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The echocardiographic assessment of diastolic function in the context of atrial fibrillation (AF) has been controversial and can be challenging and labor-intensive. We aimed to assess the actual practice of diastolic evaluation in AF in our community hospital echocardiography laboratory and to improve clinical performance by a quality improvement project.We reviewed 244 echocardiograms in patients with AF at the time of echocardiography from November 2019 to November 2020 (pre-intervention phase). We classified cases into a complete versus incomplete evaluation group according to the completeness of diastolic parameter measurement. After an educational intervention, we reviewed 68 echocardiograms in patients with AF from August 2021 to October 2021 (post-intervention phase).Our results demonstrated an improvement in a complete diastolic assessment from 69% to 91% after intervention (p .001). In the pre-intervention phase, the four parameters (mitral inflow pulsed wave Doppler image, left atrium volume index, mitral annular tissue Doppler image [TDI], and tricuspid regurgitation Vmax), mitral annular TDI was not acquired in 71 out of 244 cases (29.1%) and those cases were classified as incomplete evaluation group. Interestingly, in the pre-intervention phase, 57 out of 162 cases (35%) with preserved EF (≥50%) received significantly more incomplete diastolic evaluation than 14 out of 82 patients (17%) with reduced EF (50%) (p = .004). There were no statistically significant differences in age, BMI, the reason for requesting echocardiography, and patient level of care between the complete and incomplete evaluation groups. In the post-intervention phase, completeness of diastolic measurement in AF was significantly improved compared to the pre-intervention phase (29% vs. 9%, p .001, respectively).A quality improvement project effectively improved the clinical performance of diastolic evaluation in AF in our community echocardiography laboratory. After the intervention, we decreased an incomplete evaluation from 30% to 9%. More efforts should be needed to increase awareness and familiarity in evaluating diastolic function in AF.

BACKGROUND While previous studies have described the use of blood components in subsets of children, such as the critically ill, little is known about transfusion practices in hospitalized children across all departments and diagnostic categories. We sought to describe the utilization of red blood cell, platelet, plasma, and cryoprecipitate transfusions across hospital settings and diagnostic categories in a large cohort of hospitalized children. STUDY DESIGN AND METHODS The public datasets from 11 US academic and community hospitals that participated in the National Heart Lung and Blood Institute Recipient Epidemiology and Donor Evaluation Study-III (REDS-III) were accessed. All nonbirth inpatient encounters of children 0-18 years of age from 2013 to 2016 were included. RESULTS 61,770 inpatient encounters from 41,943 unique patients were analyzed. Nine percent of encounters involved the transfusion of at least one blood component. RBC transfusions were most common (7.5%), followed by platelets (3.9%), plasma (2.5%), and cryoprecipitate (0.9%). Children undergoing cardiopulmonary bypass were most likely to be transfused. For the entire cohort, the median (interquartile range) pretransfusion laboratory values were as follows: hemoglobin, 7.9 g/dl (7.1-10.4 g/dl); platelet count, 27 × 109 cells/L (14-54 × 109 cells/L); and international normalized ratio was 1.6 (1.4-2.0). Recipient age differences were observed in the frequency of RBC irradiation (95% in infants, 67% in children, p

BACKGROUND AND OBJECTIVES The aim of this study was to demonstrate whether academic thoracic surgeons could achieve morbidity and mortality rates in community hospitals equivalent to those seen in National Lung Screening Trial (NLST). METHODS This was a retrospective review of community hospital lung cancer procedures for clinical Stage I-III non-small-cell lung cancers from 2007 through 2014. Variables include age, comorbidities, computed tomography (CT) characterization, and operative techniques. RESULTS There were 177 patients who had lung cancers removed by a minimally invasive approach (79%), including lobectomy in 127 (72%), segmentectomy in 4 (2%), and wedge-resections in 46 (26%). The median patient age was 71 years (interquartile range [IQR], 63-76). The cohort was primarily female (58%), clinical Stage I (82%), with a median tumor size of 2.3 cm (IQR, 1.5-3.3). The median length of stay was 6 days (range: 1-35). Complications were experienced by 78 (44.1%) patients, most commonly atrial fibrillation in 20 (11.3%) followed by air-leak in 19 (10.7%). There were no in-hospital deaths. Tumor location and extent of resection were associated with complications, while larger tumor size, margin contour, and resection method were associated with air-leak (all p

This fictional case describes a managerial situation of implementing cone‐beam computed tomography faced by a solo medical physicist in a rural community hospital. The intended use of the case study, in either a facilitated learning session or self‐study, is to inspire the readers to discuss the situation, analyze the institutional and personal factors, apply relevant leadership skills, and propose action plans. This case study falls under the scope of, and is supported by, the Medical Physics Leadership Academy (MPLA). A sample facilitator’s guide or self‐study guide is included in the manuscript for reference by users of this case study.

Perinatal care leaders at a community hospital located in the Denver, Colorado metropolitan area searched for an innovative way to provide a low-intervention option that promoted physiologic birth for women seeking intrapartum care. This reasonably priced project focused on the transformation of traditional labor and delivery rooms into birth suites and included installation of birth slings, full-size beds with home-like mattresses, new sleep sofas for the partners, and the removal of computer screens and electronic fetal monitors. In addition, the team wrote a specific birth suite policy, provided nurse education focused on intermittent auscultation and labor support techniques, and developed a birth suite curriculum for patient education. This innovative model of care demonstrated outcomes similar to those seen in community-based birth centers and received positive feedback from families who labored and gave birth in these suites. In the instance when the birth suite is no longer the appropriate environment for intrapartum care secondary to risk factors, a woman's preference, or obstetric emergency management, this model allows for expeditious transfer of the woman or newborn to a location where an appropriate higher level of care can be provided. Converting 2 labor and delivery rooms to low-intervention birth suites required minimal funding and enabled a community hospital in Colorado to expand its perinatal services to women who are seeking low-intervention birth options that promote physiologic birth.

BACKGROUND There has been a growing trend toward minimally invasive surgery (MIS) for colon cancer. Pathological analysis of a minimum of 12 lymph nodes (LNs) is a benchmark for adequate resection. Here, we present a comparison of surgical techniques in achieving a full oncologic resection. METHODS Patients undergoing surgery for Stage I-III colon cancer (2010-2016) were identified from the National Cancer Database. Cases were stratified by surgical approach. Trends in approach were assessed, including whether the 12-LN benchmark was met. Uni- and multivariate regression was used to assess overall survival (OS). RESULTS A total of 290,776 colectomies were analyzed. MIS increased from 32.8% to 57.2% from 2010 to 2016 (p

Early in 2020, government leaders declared a public health emergency because of the coronavirus disease 2019 (COVID‐19) outbreak. After World Health Organization leaders declared that the spread of COVID‐19 was a pandemic, it became evident that patients suspected or confirmed to have COVID‐19 would present for surgery at our community hospital, the only facility in the county. The Maryland governor charged hospital administrators with expanding bed capacity in anticipation of a surge of critically ill patients. Concurrently, the Maryland secretary of health prohibited all elective procedures. During the early phase of preparation and response, processes, information, and hospital capabilities and capacity changed frequently and rapidly. Effective communication, teamwork, and interprofessional and interdepartmental collaboration helped us prepare to deliver safe surgical care to patients during the pandemic and maintain safety for all involved. This article describes our health care facility’s response to the pandemic and lessons learned during the process.

Background Discussions on the diagnostic and management of acquired pediatric lung pathology are usually published by large tertiary children's hospitals. It is likely that much of this pathology is actually seen and managed in nonacademic practices. Methods A 10-year retrospective review of patients under 18-years of age, treated for lung abscesses or empyema was performed. Results Nineteen empyema and four lung abscesses were included. Presenting symptoms, workup, and management are reviewed. A unique subset (n = 4) of atypical pulmonary pathology is described. A 14-year-old with a vaping history and a lung abscess misdiagnosed as an empyema. A 15-year-old with primary pulmonary Hodgkin's lymphoma presenting as a lung abscess and empyema. A 5-year-old with an empyema complicated by a bronchopleural fistula and a 21-year-old with autism and an acquired lung cyst. Conclusion Our dilemmas, experiences, and strategies in managing complex lung disease are generalized to community-based practice.

BACKGROUND Transfusion of red blood cells (RBC) is a common procedure, which when prescribed inappropriately can result in adverse patient outcomes. This study sought to determine the impact of a multi-faceted intervention on unnecessary RBC transfusions at hospitals with a baseline appropriateness below 90%. STUDY DESIGN AND METHODS A prospective medical chart audit of RBC transfusions was conducted across 15 hospitals. For each site, 10 RBCs per month transfused to inpatients were audited for a 5-month pre- and 10-month post-intervention period, with each transfusion adjudicated for appropriateness based on pre-set criteria. Hospitals with appropriateness rates below 90% underwent a 3-month intervention which included: adoption of standardized RBC guidelines, staff education, and prospective transfusion order screening by blood bank technologists. Proportions of RBC transfusions adjudicated as appropriate and the total number of RBC units transfused per month in the pre- and post-intervention period were examined. RESULTS Over the 15-month audit period, at the 13 hospital sites with a baseline appropriateness below 90%, 1950 patients were audited of which 81.2% were adjudicated as appropriate. Proportions of appropriateness and single-unit orders increased from 73.5% to 85% and 46.2% to 68.2%, respectively from pre- to post-intervention (P

Aim: To evaluate the associations between type of light-emitting diode phototherapy intervention and hospital and patient related outcomes in term neonates with non-haemolytic jaundice. Methods: A retrospective observational study in a community hospital within a disadvantaged area in Australia was conducted. Data was extracted from hospital systems and medical records regarding the use of three types of phototherapy surface-area exposure for term neonates ≤28 days with non-haemolytic neonatal jaundice. Associations between type of phototherapy management and length of stay (LOS), rate of serum bilirubin (SBR) decline and duration of phototherapy were estimated using the general linear mixed model or linear regression. Results: Of 102 neonates diagnosed with non-haemolytic jaundice between 1 June 2016 and 31 August 2017, 82 were included in final analyses. Neonates treated for jaundice during their first (birth) admission had a median LOS of 118 h for single-sided and 125 h for maximal double-sided phototherapy. Differences by phototherapy type were not statistically significant (P = 0.06). SBR rate of decline increased as surface-area of phototherapy increased (P < 0.001) with the fastest decline seen in maximal double-sided phototherapy. Estimated duration of phototherapy did not vary by phototherapy type but did vary by age at initiation of phototherapy (P = 0.006), with 16 fewer hours of phototherapy if commenced at ≥72 to

Background There is limited data on the clinical presentation and predictors of mortality in the African‐American(AA) patients hospitalized with COVID‐19 despite the disproportionately higher burden and mortality. The aim of this study is to report on the clinical characteristics and the predictors of mortality in hospitalized AA patients with COVID‐19 infection. Methods In this retrospective cohort review, we included all AA patients with confirmed COVID‐19 infection admitted to an inner‐city teaching community hospital in New York City. Demographics, clinical presentation, baseline co‐morbidities, and laboratory data were compared between survivors and non‐survivors. The predictors of mortality were assessed using multivariate logistic regression analysis. Results Of the 408 (median age, 67years) patients included, 276(66.65%, median age 63years) survived while 132(33.35%, median age 71years) died. The most common presenting symptoms were cough, myalgia, fever/chills, shortness of breath, and gastrointestinal symptoms (nausea, vomiting, diarrhea, and abdominal pain), with a prevalence of 62.50%, 43.87%, 53.68%, and 27.21%, respectively. Age (OR 1.06, CI 1.04‐1.08, P‐

Surveys confirm risk factors for the incarceration of patients with psychosis including homelessness and comorbidity. There is also agreement that severe psychosis can lead to violence. Data describing prisoners with psychosis in Germany are scarce. We aimed to compare patients with psychosis in a prison hospital and patients with psychosis in a community hospital. Demographic data were collected, as well as comorbidity in the form of substance dependence and a psychiatric assessment using the German version of the 18-item Brief Psychiatric Rating Scale (BPRS) and the Positive and Negative Syndrome Scale (PANSS). In the prison hospital group more patients were homeless (17 versus 2%) and non-German (36 versus 4%). There were also more patients with substance dependence or abuse in the prison hospital group. The total scores of BPRS and PANSS were lower in the prison hospital group (BPRS, 43.8 versus 51.2; PANSS, 71.5 versus 83.7). We assume that social disintegration for mentally disturbed offenders prior to incarceration hindered effective treatment. To avoid further social disintegration and possible further deterioration of mental health status of released offenders, which may lead to reoffending after imprisonment, discharge management after release from prison should be improved.

OBJECTIVE: To compare health care system problems or “hassles” experienced by Veterans receiving VA health care only versus those receiving dual care from both VA and non‐VA community providers. DATA SOURCES: We collected survey data in 2017‐2018 from 2444 randomly selected Veterans with four or more primary care visits in the prior year at one of 12 VA primary care clinics located in four geographically diverse regions of the United States. STUDY DESIGN: We used baseline surveys from the Coordination Toolkit and Coaching quality improvement project to explore Veterans’ experience of hassles (dependent variable), source of health care, self‐rated physical and mental health, and sociodemographics. DATA COLLECTION: Participants responded to mailed surveys by mail, telephone, or online. PRINCIPAL FINDINGS: The number of reported hassles ranged from 0 to 16; 79 percent of Veterans reported experiencing one or more hassles. Controlling for sociodemographic characteristics and self‐rated physical and mental health, zero‐inflated negative binominal regression indicated that dual care users experienced more hassles than VA‐only users (adjusted predicted average 5.5 [CI: 5.2, 5.8] vs 4.3 [CI: 4.1, 4.6] hassles [P

Background A community hospital updated its nutrition support practices in 2016 through the elimination of monitoring gastric residual volume (GRV) in accordance with the 2016 Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition. Methods This retrospective analysis (N = 61) compared incidence of feeding intolerance in 2 cohorts of adult critically ill patients pre-implementation (n = 36) and post-implementation (n = 25) of these guidelines into a nutrition support team's standard of practice policy. Differences in kilocalories and protein (gm) received and percent of daily prescribed kilocalories and protein received were also compared between the 2 cohorts. Results Mean episodes of gastrointestinal intolerance over the number of eligible days of receiving enteral nutrition in the critical care unit did not differ between the pre-implementation and post-implementation groups (P = 0.46). Compared with the pre-implementation group, the post-guideline implementation cohort was significantly more likely to meet higher percentages of both prescribed protein (71.8 ± 22.2% vs 55.9 ± 24.0%; P = 0.01) and energy requirements (93.4 ± 36.9% vs 69.6 ± 35.3%; P = 0.01), even after adjusting for potential confounders (age, body mass index, sex, and primary comorbid medical condition). Conclusion Elimination of routine monitoring of GRV may result in a greater percentage of prescribed daily nutrient requirements met by patients in the critical care setting, without adverse effects on feeding intolerance.

Objective To investigate associated risk factors for oral candidiasis in elderly patients hospitalized in a community-based acute-care hospital with no dental units. Methods Two hundred and twenty-eight elderly patients (male: 105, female: 123), who were hospitalized with several systemic diseases in a community-based acute-care hospital from May 2014 to October 2016, were retrospectively analysed by multiple logistic regression. Results Multiple logistic regression analysis shows that bacterial pneumonia has a statistically strong relationship with oral candidiasis (p = 0.000, OR: 5.173, 95% CI: 2.368-11.298). The order followed is poor oral hygiene (p = 0.001, OR: 6.095, 95% CI: 2.003-18.545) and severe dry mouth (p = 0.043, OR: 2.507, 95% CI: 1.031-6.098). Other correlated factors including diabetes mellitus, denture wearer, dysphagia, malnutrition, requiring care and use of inhalation steroids, were not statistically significant in this study. Conclusions Bacterial pneumonia correlates with oral candidiasis.

OBJECTIVES To test the effectiveness of a multicomponent care transition intervention targeted at hospitalized patients, aged 75 years and older, at high risk for hospital readmissions, return emergency department (ED) visits, and related complications. DESIGN Implementation as a quality improvement program with propensity-matched preintervention and concurrent comparison groups over a 12-month period. SETTING A 400-bed community teaching hospital. PARTICIPANTS Patients, aged 75 years and older, admitted to non-intensive care unit beds who met specific high-risk criteria. The intervention group included 202 patients, and the concurrent and preintervention comparison groups included 4142 and 4592 patients, respectively. MEASUREMENTS Primary outcomes were 30-day hospital readmissions and returns to the ED; 7-day readmissions and ED visits were secondary measures. RESULTS Among the 202 patients enrolled in the "Safe Transitions for At-Risk Patients" ("STAR") program, 37 (18.3%) were readmitted within 30 days, in contrast to 14.3% and 14.6% in the concurrent and preintervention comparison groups, respectively. Rates for 30-day return ED visits that did not result in hospitalization were 10.9% in the intervention group, and 7.2% and 7.9% in the comparison groups. STAR patients had greater 30-day ED use than patients in the preintervention comparison group (5.0 percentage points; 95% confidence interval = 0.8-9.3 percentage points; P = .020). Implementation challenges included suboptimal involvement of the participating hospital and post-acute care organizations and a relatively high proportion of patients who did not receive the intervention as planned, despite agreeing to participate before leaving the hospital. CONCLUSION A multicomponent care transitions intervention targeting high-risk patients, aged 75 years and older, admitted to a community teaching hospital was not effective in reducing 30- or 7-day readmissions or return ED visits. Our implementation experience offers many lessons for future programs for similar high-risk geriatric populations. J Am Geriatr Soc 67:2634-2642, 2019.

BACKGROUND Pathways can improve the quality of care and outcomes for children with asthma; however, we know little about how to successfully implement pathways across diverse hospital settings. Prior studies of pathways have focused on determining clinical effectiveness and the majority were conducted in children's hospitals. These approaches have left crucial gaps in our understanding of how to successfully implement pathways in community hospitals, where most of the children with asthma are treated nationally. OBJECTIVE The aim of this study was to identify the key determinants of successful pediatric asthma pathway implementation in community hospitals. METHODS We conducted a qualitative study of healthcare providers that served as project leaders in a national collaborative to improve pediatric asthma care. Data were collected by recording semi-structured discussions between project leaders and external facilitators (EF) from December 2017 to April 2018. Using inductive thematic analysis, we identified the themes that describe the key determinants of pathway implementation. RESULTS Project leaders (n = 32) from 18 hospitals participated in this study. The key determinants of pathway implementation in community hospitals included (1) building an implementation infrastructure (eg, forming a team of local champions, modifying clinical workflows, delivering education/skills training), (2) engaging and motivating providers (eg, obtaining project buy-in, facilitating multidisciplinary collaboration, handling conflict), (3) addressing organizational and resource limitations (eg, support for electronic medical record integration), and (4) devising implementation solutions with EFs (eg, potential workflow modifications). CONCLUSIONS Our identification of the key determinants of pathway implementation may help guide pediatric quality improvement efforts in community hospitals. EFs may play an important role in successfully implementing pathways in community settings.

As a newly recognized subspecialty, understanding programmatic models for pediatric hospital medicine (PHM) programs is vital to lay the groundwork for a sustainable field. Although variability has been described within university-based PHM programs, there remains no national benchmark for community-based PHM programs. In this report, we describe the workload, clinical services, employment, and perception of sustainability of 70 community-based PHM programs in 29 states through a survey of community site leaders. The median hours for a full-time hospitalist was 1,882 hours/year with those employed by community hospitals working 8% more hours/year and viewing appropriate morning pediatric census as 20% higher than those employed by university institutions. Forty-three out of 70 (63%) site leaders perceived their programs as sustainable, with no significant difference by employer structure. Future studies should further explore root causes for workload discrepancies between community and academic employed programs along with establishing potential standards for PHM program development.

Research Objective The COVID‐19 pandemic has necessitated rapid changes in healthcare delivery in the United States, including changes in the care of hospitalized children. This study aims to identify major changes in inpatient pediatric healthcare delivery and potential lessons learned. Study Design In this study, we conducted semi‐structured video interviews. We analyzed interview data using constant comparative methods to identify major healthcare delivery changes for hospitalized children during the COVID‐19 pandemic. Population Studied We purposefully sampled clinicians from both community and children's hospitals serving pediatric patients in the 6 U.S. states with the highest COVID‐19 hospitalization rates at the onset of the pandemic (NY, NJ, DC, MA, CT, LA). We recruited 2 participants from each hospital to interview (mix of administrators, physicians, and nurses). Principal Findings We interviewed 24 participants from 12 hospitals and identified several themes [Table 1]. They described how hospital leaders rapidly developed policies to: 1) ensure adequate staff for surges of COVID‐19 patients, 2) provide adequate care spaces and supplies, 3) direct use of personal protective equipment, and 4) guide medical management of COVID‐19 patients. Hospital leaders optimized communication by conducting regular meetings to discuss the current state of the pandemic, hospital operations, and policy changes. In the setting of declining volumes of hospitalized children, clinicians newly provided care for hospitalized adults. This was facilitated by developing care teams supported by adult hospitalists, educational resources, and telehealth supports. Participants described negative impacts of the pandemic on clinicians' mental health, as well as helpful supports for clinician well‐being, including mental health resources, wellness activities and spaces, and housing. Finally, participants described experiences managing multisystem inflammatory syndrome in children including diagnostic uncertainty and evolving management for this novel disease. TABLE 1 Theme Exemplary Quote Developing and evolving COVID‐related hospital policies “We have eight separate COVID related pathways. One for outpatient, one for ED, one for inpatient, and one for therapeutics. Pretty rigorous.” Successful communication with clinicians and staff “One of the things that went really well was… daily town halls and transparency for the rapidly evolving situation.” Newly providing care for hospitalized adults “They had what they called a super hospitalist, who was an adult hospitalist who would oversee…five or six different [mixed specialty care] teams and help out with some of the decision making.” Organizing spaces for COVID‐19 patient care “As [the only freestanding] children's hospital [in the city], our role ended up being kind of a referral center for all the other centers to offload their pediatric patients.” Conclusions We identified several changes in inpatient pediatric care delivery and potential lessons learned during the COVID‐19 pandemic: 1) optimizing communication aided in rapidly changing hospital policies, 2) developing new team models and educational resources helped clinicians in newly caring for hospitalized adults, and 3) providing wellness resources was helpful for supporting clinicians' mental health. Implications for Policy or Practice This study's findings will assist hospital leaders to plan for safe and high‐quality care for hospitalized children, in this ongoing pandemic and in future disaster planning. Primary Funding Source Agency for Healthcare Research and Quality.

BACKGROUND Recent province-wide audits of frozen plasma (FP) and RBC use in Ontario showed a high rate of inappropriate transfusions. STUDY DESIGN AND METHODS This was a retrospective, ecological study to determine variations in RBC and FP utilization rates across Ontario community hospitals between 2012 and 2017. Annual utilization rates were reported using descriptive statistics. Rates of blood component use were correlated with size of hospital, presence of specialized programs, and quality improvement (QI) initiatives, using Poisson regression. RESULTS RBC and FP utilization rates decreased from 2012 to 2017 (p = 0.03 for FP; p < 0.01 for RBC). There was a 10-fold difference in RBC and FP transfusion rates between the highest and lowest users. Smaller hospitals (p < 0.05) and sites with any QI initiative (p = 0.006) were associated with lower FP utilization rates. Hospitals without cancer programs (p = 0.02) and sites with RBC guidelines (p = 0.05) or with technologists who prospectively screened transfusion orders (p = 0.01) had lower RBC transfusion rates. RBC utilization rates decreased further after the implementation of RBC guidelines (p = 0.02) and order sets (p = 0.005). There was a positive correlation between FP and RBC transfusion rates for each fiscal year (p < 0.005 for all years). CONCLUSION RBC and FP utilization showed wide variation across community hospitals in Ontario. Overall, transfusion rates decreased over time. A further decrease was observed at sites with QI initiatives, supporting their implementation in reducing utilization. These data will serve as a baseline to highlight sites and practices where QI initiatives may be most beneficial and replicated in other jurisdictions.

Background Approximately 90% of pediatric emergency care is provided in community emergency departments (CEDs) that care for both adults and children. Paradoxically, the majority of pediatric emergency medicine knowledge generation, quality improvement work, and clinical training occurs in children's hospitals. There is a paucity of information of perceptions on pediatric care from CED providers. This information is needed to guide the development of strategies to improve CED pediatric readiness. Objective The objective was to explore interprofessional CED providers' perceptions of caring for pediatric patients. Methods A preparticipation survey collected data on demographics, experience, and comfort in caring for children. Emergency pediatric simulations were then utilized to prime interprofessional teams for debriefings. These discussions underwent qualitative analysis by three blinded authors who coded transcripts into themes through an inductive method derived from grounded theory. The other authors participated in confirmability and dependability checks. Results A total of 171 community hospital providers from six CEDs completed surveys (49% nurses, 22% physicians, 23% technicians). The majority were PALS trained (70%) and experienced fewer than five pediatric resuscitations in their careers (61%). Most self-reported comfort in caring for acutely ill and injured children. From the debriefings, three major challenge themes emerged: 1) knowledge and skill limitations attributed to infrequency of training and actual clinical events, 2) the emotional toll of caring for a sick child, and 3) acknowledgment of pediatric specific quality and safety deficits. Subthemes focused on causes and potential mitigating factors contributing to these challenges. A solution theme highlighted novel partnering opportunities with local children's hospitals. Conclusion Interprofessional CED providers perceive that caring for pediatric patients is challenging due to case infrequency, the emotional toll of caring for sick children, and pediatric quality and safety deficits in their systems. These areas of focus can be used to generate specific strategies for improving CED pediatric readiness.

Background Early enteral nutrition has been shown to decrease complications and improve patient outcomes. Post pyloric feeding is recommended for patients with gastric intolerance or at high risk for aspiration. Feeding tube placement can be challenging and pose risk of pulmonary complications. Reliance on radiographic confirmation for feeding tube placement exposes the patient to radiation. Electromagnetic placement device (EMPD) may offer a method to minimize pulmonary complications, increase successful placement, and decrease radiation exposure to the patient. Objective The purpose of this study was to evaluate the safety and efficacy of using EMPD verification, instead of routine abdominal radiographic confirmation, for small-bore feeding tube placement. Results Variables evaluated were adverse events, utilization of radiographs for confirmation, and success rate of feeding tube placement in the ordered location. Two time frames were reviewed. In a 1-year period, 3754 small-bore feeding tubes were placed using EMPD, with zero adverse events noted. Radiographic confirmation was utilized in 0%-29.2% of the EMPD placed tubes. Successful placement of feeding tubes using EMPD ranged from 94%-99.6%. During a 5-year period, 7081 EMPD feeding tubes were evaluated. One adverse event, pneumothorax, occurred during the placement of these 7081 tubes, for a rate of 0.014%. Conclusion Feeding tube placement confirmation is safe and efficacious via EMPD providing an effective method of feeding tube placement with a success rate >94% into the desired location. EMPD is an accurate verification method of distal tip location, eliminating the need for routine abdominal radiographic confirmation.

In 2015, perioperative nursing staff members at a community hospital designed and implemented a tool to help improve communication and performance. Our postprocedure wrap-up tool and its follow-up process have allowed us to achieve improvements in both efficiency and staff member satisfaction. By implementing a process to document problems as they occur and quickly transmit information to the staff members who are best able to correct these issues, we greatly improved our workflow. Furthermore, by inputting information into spreadsheets using problem codes, thereby replacing anecdotal information with hard data, we targeted areas that needed improvement and used that information for budget planning, training, and allocating resources. Enlisting the input of all members of the surgical team allowed us to identify the root causes of issues that interfered with the staff members' ability to provide efficient, safe, and reliable patient care.

RESEARCH OBJECTIVE: Hospitals make significant investments in quality improvement (QI) initiatives to improve clinicians' guideline adherence and care quality. However, the majority of studies report adherence declines after such initiatives end. Our objective was to identify strategies associated with sustained guideline adherence and high‐quality pediatric asthma care in community hospitals, which care for >70% of hospitalized children in the US. STUDY DESIGN: Pathways for Improving Pediatric Asthma Care (PIPA) was a national QI initiative. In a prior quantitative study, data from 34 community hospitals in PIPA were analyzed to identify sites with higher and lower performance in sustaining clinicians' guideline adherence over a 2‐year period during and after the initiative. In this qualitative study, we conducted semi‐structured interviews with clinicians from these higher‐ and lower‐performing hospitals. We used constant comparative methods to identify strategies associated with sustained guideline adherence. POPULATION STUDIED: Multi‐disciplinary clinicians (e.g., physicians, nurses, respiratory therapists). PRINCIPAL FINDINGS: Clinicians (n = 19) from 5 higher‐ and 3 lower‐performing hospitals participated. In higher‐performing hospitals, dedicated local champions used several strategies to promote sustained high‐quality care, including: (1) providing ongoing reminders of evidence‐based practices; (2) delivering ongoing education on evidence‐based practices; and (3) modifying the electronic health record (EHR) to provide decision support, often via order sets. Higher‐performing sites also had access to resources for quality monitoring, as well as a culture of firm expectation that evidence‐based practices would be adopted and followed without exception. In lower‐performing hospitals, participants described unique barriers to sustaining high‐quality care, including delays in modifying the EHR and lack of automation of EHR tools (requiring clinicians to remember and perform new EHR tasks without automated prompts to do so). Barriers to sustainability for all hospitals included: (1) challenges maintaining quality monitoring; (2) decreasing focus of local champions over time; and (3) ongoing difficulties developing consensus around evidence‐based practices. CONCLUSIONS: We outline several strategies associated with sustaining high‐quality pediatric asthma care in community hospitals. Several of these rely on a dedicated, long‐term local champion. IMPLICATIONS FOR POLICY OR PRACTICE: Supporting a dedicated local champion long‐term may be critical to reap returns on QI investments. [Table: see text] PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality.

Background More than 30 million children are cared for across 5,000 US emergency departments each year (ED). Most of these EDs are not facilities designed and operated solely for children. A web-based survey provided a national and state-by-state assessment of pediatric readiness and noted a national average score was 69 on a 100-point scale. This survey noted wide variations in ED readiness with scores ranging from 61 in low-pediatric-volume EDs to 90 in the high-pediatric-volume EDs. Additionally, the mean score at the state level ranged from 57 (Wyoming) to 83 (Florida) and for individual EDs ranged from 22 to 100. The majority of prior efforts made to improve pediatric readiness have involved providing web-based resources and online toolkits. This paper reports on the first year of a program that aimed to improve pediatric readiness across community hospitals in our state through in situ simulation-based assessment facilitated by our academic medical center. The primary aim was to improve the pediatric readiness scores in the ten participating hospitals. The secondary aim was to explore the correlation of simulation-based performance of hospital teams with pediatric readiness scores. Methods This interventional study measured the PRS prior to and after implementation of an improvement program. This program consisted of three components: (1) in-situ simulations; (2) report outs; and (3) access to online pediatric readiness resources and content experts. The simulations were conducted in situ (in the ED resuscitation bay) by multi-professional teams of doctors, nurses, respiratory therapists and technicians. Simulations and debriefings were facilitated by an expert team from a pediatric academic medical center. Three scenarios were conducted for all teams and include: a six-month-old with respiratory failure, an eight-year-old with diabetic ketoacidosis (DKA), and a six-month-old with supraventricular tachycardia (SVT). A performance score was calculated for each scenario. The improvement of PRS was compared before and after the simulation program. The correlation of the simulation performance of each hospital and the PRS was calculated. Results 41 multi-professional teams from ten EDs in Indiana participated in the study, five were of medium pediatric volume and five were medium-high volume EDs. The PRS significantly improved from the first to the second on-site verification assessment (58.4±4.8 to 74.7±2.9, p=0.009). Total adherence scores to scenario guidelines were: 54.7%, 56.4% and 62.4% in the respiratory failure, DKA and SVT scenarios respectively. We found no correlation between simulation performance and PRS scores. Medium ED pediatric volume significantly predicted higher PRS scores compared to medium-high pediatric ED volume (β=8.7; CI: 0.72, 16.8, p=0.034). Conclusion(s) Our collaborative improvement program that involved simulation was associated with improvement in pediatric readiness scores in ten EDs participating statewide. Future work will focus on further expanding of the network and establishing a national model for pediatric readiness improvement. This article is protected by copyright. All rights reserved.

Aims and objectives The aim of the study was to describe nurses’ experiences of patients’ transition from ICUs to general wards and their suggestions for improvements. Background In the ICU, the most seriously ill patients with life-threatening conditions and multiple organ dysfunction syndromes are cared for and carefully monitored by specially trained professionals using advanced techniques for the prevention of failure of vital functions. The transfer of ICU patients to general wards means a change from a high to a lower level, including the loss of one-to-one nursing and a reduction of visible monitoring equipment and general close attention. Design A qualitative descriptive design. Methods Eight nurses from three different inpatient units in Norway, five from a university hospital and three from a local hospital were selected through a convenience sample. Interviews with open questions were conducted, and qualitative content analysis was used to explore the data. Results Nurses’ experiences were described in one main category: ICU patients’ transition—a great responsibility and a huge challenge, and two generic categories: (i) a challenging transition for nurses, patients and relatives and (ii) dialogue and competencies as tools for improvement, with six subcategories. Conclusion A number of factors affected patient care, such as poor cooperation, communication, reporting, expertise and clinical gaze. It was clear that the general wards had major challenges, and a number of improvements were suggested. Relevance to clinical practice This study shows that there is still a gap between the ICU and general wards and that nurses continue to struggle with this. It is therefore important that the managers responsible for the quality of care together with the professionals take seriously the criticism in the present and previous studies and work towards a safe transition for patients.

BACKGROUND The theory that posthospitalization stress might increase the risk of postdischarge complications has never been investigated. OBJECTIVE To assess whether serum levels of stress biomarkers at discharge are associated with readmission and death after an acute-care hospitalization. DESIGN We prospectively included 346 patients aged ≥50 years admitted to the department of general internal medicine at a large community hospital between April 8, 2013 and September 23, 2013. We measured the serum levels of several biomarkers at discharge: midregional pro-adrenomedullin, copeptin, cortisol, and prolactin. All patients were followed for up to 90 days after discharge (none was lost to follow-up). The main outcome was first unplanned readmission or death within 30 days after hospital discharge. We assessed the additional value of biomarkers to 2 validated readmission prediction scores: the LACE index (Length of stay, Admission Acuity, Charlson Comorbidity Index, and number of Emergency department visits within preceding 6 months) and the HOSPITAL score (Hemoglobin level at discharge, discharge from Oncology service, Sodium level at discharge, any Procedure performed during index hospitalization, Index admission Type, number of Admissions within preceding 12 months, and Length of stay). RESULTS Forty patients (11.6%) had a 30-day unplanned readmission or death. High serum copeptin and cortisol levels were associated with an increase in the odds of unplanned readmission or death (odds ratios [95% confidence interval] 2.69 [1.29-5.64] and 3.43 [1.36, 8.65], respectively). We found no significant association with midregional pro-adrenomedullin or prolactin. Furthermore, these stress biomarkers increased the performance of two readmission prediction scores (LACE index and HOSPITAL score). CONCLUSION High serum levels of copeptin and cortisol at discharge were independently associated with 30-day unplanned readmission or death, supporting a possible negative effect of hospitalization stress during the postdischarge period. Stress biomarkers improved the performance of prediction models and therefore could help better identify high-risk patients.

tudy Objectives To evaluate the occurrence of bleeding and venous thromboembolic (VTE) events in patients receiving rivaroxaban, warfarin, or warfarin with the addition of enoxaparin during the immediate post-operative period following major orthopedic surgery. Methods Patients older than 18 years who received at least one dose of rivaroxaban the morning following surgery, adjusted dose warfarin, or adjusted dose warfarin with the addition of enoxaparin for VTE prophylaxis following major orthopedic surgery between October 1, 2011 and February 28, 2015 were included. Data collected from the electronic health record included patient demographics, renal function, inpatient aspirin, P2Y12-inhibitor and/or nonsteroidal anti-inflammatory drug (NSAID) use, type of surgery, post-operative analgesia, and presence of VTE risk factors. Adjusted incidence rate ratio for bleeding or VTE events was estimated using modified Poisson regression with robust standard errors. Covariates included in a multivariable model were age, sex, aspirin use, P2Y12-inhibitor use, NSAID use, obesity, VTE risk factors, and creatinine clearance. Results 3246 patients met study inclusion criteria. Overall, the incidence of bleeding and VTE events were rare. Bleeding event incidence ranged from 0.4% in the warfarin and warfarin with the addition of enoxaparin groups to 1.2% in the rivaroxaban group (p=0.088). There were two major bleeding events and eighteen minor bleeding events (including hemorrhagic wound complications). VTE event incidence ranged from 0.2% in the warfarin with the addition of enoxaparin group to 0.6% in the rivaroxaban group (p=0.230). Two deep vein thromboses and ten pulmonary emboli occurred. Using the multivariable model, the warfarin and warfarin with the addition of enoxaparin groups had significantly lower incidence rates of bleeding compared to rivaroxaban (IRR=0.218, p=0.0120 and IRR=0.242, p=0.021, respectively). Principal Conclusions We observed a small, yet significant, increase in rivaroxaban-related bleeding in the immediate postoperative period relative to warfarin or warfarin with the addition of enoxaparin for prevention of VTE following major orthopedic surgery. This article is protected by copyright. All rights reserved.

© 2016 by the Society for Academic Emergency Medicine Background: Millions of head computed tomography (CT) scans are ordered annually, but the extent of avoidable imaging is poorly defined. Objectives: The objective was to determine the prevalence of likely avoidable CT imaging among adults evaluated for head injury in 14 community emergency departments (EDs) in Southern California. Methods: We conducted an electronic health record (EHR) database and chart review of adult ED trauma encounters receiving a head CT from 2008 to 2013. The primary outcome was discordance with the Canadian CT Head Rule (CCHR) high-risk criteria; the secondary outcome was use of a neurosurgical intervention in the discordant cohort. We queried systemwide EHRs to identify CCHR discordance using criteria identifiable in discrete data fields. Explicit chart review of a subset of discordant CTs provided estimates of misclassification bias and assessed the low-risk cases who actually received an intervention. Results: Among 27,240 adult trauma head CTs, EHR data classified 11,432 (42.0%) discordant with CCHR recommendation. Subsequent chart review showed that the designation of discordance based on the EHR was inaccurate in 12.2% (95% confidence interval [CI] = 5.6% to 18.8%). Inter-rater reliability for attributing CCHR concordance was 95% (κ = 0.86). Thus, we estimate that 36.8% of trauma head CTs were truly likely avoidable (95% CI = 34.1% to 39.6%). Among the likely avoidable CT group identified by EHR, only 0.1% (n = 13) received a neurosurgical intervention. Chart review showed none of these were actually “missed” by the CCHR, as all 13 were misclassified. Conclusion: About one-third of head CTs currently performed on adults with head injury may be avoidable by applying the CCHR. Avoidance of CT in such patients is unlikely to miss any important injuries.

Objective To assess the impact of hospital affiliation, centralization, and managed care plan ownership on inpatient cost and quality. Data Sources Inpatient discharges from 3,957 community hospitals in 44 states and American Hospital Association Annual Survey data from 2010 to 2012. Study Design We conducted a retrospective longitudinal regression analysis using hierarchical modeling of discharges clustered within hospitals. Data Collection Detailed discharge data including costs, length of stay, and patient characteristics from the Healthcare Cost and Utilization Project State Inpatient Databases were merged with hospital survey data from the American Hospital Association. Principal Findings Hospitals affiliated with health systems had a higher cost per discharge and better quality of care compared with independent hospitals. Centralized systems in particular had the highest cost per discharge and longest stays. Independent hospitals with managed care plans had a higher cost per discharge and better quality of care compared with other independent hospitals. Conclusions Increasing prevalence of health systems and hospital managed care ownership may lead to higher quality but are unlikely to reduce hospital discharge costs. Encouraging participation in innovative payment and delivery reform models, such as accountable care organizations, may be more powerful options.

Objective To assess the implementation and effects of the strategy, introduced in June 2011, of making obstetric kits readily available in health facilities in the Adamaoua region of Cameroon. Methods We conducted a quasi-experimental study using an interrupted time series to assess the effects of the strategy, and a case study to evaluate its implementation. The reviewed data were gathered from 13 health facilities over a period from January 2008 to December 2014. Qualitative data were collected from in-depth interviews. Results The provision of obstetric kits was effective in the intervention health facilities, although some challenges existed and included lack of staff motivation and rampant illegal practices. The number of deliveries and cesareans increased. Conclusion There is a need to rethink this strategy, given its gaps and shortcomings.

Inappropriate antimicrobial use in hospitalized patients contributes to antimicrobial-resistant infections and complications. We sought to evaluate the impact, barriers, and facilitators of antimicrobial stewardship best practices in a diverse group of hospital medicine programs. This multihospital initiative included 1 community nonteaching hospital, 2 community teaching hospitals, and 2 academic medical centers participating in a collaborative with the Centers for Disease Control and Prevention and the Institute for Healthcare Improvement. We conducted multimodal physician education on best practices for antimicrobial use including: (1) enhanced antimicrobial documentation, (2) improved quality and accessibility of local clinical guidelines, and (3) a 72-hour antimicrobial "timeout." Implementation barriers included variability in physician practice styles, lack of awareness of stewardship importance, and overly broad interventions. Facilitators included engaging hospitalists, collecting real time data and providing performance feedback, and appropriately limiting the scope of interventions. In 2 hospitals, complete antimicrobial documentation in sampled medical records improved significantly (4% to 51% and 8% to 65%, P < 0.001 for each comparison). A total of 726 antimicrobial timeouts occurred at 4 hospitals, and 30% resulted in optimization or discontinuation of antimicrobials. With careful attention to key barriers and facilitators, hospitalists can successfully implement effective antimicrobial stewardship practices. Journal of Hospital Medicine 2016;11:576-580. © 2016 Society of Hospital Medicine.

Objectives The objective was to evaluate variation in the current estimated radiation dose index for pediatric cervical spine (c-spine) computed tomography (CT) examinations. Methods This was a retrospective analysis of pediatric (age younger than 19 years) c-spine CT examinations from the American College of Radiology Dose Index Registry, July 2011 through December 2014. We used the volume CT dose index (CTDIvol) as the radiation dose estimate and used summary statistics to describe patient and hospital characteristics. Results There were 12,218 pediatric CT c-spine examinations performed across 296 participating hospitals. Fifty-six percent were in male patients, and 79% were in children older than 10 years. Most hospitals (55%) were community hospitals without trauma designations, and the largest proportion of examinations (41%) were performed at these hospitals. The median CTDIvol was 15 mGy (interquartile range = 9 to 23 mGy) representing a more than 2.5-fold difference between the 25th and 75th percentiles. Pediatric hospitals (both trauma and nontrauma centers) delivered the lowest CTDIvol across all age groups and showed the least amount of variability in dose. Conclusions There is significant variation in the radiation dose index for pediatric c-spine CT examinations. Pediatric hospitals practice at lower CT dose estimates than other hospitals. Individual hospitals should examine their practices in an effort to ensure standardization and optimization of CT parameters to minimize radiation exposures to pediatric patients.

Background Rapid diagnostics for bloodstream infections have been shown to improve outcomes. Most studies have focused on rapid diagnostics for a single pathogen and have been conducted in academic medical centers. The Verigene Gram-Positive Blood Culture Test (BC-GP) identifies 12 gram-positive organisms and 3 genetic markers of antibiotic resistance from positive blood culture media in 2.5 hours. This study evaluates implementation of the Verigene BC-GP panel in combination with real-time support from the Antibiotic Stewardship Team (AST) in a community hospital system. Methods This multicenter, pre-post, quasi-experimental study was conducted at the five hospitals that compose Scripps Healthcare. Rapid diagnostic testing was performed at a central laboratory from 7 a.m.–7 p.m. Pharmacists notified physicians of results and assisted with antibiotic modifications. The primary outcomes were average time to targeted antibiotic therapy and difference in antibiotic duration for contaminants. Secondary end points included hospital length of stay, mortality, pharmacy costs, and overall hospitalization costs. Adult patients with a gram-positive bacteremia admitted in 2011 (pre-rapid testing) were compared with those admitted in 2014 (post-rapid testing). Results There were 103 patients in the preintervention group and 64 patients in the intervention group. The optimized identification process, combined with AST intervention, improved mean time to targeted antibiotic therapy (61.1 vs 35.4 hrs, p

Effective on-call clinical staffing is critical to providing perioperative services to patients requiring emergency surgical care. Without careful monitoring of continuous work hours and hours worked per week, staffing practices can adversely affect the ability of personnel to function and provide care. Managers and perioperative personnel must carefully evaluate their on-call schedule to ensure the provision of safe medical care for their patients. Perioperative leaders at two hospitals partnered to create a safety guideline for on-call staffing practices, which includes zone guides for determining workload intensity. This guideline has served to help managers evaluate the general safety of their staffing plan and identify on-call practices that may need improvement or support in their areas of responsibility. Key recommendations from the guideline can help perioperative managers at other facilities establish clinical staffing plans and on-call practices that are safe and effective.

Objectives Blood culture contamination is a common and preventable problem in the emergency department (ED). In a previous single-center study, changing the process of ED blood culture collection from the traditional “clean,” nonsterile procedure to a fully sterile procedure with standardized use of sterile gloves, large-volume chlorhexidine skin antisepsis, and fenestrated sterile drapes resulted in a substantial reduction in contamination. The objective of the current study was to evaluate the effectiveness of this sterile blood culture collection process for reducing blood culture contamination in two community hospital EDs. Methods The authors implemented the sterile blood culture collection process in the ED of two hospitals, including Hospital A, which historically had a contamination rate of approximately 5%, and Hospital B, with a 2.5% historical contamination rate. With an interrupted times-series design and segmented regression analysis to adjust for secular trends and autocorrelation, the monthly percentages of cultures contaminated at each hospital during an intervention period (sterile technique) were compared to a 10-month baseline period immediately preceding implementation (clean technique). At Hospital A, the full sterile blood culture collection process was used throughout the 16-month intervention period. At Hospital B, user feedback indicated poor adherence to the process due to difficulty implementing the fenestrated drape component; therefore, the process was simplified to the modified sterile collection process, in which the fenestrated drape component was dropped and sterile gloves and large-volume skin antisepsis were emphasized. Hence, at Hospital B, two intervention periods were compared to the baseline period: the 8-month intervention period 1 (full sterile process) and the subsequent 8-month intervention period 2 (modified sterile process). Results At Hospital A, during the baseline period, 165 of 3,417 (4.83%) cultures were contaminated, while 142 of 5,238 (2.71%) were contaminated during the intervention period (p

Objectives Emergency medical services (EMS) personnel commonly use systolic blood pressure (sBP) to triage and treat acutely ill patients. The definition of prehospital hypotension and its associated outcomes are poorly defined. The authors sought to determine the discrimination of prehospital sBP thresholds for 30-day mortality and to compare patient classification by best-performing thresholds to traditional cutoffs. Methods In a community-based cohort of adult, nontrauma, noncardiac arrest patients transported by EMS between 2002 and 2006, entries to state hospital discharge data and death certificates were linked. Prehospital sBP thresholds between 40 and 140 mm Hg in derivation (n = 132,624) and validation (n = 22,020) cohorts and their discrimination for 30-day mortality, were examined. Cutoffs were evaluated using the 0/1 distance, Youden index, and adjusted Z-statistics from multivariable logistic regression models. Results In the derivation cohort, 1,594 (1.2%) died within 24 hours, 7,404 (6%) were critically ill during hospitalization, and 6,888 (5%) died within 30 days. The area under the receiver operating characteristic (ROC) curve for sBP was 0.60 (95% confidence interval [CI] = 0.59, 0.61) for 30-day mortality and 0.64 (95% CI = 0.62 0.66) for 24-hour mortality. The 0/1 distance, Youden index, and adjusted Z-statistics found best-performing sBP thresholds between 110 and 120 mm Hg. When compared to an sBP ≤ 90 mm Hg, a cutoff of 110 mm Hg would identify 17% (n = 137) more deaths at 30 days, while overtriaging four times as many survivors. Conclusions Prehospital sBP is a modest discriminator of clinical outcomes, yet no threshold avoids substantial misclassification of 30-day mortality among noninjured patients. Resumen Los Umbrales de la Presion Arterial Sistolica Prehospitalaria: Un Estudio de Base Comunitaria Acerca de la Evolucion de los Pacientes Objetivos El personal de los sistemas de emergencias medicas (SEM) usa frecuentemente la presion arterial sistolica (PAS) para clasificar y tratar a los pacientes agudos. Las definiciones de hipotension prehospitalaria y sus resultados asociados estan pobremente definidos. Se determino la discriminacion de los umbrales de PAS prehospitalaria para la mortalidad a los 30 dias, y se comparo la clasificacion del paciente por los mejores umbrales con los puntos de corte tradicionales. Metodologia Estudio de cohorte de base comunitaria de pacientes adultos no traumatologicos ni con paradas cardiorrespiratorias transportados por los SEM entre 2002 y 2006, cuyas historias estaban vinculadas con los datos de alta hospitalaria y los certificados de mortalidad. Se examinaron los umbrales de PAS prehospitalaria entre 40 mm Hg y 140 mm Hg en las cohortes de derivacion (n = 132.624), y validacion (n = 22,020), y su discriminacion para la mortalidad a los 30 dias. Los puntos de corte se evaluaron usando la distancia 0/1, el indice de Youden y los estadisticos Z ajustados de los modelos de regresion logistica multivariable. Resultados: En la cohorte de derivacion, 1.594 (1,2%) fallecieron en las primeras 24 horas, 7.404 (6%) estuvieron criticamente enfermos durante el ingreso y 6.888 (5%) fallecieron en los 30 primeros dias. El area bajo la curva de la ROC para PAS fue 0,60 (IC 95% = 0,59–0,61) para la mortalidad a los 30 dias y 0,64 (IC 95% = 0,62–0,66) para la mortalidad a las 24 horas. La distancia 0/1, el indice de Youden y las estadisticas Z ajustadas hallaronque los mejores umbrales de PAS estaban entre 110 y 120 mm Hg. Cuando se comparo con una PAS ≤ 90 mm Hg, un punto de corte de 110 mm Hg identificaria un 17% (n = 137) mas de muertes a los 30 dias, mientras que sobreclasificaria cuatro veces mas a los supervivientes. Conclusiones La presion arterial sistolica es un discriminador modesto de resultados clinicos. No obstante, ningun umbral evita una mala clasificacion de la mortalidad a los 30 dias entre los pacientes no traumatologicos.

Study Objective Because alkalinization of the renal tubules can theoretically protect against the mechanisms of acute kidney injury, we sought to determine whether a sodium bicarbonate infusion can prevent acute kidney injury after cardiac surgery. Design Prospective, randomized, double-blind, controlled trial. Setting Cardiac surgery service in a community hospital. Patients Ninety-two patients with stage 3 or higher chronic kidney disease who underwent cardiac surgery using cardiopulmonary bypass. Intervention Forty-eight patients received a perioperative intravenous infusion of 0.9% sodium chloride 154 mEq/L, and 44 patients received an infusion of sodium bicarbonate infusion 150 mEq/L in 5% dextrose solution; the infusions were started 1 hour preoperatively and continued for 6 hours after cardiopulmonary bypass. Measurements and Main Results The primary outcome was the development of any stage of acute kidney injury within 5 days after surgery as defined by the Acute Kidney Injury Network criteria. No statistically significant difference in the primary outcome was noted between the two groups: 32% in the bicarbonate group versus 42% in the sodium chloride group (p=0.12). Likewise, no significant differences in the 30-day hospital mortality rate or other adverse outcomes were noted between the two groups. Conclusion A perioperative infusion of sodium bicarbonate did not reduce the rate of acute kidney injury or adverse outcomes in patients with chronic kidney disease who underwent cardiac surgery.

In response to complaints about the annual evaluation tool used at The Community Hospital in Munster, Indiana, the surgical services management team created a tool to rate the perioperative RNs on skills pertinent to the surgical services department. The hospital-wide evaluation tool uses vague criteria, which are regularly challenged by employees who disagree with their manager's evaluation. The new Surgical Services Employee Evaluation takes a manager approximately 30 seconds to complete and can be added to the generic hospital evaluation form to make the employee evaluation more accurate and meaningful. The tool evaluates three major categories: teamwork, patient care, and job preparation. Use of this additional tool has greatly reduced postevaluation employee complaints, and the tool is now being used in other departments, with slight department-specific variations. Employees now express less frustration with annual evaluations, and managers report a high degree of satisfaction with the tool because it helps them in the difficult task of employee evaluation and counseling.

Objectives: To assess bleeding complications and outcome of individuals receiving oral anticoagulants who were admitted to the hospital with an international normalized ratio (INR) greater than 4 by comparing them according to age (?80, >80). Design: Retrospective cohort study. Setting: Community hospital. Participants: All individuals (N = 253) admitted to the Department of Internal Medicine over a period of 4 years with an INR greater than 4: Group I, aged 80 and younger (n = 127); Group II, older than 80 (n = 126). Data included bleeding complications, survival, and quality of INR control before admission and up to 48 months after admission. Results: Atrial fibrillation was the most common indication for warfarin therapy. Its incidence was higher in the older group (88% vs 73%, P = .004). More elderly participants lived in nursing homes (23% vs 9.4%. P = .004) or received in-home assistance (38.9% vs 20.5%, P = .002). There was no difference in INR upon admission, duration of warfarin treatment, or frequency of INR tests before admission. The incidence of bleeding events was 18.1% in Group I and 12.7% in Group II (P = .30). Major bleeding events occurred in 1.6% of Group I and none of Group II (P = .50). During follow-up after the first admission, the incidence of INR greater than 4 was higher in Group II (87.3% vs 70%, P = .02), without a difference in the number of additional admissions or bleeding events. Conclusion: Primary care physicians can safely maintain warfarin treatment in elderly adults, even in those with a history of hospitalization for high INR, using frequent INR measurements.

Background: Management of elderly patients with acute coronary syndromes (ACS) is not standardized and physicians discretion for invasive versus conservative strategies lacks sufficient evidence. The purpose of this analysis was, therefore, to evaluate treatment strategies and outcomes of elderly patients with ACS and to highlight reasons for the treatment decision in a consecutive series of elderly patients. Methods: This is a retrospective analysis of 1,001 elderly patients (>75 years) presenting with ACS. Patients were identified on the basis of their final discharge diagnosis. Baseline data, past medical history, cardiac and noncardiac concomitant diseases, treatment strategy, and adverse outcomes were evaluated, using patient's charts. Various co-variates were used to determine the association or predictive value of these co-variates to the invasive versus conservative management of the subjects. Thirty-day mortality and long-term survival were assessed either directly or in discharged patients via telephone interview with the patients, the patients' relatives or the primary care physicians. Results: A total of 776 (77.5%) patients were treated invasively and 225 (22.5%) conservatively. Logistic regression analysis revealed that patients with advanced age, Killip class > II, pre-existing coronary artery disease, prior stroke, pre-existing renal failure, obesity, non-ST-elevation myocardial infarction, prior ACS, and the presence of supraventricular arrhythmias were significantly more likely to undergo conservative treatment. In-hospital mortality was significantly higher in conservatively treated patients (P < 0.001). Conclusion: In this retrospective analysis, we identified age as the main predictor for a conservative treatment strategy in elderly patients, albeit an invasive strategy was associated with a significantly better outcome. © 2012 Wiley Periodicals, Inc.

We read with interest the recent study published in Pharmacotherapy evaluating morphine dosing to treat neonatal abstinence syndrome (NAS).1 The authors attempted to address an important research question in a disease state which is a widespread problem with many unknowns related to its management.2-4 In order to address these unknowns, future research of NAS should include the following key considerations. This article is protected by copyright. All rights reserved.

Background Interventions to reduce patient-handling injuries in the hospital setting are often evaluated based on their effect on outcomes such as injury rates. Measuring intervention adoption could address how and why observed trends in the outcome occurred. Methods Unit-level data related to adoption of patient lift equipment were systematically collected at several points in time over 5 years on nursing units at two hospitals, including hours of lift equipment use, equipment accessibility, and supply purchases and availability. Results Various measures of adoption highlighted the adoption process' gradual nature and variability by hospital and between units. No single measure adequately assessed adoption. Certain measures appear well-correlated. Conclusion Future evaluation of primary preventive efforts designed to prevent patient-handling injuries would be strengthened by objective data on intermediate measures that reflect intervention implementation and adoption. Am. J. Ind. Med. 54:935–945, 2011. © 2011 Wiley Periodicals, Inc.