Antibiotic utilization variability among training services at an academic medical center: An observational study

2020 ◽  
pp. 1-5
Author(s):  
Katherine A. Cinnamon ◽  
Lucas T Schulz ◽  
Ann M. Sheehy ◽  
Sean M. O’Neill ◽  
Edward Lalik ◽  
...  
Keyword(s):  
Broad Spectrum ◽  
Medical Center ◽  
Academic Medical Center ◽  
Secondary Analysis ◽  
Senior Resident ◽  
Junior Resident ◽  
Antibiotic Prescribing ◽  
Resident Physicians ◽  
Antibiotic Utilization ◽  
Academic Medical

Abstract Objective: Evaluate the difference in antibiotic prescribing between various levels of resident training or attending types. Design: Observational, retrospective study. Setting: Tertiary-care, academic medical center in Madison, Wisconsin. Methods: We measured antibiotic utilization from January 1, 2016, through December 31, 2018, in our general medicine (GM) and hospitalist services. The GM1 service is staffed by outpatient internal medicine physicians, the GM2 service is staffed by geriatricians and hospitalists, and the GM3 service is staffed by only hospitalists. The GMA service is led by junior resident physicians, and the GMB service is led by senior resident physicians. We measured utilization using days of therapy (DOT) per 1,000 patient days (PD). In a secondary analysis based on antibiotic spectrum, we used average DOT per 1,000 PD. Results: Teaching services prescribed more antibiotics than nonteaching services (671.6 vs 575.2 DOT per 1,000 PD; P < .0001). Junior resident–led services used more antibiotics than senior resident–led services (740.9 vs 510.0 DOT per 1,000 PD; P < .0001). Overall, antibiotic prescribing was numerically similar between various attending physician backgrounds. A secondary analysis showed that GM services prescribed more broad-spectrum, anti-MRSA, and anti-pseudomonal antibiotics than the hospitalist services. GM junior resident–led services prescribed more broad-spectrum, anti-MRSA, and antipseudomonal therapy compared to their senior counterparts. Conclusions: Antibiotics were prescribed at a significantly higher rate in services associated with trainees than those without. Services led by a junior resident physician prescribed antibiotics at a significantly higher rate than services led by a senior resident. Interventions to reduce unnecessary antibiotic exposure should be targeted toward resident physicians, especially junior trainees.

scholarly journals Clinical Team Distribution and Antibiotic Use Patterns at a Tertiary-Care Academic Medical Center

2020 ◽  
Vol 41 (S1) ◽  
pp. s168-s169
Author(s):  
Rebecca Choudhury ◽  
Ronald Beaulieu ◽  
Thomas Talbot ◽  
George Nelson
Keyword(s):  
Medical Center ◽  
Academic Medical Center ◽  
Tertiary Care ◽  
Antibiotic Use ◽  
Care Hospital ◽  
Hospital Units ◽  
Antibiotic Utilization ◽  
Academic Medical ◽  
Level Data ◽  
Utilization Data

Background: As more US hospitals report antibiotic utilization to the CDC, standardized antimicrobial administration ratios (SAARs) derived from patient care unit-based antibiotic utilization data will increasingly be used to guide local antibiotic stewardship interventions. Location-based antibiotic utilization surveillance data are often utilized given the relative ease of ascertainment. However, aggregating antibiotic use data on a unit basis may have variable effects depending on the number of clinical teams providing care. In this study, we examined antibiotic utilization from units at a tertiary-care hospital to illustrate the potential challenges of using unit-based antibiotic utilization to change individual prescribing. Methods: We used inpatient pharmacy antibiotic use administration records at an adult tertiary-care academic medical center over a 6-month period from January 2019 through June 2019 to describe the geographic footprints and AU of medical, surgical, and critical care teams. All teams accounting for at least 1 patient day present on each unit during the study period were included in the analysis, as were all teams prescribing at least 1 antibiotic day of therapy (DOT). Results: The study population consisted of 24 units: 6 ICUs (25%) and 18 non-ICUs (75%). Over the study period, the average numbers of teams caring for patients in ICU and non-ICU wards were 10.2 (range, 3.2–16.9) and 13.7 (range, 10.4–18.9), respectively. Units were divided into 3 categories by the number of teams, accounting for ≥70% of total patient days present (Fig. 1): “homogenous” (≤3), “pauciteam” (4–7 teams), and “heterogeneous” (>7 teams). In total, 12 (50%) units were “pauciteam”; 7 (29%) were “homogeneous”; and 5 (21%) were “heterogeneous.” Units could also be classified as “homogenous,” “pauciteam,” or “heterogeneous” based on team-level antibiotic utilization or DOT for specific antibiotics. Different patterns emerged based on antibiotic restriction status. Classifying units based on vancomycin DOT (unrestricted) exhibited fewer “heterogeneous” units, whereas using meropenem DOT (restricted) revealed no “heterogeneous” units. Furthermore, the average number of units where individual clinical teams prescribed an antibiotic varied widely (range, 1.4–12.3 units per team). Conclusions: Unit-based antibiotic utilization data may encounter limitations in affecting prescriber behavior, particularly on units where a large number of clinical teams contribute to antibiotic utilization. Additionally, some services prescribing antibiotics across many hospital units may be minimally influenced by unit-level data. Team-based antibiotic utilization may allow for a more targeted metric to drive individual team prescribing.Funding: NoneDisclosures: None

scholarly journals 2424. Shedding of Viable Clostridiodes difficile in Patients Admitted to a Medical Intensive Care Unit

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S837-S838
Author(s):  
Vincent B Young ◽  
Micah Keidan ◽  
Rachel D Yelin ◽  
Thelma E Dangana ◽  
Pamela B Bell ◽  
...  
Keyword(s):  
Intensive Care ◽  
Medical Center ◽  
Academic Medical Center ◽  
Secondary Analysis ◽  
Icu Patients ◽  
Specific Pcr ◽  
Patient Admissions ◽  
Academic Medical ◽  
Healthcare Associated ◽  
Record Review

Abstract Background Hospitalized patients are at risk of colonization with a range of healthcare-associated bacterial pathogens, including C. difficile. In patients admitted to intensive care units (ICUs), in whom C. difficile infection (CDI) is associated with increased morbidity and mortality. To understand the risk for acquisition of C. difficile and development of CDI, we monitored ICU patients daily for shedding of C. difficile by culture. Methods We conducted a secondary analysis of daily rectal/fecal swab samples collected from medical ICU patients of a 720-bed academic medical center in Chicago, IL. Selective culture for C. difficile was performed on swab samples from patients who had 2 or more samples obtained using selective media. Confirmation of putative C. difficile isolates was done by specific PCR assays for the 16S rRNA-encoding gene and the toxin genes tcdA, tcdB, cdtA and cdtB. Clinical testing for CDI was performed using the Xpert® C. difficile PCR assay (Cepheid). Clinical and demographic metadata were collected at bedside and by electronic medical record review. Results Culture was attempted on 2106 swab samples from 451 patients (486 ICU admissions) (Figure 1). A mean of 4.33 samples was obtained from each patient. C. difficile was isolated from 211 (10%) samples from 79 patients (Table 1). The first sample was positive by culture for 48 (9.9%) of patient admissions to the ICU. 31 (6.4%) patients who were initially negative by culture had a subsequent sample from which C. difficile was isolated. Persistence of culture-positivity varied from patient to patient (Figure 2). Of 80 patients who were tested for CDI based on physician suspicion, 12 patients had a positive Cepheid PCR test; 9 had diarrhea and were treated for CDI. Conclusion Surveillance for shedding of C. difficile by daily culture reveals that patients admitted to the ICU can shed the pathogen intermittently without attributable disease. This can be in the form patients who are admitted carrying the organism as well as those who appear to acquire the organism during their stay. It is unclear whether patient or microbiome factors underlie the differences seen in patterns of shedding. Furthermore, intermittent shedding may reflect multiple episodes of exposure to C. difficile spores and asymptomatic shedding without stable colonization. Disclosures All authors: No reported disclosures.

scholarly journals The Effectiveness of Bioskills Training for Simulated Open Lumbar Laminectomy

2017 ◽  
Vol 7 (8) ◽  
pp. 794-800 ◽  
Author(s):  
Barrett S. Boody ◽  
Brett D. Rosenthal ◽  
Tyler J. Jenkins ◽  
Alpesh A. Patel ◽  
Jason W. Savage ◽  
...  
Keyword(s):  
Medical Students ◽  
Clinical Education ◽  
Medical Center ◽  
Academic Medical Center ◽  
Intervention Group ◽  
Training Session ◽  
Senior Resident ◽  
Control Group ◽  
Junior Resident ◽  
Training Module

Study Design: Randomized, prospective study within an orthopedic surgery resident program at a large urban academic medical center. Objectives: To develop an inexpensive, user-friendly, and reproducible lumbar laminectomy bioskills training module and evaluation protocol that can be readily implemented into residency training programs to augment the clinical education of orthopedic and neurosurgical physicians-in-training. Methods: Twenty participants comprising senior medical students and orthopedic surgical residents. Participants were randomized to control (n = 9) or intervention (n = 11) groups controlling for level of experience (medical students, junior resident, or senior resident). The intervention group underwent a 40-minute bioskills training module, while the control group spent the same time with self-directed study. Pre- and posttest performance was self-reported by each participant (Physician Performance Diagnostic Inventory Scale [PPDIS]). Objective outcome scores were obtained from a blinded fellowship-trained attending orthopedic spine surgeon using Objective Structured Assessment of Technical Skills (OSATS) and Objective Decompression Score metrics. Results: When compared with the control group, the intervention group yielded a significant mean improvement in OSATS ( P = .022) and PPDIS ( P = .0001) scores. The Objective Decompression Scores improved in the intervention group with a trend toward significance ( P = .058). Conclusions: We conclude that a concise lumbar laminectomy bioskills training session can be a useful educational tool for to augment clinical education. Although no direct clinical correlation can be concluded from this study, the improvement in trainee’s technical and procedural skills suggests that Sawbones training modules can be an efficient and effective tool for teaching fundamental spine surgical skills outside of the operating room.

scholarly journals Preoperative Cognitive Abnormality, Intraoperative Electroencephalogram Suppression, and Postoperative Delirium

2020 ◽  
Vol 132 (6) ◽  
pp. 1458-1468 ◽  
Author(s):  
Bradley A. Fritz ◽  
Christopher R. King ◽  
Arbi Ben Abdallah ◽  
Nan Lin ◽  
Angela M. Mickle ◽  
...  
Keyword(s):  
Effect Size ◽  
Postoperative Delirium ◽  
Medical Center ◽  
Academic Medical Center ◽  
Secondary Analysis ◽  
Confusion Assessment Method ◽  
Assessment Method ◽  
Total Effect ◽  
Academic Medical ◽  
Cognitive Abnormality

Abstract Background Postoperative delirium is a common complication that hinders recovery after surgery. Intraoperative electroencephalogram suppression has been linked to postoperative delirium, but it is unknown if this relationship is causal or if electroencephalogram suppression is merely a marker of underlying cognitive abnormalities. The hypothesis of this study was that intraoperative electroencephalogram suppression mediates a nonzero portion of the effect between preoperative abnormal cognition and postoperative delirium. Methods This is a prespecified secondary analysis of the Electroencephalography Guidance of Anesthesia to Alleviate Geriatric Syndromes (ENGAGES) randomized trial, which enrolled patients age 60 yr or older undergoing surgery with general anesthesia at a single academic medical center between January 2015 and May 2018. Patients were randomized to electroencephalogram-guided anesthesia or usual care. Preoperative abnormal cognition was defined as a composite of previous delirium, Short Blessed Test cognitive score greater than 4 points, or Eight Item Interview to Differentiate Aging and Dementia score greater than 1 point. Duration of intraoperative electroencephalogram suppression was defined as number of minutes with suppression ratio greater than 1%. Postoperative delirium was detected via Confusion Assessment Method or chart review on postoperative days 1 to 5. Results Among 1,113 patients, 430 patients showed evidence of preoperative abnormal cognition. These patients had an increased incidence of postoperative delirium (151 of 430 [35%] vs.123 of 683 [18%], P &lt; 0.001). Of this 17.2% total effect size (99.5% CI, 9.3 to 25.1%), an absolute 2.4% (99.5% CI, 0.6 to 4.8%) was an indirect effect mediated by electroencephalogram suppression, while an absolute 14.8% (99.5% CI, 7.2 to 22.5%) was a direct effect of preoperative abnormal cognition. Randomization to electroencephalogram-guided anesthesia did not change the mediated effect size (P = 0.078 for moderation). Conclusions A small portion of the total effect of preoperative abnormal cognition on postoperative delirium was mediated by electroencephalogram suppression. Study precision was too low to determine if the intervention changed the mediated effect. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

Double Trouble: Patients With Both True and False Arrhythmia Alarms

2020 ◽  
Vol 40 (2) ◽  
pp. 14-23
Author(s):  
Stella Chiu Nguyen ◽  
Sukardi Suba ◽  
Xiao Hu ◽  
Michele M. Pelter
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Medical Center ◽  
Academic Medical Center ◽  
Secondary Analysis ◽  
Altered Mental Status ◽  
False Alarms ◽  
Number Of False Alarms ◽  
Academic Medical ◽  
Using Data

Background Patients with both true and false arrhythmia alarms pose a challenge because true alarms might be buried among a large number of false alarms, leading to missed true events. Objective To determine (1) the frequency of patients with both true and false arrhythmia alarms; (2) patient, clinical, and electrocardiographic characteristics associated with both true and false alarms; and (3) the frequency and types of true and false arrhythmia alarms. Methods This was a secondary analysis using data from an alarm study conducted at a tertiary academic medical center. Results Of 461 intensive care unit patients, 211 (46%) had no arrhythmia alarms, 12 (3%) had only true alarms, 167 (36%) had only false alarms, and 71 (15%) had both true and false alarms. Ventricular pacemaker, altered mental status, mechanical ventilation, and cardiac intensive care unit admission were present more often in patients with both true and false alarms than among other patients (P &lt; .001). Intensive care unit stays were longer in patients with only false alarms (mean [SD], 106 [162] hours) and those with both true and false alarms (mean [SD], 208 [333] hours) than in other patients. Accelerated ventricular rhythm was the most common alarm type (37%). Conclusions An awareness of factors associated with arrhythmia alarms might aid in developing solutions to decrease alarm fatigue. To improve detection of true alarms, further research is needed to build and test electrocardiographic algorithms that adjust for clinical and electrocardiographic characteristics associated with false alarms.

Communication about opioid versus nonopioid analgesics in the emergency department

2015 ◽  
Vol 11 (3) ◽  
pp. 229 ◽  
Author(s):  
Danielle M. McCarthy, MD, MS ◽  
Kenzie A. Cameron, PhD, MPH ◽  
D. Mark Courtney, MD, MS ◽  
James G. Adams, MD ◽  
Kirsten G. Engel, MD
Keyword(s):  
Emergency Department ◽  
Adverse Effects ◽  
Medical Center ◽  
Academic Medical Center ◽  
Multivariable Analysis ◽  
Secondary Analysis ◽  
Academic Medical ◽  
Frequency Of Use ◽  
Nonopioid Analgesics ◽  
Attending Physicians

Objective: The Medication Communication Index (MCI) was used to compare counseling about opioids to nonopioid analgesics in the Emergency Department (ED) setting.Design: Secondary analysis of prospectively collected audio recordings of ED patient visits.Setting: Urban, academic medical center (>85,000 annual patient visits). Participants: Patient participants aged >18 years with one of four low acuity diagnoses: ankle sprain, back pain, head injury, and laceration. ED clinician participants included resident and attending physicians, nursing staff, and ED technicians.Main outcome measures: The MCI is a five-point index that assigns points for communicating the following: medication name (1), purpose (1), duration (1), adverse effects (1), number of tablets (0.5), and frequency of use (0.5). Recording transcripts were scored with the MCI, and total scores were compared between drug classes.Results: The 41 patients received 56 prescriptions (27 nonopioids, 29 opioids). Nonopioid median MCI score was 3 and opioid score was 4.5 (p = 0.0008). Patients were counseled equally about name (nonopioid 100 percent, opioid 96.6 percent, p = 0.34) and purpose (88.9 percent, 89.7 percent, p = 0.93). However, patients receiving opioids were counseled more frequently about duration of use (nonopioid 40.7 percent, opioid 69.0 percent, p = 0.03) and adverse effects (18.5 percent, 93.1 percent, p < 0.001). In multivariable analysis, opioids (β = 0.54, p = 0.04), number of medications prescribed (β = −0.49, p = 0.05), and time spent in the ED (β = 0.007, p = 0.006) were all predictors of total MCI score.Conclusions: The extent of counseling about analgesic medications in the ED differs by drug class. When counseling patients about all analgesic medications, providers should address not only medication name and purpose but also the less frequently covered topics of medication dosing, timing, and adverse effects.

scholarly journals Clostridium difficile infection in an academic medical center in Saudi Arabia: prevalence and risk factors

2020 ◽  
Vol 40 (4) ◽  
pp. 305-309
Author(s):  
Mai Alalawi ◽  
Seba Aljahdali ◽  
Bashaer Alharbi ◽  
Lana Fagih ◽  
Raghad Fatani ◽  
...  
Keyword(s):  
Risk Factors ◽  
Clostridium Difficile ◽  
Broad Spectrum ◽  
Medical Center ◽  
Academic Medical Center ◽  
Infection Prevalence ◽  
Healthcare Facilities ◽  
Broad Spectrum Antibiotics ◽  
Academic Medical ◽  
Significant Difference

ABSTRACT BACKGROUND: Clostridium difficile infection is one of the most common causes of diarrhea in healthcare facilities. More studies are needed to identify patients at high risk of C difficile infection in our community. OBJECTIVES: Estimate the prevalence of C difficile infection among adult patients and evaluate the risk factors associated with infection. DESIGN: Retrospective record review. SETTING: Tertiary academic medical center in Jeddah. PATIENTS AND METHODS: Eligible patients were adults (≥18 years old) with confirmed C difficile diagnosis between January 2013 and May 2018. MAIN OUTCOME MEASURES: Prevalence rate and types of risk factors. SAMPLE SIZE: Of 1886 records, 129 patients had positive lab results and met the inclusion criteria. RESULTS: The prevalence of C difficile infection in our center over five years was 6.8%. The mean (SD) age was 56 (18) years, and infection was more prevalent in men (53.5%) than in women (46.5%). The most common risk factors were use of proton-pump inhibitors (PPI) and broad-spectrum antibiotics. The overlapping exposure of both PPIs and broad-spectrum antibiotics was 56.6%. There was no statistically significant difference between the type of PPI ( P =.254) or antibiotic ( P =.789) and the onset of C difficile infection. CONCLUSION: The overall C difficile infection prevalence in our population was low compared to Western countries. The majority of the patients who developed C difficile infection were using PPIs and/or antibiotics. No differences were observed in the type of antibiotic or PPI and the onset of C difficile infection development. Appropriate prescribing protocols for PPIs and antibiotics in acute settings are needed. LIMITATIONS: Single center and retrospective design. CONFLICT OF INTEREST: None.

Accuracy of and prescriber perceptions related to documenting antibiotic indications during order entry at an academic medical center

2020 ◽  
Vol 77 (4) ◽  
pp. 282-287
Author(s):  
James Beardsley ◽  
Mark Vestal ◽  
Norbert Rosario ◽  
Kalyn Meosky ◽  
James Johnson ◽  
...  
Keyword(s):  
Medical Center ◽  
Academic Medical Center ◽  
Final Diagnosis ◽  
Antibiotic Prescribing ◽  
Order Entry ◽  
Empiric Antibiotics ◽  
Academic Medical ◽  
Progress Notes ◽  
Secondary Endpoints ◽  
A Minor

Abstract Purpose To assess the accuracy of antibiotic indication documentation provided during order entry and prescriber perceptions of the requirement to specify indications. Methods Patients who received 1 of 6 selected antibiotics from May 1 through June 30, 2017, were identified. Records of 30 randomly selected patients who received each study antibiotic were retrospectively reviewed. The primary endpoint was indication accuracy, defined as agreement of the indication entered during order entry with that documented in progress notes at the time of order entry. Secondary endpoints included correlation of entered indication and final diagnosis for empiric antibiotics. A brief survey was emailed to prescribers to assess the burden and perceptions of requiring an indication during order entry. Results Four thousand five hundred twenty-four patients received 1 or more doses of a study antibiotic. For the 180 patients selected for evaluation, 89.4% of indications were accurate. Indications for antibiotics ordered for prophylaxis were more likely to be inaccurate than those for empiric or definitive antibiotics (accuracy rates of 46%, 94%, and 92%, respectively, p &lt; 0.05). For empiric antibiotics, 78.5% of indications documented at order entry matched the final diagnosis. Two hundred fifty-four of 863 prescribers (29%) responded to the survey request. Most respondents felt that documenting the indication took no more than 20 seconds, was a “minor nuisance” or “occasionally burdensome,” and had no impact on their consideration of antibiotic appropriateness. Conclusion With the exception of prophylaxis, the indications documented during order entry were sufficiently accurate to assist antimicrobial stewardship efforts. Although indication documentation was perceived as a minor burden, surveyed prescribers indicated it had only a minimal beneficial effect on antibiotic prescribing.

scholarly journals Spectrum of tablet computer use by medical students and residents at an academic medical center

2015 ◽  
Author(s):  
Robert Robinson
Keyword(s):  
Medical Students ◽  
Patient Care ◽  
Computer Use ◽  
Response Rate ◽  
Medical Center ◽  
Academic Medical Center ◽  
Tablet Computer ◽  
Tablet Computers ◽  
Resident Physicians ◽  
Academic Medical

Introduction: The value of tablet computer use in medical education is an area of considerable interest, with preliminary investigations showing that the majority of medical trainees feel that tablet computers added value to the curriculum. This study investigated potential differences in tablet computer use between medical students and resident physicians. Materials & Methods: Data collection for this survey was accomplished with an anonymous online questionnaire shared with the medical students and residents at Southern Illinois University School of Medicine (SIU-SOM) in July and August of 2012. Results: There were 76 medical student responses (26% response rate) and 66 resident/fellow responses to this survey (21% response rate). Residents/fellows were more likely to use tablet computers several times daily than medical students (32% vs 20%, p = 0.035). The most common reported uses were for accessing medical reference applications (46%), e-Books (45%), and board study (32%). Residents were more likely than students to use a tablet computer to access an electronic medical record (41% vs 21%, p = 0.010), review radiology images (27% vs 12%, p = 0.019), and enter patient care orders (26% vs 3%, p < 0.001). Discussion: This study shows a high prevalence and frequency of tablet computer use among physicians in training at this academic medical center. Most residents and students use tablet computers to access medical references, e-books, and to study for board exams. Residents were more likely to use tablet computers to complete clinical tasks. Conclusions: Tablet computer use among medical students and resident physicians was common in this survey. All learners used tablet computers for point of care references and board study. Resident physicians were more likely to use tablet computers to access the EMR, enter patient care orders, and review radiology studies. This difference is likely due to the differing educational and professional demands placed on resident physicians. Further study is needed better understand how tablet computers and other mobile devices may assist in medical education and patient care.

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