scholarly journals Endoscopic management of cystic duct stones and Mirizzi’s syndrome: experience at an academic medical center

2022 ◽  
Vol 10 (01) ◽  
pp. E135-E144
Author(s):  
Rishi Pawa ◽  
Robert Dorrell ◽  
Swati Pawa
Keyword(s):  
Cystic Duct ◽  
Medical Center ◽  
Academic Medical Center ◽  
Case Series ◽  
Small Diameter ◽  
The United States ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Endoscopic Management ◽  
Electrohydraulic Lithotripsy

Abstract Background and study aims Cystic duct stones (CDS) are challenging to treat with conventional ERCP techniques due to the small diameter and tortuous nature of the cystic duct. There have been limited studies focused on endoscopic management of CDS. We present our experience managing CDS endoscopically and demonstrate that new advances in endoscopic technology have rendered CDS easier to manage. Patients and methods From 2013 to 2020, we prospectively maintained a database of patients undergoing endoscopic management of CDS. ERCP was performed in all patients, and if unsuccessful in removing stones, cholangioscopy with electrohydraulic lithotripsy (EHL) was utilized. All patients were followed in clinic for outcomes. Results Of 5,123 ERCPs performed at our institution during the study period, 21 patients were diagnosed with CDS. Six patients were successfully treated with conventional ERCP alone. Cholangioscopy with EHL was used in 15 patients undergoing 18 procedures to achieve stone clearance. CDS clearance was achieved in all patients. There was one adverse event (post-ERCP pancreatitis). Spyglass DS was associated with a significant decrease in average procedure time in comparison to first-generation SpyGlass (89.3 vs. 54.4 minutes, P = 0.004). Thirteen patients (87 %) were discharged from the hospital within 24 hours. The median follow-up duration was 23.2 months. Conclusions Endoscopy should be the preferred management strategy for CDS, especially in patients with prior cholecystectomy. Surgical outcomes have been associated with high patient morbidity and hospital length of stay. Our case series is the largest cohort of CDS patients successfully managed with cholangioscopy and EHL in the United States.

Agency for Healthcare Research and Quality Patient Safety Indicators and Mortality in Surgical Patients

2014 ◽  
Vol 80 (8) ◽  
pp. 801-804 ◽  
Author(s):  
Rajesh Ramanathan ◽  
Patricia Leavell ◽  
Luke G. Wolfe ◽  
Therese M. Duane
Keyword(s):  
Patient Safety ◽  
Length Of Stay ◽  
Medical Center ◽  
Academic Medical Center ◽  
Hospital Length ◽  
Healthcare Research ◽  
Hospital Length Of Stay ◽  
Surgical Patients ◽  
Patient Safety Indicators ◽  
Academic Medical

Patient safety indicators (PSI), developed by the Agency for Healthcare Research and Quality, use administrative billing data to measure and compare patient safety events at medical centers. We retrospectively examined whether PSIs accurately reflect patients’ risk of mortality, hospital length of stay, and intensive care unit (ICU) requirements at an academic medical center. Surgical patient records with PSIs were reviewed between October 2011 and September 2012 at our urban academic medical center. Primary outcomes studied included mortality, hospital length of stay, and ICU requirements. Subset analysis was performed for each PSI and its association with the outcome measures. PSIs were more common among surgical patients who died as compared with those alive at discharge (35.3 vs 2.7 PSIs/100 patients, P < 0.01). Although patients who died with PSIs had shorter hospital courses, they had a significantly greater ICU requirement than those without a PSI (96.0 vs 61.1%, P < 0.01) and patients who were alive at discharge (96.0 vs 48.0%, P < 0.01). The most frequently associated PSIs with mortality were postoperative metabolic derangements (41.7%), postoperative sepsis (38.5%), and pressure ulcers (33.3%). PSIs occur at a higher frequency in surgical patients who die and are associated with increased ICU requirements.

scholarly journals PT Achievement in Public Hospitals and Its Effect on Outcomes

Geriatrics ◽  
2019 ◽  
Vol 4 (4) ◽  
pp. 58
Author(s):  
Jessica S. Morton ◽  
Alex Tang ◽  
Michael J. Moses ◽  
Dustin Hamilton ◽  
Neville Crick ◽  
...  
Keyword(s):  
Physical Therapy ◽  
Length Of Stay ◽  
Medical Center ◽  
Therapy Group ◽  
Academic Medical Center ◽  
Early Mobilization ◽  
The United States ◽  
Public Hospitals ◽  
Hospital Length Of Stay ◽  
Discharge Disposition

The demand for TKA continues to rise within the United States, while increasing quality measures and cost containment became the basis of reimbursement for hospital systems. Length of stay is a major driver in the cost of TKA. Early mobilization with physical therapy has been shown to increase range of motion and decrease complications, but with mixed results in regards to length of stay. We postulate that initiating physical therapy on post-operative day zero will decrease length of stay in an urban public hospital. Retrospective chart review was performed at a large, urban, public academic medical center to identify patients who have had a primary TKA over the course of a 3-year period. Groups who underwent post-operative day zero therapy were compared with those who initiated physical therapy on post-operative day one. Length of stay was the primary outcome. Patient demographic characteristics and discharge disposition were also collected. There were 98 patients in the post-operative day-one physical therapy cohort and 58 in the post-operative day zero physical therapy group. Hospital length of stay was significantly decreased in the post-operative day zero physical therapy group. (p < 0.01) There was no difference in discharge disposition between the two groups.

Impact of Obesity on Warfarin Reversal With Fixed-Dose Factor VIII Inhibitor Bypassing Activity (aPCC)

2020 ◽  
pp. 106002802096804
Author(s):  
Amanda L. McKinney ◽  
Lindsey M. Dailey ◽  
James C. McMillen ◽  
A. Shaun Rowe
Keyword(s):  
Medical Center ◽  
Academic Medical Center ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Bleeding Complications ◽  
Fixed Dose ◽  
Factor Viii Inhibitor ◽  
End Points ◽  
Warfarin Reversal ◽  
The Impact

Background: Data are limited addressing anticoagulant reversal in obese patients using activated prothrombin complex concentrate (aPCC). Objective: Assess the impact of obesity on INR reversal with fixed aPCC dosing. Methods: Institutional review board–approved, retrospective cohort conducted in a large academic medical center. Patients 18 years or older who received fixed-dose aPCC for warfarin-associated hemorrhage were included. Patients who received aPCC for any other indications or who had no follow-up INR after aPCC administration were excluded. Patients with an INR of 5 or greater received 1000 units aPCC, whereas those with INR less than 5 received 500 units aPCC, per institutional protocol. Patients were stratified into obese and nonobese based on body mass index. Primary end point was INR reversal, defined as repeat INR of 1.4 or less within 4 hours following aPCC treatment, without a repeated dose. Secondary end points included percentage change in INR, proportion of patients requiring an additional dose of aPCC, bleeding complications, thrombotic complications, hospital length of stay, and in-hospital mortality. Results: 259 patients were included, of whom 83 were obese (32%). A significantly higher proportion of nonobese patients achieved an INR of 1.4 or less within 4 hours of treatment (169 [96.02%] vs 69 [83.13%]; P = 0.0004). There were no differences in any secondary end points. Conclusion and Relevance: When fixed-dose aPCC is used for warfarin reversal, obesity is associated with a significantly lower rate of INR reversal, without increased bleeding. This study adds to the limited amount of literature on aPCC dosing in obesity.

scholarly journals Perioperative Sedation in Mechanically Ventilated Cardiac Surgery Patients With Dexmedetomidine-Based Versus Propofol-Based Regimens

2018 ◽  
Vol 53 (1) ◽  
pp. 5-12 ◽  
Author(s):  
Taylor Chuich ◽  
Christopher Lewis Cropsey ◽  
Yaping Shi ◽  
Daniel Johnson ◽  
Matthew S. Shotwell ◽  
...  
Keyword(s):  
Cardiac Surgery ◽  
Length Of Stay ◽  
Medical Center ◽  
Artery Bypass ◽  
Academic Medical Center ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Suitable Alternative ◽  
Replacement Surgery ◽  
Icu Discharge

Background: Sedative agents used during cardiac surgery can influence the patient’s time to extubation, intensive care unit (ICU) and hospital length of stay, and incidence of delirium. Objective: This study evaluates the effects of the intraoperative and postoperative use of dexmedetomidine versus propofol infusions. Methods: This 19-month retrospective observational study at an academic medical center included 278 patients 18 years of age or older who underwent coronary artery bypass grafting (CABG), valve replacement surgery, or combined CABG plus valve surgery, who received either a dexmedetomidine or propofol infusion in addition to general anesthesia intraoperatively. The primary outcome was time to extubation. The secondary outcomes were ICU and hospital length of stay and incidence of delirium. Results: Use of dexmedetomidine (n = 69) as an intraoperative and postoperative sedative as opposed to propofol (n = 209) was significantly associated with increased likelihood of extubation (ie, shorter time to extubation; hazard ratio = 1.63, 95% CI = 1.21-2.19, P = 0.001). There was no significant association between use of dexmedetomidine and ICU discharge ( P = 0.99), hospital discharge ( P = 0.52), and incidence of delirium ( P = 0.27) after adjusting for other covariates. Conclusion and Relevance: Dexmedetomidine increased the likelihood of extubation when compared with propofol, with no increase in ICU or hospital length of stay or incidence of delirium. Our study is unique in that there was no crossover between patients who received dexmedetomidine and propofol infusions intraoperatively and postoperatively Dexmedetomidine-based regimens could serve as a suitable alternative to propofol-based regimens for fast-track extubation.

Capacity Pooling in Hospitals: The Hidden Consequences of Off-Service Placement

2020 ◽  
Vol 66 (9) ◽  
pp. 3825-3842 ◽  
Author(s):  
Hummy Song ◽  
Anita L. Tucker ◽  
Ryan Graue ◽  
Sarah Moravick ◽  
Julius J. Yang
Keyword(s):  
Medical Center ◽  
Academic Medical Center ◽  
Capacity Allocation ◽  
Hospital Length ◽  
Healthcare Management ◽  
Hospital Length Of Stay ◽  
Surgical Patients ◽  
Hospital Managers ◽  
Service Placement ◽  
Variable Approach

Hospital managers struggle with the day-to-day variability in patient admissions to different clinical services, each of which typically has a fixed allocation of hospital beds. In response, many hospitals engage in capacity pooling by assigning patients from a service whose designated beds are fully occupied to an available bed in a unit designated for a different service. This “off-service placement” occurs frequently, yet its impact on patient and operational measures has not been rigorously quantified. This is, in part, because of the challenge of properly accounting for the endogenous selection of off-service patients. We use an instrumental variable approach to quantify the causal effects of off-service placement of hospitalized medical/surgical patients, having accounted for the endogeneity issues. Using data from a large academic medical center with 19.6% of medical/surgical patients placed off service on average, we find that off-service placement is associated with a 22.8% increase in remaining hospital length of stay (LOS) and a 13.1% increase in the likelihood of hospital readmission within 30 days. We find no significant effect on in-hospital mortality or clinical trigger (rapid response) activation. We identify longer distances to the service’s home unit as a key mechanism that drives the effect on LOS. In contrast, a mismatch in nursing specialization does not seem to explain this effect. By quantifying the effects of off-service placement on patient and operational outcomes, we enable clinicians and hospital managers to make better-informed short-term decisions about off-service placement and longer-term decisions about capacity allocation. This paper was accepted by Stefan Scholtes, healthcare management.

Experience With Rapid Microarray-Based Diagnostic Technology and Antimicrobial Stewardship for Patients With Gram-Positive Bacteremia

2016 ◽  
Vol 37 (11) ◽  
pp. 1361-1366 ◽  
Author(s):  
Elizabeth A. Neuner ◽  
Andrea M. Pallotta ◽  
Simon W. Lam ◽  
David Stowe ◽  
Steven M. Gordon ◽  
...  
Keyword(s):  
Antimicrobial Stewardship ◽  
Medical Center ◽  
Academic Medical Center ◽  
Hospital Length ◽  
Blood Cultures ◽  
Hospital Length Of Stay ◽  
Post Intervention ◽  
Gram Positive ◽  
Diagnostic Technology ◽  
The Impact

OBJECTIVETo describe the impact of rapid diagnostic microarray technology and antimicrobial stewardship for patients with Gram-positive blood cultures.DESIGNRetrospective pre-intervention/post-intervention study.SETTINGA 1,200-bed academic medical center.PATIENTSInpatients with blood cultures positive for Staphylococcus aureus, Enterococcus faecalis, E. faecium, Streptococcus pneumoniae, S. pyogenes, S. agalactiae, S. anginosus, Streptococcus spp., and Listeria monocytogenes during the 6 months before and after implementation of Verigene Gram-positive blood culture microarray (BC-GP) with an antimicrobial stewardship intervention.METHODSBefore the intervention, no rapid diagnostic technology was used or antimicrobial stewardship intervention was undertaken, except for the use of peptide nucleic acid fluorescent in situ hybridization and MRSA agar to identify staphylococcal isolates. After the intervention, all Gram-positive blood cultures underwent BC-GP microarray and the antimicrobial stewardship intervention consisting of real-time notification and pharmacist review.RESULTSIn total, 513 patients with bacteremia were included in this study: 280 patients with S. aureus, 150 patients with enterococci, 82 patients with stretococci, and 1 patient with L. monocytogenes. The number of antimicrobial switches was similar in the pre–BC-GP (52%; 155 of 300) and post–BC-GP (50%; 107 of 213) periods. The time to antimicrobial switch was significantly shorter in the post–BC-GP group than in the pre–BC-GP group: 48±41 hours versus 75±46 hours, respectively (P<.001). The most common antimicrobial switch was de-escalation and time to de-escalation, was significantly shorter in the post-BC-GP group than in the pre–BC-GP group: 53±41 hours versus 82±48 hours, respectively (P<.001). There was no difference in mortality or hospital length of stay as a result of the intervention.CONCLUSIONSThe combination of a rapid microarray diagnostic test with an antimicrobial stewardship intervention improved time to antimicrobial switch, especially time to de-escalation to optimal therapy, in patients with Gram-positive blood cultures.Infect Control Hosp Epidemiol 2016;1–6

Characterization of Pharmacy Resident Interventions on an Academic Inpatient Internal Medicine Rotation

2018 ◽  
Vol 32 (6) ◽  
pp. 625-628
Author(s):  
Sarah E. Petite
Keyword(s):  
Internal Medicine ◽  
Positive Impact ◽  
Medical Center ◽  
Academic Medical Center ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Clinical Interventions ◽  
Medication Therapy ◽  
Therapy Effectiveness ◽  
Acceptance Rates

Purpose: To characterize the clinical interventions of postgraduate year 1 (PGY-1) pharmacy residents on a required, 1-month, inpatient adult internal medicine service at an academic medical center. Methods: The interventions completed by PGY-1 pharmacy residents on a required, adult internal medicine rotation were analyzed. Documentation of clinical interventions was performed by the PGY-1 residents, and the significance of the intervention was subsequently determined. Acceptance rates of clinical interventions were also documented and reviewed. Results: A total of 2161 interventions were documented by 14 PGY-1 pharmacy residents between January 2016 and May 2017. Of these interventions, 2016 (93.3%) had a positive, or accepted, outcome. The significance of the majority of interventions was moderate (93.5%), indicating that either an improvement in drug therapy effectiveness, decreased hospital length of stay, reduction in cost, or prevention in harm had occurred. The most common intervention types were recommendations to add, change, or discontinue a medication therapy, completion of a pharmacy dosing consult or conducting an admission medication reconciliation. Conclusion: PGY-1 pharmacy residents have a positive impact on patient care in the inpatient adult internal medicine setting.

scholarly journals Once Daily Dosing of Ceftriaxone and Metronidazole in Children With Perforated Appendicitis

2016 ◽  
Vol 21 (2) ◽  
pp. 140-145
Author(s):  
Ji Yeon Lee ◽  
Saudia Ally ◽  
Brian Kelly ◽  
David Kays ◽  
Lisa Thames
Keyword(s):  
Length Of Stay ◽  
Wound Infection ◽  
Medical Center ◽  
Controlled Trial ◽  
Academic Medical Center ◽  
Perforated Appendicitis ◽  
Infectious Complications ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Once Daily

OBJECTIVES: The aim of this study was to compare hospital length of stay and rate of infectious complications in children with perforated appendicitis based on the postoperative antibiotic administered. METHODS: This study was a retrospective analysis of children with perforated appendicitis who underwent an appendectomy at a large academic medical center from 2008 to 2013. The primary outcome was hospital length of stay. The secondary outcomes were rates of abscess formation, wound infection, and 30-day readmissions. RESULTS: One hundred and twenty-three patients were included. Sixty-six patients (53%) were administered ceftriaxone and metronidazole once daily; 57 (47%) were administered other antibiotic regimens, which consisted of single, double, or triple antibiotic therapy with a beta-lactam backbone. There was no difference between the groups in terms of postoperative length of stay (5.7 versus 5.8 days, p = 0.83), postoperative abscess rate (8% versus 4%, p = 0.57), postoperative wound infection rate (5% versus 2%, p = 0.73), and 30-day readmissions (3% versus 11%, p = 0.19). CONCLUSIONS: While there was no statistically significant difierence in the outcomes evaluated, the rate of infectious complications was twofold higher in those given ceftriaxone and metronidazole than in others. A larger prospective randomized controlled trial is warranted to better understand the risks of using these agents.

scholarly journals 198. Evaluation of Oral Step-down versus Continued Intravenous Antimicrobial Therapy in Immunocompromised Patients Hospitalized with Gram-Negative Bacteremia

2021 ◽  
Vol 8 (Supplement_1) ◽  
pp. S207-S207
Author(s):  
Heather Savage ◽  
Catherine H Vu ◽  
DeMaurian Mitchner ◽  
Amir Zaki
Keyword(s):  
Length Of Stay ◽  
Academic Medical Center ◽  
The United States ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Immunocompromised Patients ◽  
Clinical Failure ◽  
Gram Negative ◽  
Gram Negative Bacteremia ◽  
Step Down

Abstract Background Bloodstream infections are associated with considerable morbidity and mortality in the United States. Most patients initially receive parenteral antibiotics for gram-negative bacteremia, and more data is emerging supporting de-escalation to oral (PO) antibiotics to complete treatment. Previous studies evaluating PO antibiotics for gram-negative bacteremia often exclude or have underrepresented immunocompromised patients. This study evaluated clinical failure in immunocompromised patients receiving intravenous (IV) antibiotics compared to patients transitioned to PO antibiotics for gram-negative bacteremia. Methods A single center, retrospective cohort study was conducted at 446-bed academic medical center. Patients were included if they were immunocompromised and admitted with a positive blood culture for E. coli, Klebsiella spp., Citrobacter spp., Serratia spp., Enterobacter spp., Proteus spp., P. aeruginosa. between November 4, 2017 to November 4, 2020. Patients were excluded from this study if they had polymicrobial bacteremia, no source control within the first 5 days, or an indication for prolonged duration of treatment. The primary endpoint of this study was clinical failure defined as an escalation from PO to IV antibiotics, worsening clinical status, or readmission for the same infection within 30 days of discharge. The secondary endpoints included 30-day mortality, 90-day mortality, 30-day readmission, and time to microbiologic clearance. Results A total of 31 immunocompromised patients were included in the study with 26 patients receiving PO step-down therapy and 5 patients being continued on IV treatment for gram-negative bacteremia. There was no difference in the primary outcome of clinical failure between the PO step-down group versus the IV therapy group (15.4% vs 20%; p = 0.613). The most common immunocompromised state in both groups was being HIV positive. Patients in the PO step-down group had a significantly shorter hospital length of stay (7.4 days vs. 13.6 days; p = 0.016). Conclusion Oral step-down therapy for gram-negative bacteremia showed similar clinical failure rates to continuous IV therapy in the immunocompromised patient population and may be an option to shorten hospital length of stay. Disclosures All Authors: No reported disclosures

Rapid Identification of Bloodstream Pathogens and Timely Reporting Resulting in Effective Antibiotic Interventions Optimizing Patient Care

2019 ◽  
Vol 152 (Supplement_1) ◽  
pp. S144-S144
Author(s):  
Bo Lin ◽  
Manan Christian ◽  
Margarita Kogan ◽  
Alejandro Zuretti
Keyword(s):  
Blood Culture ◽  
Patient Care ◽  
Median Time ◽  
Medical Center ◽  
Antibiotic Use ◽  
The United States ◽  
Rapid Identification ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Culture Identification

Abstract Objectives Bloodstream infection is a major cause of morbidity and mortality in the United States. Rapid identification of bloodstream pathogens is a critical laboratory practice that allows rapid transition to direct targeted therapy, providing timely and effective patient care. Here, we examined the utilization impact of Biofire blood culture identification panel in identifying bloodstream pathogens and subsequent implementation of treatment on patient care at our medical center. Methods Results of patients’ blood culture results and the subsequent medical interventions were reviewed. A policy of reviewing and reporting positive blood culture results every 2 hours was implemented and the results before and after the policy implementation were compared. Results We reviewed blood culture results from 288 patients during 1/20/2018 to 4/30/2018. In total, 96.5% of patients had antibiotic interventions. Based on the blood culture results, the interventions were adjusted: 32% changed in dosing, 32% escalated, 25% deescalated, and 11% added sensitivity. After the every 2-hour blood culture result reporting policy was implemented, the median time for physicians to order escalation dropped from 3 hours to 1 hour and median time to deescalate also dropped from 2 hours to 1 hour. Conclusion We were able to improve the timeliness of identifying bloodstream pathogens and support effective patient care by using the Biofire blood culture identification panel with timely result reports. Rapid identification of bloodstream pathogens had impacted patient outcomes in multiple ways, including reductions in mortality, morbidity, hospital length of stay, antibiotic use, and patient care cost.

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