Implementation of a Clinical Pathway to Reduce Rates of Postextubation Stridor

2018 ◽  
Vol 38 (5) ◽  
pp. 34-41
Author(s):  
Megan Lange ◽  
Neeraj Badjatia ◽  
Wan-Tsu Chang
Keyword(s):  
Clinical Pathway ◽  
Neurocritical Care ◽  
Medical Center ◽  
Academic Medical Center ◽  
Compliance Rate ◽  
Hospital Costs ◽  
Hospital Length ◽  
Laryngeal Edema ◽  
Implementation Phase ◽  
Postextubation Stridor

Background Unsuccessful extubation is associated with increased intensive care unit and hospital length of stays, hospital costs, morbidity, and mortality. The most common cause of reintubation is laryngeal edema, often evidenced by postextubation stridor. Objective To reduce the rates of postextubation stridor and reintubation in the neurocritical care unit at a large urban academic medical center. Methods A clinical pathway was created to aid in detecting patients expected to experience postextubation stridor and to guide prophylactic treatment. During the 12-week implementation phase, the pathway was completed on all intubated patients daily. Results The 12-week trial included a total of 606 days of mechanical ventilation. Checklists were completed for 531 days, a compliance rate of 88% for use of the clinical pathway. Of the 56 patients who were extubated during the trial, 54 had a checklist completed, for 96% compliance on the day of extubation. Outcomes after all nonpalliative extubations (n = 43) during the 12 weeks before and after implementation of the pathway (n = 56 periods) were evaluated by using χ2 tests. Implementation of the pathway was associated with a significant reduction in rates of postextubation stridor (χ2 = 6.2; P = .01), reintubation (χ2 = 5.5; P = .02), and reintubation due to postextubation stridor (χ2 = 8.3; P = .004). Conclusion The clinical pathway implemented in the neurocritical care unit was safe and effective in reducing rates of reintubation and reintubation due to postextubation stridor.

Economic Evaluation of a Pharmacist-Led 5-Day Therapeutic Hold of IV Levothyroxine at an Academic Medical Center

2020 ◽  
pp. 001857872097045
Author(s):  
Blake T. Barlow ◽  
Russel J. Roberts ◽  
Kelly Newman ◽  
Sarah K. Harrison ◽  
Jonathan H. Sin
Keyword(s):  
Medical Center ◽  
Financial Burden ◽  
Academic Medical Center ◽  
Cost Savings ◽  
Surgical Trauma ◽  
Implementation Phase ◽  
Academic Medical ◽  
Pharmacokinetic Properties ◽  
Utilization Data ◽  
Surgical Icu

Objective: Providers often admit patients with active outpatient prescriptions for levothyroxine. During an inpatient admission, providers may instruct critically ill patients to take nothing by mouth, or nil per os (NPO). Thus, they may prescribe the intravenous (IV) formulation of levothyroxine during this period. However, levothyroxine possesses a prolonged half-life of up to 7 days; therefore, immediate transition to IV levothyroxine may not be clinically necessary in the acute NPO setting. Intravenous levothyroxine is significantly more expensive than equivalent oral doses and may prove to be a financial burden for an institution. By understanding the pharmacokinetic properties of levothyroxine, we implemented a cost-saving initiative involving a 5-day therapeutic hold of IV levothyroxine. Methods: This was a retrospective evaluation in 2 intensive care units (ICU): a 20-bed surgical/trauma ICU and an 18-bed mixed medical/surgical ICU. Patient data, utilization data, and documented pharmacist interventions were collected for 6 months prior to implementation of the 5-day IV levothyroxine therapeutic hold and for 6 months post-implementation. All patients prescribed IV levothyroxine during these timeframes were included. Results: During the 6-month pre-implementation phase, 674 doses (691 vials) of IV levothyroxine for 77 unique patients were dispensed from the 2 ICUs. During the 6-month post-implementation phase, 168 doses (188 vials) of IV levothyroxine were dispensed for 44 unique patients. Of the 44 patients (48 orders) who still received IV levothyroxine, 22.9% of orders were deemed clinically necessary by the pharmacist and were not recommended to be held under the protocol, 64.6% were due to the verifying pharmacist being unaware of the protocol, 8.3% of orders were due to protocol non-compliance, and 4.2% were verified after the 5-day hold was complete as the patient remained NPO. This pharmacy-led initiative resulted in a 75% decrease in usage post-implementation and an estimated annualized savings of $80,000. Conclusion: A pharmacy-led initiative comprised of a 5-day therapeutic hold of IV levothyroxine was feasible and led to a 75% reduction in usage and cost over a 6-month period in 2 ICU’s. Future steps include additional staff education for improved protocol adherence and expanding the protocol institution-wide for an even greater cost-savings potential.

scholarly journals Quality improvement and reconciliation process for automated dispensing cabinet medication overrides

2021 ◽  
Author(s):  
James A M Rhodes ◽  
Deborah S Bondi ◽  
Laura Celmins ◽  
Charlene Hope ◽  
Randall W Knoebel
Keyword(s):  
Quality Improvement ◽  
Medical Center ◽  
Academic Medical Center ◽  
Compliance Rate ◽  
Medication Use ◽  
Governance Structure ◽  
Dosage Forms ◽  
Academic Medical ◽  
Dispensing Practices ◽  
Reconciliation Process

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 describe a pharmacist-led reconciliation process for automated dispensing cabinet (ADC) medication override setting maintenance at an academic medical center. Summary ADC override management requires alignment of people, processes, and technology. This evaluation describes system-wide improvements to enhance institutional medication override policy compliance by establishing a formalized evaluation and defined roles to streamline ADC dispense setting management. A pharmacist-led quality improvement initiative revised the institutional medication override list to improve medication dispensing practices across an academic medical center campus with a pediatric hospital and 2 adult hospitals. This initiative included removal of patient care unit designations from the medication override list, revision of institutional override policy, creation of an online submission form, and selection of ADC override metrics for surveillance. A conceptual framework guided decisions for unique dosage forms and interdisciplinary engagement. Employing this framework revised workflows for stakeholders in the medication-use process through clinical pharmacist evaluation, existing shared governance structure communication, and pharmacy automation support. The revised policy increased the number of medications available for override from 80 to 106 (33% increase) and unique dosage forms from 166 to 191 (15% increase). The total number of medication dispense settings was reduced from 5,600 to 541 (90% decrease). The proportion of override dispenses compliant with policy increased from 59% to 98% (P < 0.001). Median monthly ADC overrides remained unchanged following policy revision (P = 0.995). ADC override rate reduction was observed across the institution, with the rate decreasing from 1.4% to 1.2% (P < 0.001). Similar ADC override rate reductions were observed for adult, pediatric, and emergency department ADCs. Conclusion This initiative highlights pharmacists’ role in leading institutional policy changes that influence the medication-use process through ADC dispensing practices. A pharmacist-led reconciliation process that removed practice area designations from our medication override policy streamlined ADC setting maintenance, increased the compliance rate of ADC override transactions, and provided a formalized process for future evaluation of medication overrides.

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.

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 Attributable Costs of Enterococcal Bloodstream Infections in a Nonsurgical Hospital Cohort

2010 ◽  
Vol 31 (1) ◽  
pp. 28-35 ◽  
Author(s):  
Anne M. Butler ◽  
Margaret A. Olsen ◽  
Liana R. Merz ◽  
Rebecca M. Guth ◽  
Keith F. Woeltje ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Propensity Score ◽  
Medical Center ◽  
Academic Medical Center ◽  
Hospital Costs ◽  
Bloodstream Infections ◽  
Generalized Least Squares ◽  
Vancomycin Resistance ◽  
Independent Effect ◽  
Matched Pairs

Background.Vancomycin-resistantEnterococcus(VRE) bloodstream infections (BSIs) are associated with increased morbidity and mortality.Objective.To determine the hospital costs and length of stay attributable to VRE BSI and vancomycin-sensitiveEnterococcus(VSE) BSI and the independent effect of vancomycin resistance on hospital costs.Methods.A retrospective cohort study was conducted of 21,154 nonsurgical patients admitted to an academic medical center during the period from 2002 through 2003. Using administrative data, attributable hospital costs (adjusted for inflation to 2007 US dollars) and length of stay were estimated with multivariate generalized least-squares (GLS) models and propensity score-matched pairs.Results.The cohort included 94 patients with VRE BSI and 182 patients with VSE BSI. After adjustment for demographics, comorbidities, procedures, nonenterococcal BSI, and early mortality, the costs attributable to VRE BSI were $4,479 (95% confidence interval [CI], $3,500-$5,732) in the standard GLS model and $4,036 (95% CI, $3,170-$5,140) in the propensity score-weighted GLS model, and the costs attributable to VSE BSI were $2,250 (95% CI, $l,758-$2,880) in the standard GLS model and $2,023 (95% CI, $1,588-$2,575) in the propensity score-weighted GLS model. The median values of the difference in costs between matched pairs were $9,949 (95% CI, $1,579-$24,693) for VRE BSI and $5,282 (95% CI, $2,042-$8,043) for VSE BSI. The costs attributable to vancomycin resistance were $1,713 (95% CI, $1,338-$2,192) in the standard GLS model and $1,546 (95% CI, $1,214-$1,968) in the propensity score-weighted GLS model. Depending on the statistical method used, attributable length of stay estimates ranged from 2.2 to 3.5 days for patients with VRE BSI and from 1.1 to 2.2 days for patients with VSE BSI.Conclusions.VRE BSI and VSE BSI were independently associated with increased hospital costs and increased length of stay. Vancomycin resistance was associated with increased costs.

Delirium in Trauma Patients: Prevalence and Predictors

2017 ◽  
Vol 37 (1) ◽  
pp. 40-48 ◽  
Author(s):  
Kathryn T. Von Rueden ◽  
Breighanna Wallizer ◽  
Paul Thurman ◽  
Karen McQuillan ◽  
Tiffany Andrews ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Mechanical Ventilation ◽  
Intensive Care ◽  
Vision Loss ◽  
Medical Center ◽  
Academic Medical Center ◽  
Hospital Costs ◽  
Assessment Method ◽  
Trauma Patients ◽  
Intermediate Care

BACKGROUNDDelirium is associated with increased mortality, morbidity, hospital costs, and postdischarge cognitive dysfunction. Most research focuses on nontrauma patients receiving mechanical ventilation in the intensive care unit.OBJECTIVESTo determine the prevalence and predictors of delirium in trauma patients residing in intensive and intermediate care units of an academic medical center.METHODSTrauma patients were screened for delirium by using the Confusion Assessment Method for the Intensive Care Unit. Exclusion criteria included documented brain injury, history of psychosis or cognitive impairment, not speaking English, and hearing or vision loss.RESULTSOf the 215 study patients, 24% were positive for delirium; 36% of patients in the intensive care unit and 11% of patients in the intermediate care unit. Delirium-positive patients were older (mean age, 53.4 years) than patients who were not (mean age, 44 years; P = .004). Although mechanical ventilation (odds ratio, 4.73, P = .004) was the strongest independent risk factor for delirium, 12% of delirium-positive patients were not receiving mechanical ventilation. Other predictors of delirium were use of antipsychotic medications, higher scores on the Acute Physiology and Chronic Health Evaluation III, and lower scores on the Richmond Agitation-Sedation Scale.CONCLUSIONSPatients in both the intermediate and intensive care units, whether mechanical ventilation was used or not, were positive for delirium. Delirium prevention protocols may benefit trauma patients regardless of their inpatient location.

Evaluation and Enhancement of a Comprehensive Controlled Substances Management Process at an Academic Medical Center

2021 ◽  
pp. 089719002110222
Author(s):  
Bailey E Eason ◽  
Tyler A Vest ◽  
Katherine D. Mieure ◽  
Danielle Neal ◽  
Jennifer Tryon
Keyword(s):  
Direct Observation ◽  
Gap Analysis ◽  
Work Group ◽  
Medical Center ◽  
Phase 1 ◽  
Academic Medical Center ◽  
Compliance Rate ◽  
Analysis Tool ◽  
Controlled Substances ◽  
Current State

Purpose: Controlled substances management is highly regulated, and requires institutions to have processes in place to maintain a closed-loop. This study was conducted to comprehensively evaluate the current state of controlled substances management, propose optimization opportunities, and implement steps to align the medication use process (MUP) to a defined desired state. Methods: This evaluation was conducted in 2 phases. In phase 1, the current state of controlled substances management was assessed in order to develop a gap analysis tool and failure mode and effects analysis (FMEA). In phase 2, a work group was assembled to address opportunities within the FMEA. The work group prioritized opportunities using the risk priority number (RPN), and formulated action steps to align processes with the defined desired state. Results: Through the literature evaluation, a desired state, consisting of 86 segments, was defined and compared with a gap analysis tool. Direct observation of the MUP allowed for development of 13 process maps depicting current state. Of the 86 segments, it was determined the study institution had a compliance rate of 62%. The remaining 38% correlated with 55 actionable process opportunities that were included in the FMEA. To date, 31 of the 55 (56%) opportunities have been successfully addressed by the work group. Conclusion: Use of direct observation to formulate a gap analysis tool and FMEA is an effective modality to evaluate controlled substances processes. These tools allow for pharmacy departments to identify and prioritize opportunities to optimize controlled substances management within an academic medication center

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.

Development and Impact of an Institutional Enhanced Recovery Program on Opioid Use, Length of Stay, and Hospital Costs Within an Academic Medical Center

2020 ◽  
Vol Publish Ahead of Print ◽  
Author(s):  
Robert H. Thiele ◽  
Bethany M. Sarosiek ◽  
Susan C. Modesitt ◽  
Timothy L. McMurry ◽  
Mohamed Tiouririne ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Enhanced Recovery ◽  
Medical Center ◽  
Academic Medical Center ◽  
Hospital Costs ◽  
Opioid Use ◽  
Enhanced Recovery Program ◽  
Academic Medical ◽  
Recovery Program

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.

Sign in / Sign up

Export Citation Format

Share Document