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Background: Recently, a singular survey titled “Measure of Moral Distress—Healthcare Professionals,” which addresses shortcomings of previous instruments, has been validated. Aim: To determine how moral distress affects nurses and physicians differently across the various wards of a community hospital. Participant and research context: We distributed a self-administered, validated survey titled “Measure of Moral Distress—Healthcare Professionals” to all nurses and physicians in the medical/surgical ward, telemetry ward, intensive care units, and emergency rooms of a community hospital. Findings: A total of 101 surveys were included in the study. The mean Measure of Moral Distress—Healthcare Professionals score for all respondents was 143.0 (standard deviation = 79.8). The mean Measure of Moral Distress—Healthcare Professionals score was 1.75 greater for nurses than for physicians (92.5 vs 161.5, p < .001), and nurses were 2.52 times more likely to consider leaving their position due to moral distress (68% vs 27%). The mean Measure of Moral Distress—Healthcare Professionals score for moral distress was least prevalent in the medical/surgical ward (92.5, SD = 38.2) and highest in the telemetry ward (197.7, SD = 83.6). The intensive care unit ward had a mean Measure of Moral Distress—Healthcare Professionals score mildly greater than the emergency room. Ethical considerations: No participant identifying information or information connecting a survey response to an individual was collected. This study was approved by the Raritan Bay Medical Center’s Institutional Review Board. Discussion: This study provides insight into the level of moral distress in the community hospital setting. Telemetry nurses experience significantly more than nurses in other wards. Telemetry nurses typically manage patients sicker than medical/surgical wards, however do not have the resources of the critical care units. This scenario presents challenges for telemetry nurses and may explain their elevated moral distress. Conclusion: In community hospitals, telemetry nurses experience a considerably greater amount of moral distress compared to their colleagues in other wards. As measured by the Measure of Moral Distress—Healthcare Professionals questionnaire, moral distress continues to be higher among nurses compared to physicians.

Aim: To assess hypothesized effects of decentralized nursing models on adult inpatient outcomes, patient medical records and satisfaction surveys were analyzed from two rural community hospitals that transitioned from centralized to decentralized nursing unit designs in 2015. Background: The objective to place nurses closer to patients precipitates broad use of decentralized nursing unit designs over models with centralized nurse stations. Decentralized models have been hypothesized to improve patient outcomes, but few studies have empirically measured effects. Methods: A cross-sectional, pre–post study used regression and interrupted time series models of adult inpatient data. Encounter-level patient records and survey responses across both sites were analyzed for a change in length of stay (LOS) and patient satisfaction from the preperiod (centralized) to the postperiod (decentralized). Results: LOS decreased in the postperiod compared to the preperiod at one site, and there was no change in LOS at the other. Patient satisfaction mostly improved at both hospitals in the decentralized model; however, most upward trends started prior to the move, with no change postmove. Patient satisfaction significantly improved regarding quietness at night and overall hospital rating at one hospital and decreased regarding receiving help as soon as wanted at the other hospital. These changes occurred at the time of the move but may not be solely attributable to the decentralized nursing model. Conclusions: Overall, the results were mixed. One hospital experienced positive changes while the other did not, suggesting factors apart from nursing unit design are important to assess.

Objective: To evaluate the use of tocilizumab in a community hospital setting for critically ill patients with severe COVID-19. Design: A retrospective case series Setting: Five community hospitals within 1 urban health system Patients: Adult patients whom received tocilizumab between March 27th, 2020 to April 30th, 2020 for severe COVID-19. Interventions: None. Measurements and Main Results Sixteen patients in total were evaluated from the 5 community hospitals. The mean (± SD) age of the patients was 53.9 ± 9.2 years, 56% were men, and the most common comorbidities present on admission were hypertension (31%) and diabetes mellitus (25%). All patients received at least 1 other treatment modality for COVID-19 (steroids, hydroxychloroquine, or convaslescent plasma). Additionally, all patients on admission to intensive care units had severe COVID-19 with 56% requiring mechanical ventilation with a pre-tocilizumab median (IQR) Pao2: Fio2 of 84 (69 – 108.6), 19% requiring vasopressor support, and inflammatory markers (CRP, LDH, ferritin, and IL-6) were elevated. The median (IQR) tocilizumab dose was 400 mg (400-600) which correlated with a weight-based mean (± SD) dose of 5.4 mg/kg ± 1.3. Of the 16 patients that received tocilizumab, 8 (50%) were discharged home, 7 (44%) died, and 1 (6%) was still hospitalized at the end of data collection. Patients who died were more likely to be older 62 ± 2 years, female (57%), had a higher rate of mechanical ventilation (86%) and vasopressors (43%) use at baseline, and had a higher median (IQR) IL-6 level prior to tocilizumab administration 550 pg/mL (IQR 83-1924). There were no reported adverse drug reactions reported after the administration of tocilizumab for any patient. Conclusions: Our findings do not support the effectiveness of tocilizumab in treatment of severe COVID-19 infection in critically ill patients.

Background: Community hospitals account for over 84% of all hospitals and over 94% of hospital admissions in the United States. In academic settings, implementation of an Inpatient Diabetes Management Service (IDMS) model of care has been shown to reduce rates of hyper- and hypoglycemia, hospital length of stay (LOS), and associated hospital costs. However, few studies to date have evaluated the implementation of a dedicated IDMS in a community hospital setting. Methods: This retrospective study examined the effects of changing the model of inpatient diabetes consultations from a local, private endocrine practice to a full-time endocrine hospitalist on glycemic control, LOS, and 30-day readmission rates in a 267-bed community hospital. Results: Overall diabetes patient days for the hospital were similar pre- and post-intervention (20,191 vs 20,262); however, the volume of patients seen by IDMS increased significantly after changing models. Rates of hyperglycemia decreased both among patients seen by IDMS (53.8% to 42.5%, P < .0001) and those not consulted on by IDMS (33.2% to 29.9%; P < .0001). When examined over time, rates of hypoglycemia steadily decreased in the 24 months after dedicated IDMS initiation ( P = .02); no such time effect was seen prior to IDMS ( P = .34). LOS and 30DRR were not significantly different between IDMS models. Conclusions: Implementation of an endocrine hospitalist-based IDMS at a community hospital was associated with significantly decreased hyperglycemia, while avoiding concurrent increases in hypoglycemia. Further studies are needed to investigate whether these effects are associated with improvements in clinical outcomes, patient or staff satisfaction scores, or total cost of care.

Objectives: Our goal was to optimize infection control of paired environmental control interventions within hospitals to reduce methicillin-resistant Staphylococcus aureus (MRSA), carbapenem-resistant Enterobacteriaceae (CRE), and vancomycin-resistant Enterococci (VRE). Background: The most widely used infection control interventions are deployment of handwashing (HW) stations, control of relative humidity (RH), and negative pressure (NP) treatment rooms. Direct costs of multidrug-resistant organism (MDRO) infections are typically not included in the design of such interventions. Methods: We examined the effectiveness of pairing HW with RH and HW with NP. We used the following three data sets: A meta-analysis of progression rates from uncolonized to colonized to infected, 6 years of MDRO treatment costs from 400 hospitals, and 8 years of MDRO incidence rates at nine army hospitals. We used these data as inputs into an Infection De-Escalation Model with varying budgets to obtain optimal intervention designs. We then computed the infection and prevention rates and cost savings resulting from these designs. Results: The average direct cost of an MDRO infection was $3,289, $1,535, and $1,067 for MRSA, CRE, and VRE. The mean annual incidence rates per facility were 0.39%, 0.034%, and 0.011% for MRSA, CRE, and VRE. After applying the cost-minimizing intervention pair to each scenario, the percentage reductions in infections (and annual direct cost savings) in large, community, and small acute care hospitals were 69% ($1.5 million), 73% ($631K), 60% ($118K) for MRSA, 52% ($460.5K), 58% ($203K), 50% ($37K) for CRE, and 0%, 0%, and 50% ($12.8K) for VRE. Conclusion: The application of this Infection De-Escalation Model can guide cost-effective decision making in hospital built environment design to improve control of MDRO infections.

Background: Significant geographical variations exist in amputation rates and utilization of diagnostic and therapeutic vascular procedures before lower extremity amputations in the United States. The purpose of this study was to evaluate the rates of diagnostic and therapeutic vascular procedures in the year prior to amputation in a contemporary population and correlate with pathological findings of the amputation specimens. Methods: A retrospective analysis was conducted of non-traumatic amputations from 2011 to 2017 at a rural community hospital. We reviewed the proportion of patients undergoing diagnostic (ankle brachial index with duplex ultrasound, computerized tomography angiogram and invasive angiogram) and therapeutic (endovascular and surgical revascularization) vascular procedures in the year prior to amputation. Prevalence of tissue viability and osteomyelitis were evaluated in all amputated specimens and atherosclerotic vascular disease (ASVD) was evaluated in major amputations. We also analyzed primary amputation rates among different subgroups. Results: 698 patients were included with 248 (36%) major amputations and 450 (64%) minor amputations. Any diagnostic procedure was performed in 59% of the major amputations and 49% of the minor amputations (P = 0.01). Any therapeutic revascularization procedure was performed in 34% of the major amputations and 28% of the minor amputations (P = 0.08). The pathology of major amputation specimens revealed severe ASVD in 57% and mild-moderate ASVD in 27% of specimens. Tissue viability was significantly higher in major amputations (90% vs 30%, P = 0.04) and osteomyelitis was significantly higher in minor amputations (50% vs 14%, P = 0.03). Primary amputations were performed in 66% of major amputations, 72% of minor amputations, 81% with mild to moderate ASVD and 54% with severe ASVD. Conclusion: Diagnostic and therapeutic vascular procedures appear under-utilized for patients undergoing lower extremity amputations at a rural community hospital. ASVD rates and tissue viability imply that revascularization could be of significant benefit to avoid major amputation.

The (Spiritual) Self-Assessment Tool Study was designed to test the novel engagement tool’s effectiveness. Providing the (Spiritual) Self-Assessment Tool Study to newly admitted medical patients led to few instances where the tool was completed. Nevertheless, the (Spiritual) Self-Assessment Tool Study patient questionnaire generated significant secondary findings: a third of responding patients consider their hospital care incomplete without their care team having access to (Spiritual) Self-Assessment Tool data. Nursing staff also desire this data, but are unable to access it without the (Spiritual) Self-Assessment Tool or an equivalent source.

Introduction Immune checkpoint inhibitors (ICI) are novel oncolytic therapies associated with various immune related adverse events (irAEs) affecting multiple organ systems, which may have a delayed presentation. Identification of irAEs and prompt initiation of appropriate treatment represents a challenge to clinicians. The purpose of this study was to evaluate the effectiveness of a pharmacy consult service in identification and management of irAEs. Methodology: This was a single center, retrospective study. Patients included were: ≥18 years old, admitted as inpatients, and reported a history of cancer treatment within the last year. A pharmacy consult was developed and implemented for patients who reported a history of ICI therapy within the last year. Education regarding the consult service was provided to select physicians, nurses, and all pharmacists. Primary outcome: percent of admitted patients reporting ICI therapy within the last year, who required pharmacist intervention for an irAE. Secondary outcomes: types of interventions performed, percentage of recommendation acceptance, pharmacist time spent. Results Fifty-one patients received a pharmacy immunotherapy consult. Seventeen patients (33%) met the primary outcome. Thirty-three separate recommendations were made by pharmacists for these 17 patients. The secondary outcomes of interventions made and percentage accepted (n; % accepted): Initiation/adjustment of steroid therapy (20; 40%), placement of a consult for oncology or other specialist (10; 70%), other therapeutic interventions (3; 67%). Average time spent by pharmacist on initial consultations (SD): 29 minutes (15). Conclusion A pharmacy consult service may help to increase identification of patients receiving immune checkpoint inhibitors and initiate timely interventions.

Background Vascular prosthetic graft infections are rare but associated with high morbidity and mortality. Treatment involves removal of the infected graft requiring arteriotomy closure. Previously this was performed with autologous graft, but bovine tissue has increasingly been used. The objective of this paper is to review the community hospital experience with bovine tissue repair in an infected vascular field. Materials and Methods A retrospective review of all cases performed by a single surgeon in a community hospital for infected prosthetic grafts was completed. Sixteen cases were included where bovine tissue was used for repair. Presentation, location of graft, and causative organism were reviewed, and outcomes including reoperation and mortality were recorded. Results Of the 16 patients, 15 (94%) had positive cultures of the graft. Methicillin-Resistant Staph Aureus was the most commonly isolated organism (50%). There were 3 unplanned reoperations including a revision from below to above knee amputation, drainage of a hematoma, and a wound debridement within the first year. Over the 1 year follow up period, 3 patients died for a mortality of 19%. There were no reinfections during follow-up. Discussion Prosthetic graft infection is a rare but serious vascular surgery complication. The causative organism has shifted in the last few years to become increasingly drug resistant. Treatment requires excision, and bovine tissue has been demonstrated to provide a safe and durable method of repair.

Background: A local health authority in Canada implemented its own Antimicrobial Stewardship Program (ASP) which provide guidelines to clinicians to utilize when treating infectious diseases such as community-acquired pneumonia (CAP). Objectives: The primary objective is to describe antibiotic usage patterns at the community hospital’s emergency department (ED) and to analyze the patterns in relation to ASP goals of reducing risk of infections, adverse drug events and antibiotic resistance, and to identify potential areas of improvement. Methods: This retrospective chart review included 156 adult patients with a diagnosis of CAP admitted to a community hospital ED from December 1, 2015 to November 30, 2016. Results: 50.6% patients were prescribed moxifloxacin across all severity of CAP patients. Low and moderate severity CAP patients were most often prescribed antibiotic duration > 7 days. In low, moderate and high severity CAP patients who were treated using ceftriaxone, 100%, 88.9% and 66.6% patients were treated with ceftriaxone 2000 mg daily respectively. Conclusions: Antibiotic prescribing patterns suggest fluoroquinolones were frequently being over-prescribed, ceftriaxone dosages were often too high, and duration of antibiotics for low and moderate severity CAP were too long. More efforts are needed to promote appropriate antibiotic usage and optimize patient care.

Purpose: The aim of this national survey was to assess the overall impact of the coronavirus disease 2019 (COVID-19) pandemic on the provision of interventional radiology (IR) services in Canada. Methods: An anonymous electronic survey was distributed via national and regional radiology societies, exploring (1) center information and staffing, (2) acute and on-call IR services, (3) elective IR services, (4) IR clinics, (5) multidisciplinary rounds, (6) IR training, (7) personal protection equipment (PPE), and departmental logistics. Results: Individual responses were received from 142 interventional radiologists across Canada (estimated 70% response rate). Nearly half of the participants (49.3%) reported an overall decrease in demand for acute IR services; on-call services were maintained at centers that routinely provide these services (99%). The majority of respondents (73.2%) were performing inpatient IR procedures at the bedside where possible. Most participants (88%) reported an overall decrease in elective IR services. Interventional radiology clinics and multidisciplinary rounds were predominately transitioned to virtual platforms. The vast majority of participants (93.7%) reported their center had disseminated an IR specific PPE policy; 73% reported a decrease in case volume for trainees by at least 25% and a proportion of trainees will either have a delay in starting their careers as IR attendings (24%) or fellowship training (35%). Conclusion: The COVID-19 pandemic has had a profound impact on IR services in Canada, particularly for elective cases. Many centers have utilized virtual platforms to provide multidisciplinary meetings, IR clinics, and training. Guidelines should be followed to ensure patient and staff safety while resuming IR services.

Background: Musculoskeletal disorders (MSDs) are the leading cause of pain and disability among nurses and are frequently accompanied by depression. However, the association between the comorbidity of MSDs and depression and working conditions has not been studied, which was the aim of this study. Methods: In 2015, all nurses ( n = 1,102) employed at a community hospital in the Northeast United States were invited to participate in this cross-sectional study. A survey was distributed in which participants were asked to report on MSDs, depressive symptoms, as well as subjective working conditions assessed including physical demands, psychological demands, decision authority, social support, and work–family conflict. Findings: 397 nurses responded (36%), and the prevalence of the comorbidity of MSDs and depression was 14.5%. Poisson regression (PR) models suggested that work–family conflict was associated with increased risk of the comorbidity (PR = 2.18; 95% confidence interval [CI] = 1.33–3.58), as was 8-hour night shift (PR = 2.77; 95% CI = [1.22, 6.31]) or 12-hour day shift (PR = 2.20; 95% CI = [1.07, 4.50]). Other working conditions were not directly associated with the comorbidity. Conclusions/Application to Practice: The comorbidity of MSDs and depression is prevalent among hospital nurses, and work–family conflict and working night shift or longer shifts were significantly associated with this. Effective workplace programs are needed to address nurses’ working conditions to reduce their work–family conflict, thereby improving their musculoskeletal and mental health.

Purpose: Ultrasound-facilitated, catheter-directed, low-dose fibrinolysis (USAT) appears to provide promising results for the management of acute submassive pulmonary embolisms (ASMPEs) at tertiary care centers. This study assessed outcome measures at a community-based hospital systems and compared results to known studies. Materials and Methods: This is a single-center, retrospective study assessing clinical outcomes of the EkoSonic Endovascular System intervention for ASMPEs performed by three surgical 3 subspecialties (interventional radiology, interventional cardiology, and vascular surgery) part of a pulmonary embolism response team (PERT). We reviewed 146 PERT activations from June 2013 to December 2017. Eighty-three patients with ASMPEs underwent USAT. Results: Our study showed greater differences ( P = .01) between baseline and follow-up pulmonary artery systolic pressures (20.9 ± 9.8 mm Hg [n = 14]) compared to the ULTIMA study (12.3 ± 10 mm Hg [n = 30]). Our length-of-stay measures were shorter (6.1 ± 5.1 [n = 83]; P = .0001) compared to the SEATTLE II study (8.8 ± 5.0 [n = 150]). Preprocedure transthoracic echocardiograms (TTEs) were performed for 54 (65%) of 83 patients. Postprocedure TTEs at 48 hours was performed for 52 (62%) of 83 patients. Use of TTEs before and after intervention did not change outcomes. Intracranial hemorrhage was not observed in our patient population. There was no difference in outcomes between the three subspecialties in our study. Conclusions: Use of USAT in a community-based hospital PERT has similar outcomes to tertiary care centers. Furthermore, similar outcomes were observed between the three subspecialties suggesting development of a comprehensive care team for management of ASMPEs.

Hospitalizations can significantly disrupt patient sleep patterns and contribute to insomnia, which places patients at a higher risk of altered mental status as well as other complications. Despite attempts to control environmental factors, deliriogenic medications are often prescribed for the management of hospital-related insomnia. The primary objective of this study is to compare patient-perceived effectiveness of zolpidem versus melatonin in hospitalized patients. All inpatients who received melatonin or zolpidem the previous night as asleep aid and had no acute psychological issues or history of substance abuse were eligible for participation in this single-center, prospective, observational cohort study. The Verran and Snyder-Halpern sleep scale was utilized to evaluate sleep perception in 3 domains: sleep disturbance, effectiveness, and supplementation. A total of 439 patients were screened and 100 patients met study criteria and consented to the study. In the melatonin and zolpidem groups, the estimated adjusted means for the total sleep effectiveness (206.8 mm, 95% confidence interval [CI], 168.7-253.5vs 187.4 mm, 95% CI, 152.8-229.7; P=.513), sleep disturbance(362.1 mm, 95% CI, 310.1-422.7 vs 339.54 mm, 95% CI, 290.8-396.4; P=.573), and sleep supplementation (111.4 mm, 95% CI, 86.3-143.8 vs 120.9 mm, 95% CI, 94.1-155.2; P=.661) domains were not statistically different. Both melatonin and zolpidem were well tolerated with grogginess and headache as the only reported adverse effects. Melatonin demonstrated no significant difference in patient-perceived sleep effectiveness, disturbance, supplementation, or adverse effects when compared to zolpidem.

Objectives: This research aims to explore the perceptions of nursing staff regarding the effects of daylighting on behavioral factors including mood, stress, satisfaction, medical error, and efficiency. Background: In spite of an extensive body of literature seeking to investigate the impact of daylighting on patients, a limited number of studies have been done for the sake of nurses’ perceptions and behavioral responses. Method: A mixed-methods approach, comprised of qualitative explorations (structured interviews) and a validated survey, was applied and the results were compared and triangulated. Five nurses were interviewed and 156 nurses volunteered for a lighting survey from six departments of three inpatient facilities in Iran. Results: The findings of this study are consistent with the existing evidence that daylighting and view to the outside enhance nurses’ perceptions regarding satisfaction, mood, stress, medical error, and alertness, while reducing fatigue and stress. Conclusion: Patient rooms and work stations are the most crucial areas to provide daylighting from nurses’ perspectives.

Purpose As immune checkpoint inhibitors continue to acquire new indications, it is important to understand the impact their use has on patients. This study adds to current literature by presenting an analysis of hospitalizations in this population. The primary objective was to assess the reasons for an emergency department visit or hospital admission in patients who receive immune checkpoint inhibitors. Secondary objectives included identifying the frequency of suspected or confirmed immune related adverse events, types of immune related adverse events, number of preventable admissions, duration of immunotherapy, and length of stay. Methods This study was a retrospective, multi-center, chart review of patients hospitalized after receiving an immune checkpoint inhibitor. The population included patients aged 18 and above who received at least one dose of an immune checkpoint inhibitor at a network facility and had a documented admission within one year following the initiation of immunotherapy. Descriptive statistics were performed along with inferential comparisons and a Poisson regression to determine if the immune checkpoint blocker or cancer type predicted admission or reason for admission. Results The 99 patients who met inclusion criteria had a total of 202 admissions. Of these patients, 56 (56.6%) had multiple admissions within the year following initiation of immunotherapy. The most common diagnoses on initial admissions were shortness of breath, pain, and pneumonia. A total of 104 admissions (51.5%) were considered potentially preventable. Suspected or confirmed immune related adverse events were identified in 15.6% of all admissions. There were no significant predictors of admissions or reason for admission. Conclusion Reasons for admission in the study population were comparable to those identified in the general cancer population, with immune related adverse events being associated with a minority of both total and potentially preventable admissions.

Introduction: Sepsis is a serious and emergency condition that may lead to acute circulatory failure associated with infection. Serum lactate level of over 4 mmol/L is associated with sepsis mortality. However, there is limited data on using a point of care (POC) for fingertip lactate level on sepsis mortality in community hospital setting. This study aimed to evaluate roles of POC for serum lactate with combination of clinical factors on mortality prediction in sepsis patients. Methods: This was a retrospective cohort study conducted at 7 community hospitals. The inclusion criteria were adult patients with diagnosis of sepsis who were tested for POC lactate level. Electronic chart reviews of eligible patients were performed. Predictors for mortality were computed using clinical factors and POC lactate level. Results: There were 1641 patients met the study criteria. The mortality rate was 8.96% (147 patients). There were 3 independent factors associated with mortality: age, co-morbid diseases, and POC lactate level. The adjusted odds ratio (95% CI) of POC lactate level was 1.025 (1.002, 1.048). The cut point of serum lactate was 1.6 mmol/L gave sensitivity of 79.59% and specificity of 32.10%. Conclusion: POC serum lactate level may be associated with mortality in sepsis patients at community hospitals. Lactate level of 1.6 mmol/L may be an indicator for mortality with good sensitivity. Physicians may consider more aggressive and prompt management in individuals with sepsis and POC serum lactate of 1.6 mmol/L or over.

By September 20, 2021, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been pandemic in 237 countries and regions, resulting in 228,506,698 confirmed cases and 4,692,361 deaths. At the same time, a total of 1123 cases of COVID-19 had been confirmed in Beijing, China. Peking University Shougang Hospital has 4 community hospitals with 174 staff members, covering 230,000 residents in Shijingshan district, Beijing. The community hospitals were the basic units of China’s healthcare system for public health services, as the main battlefield for screening and controlling of COVID-19. We reported our experience about the prevention of SARS-CoV-2. We suggest that community hospitals should change their process for admitting patients. While the screening of suspected cases of COVID-19 is vital, patients with suspected infections should be isolated immediately.

Ventilator-associated pneumonia (VAP) is linked to increased morbidity and mortality and clinical protocols (VAP bundles) have evolved to minimize VAP. In 2009, a quality improvement project was implemented at our institution to decrease VAP rates in adult trauma patients. AVAP prevention committee was developed, and formal evidence-based education for the nursing and physician staff was introduced. During the study period (2009–2016), 2380 patients required ICU admission to our Level II trauma center. The mean Injury Severity Score was 33 1 12, and there were 17 per cent penetrating and 83 per cent blunt injuries. The early compliance (2010) with the VAP bundle was 65 per cent. Within one year of the implementation of VAP prevention, the compliance increased to >90 per cent. Compliance has been carefully trended and has remained at 100 per cent. All of the aforementioned interventions have resulted in a sustained dramatic decline in VAP, from 12 per cent in 2009 to 0 per cent in 2016. Ongoing education and ICU policy development has become the mainstay of our trauma ICU program. The introduction of evidence-based care education imparted a culture of excellence resulting in favorable outcomes in high-risk trauma patients related to VAP prevention. Ongoing monitoring and education is required to sustain these promising outcomes.

Background: Intravenous ketamine has been established as an efficacious and safe treatment, with transient effect, for treatment-resistant depression. However, the effectiveness of intravenous ketamine in non-research settings and with ultraresistant depression patients remains understudied. Aims: This study aims to measure the response and remission rates in ultraresistant depression patients in a clinical setting by means of a retrospective, open label, database study. Secondarily, the study will attempt to support previous findings of clinical predictors of effectiveness with intravenous ketamine treatment. Methods: Fifty patients with ultraresistant depression were treated between May 2015–December 2016, inclusive, in two community hospitals in Edmonton using six ketamine infusions of 0.5 mg/kg over 40 min over 2–3 weeks. Data were collected retrospectively from inpatient and outpatient charts. Statistical analysis to investigate clinical predictors of effectiveness included logistic regression analysis using a dependent variable of a 50% reduction in rating scale score at any point during treatment. Results: At baseline, the average treatment resistance was severe, with a Maudsley Staging Method score of 12.1 out of 15, 90.0% were resistant to electroconvulsive therapy, and the average Beck Depression Inventory score was 34.2. The response rate was 44% and remission rate was 16%. As a single predictor, moderate or severe anhedonia at baseline predicted a 55% increased likelihood of response. As a combined predictor, this level of anhedonia at baseline with a diagnosis of bipolar depression predicted a 73% increase in likelihood of response. Conclusion: In a clinical setting, intravenous ketamine showed effectiveness in a complex, severely treatment-resistant, depressed population on multiple medication profiles concurrently. This study gave support to anhedonia and bipolar depression as clinical predictors of effectiveness.

Introduction. We performed a retrospective study to evaluate demographics, clinical course, outcome, and radiological findings of children with respiratory syncytial virus (RSV) infection. Methods. Four hundred patients admitted between October 2013 and May 2016 were enrolled. Clinical and radiographic trends were evaluated for association with severity of RSV presentation. Severity was defined as hospitalization >2 days, pediatric intensive care unit admission, or need for mechanical ventilation. Results. Common clinical findings included fever (78.5%), coughing (97%), rhinorrhea/congestion (93%), and hypoxia (44.8%). Hypoxia was seen in 64.7% of the severe group compared with 32.0% in the nonsevere group ( P < .001). Airspace opacification was seen in 49.2% of chest X-rays of the severe group compared with 26.4% in the nonsevere group ( P < .001). Conclusion. Higher incidence of hypoxia or airspace opacification on chest X-ray may be predictors of poorer outcomes for patients with RSV infection.

Purpose The purpose of this study was to evaluate perinatal outcomes and experiences of managing gestational diabetes (GDM) in a multiethnic cohort from a community hospital. Methods A retrospective cohort study of 647 ethnically diverse women with GDM was conducted. Multivariable logistic regression models were used to examine ethnic differences in cesarean delivery rates and emergency department (ED) utilization during pregnancy. Semi-structured interviews were conducted to evaluate experiences of GDM and perceptions of type 2 diabetes risk. Results Significant differences were observed between sample groups in mother’s age ( P = .004), education level ( P < .001), family history of diabetes ( P < .001), and baby birthweight ( P = .004). In the fully adjusted model, controlling for maternal age, BMI category, ED utilization during pregnancy, and family history of diabetes, Southeast and East Asian women had the lowest rates of cesarean delivery and ED utilization during pregnancy, with significantly higher rates of cesarean delivery in Hispanic, non-Hispanic white, and Asian Indian women ( P < .001). There was preliminary evidence for higher ED utilization rates during pregnancy in Hispanic women with GDM (odds ratio = 3.21; 95% CI, 0.79-4.08; P = .005). Interview analyses reflected strong psychological impact of GDM diagnoses. Women expressed shock and disappointment over diagnoses and highlighted need for psychological support from health care professionals. Risk perceptions for type 2 diabetes were low. Conclusions Findings support significant ethnic differences in cesarean delivery and ED utilization among women with GDM. Qualitative analysis suggests that culturally sensitive approaches informing psychosocial support and dietary recommendations are important considerations for a diverse GDM patient population.

We aimed to determine median cumulative radiation exposure in pediatric intensive care unit (PICU) patients, proportion of patients with high radiation exposure (above annual average radiation per person of 6.2 mSv), and determine risk factors for high exposure. This was a retrospective chart review of PICU patients up to 18 years of age admitted to a large community hospital over 2 years. Radiologic studies and radiation exposure were determined for each patient, and total hospital radiation exposure was classified as high (>6.2 mSv) or not (≤6.2 mSv). Median radiation exposure per patient was 0.2 mSv (interquartile range = 2.1) and 11.7% of patients received >6.2 mSv radiation during their hospitalization. Factors associated with high radiation exposure included admission for trauma or surgery, number of computed tomography scans, age, and PICU length of stay (all P < .0001). We concluded that subsets of PICU patients are at risk of high radiation exposure. Policies and protocols may help minimize radiation exposure among PICU patients.

The proper evaluation of cancer chemotherapy orders is necessary for patients to receive safe and effective treatment. The chemotherapy treatment setting is evolving resulting in hospital pharmacists without extensive oncology training or experience now being responsible for evaluation of chemotherapy orders. The primary objective was to create a step-by-step chemotherapy order evaluation guide with a detailed explanation for each step. The secondary objective was to evaluate non-oncology trained pharmacists' ability to accurately review simulated chemotherapy orders post-education using the guide. A two-page chemotherapy order evaluation guide was created based on an accepted method of chemotherapy order review consisting of the following eight steps: regimen verification, clinical trial protocol verification, body surface area calculation, dose calculation, laboratory values, emesis prophylaxis, adjunctive or supportive care measures, and pharmacy labels. A literature search was performed for each step. A detailed explanation for each step was written as a separate component from the guide to encompass the literature search information and current guidelines in a more comprehensive manner. Non-oncology trained community hospital pharmacists were educated on use of the guide for approximately 30 min. The guide was evaluated using timed simulated chemotherapy orders pre- and post-education consisting of a general chemotherapy order and a carboplatin dosing order. Nineteen pharmacists were tested with simulated chemotherapy orders. A significant difference was detected between the pre- and post-education for both the general chemotherapy (p = 0.00032) order and carboplatin dosing order (p = 0.031).

Background: Despite large interpatient variability in dose response, heparin is utilized for treatment of venous thromboembolism (VTE). Current data on the optimal heparin dosing in obese patients are conflicting. Objective: The objective was to evaluate the time and dose required to achieve a therapeutic activated partial thromboplastin time (aPTT) in nonobese, obese, and severely obese patients using a pharmacist-directed heparin dosing protocol. Methods: This was a retrospective cohort study in a single-center community hospital inpatient setting. Adult patients receiving heparin for VTE treatment from July 1, 2013, to July 31, 2015, were evaluated. Patients were categorized into 3 groups: nonobese (BMI < 30 kg/m2), obese (BMI = 30-39.9 kg/m2), and severely obese (BMI ≥ 40 kg/m2). Data on height, weight, initial bolus dose, initial infusion rate, time to therapeutic aPTT, and therapeutic infusion rate were collected. Dosing body weight (DBW) was utilized for patients 20% over their ideal body weight (IBW). The primary outcome was time to therapeutic aPTT. Results: Analysis included 298 patients. Median times to therapeutic aPTT (hours:minutes) in the nonobese, obese, and severely obese were 15:00 (interquartile range [IQR] = 8:05-23:21), 15:40 (IQR = 9:22-25:10), and 15:22 (IQR = 7.54-23:40), respectively ( P = 0.506). There was no difference in bleeding among the nonobese (14%), obese (13.9%), or severely obese groups (7.9%; P = 0.453). No adverse thrombotic events occurred during hospitalization. Conclusion: Using a DBW for heparin dosing in patients 20% over their IBW resulted in similar times to therapeutic aPTT and adverse events in the nonobese, obese, and severely obese.

Background: Patients who receive early palliative care consults have clinical courses and outcomes more consistent with their goals. Nurses have been shown to be advocates for early palliative care involvement and are able to lead advanced care planning discussions. Objective: The purpose of this study was to assess whether after a brief educational session, nurses at a suburban, community hospital could demonstrate knowledge of palliative care principles, would want to independently initiate end-of-life conversations with patients and families, and would want to place specialty palliative care consults. Design: Four 1 hour presentations were made at 4 nursing leadership council meetings from November through December 2015. Anonymous pre- and post-presentation surveys were distributed and collected in person. Setting/Participant: Nonprofit, suburban, community hospital in Maryland. Participants were full-time or part-time hospital employees participating in a nursing leadership council who attended the presentation. Measurements: We compared responses from pre- and post-presentation surveys. Results: Fifty nurses (19 departments) completed pre-presentation surveys (100% response rate) and 49 nurses completed post-presentation surveys (98% response rate). The average score on 7 index questions increased from 71% to 90%. After the presentations, 86% strongly agreed or agreed that nurses should be able to independently order a palliative care consult and 88% strongly agreed or agreed with feeling comfortable initiating an end-of-life conversation. Conclusion: Brief educational sessions can teach palliative care principles to nurses. Most participants of the study would want to be able to directly consult palliative care and would feel comfortable initiating end-of-life conversations after this educational session.

Introduction Intensivist involvement for patients with sepsis is associated with decreased complications and mortality, and lower hospital resource utilization, but few studies have evaluated outcomes for patients exposed to electronic intensive care unit (eICU) telemedicine sepsis management in the emergency department (ED). In this study, we assess whether eICU cart exposure in the ED improved compliance with components of the 2010 Surviving Sepsis Campaign bundles, length of stay (LOS), disposition and hospital costs. Methods An institutional review board-approved, retrospective cohort study was completed on patients with confirmed sepsis who presented to our ED from July 2010 through February 2013. Results Of 711 patient ED encounters, 314 cases met criteria for analysis (95 exposed and 219 non-exposed). Patient cohorts had similar demographics and comorbid International Classification of Diseases, Ninth Edition (ICD-9) diagnoses. The exposed cohort received antibiotics more quickly (122.3 minutes ±83.3 versus 163.4 minutes ±204.4, p = 0.043) and were more likely to have lactic acid levels drawn within six hours (98.9% vs. 90%, p = 0.019). The exposed cohort had a shortened ED LOS (in days) 0.08 ± 0.28 versus 0.16 ± 0.37, p = 0.036. Hospital LOS, disposition and death were similar in both cohorts. Total hospital costs for the exposed cohort were lower and less variable (US$19,713 ± 16,550 vs. US$24,364 ± 25068), but this was not significant ( p = 0.274). Discussion Our findings suggest that in individuals with confirmed sepsis, ED exposure to a telemedicine-based eICU cart impacted adherence to aspects of the Surviving Sepsis Campaign recommended bundle, but did not impact overall survival and medical costs.

Background: Insulin pen injectors (“pens”) are intended to facilitate a patient’s self-administration of insulin and can be used in hospitalized patients as a learning opportunity. Unnecessary or duplicate dispensation of insulin pens is associated with increased healthcare costs. Methods: Inpatient dispensation of insulin pens in a 240-bed community hospital between July 2018 and July 2019 was analyzed. We calculated the percentage of insulin pens unnecessarily dispensed for patients who had the same type of insulin pen assigned. The estimated cost of insulin pen waste was calculated. A pharmacist-led task force group implemented hospital-wide awareness and collaborated with hospital leadership to define goals and interventions. Results: 9516 insulin pens were dispensed to 3121 patients. Of the pens dispensed, 6451 (68%) were insulin aspart and 3065 (32%) were glargine. Among patients on insulin aspart, an average of 2.2 aspart pens was dispensed per patient, but only an estimated 1.2 pens/patient were deemed necessary. Similarly, for inpatients prescribed glargine, an average of 2.1 pens/patient was dispensed, but only 1.3 pens/patient were necessary. A number of gaps were identified and interventions were undertaken to reduce insulin pen waste, which resulted in a significant decrease in both aspart (p = 0.0002) and glargine (p = 0.0005) pens/patient over time. Reductions in pen waste resulted in an estimated cost savings of $66 261 per year. Conclusions: In a community hospital setting, identification of causes leading to unnecessary insulin dispensation and implementation of hospital-wide staff education led to change in insulin pen dispensation practice. These changes translated into considerable cost savings and facilitated diabetes self-management education.

Objective This study investigated the use of prosthetic condensed polytetrafluoroethylene (cPTFE) for laparoscopic ventral hernia repair (LVHR) in an outpatient community-hospital setting. Methods Patients underwent LVHR with cPTFE at one of three community hospitals. Primary endpoint was hernia recurrence at 1-year postoperatively. Secondary endpoints included pain, surgical site infection, medical/surgical complications, and patient-reported outcomes. Results This study included 65 females and 52 males, aged 46.6 ± 13.2 years (mean ± SD; range 18–84 years). Mean prosthetic size was 413.8 ± 336.11 cm2 (range 165–936 cm2). Mean follow-up was 30 months (range 12–46 months). Hernia recurrence rate was 4.3%. Rate of hospitalization in the first postoperative week was 2.6%. Early and late secondary endpoint complication rates were 24.8% and 27.4%, respectively; pain was the most common complication, followed by seroma (8.5%). Conclusions Outpatient LVHR using cPTFE is feasible in community hospitals. Complication rates were similar to previous reports, and the seroma rate was markedly lower.

Objectives Per the Breast Imaging Reporting and Data System (BI-RADS) manual, a lesion designated as BI-RADS 3 should have less than a 2% chance of becoming malignancy. With this study, we evaluated the outcome of patients given a BI-RADS 3 designation in the community hospital. Specifically, whether our cancer detection rate for BI-RADS 3 lesions was less than 2% and comparable to rates obtained at other institutions. Methods The records of 1037 patients given a BI-RADS 3 on screening mammogram were reviewed over a 1-year period between May 2007 and May 2008. A total of 142 of these patients were lost to follow-up, leaving 885 patients. Some of these patients had more than 1 BI-RADS 3 lesion during this study period, yielding a total of 923 BI-RADS 3 lesions to evaluate out of the 885 patients remaining. Of these, 478 of the patients' lesions were biopsied. The pathology was then reviewed to determine whether the lesions were cancerous. Results Only 6 of the 882 lesions initially classified as a BI-RADS 3 were later diagnosed as cancer, or 0.65% of the study population. The positive predictive value of receiving a BI-RADS 3 was 99.3%, which demonstrates a high accuracy in predicting that a lesion is not cancerous. Conclusion Most lesions that are diagnosed as a BI-RADS 3 have a very low probability of eventually being diagnosed as cancer. The findings from this study are comparable to studies performed at other institutions.

Background: Dexmedetomidine is a widely utilized agent in the intensive care unit (ICU) because it does not suppress respiratory drive and may be associated with less delirium than midazolam or propofol. Cost of dexmedetomidine therapy and debate as to the proper duration of use has brought its use to the forefront of discussion. Objective: To validate the efficacy and cost savings associated with pharmacy-driven dexmedetomidine appropriate use guidelines and stewardship in mechanically ventilated patients. Methods: This was a retrospective cohort study of adult patients who received dexmedetomidine for ICU sedation while on mechanical ventilation at a 433-bed not-for-profit community hospital. Included patients were divided into pre-enactment (PRE) and postenactment (POST) of dexmedetomidine guideline groups. Results: A total of 100 patients (50 PRE and 50 POST) were included in the analysis. A significant difference in duration of mechanical ventilation (11.1 vs 6.2 days, P = 0.006) and incidence of reintubation (36% vs 18% of patients, P = 0.043) was seen in the POST group. Aggregate use of dexmedetomidine 200-µg vials (37.1 vs 18.4 vials, P = 0.010) and infusion days (5.4 vs 2.5 days, P = 0.006) were significantly lower in the POST group. Dexmedetomidine acquisition cost savings were calculated at $374 456.15 in the POST group. There was no difference between the PRE and POST groups with regard to ICU length of stay, expected mortality, and observed mortality. Conclusions: Pharmacy-driven dexmedetomidine appropriate use guidelines decreased the use of dexmedetomidine and increased cost savings at a community hospital without adversely affecting clinical outcomes.