Abstract 319: A Multi-faceted Programmatic Approach Associated with Over 50% Reduction in In-hospital Mortality

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_4) ◽  
Author(s):  
Amrita Mukhopadhyay ◽  
Wai Sha (Sally) Cheung ◽  
Eugene Yuriditsky ◽  
Karsten Drus ◽  
Quyen Wong ◽  
...  
Keyword(s):  
Hospital Mortality ◽  
Care Facility ◽  
Interrupted Time Series ◽  
The United States ◽  
Outpatient Setting ◽  
Evidence Based ◽  
Rapid Response Teams ◽  
Affiliate Hospital ◽  
Main Hospital ◽  
Hospital Patients

Introduction: In the United States, the chance of dying in the hospital widely varies by hospital, with bottom-decile hospitals having twice the rates of risk-adjusted mortality when compared to top-decile hospitals. This suggests a need for improvement in health systems nationwide. Here, we describe the implementation of, and associated outcomes for a multi-faceted, evidence-based approach to reducing in-hospital mortality. Methods: This is a retrospective interrupted time-series conducted at a large, urban, academic health system. Specifically, we describe the implementation of the following evidence-based methods: 1) escalation of communication guidelines, 2) proactive rounding with nurse response teams, and 3) rapid response teams with dedicated staff. We then quantify the associated observed-to-expected (O:E) in-hospital mortality over a 12-year period at our main hospital, and subsequently over a 3-year period at an affiliated hospital where the same interventions were later implemented. Results: Over 12 years, 445,308 patients were discharged from our main hospital, with 3,948 (0.9%) being discharged to an acute care facility, 4,558 (1.0%) discharged to hospice, and 4,648 (1.0%) expiring in the hospital. Patients had an average age of 53.1 years (std.dev 22.8 years), with the majority being female (59.0%), non-Hispanic white (66.1%), and admitted from the outpatient setting (93.3%). From the years 2010 to 2013, there was decline in O:E mortality by 59.0% (Figure 1A). This effect was sustained from 2014-2018. At the affiliate hospital, there was a similar decline in O:E mortality after implementation of the same interventions (60.5%, Figure 1B). Conclusion: Our multi-faceted, programmatic approach was associated with over 50% reductions in in-hospital mortality that were sustained for several years after implementation, and were reproduced at an affiliated hospital.

scholarly journals Incorporating Point-of-Care Bacterial Fluorescence into a Wound Clinic Antimicrobial Stewardship Program

Diagnostics ◽  
2020 ◽  
Vol 10 (12) ◽  
pp. 1010
Author(s):  
Thomas E. Serena
Keyword(s):  
Fluorescence Imaging ◽  
Antimicrobial Stewardship ◽  
Chronic Wounds ◽  
The United States ◽  
Outpatient Setting ◽  
Joint Commission ◽  
World Health ◽  
Evidence Based ◽  
Hospital Inpatient ◽  
Imaging Device

Background: In 2014 the World Health Organization (WHO) warned of an emerging world-wide crisis of antibiotic-resistant microorganisms. In response, government and professional organizations recommended that health care systems adopt antimicrobial stewardship programs (ASPs). In the United States, the Centers for Medicare Services (CMS) mandated antimicrobial stewardship in the hospital inpatient setting. Effective 1 January 2020, the Joint Commission required ambulatory centers that prescribe antibiotics, such as wound centers, to institute an ASP. Chronic wounds often remain open for months, during which time patients may receive multiple courses of antibiotics and numerous antimicrobial topical treatments. The wound clinician plays an integral role in reducing antimicrobial resistance in the outpatient setting: antibiotics prescribed for skin and soft tissue infections are among the most common in an outpatient setting. One of the most challenging aspects of antimicrobial stewardship in treating chronic wounds is the inaccuracy of bacterial and infection diagnosis. Methods: Joint Commission lists five elements of performance (EP): (1) identifying an antimicrobial stewardship leader; (2) establishing an annual antimicrobial stewardship goal; (3) implementing evidence-based practice guidelines related to the antimicrobial stewardship goal; (4) providing clinical staff with educational resources related to the antimicrobial stewardship goal; and (5) collecting, analyzing, and reporting data related to the antimicrobial stewardship goal. This article focuses on choosing and implementing an evidence-based ASP goal for 2020. Discussion: Clinical trials have demonstrated the ability of fluorescence imaging (MLiX) to detect clinically significant levels of bacteria in chronic wounds. Combined with clinical examination of signs and symptoms of infection, the MLiX procedure improves the clinician’s ability to diagnose infection and can guide antimicrobial use. In order to satisfy the elements of performance, the MLiX procedure was incorporated into the annual ASP goal for several wound care centers. Clinicians were educated on the fluorescence imaging device and guidelines were instituted. Collection of antimicrobial utilization data is underway.

Abstract 11781: Association of Rapid Response Teams With Hospital Mortality in Medicare Patients

Circulation ◽  
2021 ◽  
Vol 144 (Suppl_2) ◽  
Author(s):  
Saket Girotra ◽  
Philip Jones ◽  
Mary A Peberdy ◽  
Mary S Vaughan Sarrazin ◽  
Paul S Chan
Keyword(s):  
Hospital Mortality ◽  
Median Duration ◽  
Interrupted Time Series ◽  
Rapid Response ◽  
Annual Number ◽  
Rapid Response Teams ◽  
Implementation Period ◽  
Using Data ◽  
Expected Mortality ◽  
Get With The Guidelines

Background: Rapid response teams (RRT) have been promoted as a strategy to reduce unexpected hospital deaths, as they are designed to evaluate and treat patients experiencing sudden decline. However, evidence to support their effectiveness in reducing in-hospital mortality remains uncertain. Methods: Using data from 56 hospitals participating in Get With The Guidelines Resuscitation linked to Medicare, we calculated annual rates of case-mix adjusted mortality for each hospital during 2000-2014. We constructed a hierarchical interrupted time series model to determine whether implementation of a RRT was associated with a reduction in mortality that was larger than expected based on pre-implementation trends alone. Results: Over the study period, the median annual number of Medicare admissions across study hospitals was 5214 (range: 408-18,398). The median duration of the pre-implementation period was 7.6 years comprising ~2.5 million admissions, and the median duration of the post-implementation period was 7.2 years comprising ~2.6 million admissions. Before implementation of RRTs, hospital mortality was already decreasing by 2.7% annually (Figure). Implementation of RRTs was not associated with change in mortality in the initial year of implementation (RR for model intercept: 0.98; 95% CI 0.94-1.02; P= 0.30) or in the mortality trend over time (RR for model slope: 1.01 per-year; 95% CI 0.99-1.02; P =0.30). Within individual hospitals, a RRT was associated with a significantly lower than expected mortality at 4 (7.1%) of hospitals, and significantly higher than expected mortality at 2 (3.6%), when compared to pre-implementation trends. Conclusion: Among a diverse sample of U.S. hospitals, we found that the implementation of a RRT was not associated with a significant reduction in hospital mortality. Given their prevalence in most U.S. hospitals, further studies are needed to understand best practices in composition, design, and implementation of RRTs.

scholarly journals Trends in Tracheostomy After Stroke: Analysis of the 1994 to 2013 National Inpatient Sample

2018 ◽  
Vol 8 (4) ◽  
pp. 171-176 ◽  
Author(s):  
Abhinaba Chatterjee ◽  
Monica Chen ◽  
Gino Gialdini ◽  
Michael E. Reznik ◽  
Santosh Murthy ◽  
...  
Keyword(s):  
Hospital Mortality ◽  
Care Facility ◽  
International Classification Of Diseases ◽  
The United States ◽  
National Inpatient Sample ◽  
Real World Data ◽  
Discharge Disposition ◽  
Home Discharge ◽  
Index Stroke ◽  
Nationally Representative

Background: Real-world data on long-term trends in the use of tracheostomy after stroke are limited. Methods: Patients who underwent tracheostomy for acute ischemic stroke (AIS), intracerebral hemorrhage (ICH), or subarachnoid hemorrhage (SAH) were identified from the 1994 through 2013 releases of the National Inpatient Sample using previously validated International Classification of Diseases, Ninth Revision, Clinical Modification codes. Survey weights were used to report nationally representative estimates. Our primary outcome was the trend in tracheostomy use during the index stroke hospitalization over the last 20 years. Additionally, we evaluated trends in in-hospital mortality, timing of placement, and discharge disposition among patients who received a tracheostomy. Results: We identified 9.9 million patients with AIS, ICH, or SAH in the United States from 1994 to 2013, of which 170 255 (1.7%; 95% confidence interval [CI]: 1.6%-1.8%) underwent tracheostomy. Among all patients with stroke, tracheostomy use increased from 1.2% (95% CI: 1.1%-1.4%) in 1994 to 1.9% (95% CI: 1.8%-2.1%) in 2013, with similar trends across stroke types. From 1994 to 2013, the timing of tracheostomy decreased from 16.5 days (95% CI: 14.9-18.1 days) to 10.3 days (95% CI: 9.9-10.8 days) after mechanical ventilation. In-hospital mortality decreased from 32.6% (95% CI: 29.1%-36.1%) to 13.8% (95% CI: 12.3%-15.3%) among tracheostomy patients; however, discharge to a nonacute care facility increased from 42.9% (95% CI: 38.0%-47.8%) to 83.3% (95% CI: 81.6%-85.0%) and home discharge declined from 9.3% (95% CI: 7.3%-11.3%) to 2.9% (95% CI: 2.1%-3.7%). Conclusion: Over the past 2 decades, tracheostomy use has increased among patients with stroke. This increase was associated with earlier placement, reduced in-hospital mortality, and lower rates of home discharge.

scholarly journals Incorporating Point-of-Care Bacterial Fluorescence into a Wound Clinic Antimicrobial Stewardship Program

2020 ◽  
Author(s):  
Thomas Serena
Keyword(s):  
Fluorescence Imaging ◽  
Antimicrobial Stewardship ◽  
Chronic Wounds ◽  
The United States ◽  
Outpatient Setting ◽  
Joint Commission ◽  
World Health ◽  
Evidence Based ◽  
Hospital Inpatient ◽  
Imaging Device

Background: In 2014 the World Health Organization (WHO) warned of an emerging world-wide crisis of antibiotic resistant microorganisms. In response, government and professional organizations recommended that health care systems adopt antimicrobial stewardship programs (ASPs). In the United States, the Centers for Medicare Services (CMS) mandated antimicrobial stewardship in the hospital inpatient setting. Effective January 1, 2020, the Joint Commission required ambulatory centers that prescribe antibiotics, such as wound centers, to institute an ASP. Chronic wounds often remain open for months, during which time patients may receive multiple courses of antibiotics and numerous antimicrobial topical treatments. The wound clinician plays an integral role in reducing antimicrobial resistance in the outpatient setting: antibiotics prescribed for skin and soft tissue infections are among the most common in an outpatient setting. One of the most challenging aspects of antimicrobial stewardship in treating chronic wounds is the inaccuracy of bacterial and infection diagnosis. Methods: Joint Commission lists five elements of performance (EP): (1) Identifying an antimicrobial stewardship leader, (2) establishing an annual antimicrobial stewardship goal, (3) implementing evidence-based practice guidelines related to the antimicrobial stewardship goal, (4) providing clinical staff with educational resources related to the antimicrobial stewardship goal, and (5) collecting, analyzing, and reporting data related to the antimicrobial stewardship goal. This article focuses on choosing and implementing an evidence-based ASP goal for 2020. Discussion: Clinical trials have demonstrated the ability of fluorescence imaging (MLiX) to detect clinically significant levels of bacteria in chronic wounds. Combined with clinical examination of signs and symptoms of infection, the MLiX procedure improves the clinician’s ability to diagnose infection and can guide antimicrobial use. In order to satisfy the elements of performance, the MLiX procedure was incorporated into the annual ASP goal for several wound care centers. Clinicians were educated on the fluorescence imaging device and guidelines were instituted. Collection of antimicrobial utilization data is underway.

The Speech-Language Assessment of English Language Learning Students: A Non-Standardized Approach

2013 ◽  
Vol 14 (4) ◽  
pp. 95-101 ◽  
Author(s):  
Robert Kraemer ◽  
Allison Coltisor ◽  
Meesha Kalra ◽  
Megan Martinez ◽  
Bailey Savage ◽  
...  
Keyword(s):  
Language Learning ◽  
Language Impairment ◽  
Specific Language Impairment ◽  
English Language ◽  
Language Assessment ◽  
The United States ◽  
English Language Learning ◽  
Assessment Practices ◽  
Evidence Based ◽  
English Speaking

English language learning (ELL) children suspected of having specific-language impairment (SLI) should be assessed using the same methods as monolingual English-speaking children born and raised in the United States. In an effort to reduce over- and under-identification of ELL children as SLI, speech-language pathologists (SLP) must employ nonbiased assessment practices. This article presents several evidence-based, nonstandarized assessment practices SLPs can implement in place of standardized tools. As the number of ELL children SLPs come in contact with increases, the need for well-trained and knowledgeable SLPs grows. The goal of the authors is to present several well-establish, evidence-based assessment methods for assessing ELL children suspected of SLI.

440: Barriers to the Practice of Evidence Based Urology in the United States

2007 ◽  
Vol 177 (4S) ◽  
pp. 147-148
Author(s):  
Philipp Dahm ◽  
Hubert R. Kuebler ◽  
Susan F. Fesperman ◽  
Roger L. Sur ◽  
Charles D. Scales ◽  
...  
Keyword(s):  
United States ◽  
The United States ◽  
Evidence Based

Refining Evidence-Based Treatments for Late-Life Depression

GeroPsych ◽  
2015 ◽  
Vol 28 (2) ◽  
pp. 67-76
Author(s):  
Grace C. Niu ◽  
Patricia A. Arean
Keyword(s):  
Older Adults ◽  
Mental Illness ◽  
Brain Plasticity ◽  
Late Life ◽  
Aging Population ◽  
The United States ◽  
Future Research ◽  
Evidence Based ◽  
Late Life Depression ◽  
Evidence Based Treatments

The recent increase in the aging population, specifically in the United States, has raised concerns regarding treatment for mental illness among older adults. Late-life depression (LLD) is a complex condition that has become widespread among the aging population. Despite the availability of behavioral interventions and psychotherapies, few depressed older adults actually receive treatment. In this paper we review the research on refining treatments for LLD. We first identify evidence-based treatments (EBTs) for LLD and the problems associated with efficacy and dissemination, then review approaches to conceptualizing mental illness, specifically concepts related to brain plasticity and the Research Domain Criteria (RDoc). Finally, we introduce ENGAGE as a streamlined treatment for LLD and discuss implications for future research.

Hospice Care in the United States: The Process Begins

1983 ◽  
Vol 13 (2) ◽  
pp. 159-171 ◽  
Author(s):  
Robert W. Buckingham
Keyword(s):  
Home Care ◽  
Hospice Care ◽  
Care Facility ◽  
The United States ◽  
Considerable Change ◽  
Educational Institutions ◽  
Hospice Movement ◽  
Treatment Equipment ◽  
Centered Care ◽  
The Individual

The hospice concept represents a return to humanistic medicine, to care within the patient's community, for family-centered care, and the view of the patient as a person. Medical, governmental, and educational institutions have recognized the profound urgency for the advocacy of the hospice concept. As a result, a considerable change in policy and attitude has occurred. Society is re-examining its attitudes toward bodily deterioration, death, and decay. As the hospice movement grows, it does more than alter our treatment of the dying. Hospices and home care de-escalate the soaring costs of illness by reducing the individual and collective burdens borne by all health insurance policyholders. Because hospices and home care use no sophisticated, diagnostic treatment equipment, their overhead is basically for personal care and medication. Also, the patient is permitted to die with dignity. Studies indicated that the patient of a hospice program will not experience the anxiety, helplessness, inadequacy, and guilt as will an acute care facility patient. Consequently, a hospice program can relieve family members and loved ones of various psychological disorders.

SARS-CoV-2 and The Case for Empirical Treatment (Preprint)

2020 ◽  
Author(s):  
Richard P Bartlett ◽  
Alexandria Watkins
Keyword(s):  
Diabetes Mellitus ◽  
Type Ii Diabetes ◽  
The United States ◽  
Type Ii Diabetes Mellitus ◽  
Outpatient Setting ◽  
Empirical Treatment ◽  
Residual Effects ◽  
Type Ii ◽  
West Texas

UNSTRUCTURED Background: This is an outpatient case study that examines two patients in the United States with unique cases that involve oncology, hypertension, Type II Diabetes Mellitus, and Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2), also known as COVID-19. This case study involves two patients in the outpatient setting - treated via telemedicine, with laboratory-confirmed SARS-CoV-2 infection in the West Texas region between March 29th, 2020, and May 14th, 2020. Case Report: The first patient is a 63-year-old female, non-smoker, who is diagnosed with Waldenstrom’s Macroglobulinemia (2012) and Primary Cutaneous Marginal Zone Lymphoma (2020) and the second patient is a 38-year-old male, non-smoker, who has the following comorbidities: Type II Diabetes Mellitus (DM), hypertension, and gout. Both patients were empirically started on budesonide 0.5mg nebulizer twice daily, clarithromycin (Biaxin) 500mg tab twice daily for ten days, Zinc 50mg tab twice daily, and aspirin 81mg tab daily. Both patients have fully recovered with no residual effects. Conclusion: The goal is to call attention to the success of proactive, early empirical treatment, combining a classic corticosteroid (budesonide) administered via a nebulizer and an oral macrolide antibiotic known as clarithromycin (Biaxin).

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