Loop diuretic use following fluid resuscitation in the critically ill

Abstract Disclaimer In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Purpose To identify the incidence of continuation of newly initiated loop diuretics upon intensive care unit (ICU) and hospital discharge and identify factors associated with continuation. Methods This was a single-center retrospective study using electronic health records in the setting of adult ICUs at a quaternary care academic medical center. It involved patients with sepsis admitted to the ICU from January 1, 2014, to June 30, 2019, who received intravenous fluid resuscitation. The endpoints of interest were (1) the incidence of loop diuretic use during an ICU stay following fluid resuscitation, (2) continuation of loop diuretics following transition of care, and (3) potential factors associated with loop diuretic continuation after transition from the ICU. Results Of 3,591 patients who received intravenous fluid resuscitation for sepsis, 39.4% (n = 1,415) were newly started on loop diuretics during their ICU stay. Among patients who transitioned to the hospital ward from the ICU, loop diuretics were continued in 33% (388/1,193) of patients. At hospital discharge, 13.4% (52/388) of these patients were prescribed a loop diuretic to be used in the outpatient setting. History of liver disease, development of acute kidney injury, being on vasopressors while in the ICU, receiving blood products, and receiving greater than 90 mL/kg of bolus fluids were significant potential factors associated with loop diuretic continuation after transition from the ICU. Conclusion New initiation of loop diuretics following intravenous fluid resuscitation in patients with sepsis during an ICU stay is a common occurrence. Studies are needed to assess the effect of this practice on patient outcomes and resource utilization.

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1102. Evaluation of Vancomycin Accumulation in Patients with Obesity

Open Forum Infectious Diseases ◽

10.1093/ofid/ofab466.1296 ◽

2021 ◽

Vol 8 (Supplement_1) ◽

pp. S642-S643

Author(s):

Maha Assadoon ◽

Jeffrey C Pearson ◽

David W Kubiak ◽

Mary P Kovacevic ◽

Brandon Dionne

Keyword(s):

Severe Renal Impairment ◽

Medical Center ◽

Academic Medical Center ◽

Kidney Injury ◽

Volume Of Distribution ◽

Obesity Class ◽

Factors Associated ◽

Days Of Therapy ◽

Trough Concentrations ◽

Potential Factors

Abstract Background Current vancomycin guidelines recommend using actual body weight for dosing. However, in patients with obesity, this may result in lower initial vancomycin concentrations that can accumulate with continued doses due to differences in volume of distribution. The objective of this study is to evaluate the incidence of vancomycin accumulation in patients with obesity and identify potential factors associated with accumulation. Methods This is a single-center, retrospective, observational study at a tertiary academic medical center. Adult patients with a BMI ≥ 30 kg/m2 and with ≥ 2 vancomycin serum trough concentrations within the same encounter in 2019 were screened. Patients were excluded if they were pregnant, had unstable renal function or severe renal impairment, received < 3 doses before a concentration was drawn, or had inconsistent dosing prior to a concentration draw. Linear kinetics were used to correct for differences in timing of concentration or dose changes. The major endpoint was the incidence of vancomycin accumulation, defined as a 20% increase in trough concentration between the first and any subsequent trough concentrations within the first 10 days of therapy. Minor endpoints included the percentage of supratherapeutic concentrations and the incidence of acute kidney injury (AKI). Descriptive statistics were used to evaluate endpoints and multivariable logistic regression was used to evaluate factors associated with accumulation. Results We screened 543 patients, and 162 were included in our analysis. The median age was 56.5 years (interquartile range [IQR] 43 - 65.3), and 62.3% were male. The median weight was 112.7 kg (IQR 99.8 - 122.6) and the median BMI was 36.8 kg/m2 (IQR 33.1 - 41). The median total daily vancomycin dose at initiation was 28.7 mg/kg/day (IQR 25.4 - 31.2). Vancomycin accumulation occurred in 99 patients (61.1%) within the first 10 days of therapy and AKI occurred in 21 patients (14.9%). No factors studied, including age, gender, obesity class, initial dose, SCr, or frequency were associated with accumulation. Conclusion Most patients with obesity experienced vancomycin accumulation within the first 10 days of therapy. Providers should be cautious when assessing a vancomycin concentration early in the treatment course. Disclosures All Authors: No reported disclosures

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Disparities in Pediatric Patient Portal Activation and Feature Use

JAMIA Open ◽

10.1093/jamiaopen/ooab086 ◽

2021 ◽

Vol 4 (3) ◽

Author(s):

Jennifer H LeLaurin ◽

Oliver T Nguyen ◽

Lindsay A Thompson ◽

Jaclyn Hall ◽

Jiang Bian ◽

...

Keyword(s):

Medical Center ◽

Academic Medical Center ◽

White Female ◽

Patient Portal ◽

Patient Portals ◽

Electronic Health Record Data ◽

Factors Associated ◽

Academic Medical ◽

Vulnerable Individual ◽

Records Access

Abstract Objective Disparities in adult patient portal adoption are well-documented; however, less is known about disparities in portal adoption in pediatrics. This study examines the prevalence and factors associated with patient portal activation and the use of specific portal features in general pediatrics. Materials and methods We analyzed electronic health record data from 2012 to 2020 in a large academic medical center that offers both parent and adolescent portals. We summarized portal activation and use of select portal features (messaging, records access and management, appointment management, visit/admissions summaries, and interactive feature use). We used logistic regression to model factors associated with patient portal activation among all patients along with feature use and frequent feature use among ever users (ie, ≥1 portal use). Results Among 52 713 unique patients, 39% had activated the patient portal, including 36% of patients aged 0–11, 41% of patients aged 12–17, and 62% of patients aged 18–21 years. Among activated accounts, ever use of specific features ranged from 28% for visit/admission summaries to 92% for records access and management. Adjusted analyses showed patients with activated accounts were more likely to be adolescents or young adults, white, female, privately insured, and less socioeconomically vulnerable. Individual feature use among ever users generally followed the same pattern. Conclusions Our findings demonstrate that important disparities persist in portal adoption in pediatric populations, highlighting the need for strategies to promote equitable access to patient portals.

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Potentially Inappropriate Durations of Anti-Infective Therapy at Hospital Discharge Despite Inpatient Antimicrobial Stewardship

Open Forum Infectious Diseases ◽

10.1093/ofid/ofx163.782 ◽

2017 ◽

Vol 4 (suppl_1) ◽

pp. S330-S330

Author(s):

Neal Fox ◽

Lauren Haines ◽

Rachel Bull ◽

Zachary Jenkins ◽

John Ballentine ◽

...

Keyword(s):

Hospital Discharge ◽

Antimicrobial Stewardship ◽

Medical Center ◽

Academic Medical Center ◽

Total Duration ◽

Final Analysis ◽

Unintended Consequences ◽

Duration Of Therapy ◽

Days Of Therapy ◽

Chi Squared

Abstract Background Excess durations of anti-infective therapy are a common problem that may lead to unintended consequences. Antimicrobial stewardship (AMS) is a growing field that largely focuses on inpatient anti-infective use. For this study, one site was an academic medical center whose AMS uses prospective auditing; the other was a community hospital with pharmacy-driven AMS. Little research has examined durations of anti-infective therapy at hospital discharge. Methods Patient charts were reviewed and 284 were included in the final analysis. Patients were excluded if discharged on non-oral anti-infectives or only agents for a non-study indication. Patients were included if they were discharged on oral anti-infective therapy for CAP, healthcare-associated pneumonia (HCAP), UTI, cellulitis, and superficial abscess. Evidence-based durations of therapy were utilized to determine the potential inappropriateness of anti-infective therapy. Guidelines from the study period were used. Total duration of therapy was derived from the combination of outpatient therapy plus inpatient therapy beginning with the first day of relevant coverage for the given indication. Descriptive statistics were utilized to compare durations of therapy. Chi-squared tests were utilized to examine differences in expected frequencies. All statistics were performed in SPSS v. 24. Results The average combined duration of therapy was 11.3 days. 190 patients (66.9%) were found to have a potentially inappropriate duration of oral anti-infective therapy at hospital discharge. Only 2 durations were too short. Figure 1 displays the distribution of excess days of therapy. Figure 2 shows the breakdown of potential inappropriateness of duration by diagnosis. Figure 3 displays the percentage of potentially inappropriate cases by site. There were no significant differences in the primary outcome between the sites. Conclusion CAP and cellulitis appear to be areas that are often overtreated. Discharge durations of therapy should be a focus of AMS teams. Many patients receive potentially inappropriate durations of therapy at discharge without any discernible benefit. Further research is needed in this area. Disclosures All authors: No reported disclosures.

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Abstract 9740: Factors Associated With Performing Urgent Coronary Angiography in Out-of-Hospital Cardiac Arrest

Circulation ◽

10.1161/circ.132.suppl_3.9740 ◽

2015 ◽

Vol 132 (suppl_3) ◽

Author(s):

David H Lam ◽

Lauren M Glassmoyer ◽

Roger B Davis ◽

Donald E Cutlip ◽

Michael W Donnino ◽

...

Keyword(s):

Myocardial Infarction ◽

Cardiac Arrest ◽

Coronary Angiography ◽

Medical Center ◽

Academic Medical Center ◽

Do Not Resuscitate ◽

Factors Associated ◽

Shockable Rhythm ◽

History Of ◽

Hospital Cardiac Arrest

Introduction: Out-of-hospital cardiac arrest (OHCA) is associated with high mortality and is most commonly caused by cardiovascular disease. Current guidelines recommend urgent coronary angiography (UCA) if ST-elevation myocardial infarction (STEMI) or high suspicion of acute myocardial infarction exist. Some have advocated for UCA in all OHCA without an obvious non-cardiac cause of arrest. The reasons for large clinical variation in performance of UCA in OHCA are not well understood. Objective: We sought to identify factors associated with performing UCA in OHCA. Methods: A retrospective chart review was conducted on 535 consecutive cardiac arrest patients who achieved return of spontaneous circulation (ROSC) and were admitted at a tertiary academic medical center from January 2008 to August 2014. Exclusion criteria included in-hospital cardiac arrests (201), outside hospital UCA (8), and lack of medical records (1). Univariable analysis followed by multivariable forward selection forcing age and gender were used to determine correlates of performing UCA, defined as within 6 hours of presentation. Results: Out of 325 resuscitated OHCA patients (mean age, 64; women, 35%), 69 were taken to UCA. Factors associated with performing UCA were history of coronary artery disease (CAD) (OR 2.76, 95% CI 1.22-6.28), initial shockable rhythm (OR 3.04, 95% CI 1.31-7.06), following commands post-ROSC (OR 2.77, 95% CI 1.06-7.25), and STEMI (OR 15.17, 95% CI 6.57-35.04). Increasing age (OR 0.97, 95% CI 0.95-0.999) and obvious non-cardiac cause of arrest (OR 0.10, 95% CI 0.03-0.37) were negatively associated. Gender, prior stroke, dementia, bystander cardiopulmonary resuscitation, hypotension, contraindication to anticoagulant, presenting from nursing home or rehabilitation, do not resuscitate order prior to admission, non-English primary language, and presenting during off-hours were not associated with the decision for UCA. Conclusions: In resuscitated out-of-hospital cardiac arrest patients, history of CAD, shockable rhythm, ability to follow commands, and STEMI were associated with performing urgent coronary angiography. Older patients and those with an obvious non-cardiac cause of arrest were less likely to receive coronary angiography.

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Factors Associated With Breast Cancer Clinical Trials Participation and Enrollment at a Large Academic Medical Center

Journal of Clinical Oncology ◽

10.1200/jco.2004.03.005 ◽

2004 ◽

Vol 22 (11) ◽

pp. 2046-2052 ◽

Cited By ~ 103

Author(s):

Michael S. Simon ◽

Wei Du ◽

Lawrence Flaherty ◽

Philip A. Philip ◽

Patricia Lorusso ◽

...

Keyword(s):

Breast Cancer ◽

Clinical Trials ◽

Medical Center ◽

Performance Status ◽

Academic Medical Center ◽

Comprehensive Cancer Center ◽

Cancer Center ◽

Poor Performance Status ◽

Cancer Clinical Trials ◽

Factors Associated

Purpose The practice patterns of medical oncologists at a large National Cancer Institute Comprehensive Cancer Center in Detroit, MI were evaluated to better understand factors associated with accrual to breast cancer clinical trials. Patients and Methods From 1996 to 1997, physicians completed surveys on 319 of 344 newly evaluated female breast cancer patients. The 19-item survey included clinical data, whether patients were offered clinical trial (CT) participation and enrollment, and when applicable, reasons why they were not. Multivariate analyses using logistic regression were performed to evaluate predictors of an offer and enrollment. Results The patients were 57% white, 32% black, and 11% other/unknown race. One hundred six (33%) were offered participation and 36 (34%) were enrolled. In multivariate analysis, CTs were less likely offered to older women (mean age, 52 years for those offered v 57 years for those not offered; P = .0005) and black women (21% of blacks offered v 42% of whites; P = .0009). Women with stage 1 disease, poor performance status, and those who were previously diagnosed were also less likely to be offered trials. None of these factors were significant predictors of enrollment. Women were not offered trials because of ineligibility (57%), lack of available trials (41%), and noncompliance (2%). Reasons for failed enrollment included patient refusal (88%) and failed eligibility (12%). Conclusion It is important for cooperative groups to design studies that will accommodate a broader spectrum of patients. Further work is needed to assess ways to improve communication about breast cancer CT participation to all eligible women.

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A Decision for Predicting Successful Extubation of Patients in Intensive Care Unit

BioMed Research International ◽

10.1155/2018/6820975 ◽

2018 ◽

Vol 2018 ◽

pp. 1-11 ◽

Cited By ~ 4

Author(s):

Chang-Shu Tu ◽

Chih-Hao Chang ◽

Shu-Chin Chang ◽

Chung-Shu Lee ◽

Ching-Ter Chang

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Medical Center ◽

Minute Ventilation ◽

Bootstrap Method ◽

Academic Medical Center ◽

Icu Stay ◽

Rapid Shallow Breathing Index ◽

Prolonged Icu Stay ◽

Successful Extubation

Approximately 40% of patients admitted to the medical intensive care unit (ICU) require mechanical ventilation. An accurate prediction of successful extubation in patients is a key clinical problem in ICU due to the fact that the successful extubation is highly associated with prolonged ICU stay. The prolonged ICU stay is also associated with increasing cost and mortality rate in healthcare system. This study is retrospective in the aspect of ICU. Hence, a total of 41 patients were selected from the largest academic medical center in Taiwan. Our experimental results show that predicting successful rate of 87.8% is obtained from the proposed predicting function. Based on several types of statistics analysis, including logistic regression analysis, discriminant analysis, and bootstrap method, three major successful extubation predictors, namely, rapid shallow breathing index, respiratory rate, and minute ventilation, are revealed. The prediction of successful extubation function is proposed for patients, ICU, physicians, and hospital for reference.

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Factors associated with posttraumatic growth among healthcare workers at an academic‐medical center: A correlational study

Perspectives In Psychiatric Care ◽

10.1111/ppc.12817 ◽

2021 ◽

Author(s):

Chizimuzo T. C. Okoli ◽

Sarret Seng

Keyword(s):

Posttraumatic Growth ◽

Healthcare Workers ◽

Medical Center ◽

Academic Medical Center ◽

Correlational Study ◽

Factors Associated ◽

Academic Medical

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Barriers in communicating medication changes at hospital discharge: Informing CancelRx design requirements

Journal of Patient Safety and Risk Management ◽

10.1177/25160435211005928 ◽

2021 ◽

pp. 251604352110059

Author(s):

Yushi Yang ◽

Samantha I Pitts ◽

Allen R Chen

Keyword(s):

Hospital Discharge ◽

Medical Center ◽

Academic Medical Center ◽

Structured Interviews ◽

Medication Discontinuation ◽

Academic Medical ◽

Receive System ◽

Design Requirements ◽

To Receive ◽

Medication Changes

Objectives This operational study aims to investigate the barriers in communicating medication changes at hospital discharge, and to inform design requirements of the CancelRx functionality to better support the communication. Methods We conducted seven semi-structured interviews with inpatient prescribers at an urban academic medical center. The interview protocol was framed from a human factors perspective, specifically the work system design approach. We took notes of the interviews and identified the initial themes of system barriers that may impact patient safety. Results Medication changes need to be communicated to multiple stakeholders. We identified two initial themes of the system barriers: the lack of an information flow that connects all the involved stakeholders, and the difficulties to communicate key pieces of information. We identified three key pieces of information that are difficult to communicate: the discontinuation reasons, the notification urgency, and the duration of changes. Conclusions While the CancelRx functionality can facilitate the communication (e.g. prescribers no longer need to call pharmacists when a medication is discontinued), enhancements are needed to address the system barriers. We proposed enhanced design requirements of the CancelRx functionality, e.g., to allow users to specify a reason for a medication discontinuation and transmit the reasons to other stakeholders, to indicate the urgency of notification, to specify the duration of a change, and to receive system status feedback .

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Perioperative Factors Associated With Chronic Opioid Use After Spine Surgery

Global Spine Journal ◽

10.1177/21925682211035723 ◽

2021 ◽

pp. 219256822110357

Author(s):

Eric Y. Montgomery ◽

Mark N. Pernik ◽

Zachary D. Johnson ◽

Luke J. Dosselman ◽

Zachary K. Christian ◽

...

Keyword(s):

Risk Factors ◽

Spine Surgery ◽

Medical Center ◽

Lumbar Fusion ◽

Academic Medical Center ◽

Opioid Use ◽

Retrospective Case ◽

Opioid Prescription ◽

Factors Associated ◽

Chronic Opioid Use

Study Design: Retrospective case control. Objectives: The purpose of the current study is to determine risk factors associated with chronic opioid use after spine surgery. Methods: In our single institution retrospective study, 1,299 patients undergoing elective spine surgery at a tertiary academic medical center between January 2010 and August 2017 were enrolled into a prospectively collected registry. Patients were dichotomized based on renewal of, or active opioid prescription at 3-mo and 12-mo postoperatively. The primary outcome measures were risk factors for opioid renewal 3-months and 12-months postoperatively. These primarily included demographic characteristics, operative variables, and in-hospital opioid consumption via morphine milligram equivalence (MME). At the 3-month and 12-month periods, we analyzed the aforementioned covariates with multivariate followed by bivariate regression analyses. Results: Multivariate and bivariate analyses revealed that script renewal at 3 months was associated with black race ( P = 0.001), preoperative narcotic ( P < 0.001) or anxiety/depression medication use ( P = 0.002), and intraoperative long lumbar ( P < 0.001) or thoracic spine surgery ( P < 0.001). Lower patient income was also a risk factor for script renewal ( P = 0.01). Script renewal at 12 months was associated with younger age ( P = 0.006), preoperative narcotics use ( P = 0.001), and ≥4 levels of lumbar fusion ( P < 0.001). Renewals at 3-mo and 12-mo had no association with MME given during the hospital stay or with the usage of PCA ( P > 0.05). Conclusion: The current study describes multiple patient-level factors associated with chronic opioid use. Notably, no metric of perioperative opioid utilization was directly associated with chronic opioid use after multivariate analysis.

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