Impact of Targeted Educational Interventions on Clostridium difficile Infection Treatment in Critically Ill Adults

Background Clostridium diffcile infection (CDI) is a growing clinical and economic burden throughout the world. Pharmacists often are members of the primary care team in the intensive care unit (ICU) setting; however, the impact of pharmacists educating other health care providers on appropriateness of CDI treatment has not been previously examined. Objective This study was performed to determine the impact of structured educational interventions on CDI treatment on appropriateness of CDI treatment and clinical outcomes. Methods This was a single-center, retrospective, cohort study of patients with CDI in the medical ICU at an academic medical center between January and June 2014 (pre-period) and 2015 (post-period). All patients were evaluated for appropriate CDI treatment before and after implementing pharmacist-provided educational interventions on CDI treatment. Results Patients in the post-period were prescribed appropriate CDI treatment more frequently than patients in the pre-period (91.7% vs 41.7%; p = .03) and received fewer inappropriate doses of a CDI treatment agent (14 doses vs 30 doses). Patients in the pre-period had a shorter ICU length of stay [1.5 days (range, 1–19) vs 3.5 days (range, 2–36); p = .01] and a similar hospital length of stay [9.5 days (range, 4–24) vs 11.5 days (range, 3–56); p = .30]. Total time spent providing interventions was 4 hours. Conclusion Patients had appropriate CDI treatment initiated more frequently in the post-period. This low-cost intervention strategy should be easy to implement in institutions where pharmacists interact with physicians during clinical rounds and should be evaluated in institutions where interactions between pharmacists and physicians occur more frequently in non-rounding situations.

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Clinical Outcomes of Student Pharmacist–Driven Medication Histories at an Academic Medical Center

Journal of Pharmacy Practice ◽

10.1177/0897190018759224 ◽

2018 ◽

Vol 32 (4) ◽

pp. 404-411 ◽

Cited By ~ 1

Author(s):

Justine S. Gortney ◽

Lynette R. Moser ◽

Priyasha Patel ◽

Joshua N. Raub

Keyword(s):

Clinical Outcomes ◽

Health Care Providers ◽

Positive Impact ◽

Medical Center ◽

Academic Medical Center ◽

Care Providers ◽

Medication List ◽

Discharge Medication ◽

Ed Visits ◽

The Impact

Background: Many studies have shown the positive impact that student pharmacists have on patients’ health; however, no studies have been published evaluating student pharmacists’ impact on direct patient outcomes (ie, readmission, emergency department [ED] visits, length of stay) related to the medication history process. Objective: To evaluate the impact of student pharmacist–obtained medication histories on identification of medication discrepancies and clinical outcomes. Methods: Student pharmacists obtained medication histories and then compared the history to that obtained by other health-care providers. Students documented discrepancies and interventions were completed. Control patients were identified and discharge medication list and 30-day readmissions were compared. Results: Seventeen students conducted 215 patient interviews, and 1848 modifications were made to documented home medications in the electronic medical record. Compared to controls (n = 148 student pharmacist, 149 controls), a nonsignificant improvement was found in discharge medication list completeness scores in patients seen by student pharmacists (3.94 vs 3.63; P = .06); but no difference was found in accuracy scores (0.92 vs 0.93; P = .41). Fewer ED visits at 30 days were found in the student pharmacist group (8 vs 18; P = .045), with no difference in readmissions. Conclusions: Student pharmacist–obtained medication histories improved the information available for identifying drug-related problems for inpatients, completeness of the discharge medication list, and ED visits within 30 days.

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Inpatient Communication Networks: Leveraging Secure Text-Messaging Platforms to Gain Insight into Inpatient Communication Systems

Applied Clinical Informatics ◽

10.1055/s-0039-1692401 ◽

2019 ◽

Vol 10 (03) ◽

pp. 471-478 ◽

Cited By ~ 1

Author(s):

Philip A. Hagedorn ◽

Eric S. Kirkendall ◽

S. Andrew Spooner ◽

Vishnu Mohan

Keyword(s):

Communication Network ◽

Network Analysis ◽

Health Care Providers ◽

Text Messaging ◽

Communication Systems ◽

Medical Center ◽

Academic Medical Center ◽

Care Providers ◽

Academic Medical ◽

The Impact

Objective This study attempts to characterize the inpatient communication network within a quaternary pediatric academic medical center by applying network analysis methods to secure text-messaging data. Methods We used network graphing and statistical software to create network models of an inpatient communication system with secure text-messaging data from physicians, nurses, and other ancillary staff in an academic medical center. Descriptive statistics about the network, users within the network, and visualizations informed the team's understanding of the network and its components. Results Analysis of messages exchanged over approximately 23 days revealed a large, scale-free network with 4,442 nodes and 59,913 edges. Quantitative description of user behavior (messages sent and received) and network metrics (i.e., importance of nodes within a network) revealed several operational and clinical roles both sending and receiving > 1,000 messages over this time period. While some of these nodes represented expected “dispatcher” roles in our inpatient system, others occupied important frontline clinical roles responsible for bedside clinical care. Conclusion Quantitative and network analysis of secure text-messaging logs revealed several key operational and clinical roles at risk for alert fatigue and information overload. This analysis also revealed a communication network highly reliant on these key roles, meaning disruption to these individuals or their workflows could lead to dysfunction of the communication network. While secure text-messaging applications play increasingly important roles in facilitating inpatient communication, little is understood about the impact these systems have on health care providers. Developing methods to understand and optimize communication between inpatient providers might help operational and clinical leaders to proactively prevent poorly understood pitfalls associated with these systems and build resilient and effective communication structures.

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391. Small Towns, Big Cities: Rural and Urban Disparities Among Hospitalized Patients with COVID-19

Open Forum Infectious Diseases ◽

10.1093/ofid/ofab466.592 ◽

2021 ◽

Vol 8 (Supplement_1) ◽

pp. S297-S298

Author(s):

Caroline Hamilton ◽

Deepak Nag Ayyala ◽

David Walsh ◽

Christian-Jevon Bramwell ◽

Christopher Walker ◽

...

Keyword(s):

Length Of Stay ◽

Census Data ◽

Medical Center ◽

Academic Medical Center ◽

Hospitalized Patients ◽

Hospital Length Of Stay ◽

Level Of Care ◽

P Value ◽

Rural And Urban ◽

The Impact

Abstract Background More than half of all hospitals in the U.S. are rural hospitals. Frequently understaffed and resource limited, community hospitals serve a population that tends to be older and have less access to care with increased poverty and medical co-morbidities. There is a lack of data surrounding the impact of COVID-19 among rural minority communities. This study seeks to determine rural and urban disparities among hospitalized individuals with COVID-19. Methods This is a descriptive, retrospective analysis of the first 155 adult patients admitted to a tertiary hospital with a positive COVID-19 nasopharyngeal PCR test. Augusta University Medical Center serves the surrounding rural and urban counties of the Central Savannah River Area. Rural and urban categories were determined using patient address and county census data. Demographics, comorbidities, admission data and 30-day outcomes were evaluated. Results Of the patients studied, 62 (40%) were from a rural county and 93 (60%) were from an urban county. No difference was found when comparing the number of comorbidities of rural vs urban individuals; however, African Americans had significantly more comorbidities compared to other races (p-value 0.02). In a three-way comparison, race was not found to be significantly different among admission levels of care. Rural patients were more likely to require an escalation in the level of care within 24 hours of admission (p-value 0.02). Of the patients that were discharged or expired at day 30, there were no differences in total hospital length of stay or ICU length of stay between the rural and urban populations. Baseline Characteristics of Hospitalized Patients with COVID-19 Day 30 Outcomes and Characteristics Level of Care at Time of Admission Conclusion This study suggests that patients in rural communities may be more critically ill or are at a higher risk of early decompensation at time of hospitalization compared to patients from urban communities. Nevertheless, both populations had similar lengths of stay and outcomes. Considering this data is from an academic medical center with a large referral area and standardized inpatient COVID-19 management, these findings may prompt further investigations into other disparate outcomes. Disclosures All Authors: No reported disclosures

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Pharmacists’ Perceptions on Their Role, Activities, Facilitators, and Barriers to Practicing in a Post-Intensive Care Recovery Clinic

Hospital Pharmacy ◽

10.1177/0018578718823740 ◽

2019 ◽

Vol 55 (2) ◽

pp. 119-125

Author(s):

Antoinette B. Coe ◽

Rebecca E. Bookstaver ◽

Andrew C. Fritschle ◽

Michael T. Kenes ◽

Pamela MacTavish ◽

...

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Health Care Providers ◽

Medical Center ◽

Academic Medical Center ◽

Direct Patient Care ◽

Care Providers ◽

Medication Regimen ◽

Medication Reviews ◽

Facilitators And Barriers

Background: Complex medication regimen changes burden intensive care unit (ICU) survivors and their caregivers during the transition to home. Intensive care unit recovery clinics are a prime setting for pharmacists to address patients’ and their caregivers’ medication-related needs. The purpose of this study was to describe ICU recovery clinic pharmacists’ activities, roles, and perceived barriers and facilitators to practicing in ICU recovery clinics across different institutions. Methods: An expert panel of ICU recovery clinic pharmacists completed a 15-item survey. Survey items addressed the pharmacists’ years in practice, education and training, activities performed, their perceptions of facilitators and barriers to practicing in an ICU recovery clinic setting, and general ICU recovery clinic characteristics. Descriptive statistics were used. Results: Nine ICU recovery clinic pharmacists participated. The average number of years in practice was 16.5 years (SD = 13.5, range = 2-38). All pharmacists practiced in an interprofessional ICU recovery clinic affiliated with an academic medical center. Seven (78%) pharmacists always performed medication reconciliation and a comprehensive medication review in each patient visit. Need for medication education was the most prevalent item found in patient comprehensive medication reviews. The main facilitators for pharmacists’ successful participation in an ICU recovery clinic were incorporation into clinic workflow, support from other health care providers, and adequate space to see patients. The ICU recovery clinic pharmacists perceived the top barriers to be lack of dedicated time and inadequate billing for services. Conclusions: The ICU recovery clinic pharmacists address ICU survivors’ medication needs by providing direct patient care in the clinic. Strategies to mitigate pharmacists’ barriers to practicing in ICU recovery clinics, such as lack of dedicated time and adequate billing for pharmacist services, warrant a multifaceted solution, potentially including advocacy and policy work by national pharmacy professional organizations.

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Evaluation of a Multidisciplinary Pain, Agitation, and Delirium Guideline in Mechanically Ventilated Critically Ill Adults

Hospital Pharmacy ◽

10.1177/0018578718769570 ◽

2018 ◽

Vol 54 (2) ◽

pp. 119-124

Author(s):

Melissa Heim ◽

Ryan Draheim ◽

Anna Krupp ◽

Paula Breihan ◽

Ann O’Rourke ◽

...

Keyword(s):

Clinical Outcomes ◽

Critically Ill ◽

Medical Center ◽

Guideline Implementation ◽

Academic Medical Center ◽

Retrospective Chart Review ◽

Hospital Length Of Stay ◽

Mechanically Ventilated ◽

The Impact ◽

Daily Sedation Interruption

Background: A multidisciplinary team updated an institution-specific pain, agitation, and delirium (PAD) guideline based on the recommendations from the Society of Critical Care Medicine (SCCM) PAD guidelines. This institution-specific guideline emphasized protocolized sedation with increased as needed boluses, and nonbenzodiazepine infusions, daily sedation interruption, and pairing of spontaneous awakening (SAT) and breathing trials (SBT). Objective: The purpose of this study was to evaluate the impact of implementation of a PAD guideline on clinical outcomes and medication utilization in an academic medical center intensive care unit (ICU). It was hypothesized that implementation of an updated guideline would improve clinical outcomes and decrease usage of benzodiazepine infusions. Methods: Pre-post retrospective chart review of 2417 (1147 pre, 1270 post) critically ill, mechanically ventilated adults in a medical/surgical ICU over a 2-year period (1 year pre and post guideline implementation). Results: After guideline implementation, average ventilation days was reduced (3.98 vs 3.43 days, P = .0021), as well as ICU and hospital length of stay (LOS) (4.79 vs 4.34 days, P = .048 and 13.96 vs 12.97 days, P = .045, respectively). Hospital mortality (19 vs 19%, P = .96) and acute physiology and chronic health evaluation (APACHE) IV scores (77.28 vs 78.75, P = .27) were similar. After guideline implementation, the percentage of patients receiving midazolam infusions decreased (422/1147 [37%] vs 363/1270 patients [29%], P = .0001). The percentage of patients receiving continuous infusion propofol (679/1147 [59%] vs 896/1270 [70%], P = .0001) and dexmedetomidine (78/1147 [7%] vs 147/1270 [12%], P = .0001) increased. Conclusions: Implementing a multidisciplinary PAD guideline utilizing protocolized sedation and daily sedation interruption decreased ventilation days and ICU and hospital LOS while decreasing midazolam drip usage.

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Patients’ Perceptions of Portal Use Across Care Settings: Qualitative Study (Preprint)

10.2196/preprints.13126 ◽

2018 ◽

Author(s):

Ann Scheck McAlearney ◽

Cynthia J Sieck ◽

Alice Gaughan ◽

Naleef Fareed ◽

Jaclyn Volney ◽

...

Keyword(s):

Health Care Providers ◽

Medical Center ◽

Academic Medical Center ◽

Patient Centered Care ◽

Theory Approach ◽

Access To Information ◽

Engagement In Care ◽

Care Providers ◽

Patient Centered ◽

Centered Care

BACKGROUND Patient portals are a promising instrument to improve patient-centered care, as they provide patients information and tools that can help them better manage their health. The implementation of portals in both the inpatient and outpatient setting gives health care providers an opportunity to support patients both during hospitalization and after discharge. Thus, there is a need to better understand how inpatient and outpatient portals are used across care contexts. OBJECTIVE This study aimed to examine patients’ perceptions of using inpatient and outpatient portals across the care settings, including how they used the portals and the benefits and concerns associated with portal use. METHODS This study was conducted in a large Midwestern academic medical center consisting of seven hospitals. We interviewed 120 patients who had used an inpatient portal during their hospitalization, at 15 days and 6 months postdischarge, to determine their perspectives of portal use in both hospital and outpatient settings. Interview transcripts were analyzed inductively and deductively by using team coding processes consistent with a grounded theory approach. RESULTS Interviews focused on three main areas of portal use: experience with the portal features, perceived benefits, and concerns. Responses at 15 days (n=60) and 6 months (n=60) postdischarge were consistent with respect to perceptions about portal use. Patients identified viewing their health information, managing their schedule, and communicating with providers as notable activities. Convenience, access to information, and better engagement in care were indicated as benefits. Concerns were related to technology issues and privacy/security risks. CONCLUSIONS Implementation of inpatient portals as a complement to outpatient portals is increasing and can enable patients to better manage aspects of their care. Although care processes vary substantively across settings, the benefits of convenience, improved access to information, and better engagement in care provide opportunities for portal use across care settings to support patient-centered care.

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The increasing impact of length of stay “outliers” on length of stay at an urban academic hospital

BMC Health Services Research ◽

10.1186/s12913-021-06972-6 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Andrew H. Hughes ◽

David Horrocks ◽

Curtis Leung ◽

Melissa B. Richardson ◽

Ann M. Sheehy ◽

...

Keyword(s):

Length Of Stay ◽

Medical Center ◽

Academic Medical Center ◽

Improve Patient Care ◽

National Sample ◽

Hospital Length Of Stay ◽

Rare Occurrence ◽

Data Reporting ◽

Targeted Interventions ◽

Hospital Capacity

Abstract Background As healthcare systems strive for efficiency, hospital “length of stay outliers” have the potential to significantly impact a hospital’s overall utilization. There is a tendency to exclude such “outlier” stays in local quality improvement and data reporting due to their assumed rare occurrence and disproportionate ability to skew mean and other summary data. This study sought to assess the influence of length of stay (LOS) outliers on inpatient length of stay and hospital capacity over a 5-year period at a large urban academic medical center. Methods From January 2014 through December 2019, 169,645 consecutive inpatient cases were analyzed and assigned an expected LOS based on national academic center benchmarks. Cases in the top 1% of national sample LOS by diagnosis were flagged as length of stay outliers. Results From 2014 to 2019, mean outlier LOS increased (40.98 to 45.11 days), as did inpatient LOS with outliers excluded (5.63 to 6.19 days). Outlier cases increased both in number (from 297 to 412) and as a percent of total discharges (0.98 to 1.56%), and outlier patient days increased from 6.7 to 9.8% of total inpatient plus observation days over the study period. Conclusions Outlier cases utilize a disproportionate and increasing share of hospital resources and available beds. The current tendency to exclude such outlier stays in data reporting due to assumed rare occurrence may need to be revisited. Outlier stays require distinct and targeted interventions to appropriately reduce length of stay to both improve patient care and maintain hospital capacity.

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

The American Surgeon ◽

10.1177/000313481408000832 ◽

2014 ◽

Vol 80 (8) ◽

pp. 801-804 ◽

Cited By ~ 3

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.

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PT Achievement in Public Hospitals and Its Effect on Outcomes

Geriatrics ◽

10.3390/geriatrics4040058 ◽

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.

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

Annals of Pharmacotherapy ◽

10.1177/1060028020968049 ◽

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.

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