratory complications in this population.

Objectives: The COVID-19 pandemic disrupted antimicrobial stewardship and infection prevention operations worldwide, raising concerns for an acceleration of antimicrobial resistance (AMR). Therefore, we aimed to define the scope of peer reviewed research comparing AMR in inpatient bacterial clinical cultures before and after the start of the COVID-19 pandemic. Methods: We conducted a scoping review and searched PubMed, Scopus, and Web of Science through 15 June 2023. Our inclusion criteria were: (1) English language, (2) primary evidence, (3) peer-reviewed, (4) clinical culture data from humans, (5) AMR data for at least one bacterial order/species, (6) inpatient setting, (7) use of statistical testing to evaluate AMR data before and during the COVID-19 pandemic. Reviewers extracted country, study design, type of analysis, study period, setting and population, number of positive cultures or isolates, culture type(s), method of AMR analysis, organisms, and AMR results. Study results were organised by organism and antibiotic class or resistance mechanism. AMR results are also summarised by individual study and across all studies. Results: In total, 4805 articles were identified with 55 papers meeting inclusion criteria. Acinetobacter baumannii, Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Staphylococcus aureus were the most commonly studied organisms. There were 464 bacterial AMR results across all studies with 82 (18%) increase, 71 (15%) decrease, and 311 (67%) no change results. Conclusions: The literature examining the impact of COVID-19 on AMR among inpatients is diverse with most results reflecting no change pre/post pandemic. Ongoing inquiry is needed into evolving patterns in AMR post COVID-19.

Although the emergency department (ED) is the initial care setting for the majority of older adults requiring hospital admission, there is a paucity of ED-based dysphagia research in this at-risk population. This is driven by barriers to dysphagia evaluation in this complex care environment. Therefore, we assessed the reliability of trained, non-clinical ED research staff in administering dysphagia screening tools compared to trained speech pathologists (SLPs). We also aimed to determine perceptual screening discrepancies (e.g. voice change) between clinical and non-clinical staff. Forty-two older adults with suspected pneumonia were recruited during an ED visit and underwent dysphagia (Toronto Bedside Swallow Screening Tool; TOR-BSST©) and aspiration (3-oz water swallow test; 3-oz WST) screening by trained non-clinical research staff. Audio-recordings of screenings were re-rated post-hoc by trained, blinded SLPs with discrepancies resolved via consensus. Cohen’s kappa (unweighted) revealed moderate agreement in pass/fail ratings between clinical and non-clinical staff for both the TOR-BSST© (k = 0.75) and the 3 oz WST (k = 0.66) corresponding to excellent sensitivity and good specificity for both the TOR-BSST (SN = 94