1144. Evaluation of Procalcitnonin Usage in Neonates Presenting with Fever or Suspected Sepsis

Abstract Background Clinical evaluation alone is not effective in identifying serious bacterial infections (SBI) in neonates presenting with suspected sepsis and fever. A clinical decision making tool to aide in evaluating neonates presenting to the pediatric emergency department (PED) uses urinalysis, absolute neutrophil count (ANC), and procalcitonin (PCT) and together has high negative predictive value (NPV) for SBI. Use may decrease invasive testing, antibiotic exposure, and rates of admission. The tool was incorporated into hospital guidelines in October 2020. The purpose is to assess implementation and prediction of SBIs. Methods This is a single-center quality improvement study at an academic medical center. Neonates less than 60 days presenting with fever or suspected sepsis were included in the baseline group from October 2019- March 2020 or the post-implementation group from October 2020- March 2021. Exclusion criteria were receiving antibiotics 48 hours before PED visit, pre-existing medical conditions, indwelling devices, soft-tissue infections, and ≤ 36 weeks gestation. Implementation and guideline compliance was assessed in neonates aged 29-60 days as the primary outcome. Secondary endpoints include initiation of empiric antibiotics, rates of admission, rates of re-presentation within 30 days, and rates of lumbar punctures in all included patients. Results The baseline group had 29 patients and the post-implementation group had 35 patients who met inclusion/exclusion criteria. Baseline characteristics were similar with higher SBI rates in the post-implementation group having 8 SBIs while the baseline group had 4. There were 16 patients aged 29-60 days in the baseline (55%) and 17 in the post-implementation groups (49%). Complete labs were available for 9 patients (53%) and guideline compliance was 89%. NPV in neonates aged 0-60 days with negative urinalysis, ANC, and PCT was 100%. Rates of secondary endpoints were slightly higher in the post-implementation group along with higher rates of infections. Conclusion High NPV in this small cohort is an indication for continued use of this tool in neonates presenting to the PED with suspected sepsis or fever. Further education to increase use and expansion to all neonates should be considered based on overall NPV and previous studies. Disclosures All Authors: No reported disclosures

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Qualitative exploration of the medical learner’s journey into correctional health care at an academic medical center and its implications for medical education

Advances in Health Sciences Education ◽

10.1007/s10459-020-09997-4 ◽

2020 ◽

Cited By ~ 1

Author(s):

Ahmar H. Hashmi ◽

Alina M. Bennett ◽

Nadeem N. Tajuddin ◽

Rebecca J. Hester ◽

Jason E. Glenn

Keyword(s):

Learning Environment ◽

Clinical Decision Making ◽

Ethical Issues ◽

Medical Center ◽

Academic Medical Center ◽

Clinical Decision ◽

Diagnostic Laboratory ◽

Lower Priority ◽

Academic Medical ◽

Qualitative Exploration

Abstract Correctional systems in several U.S. states have entered into partnerships with academic medical centers (AMCs) to provide healthcare for persons who are incarcerated. One AMC specializing in the care of incarcerated patients is the University of Texas Medical Branch at Galveston (UTMB), which hosts the only dedicated prison hospital in the U.S. and supplies 80% of the medical care for the entire Texas Department of Criminal Justice (TDCJ). Nearly all medical students and residents at UTMB take part in the care of the incarcerated. This research, through qualitative exploration using focus group discussions, sets out to characterize the correctional care learning environment medical trainees enter. Participants outlined an institutional culture of low prioritization and neglect that dominated the learning environment in the prison hospital, resulting in treatment of the incarcerated as second-class patients. Medical learners pointed to delays in care, both within the prison hospital and within the TDCJ system, where diagnostic, laboratory, and medical procedures were delivered to incarcerated patients at a lower priority compared to free-world patients. Medical learners elaborated further on ethical issues that included the moral judgment of those who are incarcerated, bias in clinical decision making, and concerns for patient autonomy. Medical learners were left to grapple with complex challenges like the problem of dual loyalties without opportunities to critically reflect upon what they experienced. This study finds that, without specific vulnerable populations training for both trainees and correctional care faculty to address these institutional dynamics, AMCs risk replicating a system of exploitation and neglect of incarcerated patients and thereby exacerbating health inequities.

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Compliance with National Comprehensive Cancer Network guidelines for antiemesis in cisplatin regimens.

Journal of Clinical Oncology ◽

10.1200/jco.2016.34.7_suppl.280 ◽

2016 ◽

Vol 34 (7_suppl) ◽

pp. 280-280

Author(s):

Terri P. Wolf ◽

Dana Ann Little

Keyword(s):

National Comprehensive Cancer Network ◽

Medical Center ◽

Academic Medical Center ◽

Cancer Center ◽

Adherence Rate ◽

Cancer Centers ◽

Nccn Guidelines ◽

Guideline Compliance ◽

Cancer Network ◽

The Impact

280 Background: The members of a network of community cancer centers affiliated with an academic medical center report following National Comprehensive Cancer Network (NCCN) guidelines. To determine guideline compliance, cisplatin regimens were audited. Cisplatin was selected because of its wide use, high emetic potential, and the impact on QOL for patients with unmanaged nausea and vomiting.The community cancer centers affiliated with an academic medical center report following National Comprehensive Cancer Network (NCCN) guidelines for treatment plans. To determine guideline compliance rates, cisplatin regimens were audited. Cisplatin was selected because of its wide use, high emetic potential, and the impact on QOL for patients with unmanaged nausea and vomiting. Methods: Prior to a chart audit, medical oncologists were surveyed on their knowledge of NCCN antiemesis guidelines, frequency of prescribing based on guidelines, and reasons for not using guidelines. Auditors identified patient charts through billing records and reviewed cycle 1 day 1 orders of cisplatin regimens. Secondary data was collected on hydration orders and home medications for antiemesis. Results: Guideline adherence varied from 0% to 76% with overall adherence at 28%. Dexamethasone doses ranged from 2-20 mg (guideline 12 mg) as did serotonin antagonists (5HT3) ordered at higher IV doses of 24-32 mg (guideline 8-16 mg). Conclusions: Although cancer centers report following the guidelines, this study did not find consistent adherence. The cancer center with the highest adherence rate works closely with a pharmacist and has built order sets with the guidelines. One cancer center had wide variances among practitioners. The variances increase the potential for error. The cancer center with lowest adherence rate used 10 mg doses of dexamethasone because the drug is delivered in 10 mg vials. This study identified multiple systems issues impacting guideline compliance. Managing nausea and vomiting is important for patient QOL and to manage costs by decreasing hospitalizations, treatment delays, and nutritional deficits. Understanding prescribing habits relative to guidelines provides an opportunity to change practice and reduce variability.

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Intravenous Immune Globulin Stewardship Program at a Tertiary Academic Medical Center

Annals of Pharmacotherapy ◽

10.1177/1060028016673071 ◽

2016 ◽

Vol 51 (2) ◽

pp. 135-139 ◽

Cited By ~ 4

Author(s):

Megan A. Rocchio ◽

James W. Schurr ◽

Aaron P. Hussey ◽

Paul M. Szumita

Keyword(s):

Immune Globulin ◽

Medical Center ◽

Academic Medical Center ◽

Intravenous Immune Globulin ◽

Solid Organ ◽

Organ Rejection ◽

Guideline Compliance ◽

Stewardship Program ◽

Academic Medical ◽

Number Of Patients

Background: In October 2010, a pharmacist-driven stewardship program was implemented at the Brigham and Women’s Hospital to ensure continued adherence to the prescribing guideline, focusing on indications for intravenous immune globulin (IVIG) use and dosing per ideal body weight. Objective: The primary objective was to describe an IVIG stewardship program at a tertiary academic medical center. Methods: This was a prospective, observational study from January 2013 through December 2014. All patients ordered to receive IVIG during the defined study period were included. The intervention assessed describes a pharmacist-driven IVIG stewardship program for medication approval. The primary end point was guideline compliance based on indication, dose, dosing weight, and frequency. Secondary end points included the number of patients receiving IVIG, indications, orders discontinued as a result of guideline nonadherence, and total amount dispensed. Results: A total of 418 patients were identified during the study time frame. The top indications were: hypogammaglobulinemia in bone marrow transplantation and hematological malignancy (50.7%), acute solid organ rejection (11.8%), and immune thrombocytopenia with bleeding (10.1%). In all, 12 patients (2.9%) received IVIG for an indication nonadherent with the IVIG prescribing guideline; 9 patients (2.2%) and 2 patients (0.5%), respectively, received a different dose or frequency per the prescribed indication; and 12 orders (2.9%) for indications nonadherent to the guideline were discontinued. A total of 26 033 g of IVIG were dispensed during the study period. Conclusions: An IVIG stewardship program, including an institution-specific prescribing guideline and a pharmacist-driven stewardship program, may ensure guideline compliance for appropriateness of indication and dose at an academic medical center.

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Talking about firearm injury prevention with patients: a survey of medical residents

BMC Medical Education ◽

10.1186/s12909-021-03024-9 ◽

2022 ◽

Vol 22 (1) ◽

Author(s):

Rocco Pallin ◽

Sara Teasdale ◽

Alicia Agnoli ◽

Sarabeth Spitzer ◽

Rameesha Asif-Sattar ◽

...

Keyword(s):

Medical Education ◽

Injury Prevention ◽

Medical Training ◽

Medical Center ◽

Academic Medical Center ◽

Personal Exposure ◽

Further Education ◽

Firearm Injury ◽

Significant Public Health ◽

Patients At Risk

Abstract Background Firearm injury and death are significant public health problems in the U.S. and physicians are uniquely situated to help prevent them. However, there is little formal training in medical education on identifying risk for firearm injury and discussing safe firearm practices with patients. This study assesses prior education, barriers to counseling, and needs for improved training on firearm safety counseling in medical education to inform the development of future education on clinical strategies for firearm injury prevention. Method A 2018 survey administered to 218 residents and fellows at a large, academic medical center asked about medical training on firearm injury prevention, frequency of asking patients about firearm access, and perceived barriers. Results The most common barriers cited were not knowing what to do with patients’ answers about access to firearms (72.1%), not having enough time (66.2%), not feeling comfortable identifying patients at-risk for firearm injury (49.2%), and not knowing how to ask patients about firearm access (48.6%). Prior education on firearm injury prevention was more strongly associated with asking than was personal exposure to firearms: 51.5% of respondents who had prior medical education reported asking compared with who had not received such education (31.8%, p=0.004). More than 90% of respondents were interested in further education about interventions, what questions to ask, and legal mechanisms to separate dangerous people from their firearms. Conclusions Education on assessing risk for firearm-related harm and, when indicated, counseling on safe firearm practices may increase the likelihood clinicians practice this behavior, though additional barriers exist.

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Analysis of dosing-button compliance

American Journal of Health-System Pharmacy ◽

10.1093/ajhp/zxz192 ◽

2019 ◽

Vol 76 (21) ◽

pp. 1770-1776

Author(s):

Mary Frances Picone ◽

James P New ◽

Matthew Hunter Johnson ◽

Nihal Nilesh Desai ◽

Matthew Hebbard

Keyword(s):

Medical Center ◽

Academic Medical Center ◽

Order Entry ◽

Exclusion Criteria ◽

Computerized Provider Order Entry ◽

High Performing ◽

Academic Medical ◽

Secondary Study ◽

High Level ◽

Initial Medication

Abstract Purpose A project was undertaken at an academic medical center to assess use of available dosing buttons within the computerized provider-order-entry (CPOE) system in order to identify opportunities for optimization of medication builds. Methods A retrospective observational study was conducted to identify medication records within a CPOE system meeting prespecified inclusion and exclusion criteria. A report capturing all inpatient adult medication orders associated with the identified medication records over a 6-month period was generated. The primary endpoint was percent dosing-button compliance, calculated as the number of orders with doses consistent with existing dosing-button options divided by the total number of orders during the study period. Secondary study objectives included a comparison of high- and low-performing medication record samples and identification of potential reasons for lack of dosing-button use. Results A total of 2,506 CPOE medication records associated with a total of 694,877 medication orders entered during the study period were analyzed. Median percent dosing-button compliance was 99.92% (interquartile range, 83.33–100%). High-performing records (n = 1243) were more likely to be associated with anti-infective medications (p = 0.041) and medications not on formulary at the study institution (p < 0.001). Medications in the sample of poor-performing CPOE records (n = 614) were more likely to be agents delivered via the i.v. route (p < 0.001). There were 45 records for which poor dosing-button compliance was attributed to lack of a clinically reasonable dosing option. Conclusion A high level of dosing-button compliance was demonstrated despite the lack of routine revalidation of dosing buttons after initial medication builds. Some opportunity for optimization was identified during the project, which established a quality assurance method to facilitate future auditing of medication builds.

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A Neutrophil Subset Defined by Intracellular Olfactomedin 4 is Associated with Mortality in Sepsis

AJP Lung Cellular and Molecular Physiology ◽

10.1152/ajplung.00090.2020 ◽

2020 ◽

Author(s):

Kirsten Neudoerffer Kangelaris ◽

Regina Clemens ◽

Xiaohui Fang ◽

Alejandra Jauregui ◽

Tom Liu ◽

...

Keyword(s):

Host Response ◽

Medical Center ◽

Academic Medical Center ◽

Severity Of Illness ◽

Youden Index ◽

Prognostic Information ◽

Suspected Sepsis ◽

Neutrophil Percentage ◽

Academic Medical ◽

Poor Outcomes

Sepsis is a heterogeneous syndrome clinically and biologically but biomarkers of distinct host response pathways for early prognostic information and testing targeted treatments are lacking. We hypothesized that Olfactomedin 4 (OLFM4), a matrix glycoprotein of neutrophil specific granules defines a distinct neutrophil subset that may be an independent risk factor for poor outcomes in sepsis. In a single-center, prospective cohort study, we enrolled adults admitted to an academic medical center from the Emergency Department (ED) with suspected sepsis (identified by 2 or greater Systemic Inflammatory Response Syndrome [SIRS] criteria and antibiotic receipt) from March 2016 through December 2017, followed by sepsis adjudication according to Sepsis-3. We collected 200mL of whole blood within 24 hours of admission and stained for the neutrophil surface marker CD66b followed by intracellular staining for OLFM4 quantitated by flow cytometry. The predictor for 60-day mortality was the percentage of OLFM4+ neutrophils and at a cut-point of OLFM4+ ≥37.6% determined by the Youden Index. Of 120 enrolled patients with suspected sepsis, 97 had sepsis and 23 had non-sepsis SIRS. The mean percentage of OLFM4+ neutrophils was significantly increased in both sepsis and non-sepsis SIRS patients who died (P ≤ 0.01). Among sepsis patients with elevated OLFM4+(≥37.6%), 56% died compared to 18% with OLFM4+ <37.6% (P=0.001).The association between OLFM4+ and mortality withstood adjustment for demographics, co-morbidities and measures of severity of illness (P<0.03). In sepsis, OLFM4+ neutrophil percentage is independently associated with 60-day mortality and may represent a novel measure of the heterogeneity of host response to sepsis.

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

American Journal of Health-System Pharmacy ◽

10.1093/ajhp/zxz318 ◽

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 < 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.

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Cecal retroflexion is infrequently performed in routine practice and the retroflexed view is of poor quality

BMC Gastroenterology ◽

10.1186/s12876-021-01877-4 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Rajesh N. Keswani ◽

Charles J. Kahi ◽

Mark Benson ◽

Andrew J. Gawron ◽

Tonya R. Kaltenbach ◽

...

Keyword(s):

Medical Center ◽

Academic Medical Center ◽

Hepatic Flexure ◽

Further Education ◽

Routine Practice ◽

Colon Polyps ◽

Polyp Detection ◽

Right Colon ◽

Withdrawal Time ◽

Polyp Detection Rate

Abstract Background As right colon polyps are challenging to detect, a retroflexed view of right colon (RV) may be useful. However, cecal retroflexion (CR) without a RV to the hepatic flexure (HF) is inadequate. We aimed to determine the frequency of CR and quality of the RV in routine practice. Methods This prospective observational study performed at an academic medical center assessed colonoscopy inspection technique of endoscopists who had performed ≥ 100 annual screening colonoscopies. We video recorded ≥ 28 screening/surveillance colonoscopies per endoscopist and randomly evaluated 7 videos per endoscopist. Six gastroenterologists blindly reviewed the videos to determine if CR was performed and HF withdrawal time (cecum to HF time, excluding ileal/polypectomy time). Results Reviewers assessed 119 colonoscopies performed by 17 endoscopists. The median HF withdrawal time was 3 min and 46 s. CR was performed in 31% of colonoscopies. CR frequency varied between endoscopists with 9 never performing CR and 2 performing CR in all colonoscopies. When performed, nearly half (43%) of RVs did not extend to the HF with median RV duration of 16 s (IQR 9–30 s). Three polyps were identified in the RV (polyp detection rate of 8.1%), all identified prior to a forward view. Conclusions CR is performed infrequently in routine practice. When CR is performed, the RV is of low quality with a very short inspection duration and insufficient ascending colon examination. Further education is required to educate endoscopists in optimal technique to improve overall colonoscopy quality.

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Impact of Anticipatory Batching of Pharmacy Compounded Sterile Products on Time to Nurse Administration

Journal of Pharmacy Practice ◽

10.1177/08971900211027134 ◽

2021 ◽

pp. 089719002110271

Author(s):

Sophia Pathan ◽

Danine Sullinger ◽

Laura J. Avino ◽

Samuel E. Culli

Keyword(s):

Medical Center ◽

Academic Medical Center ◽

Medication Administration ◽

Patient Specific ◽

Nursing Services ◽

Academic Medical ◽

Secondary Endpoints ◽

The Mean ◽

The Impact ◽

Mean Time

Background: Timely medication administration is integral to patient care, and operational delays can challenge timely administration. Within an inpatient pharmacy of an academic medical center, intravenous medications were historically compounded on a patient-specific basis. In 2020, the pharmacy began batching frequently-utilized medications. This analysis explored the impact of compounded sterile batching on pharmacy and nursing services. Methods: This pre- and post-interventional study compared data from February through March 2020 with a seasonally matched period from 2019. The primary endpoint was difference in time to administration of urgent (STAT) medications. Secondary endpoints included timeframes for a pharmacy technician to prepare, a pharmacist to check, and a nurse to administer the medications, as well as reprinted labels and estimated waste. Results: On average, it took one hour and 43 minutes to administer a STAT medication in 2019 and one hour and 57 minutes in 2020 ( p = 0.122). It took about four hours to administer routine medications in 2019 and 2020 ( p = 0.488). The number of labels reprinted decreased from 616 in 2019 to 549 in 2020 ( p = 0.195), relating to decreased missing doses. The mean time to check and send a medication decreased from 2019 to 2020 for STAT orders ( p < 0.001), and there was no difference in wasted medications looking at all orders in this time. Conclusion: Anticipatory batching decreased time to prepare, check, and send medications, though there was no effect on waste or on time to administration. Future studies can examine the correlation between pharmacy operations and medication administration.

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