1
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Gohil SK, Septimus E, Kleinman K, Varma N, Avery TR, Heim L, Rahm R, Cooper WS, Cooper M, McLean LE, Nickolay NG, Weinstein RA, Burgess LH, Coady MH, Rosen E, Sljivo S, Sands KE, Moody J, Vigeant J, Rashid S, Gilbert RF, Smith KN, Carver B, Poland RE, Hickok J, Sturdevant SG, Calderwood MS, Weiland A, Kubiak DW, Reddy S, Neuhauser MM, Srinivasan A, Jernigan JA, Hayden MK, Gowda A, Eibensteiner K, Wolf R, Perlin JB, Platt R, Huang SS. Stewardship Prompts to Improve Antibiotic Selection for Pneumonia: The INSPIRE Randomized Clinical Trial. JAMA 2024:2817976. [PMID: 38639729 DOI: 10.1001/jama.2024.6248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/20/2024]
Abstract
Importance Pneumonia is the most common infection requiring hospitalization and is a major reason for overuse of extended-spectrum antibiotics. Despite low risk of multidrug-resistant organism (MDRO) infection, clinical uncertainty often drives initial antibiotic selection. Strategies to limit empiric antibiotic overuse for patients with pneumonia are needed. Objective To evaluate whether computerized provider order entry (CPOE) prompts providing patient- and pathogen-specific MDRO infection risk estimates could reduce empiric extended-spectrum antibiotics for non-critically ill patients admitted with pneumonia. Design, Setting, and Participants Cluster-randomized trial in 59 US community hospitals comparing the effect of a CPOE stewardship bundle (education, feedback, and real-time MDRO risk-based CPOE prompts; n = 29 hospitals) vs routine stewardship (n = 30 hospitals) on antibiotic selection during the first 3 hospital days (empiric period) in non-critically ill adults (≥18 years) hospitalized with pneumonia. There was an 18-month baseline period from April 1, 2017, to September 30, 2018, and a 15-month intervention period from April 1, 2019, to June 30, 2020. Intervention CPOE prompts recommending standard-spectrum antibiotics in patients ordered to receive extended-spectrum antibiotics during the empiric period who have low estimated absolute risk (<10%) of MDRO pneumonia, coupled with feedback and education. Main Outcomes and Measures The primary outcome was empiric (first 3 days of hospitalization) extended-spectrum antibiotic days of therapy. Secondary outcomes included empiric vancomycin and antipseudomonal days of therapy and safety outcomes included days to intensive care unit (ICU) transfer and hospital length of stay. Outcomes compared differences between baseline and intervention periods across strategies. Results Among 59 hospitals with 96 451 (51 671 in the baseline period and 44 780 in the intervention period) adult patients admitted with pneumonia, the mean (SD) age of patients was 68.1 (17.0) years, 48.1% were men, and the median (IQR) Elixhauser comorbidity count was 4 (2-6). Compared with routine stewardship, the group using CPOE prompts had a 28.4% reduction in empiric extended-spectrum days of therapy (rate ratio, 0.72 [95% CI, 0.66-0.78]; P < .001). Safety outcomes of mean days to ICU transfer (6.5 vs 7.1 days) and hospital length of stay (6.8 vs 7.1 days) did not differ significantly between the routine and CPOE intervention groups. Conclusions and Relevance Empiric extended-spectrum antibiotic use was significantly lower among adults admitted with pneumonia to non-ICU settings in hospitals using education, feedback, and CPOE prompts recommending standard-spectrum antibiotics for patients at low risk of MDRO infection, compared with routine stewardship practices. Hospital length of stay and days to ICU transfer were unchanged. Trial Registration ClinicalTrials.gov Identifier: NCT03697070.
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Affiliation(s)
- Shruti K Gohil
- Division of Infectious Diseases, University of California, Irvine School of Medicine, Irvine
| | - Edward Septimus
- Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical School, Boston, Massachusetts
| | - Ken Kleinman
- Biostatistics and Epidemiology, University of Massachusetts, Amherst
| | - Neha Varma
- Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Boston, Massachusetts
| | - Taliser R Avery
- Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical School, Boston, Massachusetts
| | - Lauren Heim
- Division of Infectious Diseases, University of California, Irvine School of Medicine, Irvine
| | - Risa Rahm
- HCA Healthcare, Nashville, Tennessee
| | | | | | | | | | | | | | - Micaela H Coady
- Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Boston, Massachusetts
| | - Edward Rosen
- Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Boston, Massachusetts
| | - Selsebil Sljivo
- Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Boston, Massachusetts
| | - Kenneth E Sands
- Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical School, Boston, Massachusetts
- HCA Healthcare, Nashville, Tennessee
| | | | - Justin Vigeant
- Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Boston, Massachusetts
| | - Syma Rashid
- Division of Infectious Diseases, University of California, Irvine School of Medicine, Irvine
| | - Rebecca F Gilbert
- Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Boston, Massachusetts
| | | | | | - Russell E Poland
- Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical School, Boston, Massachusetts
- HCA Healthcare, Nashville, Tennessee
| | | | | | - Michael S Calderwood
- Section of Infectious Disease and International Health, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Anastasiia Weiland
- Division of Infectious Diseases, University of California, Irvine School of Medicine, Irvine
| | | | - Sujan Reddy
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | | | - John A Jernigan
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Abinav Gowda
- Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Boston, Massachusetts
| | - Katyuska Eibensteiner
- Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Boston, Massachusetts
| | - Robert Wolf
- Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Boston, Massachusetts
| | - Jonathan B Perlin
- HCA Healthcare, Nashville, Tennessee
- Now with The Joint Commission, Oakbrook Terrace, Illinois
| | - Richard Platt
- Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical School, Boston, Massachusetts
| | - Susan S Huang
- Division of Infectious Diseases, University of California, Irvine School of Medicine, Irvine
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2
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Gohil SK, Septimus E, Kleinman K, Varma N, Avery TR, Heim L, Rahm R, Cooper WS, Cooper M, McLean LE, Nickolay NG, Weinstein RA, Burgess LH, Coady MH, Rosen E, Sljivo S, Sands KE, Moody J, Vigeant J, Rashid S, Gilbert RF, Smith KN, Carver B, Poland RE, Hickok J, Sturdevant SG, Calderwood MS, Weiland A, Kubiak DW, Reddy S, Neuhauser MM, Srinivasan A, Jernigan JA, Hayden MK, Gowda A, Eibensteiner K, Wolf R, Perlin JB, Platt R, Huang SS. Stewardship Prompts to Improve Antibiotic Selection for Urinary Tract Infection: The INSPIRE Randomized Clinical Trial. JAMA 2024:2817975. [PMID: 38639723 DOI: 10.1001/jama.2024.6259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/20/2024]
Abstract
Importance Urinary tract infection (UTI) is the second most common infection leading to hospitalization and is often associated with gram-negative multidrug-resistant organisms (MDROs). Clinicians overuse extended-spectrum antibiotics although most patients are at low risk for MDRO infection. Safe strategies to limit overuse of empiric antibiotics are needed. Objective To evaluate whether computerized provider order entry (CPOE) prompts providing patient- and pathogen-specific MDRO risk estimates could reduce use of empiric extended-spectrum antibiotics for treatment of UTI. Design, Setting, and Participants Cluster-randomized trial in 59 US community hospitals comparing the effect of a CPOE stewardship bundle (education, feedback, and real-time and risk-based CPOE prompts; 29 hospitals) vs routine stewardship (n = 30 hospitals) on antibiotic selection during the first 3 hospital days (empiric period) in noncritically ill adults (≥18 years) hospitalized with UTI with an 18-month baseline (April 1, 2017-September 30, 2018) and 15-month intervention period (April 1, 2019-June 30, 2020). Interventions CPOE prompts recommending empiric standard-spectrum antibiotics in patients ordered to receive extended-spectrum antibiotics who have low estimated absolute risk (<10%) of MDRO UTI, coupled with feedback and education. Main Outcomes and Measures The primary outcome was empiric (first 3 days of hospitalization) extended-spectrum antibiotic days of therapy. Secondary outcomes included empiric vancomycin and antipseudomonal days of therapy. Safety outcomes included days to intensive care unit (ICU) transfer and hospital length of stay. Outcomes were assessed using generalized linear mixed-effect models to assess differences between the baseline and intervention periods. Results Among 127 403 adult patients (71 991 baseline and 55 412 intervention period) admitted with UTI in 59 hospitals, the mean (SD) age was 69.4 (17.9) years, 30.5% were male, and the median Elixhauser Comorbidity Index count was 4 (IQR, 2-5). Compared with routine stewardship, the group using CPOE prompts had a 17.4% (95% CI, 11.2%-23.2%) reduction in empiric extended-spectrum days of therapy (rate ratio, 0.83 [95% CI, 0.77-0.89]; P < .001). The safety outcomes of mean days to ICU transfer (6.6 vs 7.0 days) and hospital length of stay (6.3 vs 6.5 days) did not differ significantly between the routine and intervention groups, respectively. Conclusions and Relevance Compared with routine stewardship, CPOE prompts providing real-time recommendations for standard-spectrum antibiotics for patients with low MDRO risk coupled with feedback and education significantly reduced empiric extended-spectrum antibiotic use among noncritically ill adults admitted with UTI without changing hospital length of stay or days to ICU transfers. Trial Registration ClinicalTrials.gov Identifier: NCT03697096.
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Affiliation(s)
- Shruti K Gohil
- Division of Infectious Diseases, University of California, Irvine School of Medicine, Irvine
| | - Edward Septimus
- Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical School, Boston, Massachusetts
| | - Ken Kleinman
- Biostatistics and Epidemiology, University of Massachusetts, Amherst
| | - Neha Varma
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Taliser R Avery
- Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical School, Boston, Massachusetts
| | - Lauren Heim
- Division of Infectious Diseases, University of California, Irvine School of Medicine, Irvine
| | - Risa Rahm
- HCA Healthcare, Nashville, Tennessee
| | | | | | | | | | | | | | - Micaela H Coady
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Edward Rosen
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Selsebil Sljivo
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Kenneth E Sands
- Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical School, Boston, Massachusetts
- HCA Healthcare, Nashville, Tennessee
| | | | - Justin Vigeant
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Syma Rashid
- Division of Infectious Diseases, University of California, Irvine School of Medicine, Irvine
| | - Rebecca F Gilbert
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | | | | | - Russell E Poland
- Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical School, Boston, Massachusetts
- HCA Healthcare, Nashville, Tennessee
| | | | | | - Michael S Calderwood
- Section of Infectious Disease and International Health, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Anastasiia Weiland
- Division of Infectious Diseases, University of California, Irvine School of Medicine, Irvine
| | | | - Sujan Reddy
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | | | - John A Jernigan
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Abinav Gowda
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Katyuska Eibensteiner
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Robert Wolf
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Jonathan B Perlin
- HCA Healthcare, Nashville, Tennessee
- Now with The Joint Commission, Oakbrook Terrace, Illinois
| | - Richard Platt
- Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical School, Boston, Massachusetts
| | - Susan S Huang
- Division of Infectious Diseases, University of California, Irvine School of Medicine, Irvine
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Gohil SK, Septimus E, Sands KE, Blanchard EJ, Moody J, de St. Maurice A, Yokoe D, Kwon J, Grein J, Cohen S, Uslan D, Vasudev M, Mauricio A, Mabalot S, Coady MH, Sljivo S, Smith K, Carver B, Poland R, Perlin J, Platt R, Huang SS. Coronavirus disease 2019 (COVID-19) infection prevention practices that exceed Centers for Disease Control and Prevention (CDC) guidance: Balancing extra caution against impediments to care. Infect Control Hosp Epidemiol 2023; 44:2074-2077. [PMID: 37260365 PMCID: PMC10755143 DOI: 10.1017/ice.2023.89] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 03/21/2023] [Accepted: 03/25/2023] [Indexed: 06/02/2023]
Abstract
In a survey of infection prevention programs, leaders reported frequent clinical and infection prevention practice modifications to avoid coronavirus disease 2019 (COVID-19) exposure that exceeded national guidance. Future pandemic responses should emphasize balanced approaches to precautions, prioritize educational campaigns to manage safety concerns, and generate an evidence-base that can guide appropriate infection prevention practices.
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Affiliation(s)
- Shruti K. Gohil
- Epidemiology & Infection Prevention Program, University of California Irvine Health (UC Irvine Health), Irvine, California
- Division of Infectious Diseases, University of California, Irvine School of Medicine, Irvine, California
| | - Edward Septimus
- Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical School, Boston, Massachusetts
| | | | | | | | - Annabelle de St. Maurice
- Division of Pediatric Infectious Diseases, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California
| | - Deborah Yokoe
- Division of Infectious Diseases, University of California San Francisco, San Francisco, California
| | - Jennie Kwon
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri
| | - Jonathan Grein
- Division of Infectious Diseases, Cedars Sinai Medical Center, Los Angeles, California
| | - Stuart Cohen
- Division of Infectious Diseases, University of California Davis, Davis, California
| | - Daniel Uslan
- Division of Infectious Diseases, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California
| | - Milind Vasudev
- Division of Infectious Diseases, University of California, Irvine School of Medicine, Irvine, California
| | - Amarah Mauricio
- Division of Infectious Diseases, University of California, Irvine School of Medicine, Irvine, California
| | - Shannon Mabalot
- Infection Prevention, Sharp Metropolitan Medical Campus, San Diego, California
| | - Micaela H. Coady
- Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical School, Boston, Massachusetts
| | - Selsebil Sljivo
- Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical School, Boston, Massachusetts
| | | | | | | | | | - Richard Platt
- Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical School, Boston, Massachusetts
| | - Susan S. Huang
- Epidemiology & Infection Prevention Program, University of California Irvine Health (UC Irvine Health), Irvine, California
- Division of Infectious Diseases, University of California, Irvine School of Medicine, Irvine, California
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4
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Huang SS, Septimus EJ, Kleinman K, Heim LT, Moody JA, Avery TR, McLean L, Rashid S, Haffenreffer K, Shimelman L, Staub-Juergens W, Spencer-Smith C, Sljivo S, Rosen E, Poland RE, Coady MH, Lee CH, Blanchard EJ, Reddish K, Hayden MK, Weinstein RA, Carver B, Smith K, Hickok J, Lolans K, Khan N, Sturdevant SG, Reddy SC, Jernigan JA, Sands KE, Perlin JB, Platt R. Nasal Iodophor Antiseptic vs Nasal Mupirocin Antibiotic in the Setting of Chlorhexidine Bathing to Prevent Infections in Adult ICUs: A Randomized Clinical Trial. JAMA 2023; 330:1337-1347. [PMID: 37815567 PMCID: PMC10565599 DOI: 10.1001/jama.2023.17219] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Accepted: 08/17/2023] [Indexed: 10/11/2023]
Abstract
Importance Universal nasal mupirocin plus chlorhexidine gluconate (CHG) bathing in intensive care units (ICUs) prevents methicillin-resistant Staphylococcus aureus (MRSA) infections and all-cause bloodstream infections. Antibiotic resistance to mupirocin has raised questions about whether an antiseptic could be advantageous for ICU decolonization. Objective To compare the effectiveness of iodophor vs mupirocin for universal ICU nasal decolonization in combination with CHG bathing. Design, Setting, and Participants Two-group noninferiority, pragmatic, cluster-randomized trial conducted in US community hospitals, all of which used mupirocin-CHG for universal decolonization in ICUs at baseline. Adult ICU patients in 137 randomized hospitals during baseline (May 1, 2015-April 30, 2017) and intervention (November 1, 2017-April 30, 2019) were included. Intervention Universal decolonization involving switching to iodophor-CHG (intervention) or continuing mupirocin-CHG (baseline). Main Outcomes and Measures ICU-attributable S aureus clinical cultures (primary outcome), MRSA clinical cultures, and all-cause bloodstream infections were evaluated using proportional hazard models to assess differences from baseline to intervention periods between the strategies. Results were also compared with a 2009-2011 trial of mupirocin-CHG vs no decolonization in the same hospital network. The prespecified noninferiority margin for the primary outcome was 10%. Results Among the 801 668 admissions in 233 ICUs, the participants' mean (SD) age was 63.4 (17.2) years, 46.3% were female, and the mean (SD) ICU length of stay was 4.8 (4.7) days. Hazard ratios (HRs) for S aureus clinical isolates in the intervention vs baseline periods were 1.17 for iodophor-CHG (raw rate: 5.0 vs 4.3/1000 ICU-attributable days) and 0.99 for mupirocin-CHG (raw rate: 4.1 vs 4.0/1000 ICU-attributable days) (HR difference in differences significantly lower by 18.4% [95% CI, 10.7%-26.6%] for mupirocin-CHG, P < .001). For MRSA clinical cultures, HRs were 1.13 for iodophor-CHG (raw rate: 2.3 vs 2.1/1000 ICU-attributable days) and 0.99 for mupirocin-CHG (raw rate: 2.0 vs 2.0/1000 ICU-attributable days) (HR difference in differences significantly lower by 14.1% [95% CI, 3.7%-25.5%] for mupirocin-CHG, P = .007). For all-pathogen bloodstream infections, HRs were 1.00 (2.7 vs 2.7/1000) for iodophor-CHG and 1.01 (2.6 vs 2.6/1000) for mupirocin-CHG (nonsignificant HR difference in differences, -0.9% [95% CI, -9.0% to 8.0%]; P = .84). Compared with the 2009-2011 trial, the 30-day relative reduction in hazards in the mupirocin-CHG group relative to no decolonization (2009-2011 trial) were as follows: S aureus clinical cultures (current trial: 48.1% [95% CI, 35.6%-60.1%]; 2009-2011 trial: 58.8% [95% CI, 47.5%-70.7%]) and bloodstream infection rates (current trial: 70.4% [95% CI, 62.9%-77.8%]; 2009-2011 trial: 60.1% [95% CI, 49.1%-70.7%]). Conclusions and Relevance Nasal iodophor antiseptic did not meet criteria to be considered noninferior to nasal mupirocin antibiotic for the outcome of S aureus clinical cultures in adult ICU patients in the context of daily CHG bathing. In addition, the results were consistent with nasal iodophor being inferior to nasal mupirocin. Trial Registration ClinicalTrials.gov Identifier: NCT03140423.
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Affiliation(s)
- Susan S. Huang
- University of California Irvine School of Medicine, Irvine
| | - Edward J. Septimus
- Harvard Medical School and Harvard Pilgrim Health Care, Boston, Massachusetts
- Texas A&M College of Medicine and Memorial Hermann Health System, Houston
| | | | - Lauren T. Heim
- University of California Irvine School of Medicine, Irvine
| | | | - Taliser R. Avery
- Harvard Medical School and Harvard Pilgrim Health Care, Boston, Massachusetts
| | | | - Syma Rashid
- University of California Irvine School of Medicine, Irvine
| | | | - Lauren Shimelman
- Harvard Medical School and Harvard Pilgrim Health Care, Boston, Massachusetts
| | | | | | - Selsebil Sljivo
- Harvard Medical School and Harvard Pilgrim Health Care, Boston, Massachusetts
| | - Ed Rosen
- Harvard Medical School and Harvard Pilgrim Health Care, Boston, Massachusetts
| | | | - Micaela H. Coady
- Harvard Medical School and Harvard Pilgrim Health Care, Boston, Massachusetts
| | | | | | | | | | - Robert A. Weinstein
- Rush Medical College, Chicago, Illinois
- John H. Stroger Jr. Hospital of Cook County, Chicago, Illinois
| | | | | | | | | | | | - S. Gwynn Sturdevant
- University of Massachusetts Amherst
- now with Wharton School of the University of Pennsylvania, Philadelphia
| | - Sujan C. Reddy
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | | | - Jonathan B. Perlin
- HCA Healthcare, Nashville, Tennessee
- now with The Joint Commission, Oakbrook Terrace, Illinois
| | - Richard Platt
- Harvard Medical School and Harvard Pilgrim Health Care, Boston, Massachusetts
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5
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Fawzy A, Wu TD, Wang K, Sands KE, Fisher AM, Arnold Egloff SA, DellaVolpe JD, Iwashyna TJ, Xu Y, Garibaldi BT. Clinical Outcomes Associated With Overestimation of Oxygen Saturation by Pulse Oximetry in Patients Hospitalized With COVID-19. JAMA Netw Open 2023; 6:e2330856. [PMID: 37615985 PMCID: PMC10450566 DOI: 10.1001/jamanetworkopen.2023.30856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 07/19/2023] [Indexed: 08/25/2023] Open
Abstract
Importance Many pulse oximeters have been shown to overestimate oxygen saturation in persons of color, and this phenomenon has potential clinical implications. The relationship between overestimation of oxygen saturation with timing of COVID-19 medication delivery and clinical outcomes remains unknown. Objective To investigate the association between overestimation of oxygen saturation by pulse oximetry and delay in administration of COVID-19 therapy, hospital length of stay, risk of hospital readmission, and in-hospital mortality. Design, Setting, and Participants This cohort study included patients hospitalized for COVID-19 at 186 acute care facilities in the US with at least 1 functional arterial oxygen saturation (SaO2) measurement between March 2020 and October 2021. A subset of patients were admitted after July 1, 2020, without immediate need for COVID-19 therapy based on pulse oximeter saturation (SpO2 levels of 94% or higher without supplemental oxygen). Exposures Self-reported race and ethnicity, difference between concurrent SaO2 and pulse oximeter saturation (SpO2) within 10 minutes, and initially unrecognized need for COVID-19 therapy (first SaO2 reading below 94% despite SpO2 levels of 94% or above). Main Outcome and Measures The association of race and ethnicity with degree of pulse oximeter measurement error (SpO2 - SaO2) and odds of unrecognized need for COVID-19 therapy were determined using linear mixed-effects models. Associations of initially unrecognized need for treatment with time to receipt of therapy (remdesivir or dexamethasone), in-hospital mortality, 30-day hospital readmission, and length of stay were evaluated using mixed-effects models. All models accounted for demographics, clinical characteristics, and hospital site. Effect modification by race and ethnicity was evaluated using interaction terms. Results Among 24 504 patients with concurrent SpO2 and SaO2 measurements (mean [SD] age, 63.9 [15.8] years; 10 263 female [41.9%]; 3922 Black [16.0%], 7895 Hispanic [32.2%], 2554 Asian, Native American or Alaskan Native, Hawaiian or Pacific Islander, or another race or ethnicity [10.4%], and 10 133 White [41.4%]), pulse oximetry overestimated SaO2 for Black (adjusted mean difference, 0.93 [95% CI, 0.74-1.12] percentage points), Hispanic (0.49 [95% CI, 0.34-0.63] percentage points), and other (0.53 [95% CI, 0.35-0.72] percentage points) patients compared with White patients. In a subset of 8635 patients with a concurrent SpO2 - SaO2 pair without immediate need for COVID-19 therapy, Black patients were significantly more likely to have pulse oximetry values that masked an indication for COVID-19 therapy compared with White patients (adjusted odds ratio [aOR], 1.65; 95% CI, 1.33-2.03). Patients with an unrecognized need for COVID-19 therapy were 10% less likely to receive COVID-19 therapy (adjusted hazard ratio, 0.90; 95% CI, 0.83-0.97) and higher odds of readmission (aOR, 2.41; 95% CI, 1.39-4.18) regardless of race (P for interaction = .45 and P = .14, respectively). There was no association of unrecognized need for COVID-19 therapy with in-hospital mortality (aOR, 0.84; 95% CI, 0.71-1.01) or length of stay (mean difference, -1.4 days; 95% CI, -3.1 to 0.2 days). Conclusions and Relevance In this cohort study, overestimation of oxygen saturation by pulse oximetry led to delayed delivery of COVID-19 therapy and higher probability of readmission regardless of race. Black patients were more likely to have unrecognized need for therapy with potential implications for population-level health disparities.
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Affiliation(s)
- Ashraf Fawzy
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Tianshi David Wu
- Section of Pulmonary, Critical Care, and Sleep Medicine, Baylor College of Medicine, Houston, Texas
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Administration Medical Center, Houston, Texas
| | - Kunbo Wang
- Department of Applied Mathematics and Statistics, Johns Hopkins University, Baltimore, Maryland
| | - Kenneth E. Sands
- HCA Healthcare, HCA Healthcare Research Institute (HRI), Nashville, Tennessee
| | | | | | | | - Theodore J. Iwashyna
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Yanxun Xu
- Department of Applied Mathematics and Statistics, Johns Hopkins University, Baltimore, Maryland
| | - Brian T. Garibaldi
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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6
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Fuller CC, Cosgrove A, Shinde M, Rosen E, Haffenreffer K, Hague C, McLean LE, Perlin J, Poland RE, Sands KE, Pratt N, Bright P, Platt R, Cocoros NM, Dutcher SK. Treatment and care received by children hospitalized with COVID-19 in a large hospital network in the United States, February 2020 to September 2021. PLoS One 2023; 18:e0288284. [PMID: 37432951 DOI: 10.1371/journal.pone.0288284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 06/22/2023] [Indexed: 07/13/2023] Open
Abstract
We described care received by hospitalized children with COVID-19 or multi-system inflammatory syndrome (MIS-C) prior to the 2021 COVID-19 Omicron variant surge in the US. We identified hospitalized children <18 years of age with a COVID-19 or MIS-C diagnosis (COVID-19 not required), separately, from February 2020-September 2021 (n = 126 hospitals). We described high-risk conditions, inpatient treatments, and complications among these groups. Among 383,083 pediatric hospitalizations, 2,186 had COVID-19 and 395 had MIS-C diagnosis. Less than 1% had both COVID-19 and MIS-C diagnosis (n = 154). Over half were >6 years old (54% COVID-19, 70% MIS-C). High-risk conditions included asthma (14% COVID-19, 11% MIS-C), and obesity (9% COVID-19, 10% MIS-C). Pulmonary complications in children with COVID-19 included viral pneumonia (24%) and acute respiratory failure (11%). In reference to children with COVID-19, those with MIS-C had more hematological disorders (62% vs 34%), sepsis (16% vs 6%), pericarditis (13% vs 2%), myocarditis (8% vs 1%). Few were ventilated or died, but some required oxygen support (38% COVID-19, 45% MIS-C) or intensive care (42% COVID-19, 69% MIS-C). Treatments included: methylprednisolone (34% COVID-19, 75% MIS-C), dexamethasone (25% COVID-19, 15% MIS-C), remdesivir (13% COVID-19, 5% MIS-C). Antibiotics (50% COVID-19, 68% MIS-C) and low-molecular weight heparin (17% COVID-19, 34% MIS-C) were frequently administered. Markers of illness severity among hospitalized children with COVID-19 prior to the 2021 Omicron surge are consistent with previous studies. We report important trends on treatments in hospitalized children with COVID-19 to improve the understanding of real-world treatment patterns in this population.
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Affiliation(s)
- Candace C Fuller
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, United States of America
| | - Austin Cosgrove
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, United States of America
| | - Mayura Shinde
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, United States of America
| | - Edward Rosen
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, United States of America
| | - Katie Haffenreffer
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, United States of America
| | - Christian Hague
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, United States of America
| | - Laura E McLean
- HCA Healthcare, Nashville, Tennessee, United States of America
| | - Jonathan Perlin
- HCA Healthcare, Nashville, Tennessee, United States of America
| | - Russell E Poland
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, United States of America
- HCA Healthcare, Nashville, Tennessee, United States of America
| | - Kenneth E Sands
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, United States of America
- HCA Healthcare, Nashville, Tennessee, United States of America
| | - Natasha Pratt
- US Food and Drug Administration, Silver Spring, Maryland, United States of America
| | - Patricia Bright
- US Food and Drug Administration, Silver Spring, Maryland, United States of America
| | - Richard Platt
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, United States of America
| | - Noelle M Cocoros
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, United States of America
| | - Sarah K Dutcher
- US Food and Drug Administration, Silver Spring, Maryland, United States of America
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7
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Ye S, Li D, Yu T, Caroff DA, Guy J, Poland RE, Sands KE, Septimus EJ, Huang SS, Platt R, Wang R. The impact of surgical volume on hospital ranking using the standardized infection ratio. Sci Rep 2023; 13:7624. [PMID: 37165033 PMCID: PMC10172297 DOI: 10.1038/s41598-023-33937-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 04/21/2023] [Indexed: 05/12/2023] Open
Abstract
The Centers for Medicare and Medicaid Services require hospitals to report on quality metrics which are used to financially penalize those that perform in the lowest quartile. Surgical site infections (SSIs) are a critical component of the quality metrics that target healthcare-associated infections. However, the accuracy of such hospital profiling is highly affected by small surgical volumes which lead to a large amount of uncertainty in estimating standardized hospital-specific infection rates. Currently, hospitals with less than one expected SSI are excluded from rankings, but the effectiveness of this exclusion criterion is unknown. Tools that can quantify the classification accuracy and can determine the minimal surgical volume required for a desired level of accuracy are lacking. We investigate the effect of surgical volume on the accuracy of identifying poorly performing hospitals based on the standardized infection ratio and develop simulation-based algorithms for quantifying the classification accuracy. We apply our proposed method to data from HCA Healthcare (2014-2016) on SSIs in colon surgery patients. We estimate that for a procedure like colon surgery with an overall SSI rate of 3%, to rank hospitals in the HCA colon SSI dataset, hospitals that perform less than 200 procedures have a greater than 10% chance of being incorrectly assigned to the worst performing quartile. Minimum surgical volumes and predicted events criteria are required to make evaluating hospitals reliable, and these criteria vary by overall prevalence and between-hospital variability.
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Affiliation(s)
- Shangyuan Ye
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, MA, 02215, USA
- Biostatistics Shared Resource, Knight Cancer Institute, Oregon Health and Science University, Portland, OR, 97201, USA
| | - Daniel Li
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, MA, 02215, USA
| | - Tingting Yu
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, MA, 02215, USA
| | - Daniel A Caroff
- Department of Infectious Diseases, Lahey Hospital and Medical Center, Burlington, MA, 01805, USA
| | - Jeffrey Guy
- Clinical Operations Group, HCA Healthcare, Nashville, TN, 37203, USA
| | - Russell E Poland
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, MA, 02215, USA
- Clinical Operations Group, HCA Healthcare, Nashville, TN, 37203, USA
| | - Kenneth E Sands
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, MA, 02215, USA
- Clinical Operations Group, HCA Healthcare, Nashville, TN, 37203, USA
| | - Edward J Septimus
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, MA, 02215, USA
- Texas A &M College of Medicine, Houston, TX, 77030, USA
| | - Susan S Huang
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, MA, 02215, USA
- University of California Irvine School of Medicine, Irvine, CA, 92617, USA
| | - Richard Platt
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, MA, 02215, USA
| | - Rui Wang
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, MA, 02215, USA.
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, MA, 02215, USA.
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Jones BE, Sarvet AL, Ying J, Jin R, Nevers MR, Stern SE, Ocho A, McKenna C, McLean LE, Christensen MA, Poland RE, Guy JS, Sands KE, Rhee C, Young JG, Klompas M. Incidence and Outcomes of Non-Ventilator-Associated Hospital-Acquired Pneumonia in 284 US Hospitals Using Electronic Surveillance Criteria. JAMA Netw Open 2023; 6:e2314185. [PMID: 37200031 DOI: 10.1001/jamanetworkopen.2023.14185] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/19/2023] Open
Abstract
Importance Non-ventilator-associated hospital-acquired pneumonia (NV-HAP) is a common and deadly hospital-acquired infection. However, inconsistent surveillance methods and unclear estimates of attributable mortality challenge prevention. Objective To estimate the incidence, variability, outcomes, and population attributable mortality of NV-HAP. Design, Setting, and Participants This cohort study retrospectively applied clinical surveillance criteria for NV-HAP to electronic health record data from 284 US hospitals. Adult patients admitted to the Veterans Health Administration hospital from 2015 to 2020 and HCA Healthcare hospitals from 2018 to 2020 were included. The medical records of 250 patients who met the surveillance criteria were reviewed for accuracy. Exposures NV-HAP, defined as sustained deterioration in oxygenation for 2 or more days in a patient who was not ventilated concurrent with abnormal temperature or white blood cell count, performance of chest imaging, and 3 or more days of new antibiotics. Main Outcomes and Measures NV-HAP incidence, length-of-stay, and crude inpatient mortality. Attributable inpatient mortality by 60 days follow-up was estimated using inverse probability weighting, accounting for both baseline and time-varying confounding. Results Among 6 022 185 hospitalizations (median [IQR] age, 66 [54-75] years; 1 829 475 [26.1%] female), there were 32 797 NV-HAP events (0.55 per 100 admissions [95% CI, 0.54-0.55] per 100 admissions and 0.96 per 1000 patient-days [95% CI, 0.95-0.97] per 1000 patient-days). Patients with NV-HAP had multiple comorbidities (median [IQR], 6 [4-7]), including congestive heart failure (9680 [29.5%]), neurologic conditions (8255 [25.2%]), chronic lung disease (6439 [19.6%]), and cancer (5,467 [16.7%]); 24 568 cases (74.9%) occurred outside intensive care units. Crude inpatient mortality was 22.4% (7361 of 32 797) for NV-HAP vs 1.9% (115 530 of 6 022 185) for all hospitalizations; 12 449 (8.0%) were discharged to hospice. Median [IQR] length-of-stay was 16 (11-26) days vs 4 (3-6) days. On medical record review, pneumonia was confirmed by reviewers or bedside clinicians in 202 of 250 patients (81%). It was estimated that NV-HAP accounted for 7.3% (95% CI, 7.1%-7.5%) of all hospital deaths (total hospital population inpatient death risk of 1.87% with NV-HAP events included vs 1.73% with NV-HAP events excluded; risk ratio, 0.927; 95% CI, 0.925-0.929). Conclusions and Relevance In this cohort study, NV-HAP, which was defined using electronic surveillance criteria, was present in approximately 1 in 200 hospitalizations, of whom 1 in 5 died in the hospital. NV-HAP may account for up to 7% of all hospital deaths. These findings underscore the need to systematically monitor NV-HAP, define best practices for prevention, and track their impact.
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Affiliation(s)
- Barbara E Jones
- Division of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City
- VA Salt Lake City Health Care System, Salt Lake City, Utah
| | - Aaron L Sarvet
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Jian Ying
- Division of Epidemiology, University of Utah, Salt Lake City
| | - Robert Jin
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | | | - Sarah E Stern
- Division of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City
| | - Aileen Ocho
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Caroline McKenna
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | | | - Matthew A Christensen
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Russell E Poland
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
- HCA Healthcare Inc, Nashville, Tennessee
| | | | - Kenneth E Sands
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
- HCA Healthcare Inc, Nashville, Tennessee
| | - Chanu Rhee
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
- Department of Medicine, Brigham Women's Hospital, Boston, Massachusetts
| | - Jessica G Young
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
- Department of Medicine, Brigham Women's Hospital, Boston, Massachusetts
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9
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Abstract
Importance The reported incidence of many health care-associated infections (HAIs) increased during the COVID-19 pandemic; however, it is unclear whether this is due to increased patient risk or to increased pressure on the health care system. Objective To assess HAI occurrence among patients admitted to hospitals with and without COVID-19. Design, Setting, and Participants A cross-sectional retrospective analysis of inpatients discharged both with and without laboratory-confirmed COVID-19 infection was conducted. Data were obtained between January 1, 2019, and March 31, 2022, from community hospitals affiliated with a large health care system in the US. Exposure COVID-19 infection. Main Outcomes and Measures Occurrence of central line-associated bloodstream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), methicillin-resistant Staphylococcus aureus (MRSA) bacteremia, and Clostridioides difficile infection as reported to the National Healthcare Safety Network. Results Among nearly 5 million hospitalizations in 182 hospitals between 2020 and 2022, the occurrence of health care-associated infections (HAIs) was high among the 313 200 COVID-19 inpatients (median [SD] age, 57 [27.3] years; 56.0% women). Incidence per 100 000 patient-days showed higher HAIs among those with COVID-19 compared with those without. For CLABSI, the incidence for the full 9 quarters of the study was nearly 4-fold higher among the COVID-19 population than the non-COVID-19 population (25.4 vs 6.9). For CAUTI, the incidence in the COVID-19 population was 2.7-fold higher in the COVID-19 population (16.5 vs 6.1), and for MRSA, 3.0-fold higher (11.2 vs 3.7). Quarterly trends were compared with the same quarter in 2019. The greatest increase in the incidence of HAI in comparison with the same quarter in 2019 for the entire population occurred in quarter 3 of 2020 for CLABSI (11.0 vs 7.3), quarter 4 of 2021 for CAUTI (7.8 vs 6.8), and quarter 3 of 2021 for MRSA (5.2 vs 3.9). When limited to the non-COVID-19 population, the increase in CLABSI incidence vs the 2019 incidence was eliminated, and the quarterly rates of MRSA and CAUTI were lower vs the prepandemic 2019 comparator quarter. Conclusions and Relevance In this cross-sectional study of hospitals during the pandemic, HAI occurrence among inpatients without COVID-19 was similar to that during 2019 despite additional pressures for infection control and health care professionals. The findings suggest that patients with COVID-19 may be more susceptible to HAIs and may require additional prevention measures.
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10
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Roemer K, Burgess H, Sands KE, Hodgin R. 397. Oral Vancomycin Versus Fidaxomicin for Clostridiodes difficile: A Comparative Retrospective Evaluation across a Large, Multi-center Healthcare System. Open Forum Infect Dis 2022. [PMCID: PMC9752353 DOI: 10.1093/ofid/ofac492.475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background The Infectious Diseases Society of America and Society for Healthcare Epidemiology of America recently published the 2021 Focused Clinical Practice Guideline Update on Management of Clostridioides difficile in Adults that recommends fidaxomicin as a preferred treatment for initial and recurrent C. difficile infection (CDI) over oral vancomycin. The aim of this study was to evaluate clinical outcomes of adult inpatients with CDI diagnosis treated with fidaxomicin versus oral or rectal vancomycin. Methods The patient population included adult inpatients 18 years or older admitted to a hospital within the healthcare system with CDI International Classification of Diseases, Tenth Revision (ICD-10) codes from January 1, 2017 to October 31, 2021. Data was obtained for inpatients with a discharge diagnosis of CDI and receiving fidaxomicin, oral or rectal vancomycin, or no receipt of either antibiotic. Readmission was defined as readmittance to the healthcare system within 8 weeks and a CDI diagnosis. Recurrence risk factors were defined as age 65 years or older, immunocompromised based on ICD-10 codes, and severe CDI defined as white blood cell count > 15 cells/mm3 PLUS serum creatinine > 1.5 mg/dL. Results More than 45,000 inpatients with a CDI diagnosis were evaluated. Administration rates of vancomycin, fidaxomicin, or no receipt of either was 76%, 6% and 18%, respectively. Median length of stay for vancomycin compared to fidaxomicin was 7 versus 9 days, respectively. Readmission rate was lower for total inpatients receiving vancomycin (14.6%) compared to fidaxomicin (18.5%), showing statistical significance (p < 0.0000005). Subgroup analyses were performed to evaluate inpatients with risk factors for CDI recurrence. Vancomycin had a lower readmission rate for all recurrence risk factor groups. Additionally, oral vancomycin had lower readmission rates for patients with more than one risk factor (13.4% vs. 16.1%). Conclusion The results of this study demonstrated that fidaxomicin did not result in a shorter length of stay or lower readmission rate compared to oral/rectal vancomycin. This study supports the continued use of oral/rectal vancomycin for CDI without preference for fidaxomicin. Disclosures All Authors: No reported disclosures.
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11
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Baker MA, Septimus EJ, Kleinman K, Moody J, Sands KE, Varma N, Isaacs A, McLean LE, Coady MH, Blanchard J, Poland R, Yokoe DS, Stelling J, Haffenreffer K, Clark A, Avery T, Sljivo S, Weinstein RA, Smith K, Carver B, Carver B, Meador B, Spencer-Smith C, Washington C, Bhattarai M, Shimelman L, Shimelman L, Perlin JB, Platt R, Huang SS. 2313. CLUSTER Trial An 82 U.S. Hospital Cluster Randomized Trial (CRT) to Assess the Impact of an Automated Statistical Outbreak Detection Tool and Response Protocol to Limit Hospital Transmission. Open Forum Infect Dis 2022. [DOI: 10.1093/ofid/ofac492.145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Abstract
Background
The CLUSTER trial assessed the impact of prospective identification of clusters coupled with a response protocol on the containment of hospital clusters.
Methods
This 82-hospital CRT in 16 states compared clusters of bacterial and fungal healthcare pathogens using a statistical outbreak detection tool (WHONET-SaTScan) coupled with a standardized response protocol (automated cluster detection arm) compared to routine surveillance with the response protocol (control arm). Trial periods: 24 mo Baseline (2/17–1/19); 5 mo Phase-in (2/19–6/19); 30 mo Intervention (7/19–1/22). The primary outcome was the number of additional cases occurring after initial cluster detection. Analyses used generalized linear mixed models to assess differences in additional cases between the intervention vs baseline periods across arms, clustering by hospital. Results were assessed overall and, to account for the effect of COVID-19 on hospital operations, stratified into pre-COVID-19 (7/19–6/20) and during COVID-19 (7/20–1/22) intervention periods. We also assessed the probability that a patient was in a cluster.
Results
In the baseline period, the automated cluster detection and control arms had 0.09 and 0.07 additional cluster cases/1000 admissions, respectively. The automated cluster detection arm had a 22% greater relative reduction in additional cluster cases in the intervention vs baseline period compared to control (P=0.5). Within the intervention period, the automated cluster detection arm had a significant 64% relative reduction pre-COVID-19 (P< 0.05) and a non-significant 6% relative reduction during COVID-19 (P=0.9) compared to control (Figure). When evaluating patient risk of being part of a cluster across the entire intervention period, the automated cluster detection arm had a significant 35% relative reduction vs control (P< 0.01).
Conclusion
A statistical automated tool coupled with a response protocol improved cluster containment by 64% pre-COVID-19 but not during COVID-19; there were no significant differences between the arms when using the entire intervention period. Automated cluster detection may substantially improve outbreak containment in non-pandemic periods when infection prevention programs are able to optimize containment protocols.
Disclosures
Susan S. Huang, MD, MPH, Medline: Conducted studies in which hospitals and nursing homes received contributed antiseptic and/or environmental cleaning products|Molnlyke: Conducted clinical studies in which hospitals received contributed antiseptic product|Stryker: Conducted clinical studies in which hospitals and nursing homes received contributed antiseptic products|Xttrium Laboratories: Conducted clinical studies in which hospitals and nursing homes received contributed antiseptic product.
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Affiliation(s)
- Meghan A Baker
- Department of Population Medicine, Harvard Medical School Harvard Pilgrim Healthcare Institute , Boston, MA
| | | | - Ken Kleinman
- University of Massachusetts Amherst , Amherst, Massachusetts
| | | | | | - Neha Varma
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School , Boston, MA, USA, Boston, Massachusetts
| | - Amanda Isaacs
- Harvard Medical School and Harvard Pilgrim Health Care Institute , Boston, Massachusetts
| | | | - Micaela H Coady
- Harvard Medical School and Harvard Pilgrim Health Care Institute , Boston, Massachusetts
| | | | | | - Deborah S Yokoe
- University of California San Francisco , San Francisco, California
| | - John Stelling
- Brigham and Women's Hospital , Boston, Massachusetts
| | - Katherine Haffenreffer
- Harvard Medical School and Harvard Pilgrim Health Care Institute , Boston, Massachusetts
| | - Adam Clark
- Brigham and Women's Hospital , Boston, Massachusetts
| | - Taliser Avery
- Harvard Medical School and Harvard Pilgrim Health Care Institute , Boston, Massachusetts
| | - Selsebil Sljivo
- Harvard Medical School and Harvard Pilgrim Health Care Institute , Boston, Massachusetts
| | | | | | | | | | | | | | - Chamaine Washington
- Harvard Medical School and Harvard Pilgrim Health Care Institute , Boston, Massachusetts
| | | | - Lauren Shimelman
- Massachusetts Bay Transportation Authority , Boston, Massachusetts
| | - Lauren Shimelman
- Massachusetts Bay Transportation Authority , Boston, Massachusetts
| | | | - Richard Platt
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School , Boston, MA, USA, Boston, Massachusetts
| | - Susan S Huang
- University of California, Irvine School of Medicine , Irvine, CA
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12
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Andrews L, Goldin L, Shen Y, Korwek K, Kleja K, Poland RE, Guy J, Sands KE, Perlin JB. Discontinuation of atorvastatin use in hospital is associated with increased risk of mortality in COVID-19 patients. J Hosp Med 2022; 17:169-175. [PMID: 35504528 PMCID: PMC9088329 DOI: 10.1002/jhm.12789] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 01/03/2022] [Accepted: 01/18/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Statins are a commonly used class of drugs, and reports have suggested that their use may affect COVID-19 disease severity and mortality risk. OBJECTIVE The purpose of this analysis was to determine the effect of discontinuation of previous atorvastatin therapy in patients hospitalized for COVID-19 on the risk of mortality and ventilation. METHODS Data from 146,413 hospitalized COVID-19 patients were classified according to statin therapy. Home + in hospital atorvastatin use (continuation of therapy); home + no in hospital atorvastatin use (discontinuation of therapy); no home + no in hospital atorvastatin use (no statins). Logistic regression was performed to assess the association between atorvastatin administration and either mortality or use of mechanical ventilation during the encounter. RESULTS Continuous use of atorvastatin (home and in hospital) was associated with a 35% reduction in the odds of mortality compared to patients who received atorvastatin at home but not in hospital (odds ratio [OR]: 0.65, 95% confidence interval [CI]: 0.59-0.72, p < .001). Similarly, the odds of ventilation were lower with continuous atorvastatin therapy (OR: 0.70, 95% CI: 0.64-0.77, p < .001). CONCLUSIONS Discontinuation of previous atorvastatin therapy is associated with worse outcomes for COVID-19 patients. Providers should consider maintaining existing statin therapy for patients with known or suspected previous use.
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Affiliation(s)
- Laura Andrews
- Clinical Operations GroupHCA HealthcareNashvilleTennesseeUSA
| | - Laurel Goldin
- Clinical Operations GroupHCA HealthcareNashvilleTennesseeUSA
| | - Yan Shen
- Clinical Operations GroupHCA HealthcareNashvilleTennesseeUSA
| | - Kimberly Korwek
- Clinical Operations GroupHCA HealthcareNashvilleTennesseeUSA
| | - Kacie Kleja
- Clinical Operations GroupHCA HealthcareNashvilleTennesseeUSA
| | | | - Jeffrey Guy
- Clinical Operations GroupHCA HealthcareNashvilleTennesseeUSA
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13
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Garibaldi BT, Wang K, Robinson ML, Betz J, Alexander GC, Andersen KM, Joseph CS, Mehta HB, Korwek K, Sands KE, Fisher AM, Bollinger RC, Xu Y. Real-World Effectiveness Of Remdesivir In Adults Hospitalized With Covid-19: A Retrospective, Multicenter Comparative Effectiveness Study. Clin Infect Dis 2021; 75:e516-e524. [PMID: 34910128 PMCID: PMC8754724 DOI: 10.1093/cid/ciab1035] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Indexed: 12/15/2022] Open
Abstract
Background There is an urgent need to understand the real-world effectiveness of remdesivir in the treatment of SARS-CoV-2. Methods This was a retrospective comparative effectiveness study. Individuals hospitalized in a large private healthcare network in the US from February 23, 2020 through February 11, 2021 with a positive test for SARS-CoV-2 and ICD-10 diagnosis codes consistent with symptomatic COVID-19 were included. Remdesivir recipients were matched to controls using time-dependent propensity scores. The primary outcome was time to improvement with a secondary outcome of time to death. Results Of 96,859 COVID-19 patients, 42,473 (43.9%) received at least one remdesivir dose. The median age of remdesivir recipients was 65 years, 23,701 (55.8%) were male and 22,819 (53.7%) were non-white. Matches were found for 18,328 patients (43.2%). Remdesivir recipients were significantly more likely to achieve clinical improvement by 28 days (adjusted hazard ratio [1.19, 95% confidence interval (CI), 1.16-1.22]). Remdesivir patients on no oxygen (aHR 1.30, 95% CI 1.22-1.38) or low-flow oxygen (aHR 1.23, 95% CI 1.19-1.27) were significantly more likely to achieve clinical improvement by 28 days. There was no significant impact on the likelihood of mortality overall (aHR 1.02, 95% CI 0.97-1.08). Remdesivir recipients on low-flow oxygen were significantly less likely to die than controls (aHR 0.85, 95% CI 0.77-0.92; 28-day mortality 8.4% [865 deaths] for remdesivir patients, 12.5% [1,334 deaths] for controls). Conclusions These results support the use of remdesivir for hospitalized COVID-19 patients on no or low-flow oxygen. Routine initiation of remdesivir in more severely ill patients is unlikely to be beneficial.
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Affiliation(s)
- Brian T Garibaldi
- Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore MD, USA.,COVID-19 Consortium of HCA Healthcare and Academia for Research GEneration, USA
| | - Kunbo Wang
- COVID-19 Consortium of HCA Healthcare and Academia for Research GEneration, USA.,Department of Applied Mathematics and Statistics, Johns Hopkins University, Baltimore, MD, USA
| | - Matthew L Robinson
- COVID-19 Consortium of HCA Healthcare and Academia for Research GEneration, USA.,Division of Infectious Disease, Johns Hopkins University School of Medicine, USA
| | - Joshua Betz
- COVID-19 Consortium of HCA Healthcare and Academia for Research GEneration, USA.,Division of Biostatistics, Johns Hopkins Bloomberg School of Public Health, USA
| | - G Caleb Alexander
- COVID-19 Consortium of HCA Healthcare and Academia for Research GEneration, USA.,Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore MD, USA
| | - Kathleen M Andersen
- COVID-19 Consortium of HCA Healthcare and Academia for Research GEneration, USA.,Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore MD, USA
| | - Corey S Joseph
- COVID-19 Consortium of HCA Healthcare and Academia for Research GEneration, USA.,Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore MD, USA
| | - Hemalkumar B Mehta
- COVID-19 Consortium of HCA Healthcare and Academia for Research GEneration, USA.,Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore MD, USA
| | - Kimberly Korwek
- COVID-19 Consortium of HCA Healthcare and Academia for Research GEneration, USA.,Clinical Operations Group, HCA Healthcare, Nashville TN, USA
| | - Kenneth E Sands
- COVID-19 Consortium of HCA Healthcare and Academia for Research GEneration, USA.,Clinical Operations Group, HCA Healthcare, Nashville TN, USA
| | - Arielle M Fisher
- COVID-19 Consortium of HCA Healthcare and Academia for Research GEneration, USA.,Genospace, Sarah Cannon, Boston, MA, USA
| | - Robert C Bollinger
- COVID-19 Consortium of HCA Healthcare and Academia for Research GEneration, USA.,Division of Infectious Disease, Johns Hopkins University School of Medicine, USA
| | - Yanxun Xu
- COVID-19 Consortium of HCA Healthcare and Academia for Research GEneration, USA.,Department of Applied Mathematics and Statistics, Johns Hopkins University, Baltimore, MD, USA.,Division of Biostatistics and Bioinformatics at The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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14
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Bell SK, Folcarelli P, Fossa A, Gerard M, Harper M, Leveille S, Moore C, Sands KE, Sarnoff Lee B, Walker J, Bourgeois F. Tackling Ambulatory Safety Risks Through Patient Engagement: What 10,000 Patients and Families Say About Safety-Related Knowledge, Behaviors, and Attitudes After Reading Visit Notes. J Patient Saf 2021; 17:e791-e799. [PMID: 29781979 DOI: 10.1097/pts.0000000000000494] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Ambulatory safety risks including delayed diagnoses or missed abnormal test results are difficult for clinicians to see, because they often occur in the space between visits. Experts advocate greater patient engagement to improve safety, but strategies are limited. Patient access to clinical notes ("OpenNotes") may help close the safety gap between visits. METHODS We surveyed patients and families who logged on to the patient portal and had at least one ambulatory note available in the past 12 months at two academic hospitals during June to September 2016, focusing on patient-reported effects of OpenNotes on safety knowledge, behaviors, and attitudes. RESULTS A total of 6913 (28%) of 24,722 patients at an adult hospital and 3672 (17%) of 21,579 participants at the children's hospital submitted surveys. Approximately 75% of patients and parents each reported that reading notes helped them understand the reason for both tests and referrals, and approximately 50% felt that it helped them complete tests and referrals. Roughly 75% of participants were more likely to check and understand test results. Overall, 97% of participants reported that trust in the provider, activation, patient-provider goal alignment, and teamwork were each better or the same after reading 1 note or more. Nonwhite participants and those with high school education or less were 30% to 50% more likely to report that reading notes helped them complete tests compared with white and more educated respondents, respectively. CONCLUSIONS Overall, the majority of more than 10,000 patients and parents reported reading notes helped them understand and follow through on tests and referrals. As information transparency spreads, OpenNotes can help activate patients and families, facilitate safety behaviors, and forge stronger partnerships with clinicians.
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Affiliation(s)
| | - Patricia Folcarelli
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | | | | | | | - Caroline Moore
- Department of Social Work and Patient/Family Engagement, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Kenneth E Sands
- Clinical Services Group, HCA Healthcare, Nashville, Tennessee
| | - Barbara Sarnoff Lee
- Department of Social Work and Patient/Family Engagement, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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15
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Baker MA, Sands KE, Huang SS, Kleinman K, Septimus EJ, Varma N, Blanchard J, Poland RE, Coady MH, Yokoe DS, Fraker S, Froman A, Moody J, Goldin L, Isaacs A, Kleja K, Korwek KM, Stelling J, Clark A, Platt R, Perlin JB. The Impact of COVID-19 on Healthcare-Associated Infections. Clin Infect Dis 2021; 74:1748-1754. [PMID: 34370014 PMCID: PMC8385925 DOI: 10.1093/cid/ciab688] [Citation(s) in RCA: 125] [Impact Index Per Article: 41.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Indexed: 11/14/2022] Open
Abstract
Background The profound changes wrought by COVID-19 on routine hospital operations may have influenced performance on hospital measures, including healthcare-associated infections (HAIs). We aimed to evaluate the association between COVID-19 surges and HAI and cluster rates. Methods In 148 HCA Healthcare-affiliated hospitals, 3/1/2020-9/30/2020, and a subset of hospitals with microbiology and cluster data through 12/31/2020, we evaluated the association between COVID-19 surges and HAIs, hospital-onset pathogens, and cluster rates using negative binomial mixed models. To account for local variation in COVID-19 pandemic surge timing, we included the number of discharges with a laboratory-confirmed COVID-19 diagnosis per staffed bed per month. Results Central line-associated blood stream infections (CLABSI), catheter-associated urinary tract infections (CAUTI), and methicillin-resistant Staphylococcus aureus (MRSA) bacteremia increased as COVID-19 burden increased. There were 60% (95% CI, 23-108%) more CLABSI, 43% (95% CI, 8-90%) more CAUTI, and 44% (95% CI, 10-88%) more cases of MRSA bacteremia than expected over 7 months based on predicted HAIs had there not been COVID-19 cases. Clostridioides difficile infection was not significantly associated with COVID-19 burden. Microbiology data from 81 of the hospitals corroborated the findings. Notably, rates of hospital-onset bloodstream infections and multidrug resistant organisms, including MRSA, vancomycin-resistant enterococcus and Gram-negative organisms were each significantly associated with COVID-19 surges. Finally, clusters of hospital-onset pathogens increased as the COVID-19 burden increased. Conclusion COVID-19 surges adversely impact HAI rates and clusters of infections within hospitals, emphasizing the need for balancing COVID-related demands with routine hospital infection prevention.
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Affiliation(s)
- Meghan A Baker
- Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA USA.,Brigham and Women's Hospital, Boston, MA USA
| | - Kenneth E Sands
- Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA USA.,HCA Healthcare, Nashville, Tennessee USA
| | - Susan S Huang
- University of California Irvine School of Medicine, Orange, CA USA
| | - Ken Kleinman
- University of Massachusetts Amherst, Amherst, MA USA
| | - Edward J Septimus
- Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA USA.,Texas A&M College of Medicine, Houston, Texas USA
| | - Neha Varma
- Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA USA
| | | | - Russell E Poland
- Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA USA.,HCA Healthcare, Nashville, Tennessee USA
| | - Micaela H Coady
- Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA USA
| | - Deborah S Yokoe
- University of California San Francisco, San Francisco, CA USA
| | | | - Allison Froman
- Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA USA
| | | | | | - Amanda Isaacs
- Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA USA
| | | | | | | | - Adam Clark
- Brigham and Women's Hospital, Boston, MA USA
| | - Richard Platt
- Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA USA
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16
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Sokol-Hessner L, Folcarelli PH, Annas CL, Brown SM, Fernandez L, Roche SD, Sarnoff Lee B, Sands KE, Atlas T, Benoit DD, Burke GF, Butler TP, Federico F, Gandhi T, Geller G, Hickson GB, Hoying C, Lee TH, Reynolds ME, Rozenblum R, Turner K. A Road Map for Advancing the Practice of Respect in Health Care: The Results of an Interdisciplinary Modified Delphi Consensus Study. Jt Comm J Qual Patient Saf 2018; 44:463-476. [DOI: 10.1016/j.jcjq.2018.02.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 02/14/2018] [Indexed: 10/28/2022]
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17
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Bell SK, Etchegaray JM, Gaufberg E, Lowe E, Ottosen MJ, Sands KE, Lee BS, Thomas EJ, Van Niel M, Kenney L. A Multi-Stakeholder Consensus-Driven Research Agenda for Better Understanding and Supporting the Emotional Impact of Harmful Events on Patients and Families. Jt Comm J Qual Patient Saf 2018; 44:424-435. [PMID: 30008355 DOI: 10.1016/j.jcjq.2018.03.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 03/12/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND The nature and consequences of patient and family emotional harm stemming from preventable medical error, such as losing a loved one or surviving serious medical injury, is poorly understood. Patients and families, clinicians, social scientists, lawyers, and foundation/policy leaders were brought together to establish research priorities for this issue. METHODS A one-day conference of diverse stakeholder groups to establish a consensus-driven research agenda focused on (1) priorities for research on the short-term and long-term emotional impact of harmful events on patients and families, (2) barriers and enablers to conducting such research, and (3) actionable steps toward better supporting harmed patients and families now. RESULTS Stakeholders discussed patient and family experiences after serious harmful events, including profound isolation, psychological distress, damaging aspects of medical culture, health care aversion, and negative effects on communities. Stakeholder groups reached consensus, defining four research priorities: (1) Establish conceptual framework and patient-centered taxonomy of harm and healing; (2) Describe epidemiology of emotional harm; (3) Determine how to make emotional harm and long-term impacts visible to health care organizations and society at large; and (4) Develop and implement best practices for emotional support of patients and families. The group also created a strategy for overcoming research barriers and actionable "Do Now" approaches to improve the patient and family experience while research is ongoing. CONCLUSION Emotional and other long-term impacts of harmful events can have profound consequences for patients and families. Stakeholders designed a path forward to inform approaches that better support harmed patients and families, with both immediately actionable and longer-term research strategies.
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18
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Mello MM, Kachalia A, Roche S, Niel MV, Buchsbaum L, Dodson S, Folcarelli P, Benjamin EM, Sands KE. Outcomes In Two Massachusetts Hospital Systems Give Reason For Optimism About Communication-And-Resolution Programs. Health Aff (Millwood) 2017; 36:1795-1803. [DOI: 10.1377/hlthaff.2017.0320] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Michelle M. Mello
- Michelle M. Mello is a professor of law at Stanford Law School and a professor of health research and policy at Stanford University School of Medicine, in California
| | - Allen Kachalia
- Allen Kachalia is an associate professor of medicine at Harvard Medical School and chief quality officer at Brigham Health, both in Boston, Massachusetts
| | - Stephanie Roche
- Stephanie Roche is a quality analyst at Beth Israel Deaconess Medical Center, in Boston
| | - Melinda Van Niel
- Melinda Van Niel is a project manager at Beth Israel Deaconess Medical Center
| | - Lisa Buchsbaum
- Lisa Buchsbaum was a project manager at Beth Israel Deaconess Medical Center at the time this research was conducted. She is now a patient safety program manager at Regions Hospital, in St. Paul, Minnesota
| | - Suzanne Dodson
- Suzanne Dodson was a project manager at Baystate Medical Center, in Springfield, Massachusetts, at the time this research was conducted. She is now retired
| | - Patricia Folcarelli
- Patricia Folcarelli is interim vice president for health care quality at Beth Israel Deaconess Medical Center
| | - Evan M. Benjamin
- Evan M. Benjamin is a professor of medicine at Tufts University School of Medicine, in Boston, and senior vice president at Baystate Health, in Springfield
| | - Kenneth E. Sands
- Kenneth E. Sands was senior vice president at Beth Israel Deaconess Medical Center at the time this research was conducted. He is now chief epidemiologist and chief patient safety officer at HCA, in Nashville, Tennessee
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19
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Bell SK, Gerard M, Fossa A, Delbanco T, Folcarelli PH, Sands KE, Sarnoff Lee B, Walker J. A patient feedback reporting tool for OpenNotes: implications for patient-clinician safety and quality partnerships. BMJ Qual Saf 2016; 26:312-322. [PMID: 27965416 DOI: 10.1136/bmjqs-2016-006020] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Revised: 10/25/2016] [Accepted: 11/03/2016] [Indexed: 11/04/2022]
Abstract
BACKGROUND OpenNotes, a national movement inviting patients to read their clinicians' notes online, may enhance safety through patient-reported documentation errors. OBJECTIVE To test an OpenNotes patient reporting tool focused on safety concerns. METHODS We invited 6225 patients through a patient portal to provide note feedback in a quality improvement pilot between August 2014 and 2015. A link at the end of the note led to a 9-question survey. Patient Relations personnel vetted responses, shared safety concerns with providers and documented whether changes were made. RESULTS 2736/6225(44%) of patients read notes; among these, 1 in 12 patients used the tool, submitting 260 reports. Nearly all (96%) respondents reported understanding the note. Patients and care partners documented potential safety concerns in 23% of reports; 2% did not understand the care plan and 21% reported possible mistakes, including medications, existing health problems, something important missing from the note or current symptoms. Among these, 64% were definite or possible safety concerns on clinician review, and 57% of cases confirmed with patients resulted in a change to the record or care. The feedback tool exceeded the reporting rate of our ambulatory online clinician adverse event reporting system several-fold. After a year, 99% of patients and care partners found the tool valuable, 97% wanted it to continue, 98% reported unchanged or improved relationships with their clinician, and none of the providers in the small pilot reported worsening workflow or relationships with patients. CONCLUSIONS Patients and care partners reported potential safety concerns in about one-quarter of reports, often resulting in a change to the record or care. Early data from an OpenNotes patient reporting tool may help engage patients as safety partners without apparent negative consequences for clinician workflow or patient-clinician relationships.
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Affiliation(s)
- Sigall K Bell
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Macda Gerard
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Alan Fossa
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Tom Delbanco
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Patricia H Folcarelli
- Department of Health Care Quality, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Kenneth E Sands
- Department of Health Care Quality, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Barbara Sarnoff Lee
- Department of Social Work and Patient/Family Engagement, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Jan Walker
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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20
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Heher YK, Chen Y, Pyatibrat S, Yoon E, Goldsmith JD, Sands KE. Achieving High Reliability in Histology: An Improvement Series to Reduce Errors. Am J Clin Pathol 2016; 146:554-560. [PMID: 28430956 DOI: 10.1093/ajcp/aqw148] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Despite sweeping medical advances in other fields, histology processes have by and large remained constant over the past 175 years. Patient label identification errors are a known liability in the laboratory and can be devastating, resulting in incorrect diagnoses and inappropriate treatment. The objective of this study was to identify vulnerable steps in the histology workflow and reduce the frequency of labeling errors (LEs). METHODS In this 36-month study period, a numerical step key (SK) was developed to capture LEs. The two most prevalent root causes were targeted for Lean workflow redesign: manual slide printing and microtome cutting. The numbers and rates of LEs before and after interventions were compared to evaluate the effectiveness of interventions. RESULTS Following the adoption of a barcode-enabled laboratory information system, the error rate decreased from a baseline of 1.03% (794 errors in 76,958 cases) to 0.28% (107 errors in 37,880 cases). After the implementation of an innovative ice tool box, allowing single-piece workflow for histology microtome cutting, the rate came down to 0.22% (119 errors in 54,342 cases). CONCLUSIONS The study pointed out the importance of tracking and understanding LEs by using a simple numerical SK and quantified the effectiveness of two customized Lean interventions. Overall, a 78.64% reduction in LEs and a 35.28% reduction in time spent on rework have been observed since the study began.
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Affiliation(s)
| | | | - Sergey Pyatibrat
- Department of Pathology and Laboratory Medicine, Ottawa Hospital, Ottawa, Canada
| | | | - Jeffrey D Goldsmith
- From the Department of Pathology
- Department of Pathology, Children's Hospital Boston, Boston, MA
| | - Kenneth E Sands
- Department of Healthcare Quality, Beth Israel Deaconess Medical Center, Boston, MA
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21
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Sands KE, Yokoe DS, Hooper DC, Tully JL, Horan TC, Gaynes RP, Solomon SL, Platt R. Detection of Postoperative Surgical-Site Infections: Comparison of Health Plan–Based Surveillance With Hospital-Based Programs. Infect Control Hosp Epidemiol 2015; 24:741-3. [PMID: 14587934 DOI: 10.1086/502123] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
AbstractBackground:Review of health plan administrative data has been shown to be more sensitive than other methods for identifying postdischarge surgical-site infections (SSIs), but there has not been a direct comparison between this method and hospital-based surveillance for all infections, including those diagnosed before discharge. We compared these two methods for identifying SSIs following coronary artery bypass graft (CABG) procedures:.Methods:We studied 1,352 CABG procedures performed among members of one health plan from March 1993 through June 1997. Health plan administrative records were reviewed based on claims containing diagnoses or procedures suggestive of infection or outpatient dispensing of antibiotics appropriate for SSI. Hospital-based surveillance information was also reviewed. SSI rates were calculated based on the total events identified by either mechanism.Results:Postdischarge information was reviewed for 328 (85%) of 388 procedures. SSIs were confirmed in 167 patients (13% overall risk of confirmed SSI; range, 3% to 14% in the 5 hospitals). The overall sensitivity of hospital-based surveillance was 49.7% (83 of 167), and that of health plan data was 71.8% (120 of 167). There was no significant difference among hospitals in the sensitivity of either surveillance mechanism.Conclusions:Surveillance based on health plan data identified more postoperative infections, including those occurring before discharge, than did hospital-based surveillance. Screening administrative data and pharmacy activity may be an important adjunct to SSI surveillance, allowing efficient comparison of hospital-specific rates. Interpretation of differences among hospitals' infection rates requires case mix adjustment and understanding of variations in hospitals' discharge diagnosis coding practices
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Affiliation(s)
- Kenneth E Sands
- Centers for Disease Control and Prevention, Eastern Massachusetts Prevention Epicenter, Boston, Massachusetts, USA
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22
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Howell MD, Ngo L, Folcarelli P, Yang J, Mottley L, Marcantonio ER, Sands KE, Moorman D, Aronson MD. Sustained effectiveness of a primary-team-based rapid response system. Crit Care Med 2012; 40:2562-8. [PMID: 22732285 PMCID: PMC3638079 DOI: 10.1097/ccm.0b013e318259007b] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Laws and regulations require many hospitals to implement rapid-response systems. However, the optimal resource intensity for such systems is unknown. We sought to determine whether a rapid-response system that relied on a patient's usual care providers, not a critical-care-trained rapid-response team, would improve patient outcomes. DESIGN, SETTING, AND PATIENTS An interrupted time-series analysis of over a 59-month period. SETTING Urban, academic hospital. PATIENTS One hundred seven-one thousand, three hundred forty-one consecutive adult admissions. INTERVENTION In the intervention period, patients were monitored for predefined, standardized, acute, vital-sign abnormalities or marked nursing concern. If these criteria were met, a team consisting of the patient's existing care providers was assembled. MEASUREMENTS AND MAIN RESULTS The unadjusted risk of unexpected mortality was 72% lower (95% confidence interval 55%-83%) in the intervention period (absolute risk: 0.02% vs. 0.09%, p < .0001). The unadjusted in-hospital mortality rate was not significantly lower (1.9% vs. 2.1%, p = .07). After adjustment for age, gender, race, season of admission, case mix, Charlson Comorbidity Index, and intensive care unit bed capacity, the intervention period was associated with an 80% reduction (95% confidence interval 63%-89%, p < .0001) in the odds of unexpected death, but no significant change in overall mortality [odds ratio 0.91 (95% confidence interval 0.82-1.02), p = .09]. Analyses that also adjusted for secular time trends confirmed these findings (relative risk reduction for unexpected mortality at end of intervention period: 65%, p = .0001; for in-hospital mortality, relative risk reduction = 5%, p = .2). CONCLUSIONS A primary-team-based implementation of a rapid response system was independently associated with reduced unexpected mortality. This system relied on the patient's usual care providers, not an intensive care unit based rapid response team, and may offer a more cost-effective approach to rapid response systems, particularly for systems with limited intensivist availability.
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Affiliation(s)
- Michael D Howell
- Silverman Institute for Healthcare Quality and Safety, Beth Israel Deaconess Medical Center, Boston, MA, USA.
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23
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Abstract
Claims data complement other data sources for identification of surgical site infections following breast surgery and cesarean section. We investigated using administrative claims data to identify surgical site infections (SSI) after breast surgery and cesarean section. Postoperative diagnosis codes, procedure codes, and pharmacy information were automatically scanned and used to identify claims suggestive of SSI ("indicators") among 426 (22%) of 1,943 breast procedures and 474 (10%) of 4,859 cesarean sections. For 104 breast procedures with indicators explained in available medical records, SSI were confirmed for 37%, and some infection criteria were present for another 27%. Among 204 cesarean sections, SSI were confirmed for 40%, and some criteria were met for 27%. The extrapolated infection rates of 2.8% for breast procedures and 3.1% for cesarean section were similar to those reported by the National Nosocomial Infection Surveillance program but differ in representing predominantly outpatient infections. Claims data may complement other data sources for identification of surgical site infections following breast surgery and cesarean section.
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Affiliation(s)
- Andrew L. Miner
- Harvard Medical School, Boston, Massachusetts, USA
- Harvard Pilgrim Health Care, Boston, Massachusetts, USA
- Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Kenneth E. Sands
- Harvard Medical School, Boston, Massachusetts, USA
- Brigham and Women's Hospital, Boston, Massachusetts, USA
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Deborah S. Yokoe
- Harvard Medical School, Boston, Massachusetts, USA
- Harvard Pilgrim Health Care, Boston, Massachusetts, USA
- Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | | | | | - Richard Platt
- Harvard Medical School, Boston, Massachusetts, USA
- Harvard Pilgrim Health Care, Boston, Massachusetts, USA
- Brigham and Women's Hospital, Boston, Massachusetts, USA
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24
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Yokoe DS, Noskin GA, Cunnigham SM, Zuccotti G, Plaskett T, Fraser VJ, Olsen MA, Tokars JI, Solomon S, Perl TM, Cosgrove SE, Tilson RS, Greenbaum M, Hooper DC, Sands KE, Tully J, Herwaldt LA, Diekema DJ, Wong ES, Climo M, Platt R. Enhanced identification of postoperative infections among inpatients. Emerg Infect Dis 2005; 10:1924-30. [PMID: 15550201 PMCID: PMC3329006 DOI: 10.3201/eid1011.040572] [Citation(s) in RCA: 90] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Monitoring antimicrobial exposure and diagnosis codes for certain procedures identifies more postoperative infections than routine surveillance methods. We evaluated antimicrobial exposure, discharge diagnoses, or both to identify surgical site infections (SSI). This retrospective cohort study in 13 hospitals involved weighted, random samples of records from 8,739 coronary artery bypass graft (CABG) procedures, 7,399 cesarean deliveries, and 6,175 breast procedures. We compared routine surveillance to detection through inpatient antimicrobial exposure (>9 days for CABG, >2 days for cesareans, and >6 days for breast procedures), discharge diagnoses, or both. Together, all methods identified SSI after 7.4% of CABG, 5.0% of cesareans, and 2.0% of breast procedures. Antimicrobial exposure had the highest sensitivity, 88%–91%, compared with routine surveillance, 38%–64%. Diagnosis codes improved sensitivity of detection of antimicrobial exposure after cesareans. Record review confirmed SSI after 31% to 38% of procedures that met antimicrobial surveillance criteria. Sufficient antimicrobial exposure days, together with diagnosis codes for cesareans, identified more postoperative SSI than routine surveillance methods. This screening method was efficient, readily standardized, and suitable for most hospitals.
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25
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Yu DT, Platt R, Lanken PN, Black E, Sands KE, Schwartz JS, Hibberd PL, Graman PS, Kahn KL, Snydman DR, Parsonnet J, Moore R, Bates DW. Relationship of pulmonary artery catheter use to mortality and resource utilization in patients with severe sepsis*. Crit Care Med 2003; 31:2734-41. [PMID: 14668609 DOI: 10.1097/01.ccm.0000098028.68323.64] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine the relationship of pulmonary artery catheter (PAC) use to patient outcomes, including mortality rate and resource utilization, in patients with severe sepsis in eight academic medical centers. DESIGN Case-control, nested within a prospective cohort study. SETTING Eight academic tertiary care centers. PATIENTS Stratified random sample of 1,010 adult admissions with severe sepsis. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The main outcome measures were in-hospital mortality, total hospital charge, and length of stay (LOS) for patients with and without PAC use. The case-matched subset of patients included 141 pairs managed with and without the use of a PAC. The mortality rate was slightly but not statistically significantly lower among the PAC use group compared with those not using a PAC (41.1% vs. 46.8%, p =.34). Even this trend disappeared after we adjusted for the Charlson comorbidity score and sepsis-specific Acute Physiology and Chronic Health Evaluation (APACHE) III (adjusted odds ratio, 1.02; 95% confidence interval, 0.61-1.72). In linear regression models adjusted for the Charlson comorbidity score, sepsis-specific APACHE III, surgical status, receipt of a steroid before sepsis onset, presence of a Hickman catheter, and preonset LOS, no significant differences were found for total hospital charges (139,207 US dollars vs. 148,190, adjusted mean comparing PAC and non-PAC group, p =.57), postonset LOS (23.4 vs. 26.9 days, adjusted mean, p =.32), or total LOS in intensive care unit (18.2 vs. 18.8 days, adjusted mean, p =.82). CONCLUSIONS Among patients with severe sepsis, PAC placement was not associated with a change in mortality rate or resource utilization, although small nonsignificant trends toward lower resource utilization were present in the PAC group.
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Affiliation(s)
- D Tony Yu
- Division of General Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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26
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Yu DT, Black E, Sands KE, Schwartz JS, Hibberd PL, Graman PS, Lanken PN, Kahn KL, Snydman DR, Parsonnet J, Moore R, Platt R, Bates DW. Severe sepsis: variation in resource and therapeutic modality use among academic centers. Crit Care 2003; 7:R24-34. [PMID: 12793887 PMCID: PMC270675 DOI: 10.1186/cc2171] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2002] [Revised: 02/10/2003] [Accepted: 02/25/2003] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Treatment of severe sepsis is expensive, often encompassing a number of discretionary modalities. The objective of the present study was to assess intercenter variation in resource and therapeutic modality use in patients with severe sepsis. METHODS We conducted a prospective cohort study of 1028 adult admissions with severe sepsis from a stratified random sample of patients admitted to eight academic tertiary care centers. The main outcome measures were length of stay (LOS; total LOS and LOS after onset of severe sepsis) and total hospital charges. RESULTS The adjusted mean total hospital charges varied from 69 429 dollars to US237 898 dollars across centers, whereas the adjusted LOS after onset varied from 15.9 days to 24.2 days per admission. Treatments used frequently after the first onset of sepsis among patients with severe sepsis were pulmonary artery catheters (19.4%), ventilator support (21.8%), pressor support (45.8%) and albumin infusion (14.4%). Pulmonary artery catheter use, ventilator support and albumin infusion had moderate variation profiles, varying 3.2-fold to 4.9-fold, whereas the rate of pressor support varied only 1.92-fold across centers. Even after adjusting for age, sex, Charlson comorbidity score, discharge diagnosis-relative group weight, organ dysfunction and service at onset, the odds for using these therapeutic modalities still varied significantly across centers. Failure to start antibiotics within 24 hours was strongly correlated with a higher probability of 28-day mortality (r2 = 0.72). CONCLUSION These data demonstrate moderate but significant variation in resource use and use of technologies in treatment of severe sepsis among academic centers. Delay in antibiotic therapy was associated with worse outcome at the center level.
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Affiliation(s)
- D Tony Yu
- Research Fellow, Brigham and Women's Hospital, Partners HealthCare System, Wellesley, Massachusetts, USA
| | - Edgar Black
- Associate Medical Director, Finger Lakes Blue Cross Blue Shield, Rochester, New York, USA
| | - Kenneth E Sands
- VP and Medical Director, Healthcare Quality, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - J Sanford Schwartz
- L. Davis Institute, University of Pennsylvania Health System, Philadelphia, USA
| | - Patricia L Hibberd
- Director, Clinical Research Institute, Tufts-New England Medical Center, Boston, Massachusetts, USA
| | - Paul S Graman
- Professor of Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Paul N Lanken
- Professor of Medicine, Pulmonary, Allergy and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - Katherine L Kahn
- Professor of Medicine, UCLA, Department of Medicine, Division of GIM and HSR, Los Angeles, California, USA
| | - David R Snydman
- Chief, Geographic Medicine and Infectious Diseases and Hospital Epidemiologist, Tufts-New England Medical Center, Boston, Massachusetts, USA
| | - Jeffrey Parsonnet
- Infectious Diseases Section Staff, Infectious Disease, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Richard Moore
- Professor, Medicine and Epidemiology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Richard Platt
- Interim Director, Ambulatory Care and Prevention, Harvard Pilgrim Health Care, Boston, Massachusetts, USA
| | - David W Bates
- Chief, General Medicine Division, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Perencevich EN, Sands KE, Cosgrove SE, Guadagnoli E, Meara E, Platt R. Health and economic impact of surgical site infections diagnosed after hospital discharge. Emerg Infect Dis 2003; 9:196-203. [PMID: 12603990 PMCID: PMC2901944 DOI: 10.3201/eid0902.020232] [Citation(s) in RCA: 336] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Although surgical site infections (SSIs) are known to cause substantial illness and costs during the index hospitalization, little information exists about the impact of infections diagnosed after discharge, which constitute the majority of SSIs. In this study, using patient questionnaire and administrative databases, we assessed the clinical outcomes and resource utilization in the 8-week postoperative period associated with SSIs recognized after discharge. SSI recognized after discharge was confirmed in 89 (1.9%) of 4,571 procedures from May 1997 to October 1998. Patients with SSI, but not controls, had a significant decline in SF-12 (Medical Outcomes Study 12-Item Short-Form Health Survey) mental health component scores after surgery (p=0.004). Patients required significantly more outpatient visits, emergency room visits, radiology services, readmissions, and home health aide services than did controls. Average total costs during the 8 weeks after discharge were US dollars 5,155 for patients with SSI and US dollars 1,773 for controls (p<0.001).
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Bates DW, Yu DT, Black E, Sands KE, Schwartz JS, Hibberd PL, Graman PS, Lanken PN, Kahn KL, Snydman DR, Parsonnet J, Moore R, Platt R. Resource utilization among patients with sepsis syndrome. Infect Control Hosp Epidemiol 2003; 24:62-70. [PMID: 12558238 DOI: 10.1086/502117] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To assess the resource utilization associated with sepsis syndrome in academic medical centers. DESIGN Prospective cohort study. SETTING Eight academic, tertiary-care centers. PATIENTS Stratified random sample of 1,028 adult admissions with sepsis syndrome and all 248,761 other adult admissions between January 1993 and April 1994. The main outcome measures were length of stay (LOS) in total and after onset of sepsis syndrome (post-onset LOS) and total hospital charges. RESULTS The mean LOS for patients with sepsis was 27.7 +/- 0.9 days (median, 20 days), with sepsis onset occurring after a mean of 8.1 +/- 0.4 days (median, 3 days). For all patients without sepsis, the LOS was 7.2 +/- 0.03 days (median, 4 days). In multiple linear regression models, the mean for patients with sepsis syndrome was 18.2 days, which was 11.0 days longer than the mean for all other patients (P < .0001), whereas the mean difference in total charges was $43,000 (both P < .0001). These differences were greater for patients with nosocomial as compared with community-acquired sepsis, although the groups were similar after adjusting for pre-onset LOS. Eight independent correlates of increased post-onset LOS and 12 correlates of total charges were identified. CONCLUSIONS These data quantify the resource utilization associated with sepsis syndrome, and demonstrate that resource utilization is high in this group. Additional investigation is required to determine how much of the excess post-onset LOS and charges are attributable to sepsis syndrome rather than the underlying medical conditions.
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Affiliation(s)
- David W Bates
- Division of General Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts 02115, USA
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Platt R, Kleinman K, Thompson K, Dokholyan RS, Livingston JM, Bergman A, Mason JH, Horan TC, Gaynes RP, Solomon SL, Sands KE. Using automated health plan data to assess infection risk from coronary artery bypass surgery. Emerg Infect Dis 2002; 8:1433-41. [PMID: 12498660 PMCID: PMC2737830 DOI: 10.3201/eid0812.020039] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
We determined if infection indicators were sufficiently consistent across health plans to allow comparison of hospitals' risks of infection after coronary artery bypass surgery. Three managed care organizations accounted for 90% of managed care in eastern Massachusetts, from October 1996 through March 1999. We searched their automated inpatient and outpatient claims and outpatient pharmacy dispensing files for indicator codes suggestive of postoperative surgical site infection. We reviewed full text medical records of patients with indicator codes to confirm infection status. We compared the hospital-specific proportions of cases with an indicator code, adjusting for health plan, age, sex, and chronic disease score. A total of 536 (27%) of 1,953 patients had infection indicators. Infection was confirmed in 79 (53%) of 149 reviewed records with adequate documentation. The proportion of patients with an indicator of infection varied significantly (p < 0.001) between hospitals (19% to 36%) and health plans (22% to 33%). The difference between hospitals persisted after adjustment for health plan and patients' age and sex. Similar relationships were observed when postoperative antibiotic information was ignored. Automated claims and pharmacy data from different health plans can be used together to allow inexpensive, routine monitoring of indicators of postoperative infection, with the goal of identifying institutions that can be further evaluated to determine if risks for infection can be reduced.
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Affiliation(s)
- Richard Platt
- Centers for Disease Control and Prevention Eastern Massachusetts Prevention Epicenter, Boston, USA.
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Abstract
We screened automated ambulatory medical records, hospital and emergency room claims, and pharmacy records of 2,826 health maintenance organization (HMO) members who gave birth over a 30-month period. Full-text ambulatory records were reviewed for the 30-day postpartum period to confirm infection status for a weighted sample of cases. The overall postpartum infection rate was 6.0%, with rates of 7.4% following cesarean section and 5.5% following vaginal delivery. Rehospitalization; cesarean delivery; antistaphylococcal antibiotics; diagnosis codes for mastitis, endometritis, and wound infection; and ambulatory blood or wound cultures were important predictors of infection. Use of automated information routinely collected by HMOs and insurers allows efficient identification of postpartum infections not detected by conventional surveillance.
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Affiliation(s)
- D S Yokoe
- Channing Laboratory, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA, USA.
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Abstract
Automated data, especially from pharmacy and administrative claims, are available for much of the U.S. population and might substantially improve both inpatient and postdischarge surveillance for surgical site infections complicating selected procedures, while reducing the resources required. Potential improvements include better sensitivity, less susceptibility to interobserver variation, more uniform availability of data, more precise estimates of infection rates, and better adjustment for patients' coexisting illness.
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Affiliation(s)
- R Platt
- Harvard Medical School and Harvard Pilgrim Health Care, Boston, Massachusetts, USA.
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Abstract
BACKGROUND Nosocomial bloodstream infections (NBSIs) occur frequently in neonatal intensive care units (NICUs) and are associated with substantial morbidity and mortality. Little has been published regarding variation in NBSI among institutions. OBJECTIVE To determine NBSI incidence among six NICUs and to explore how much variation is explained by patient characteristics and NICU practice patterns. METHODS From October, 1994, to June, 1996, six regional NICUs prospectively abstracted clinical records of all neonates weighing <1,500 g. Occurrence of NBSI, defined as first positive culture occurring >48 h after admission, was analyzed in relation to baseline patient characteristics and several common therapeutic interventions. Variables significant in univariate analyses were analyzed by Cox proportional hazards regression. RESULTS There were 258 NBSIs (incidence, 19.1%) among 1,354 inborn first admissions. Incidence varied significantly by site, from 8.5 to 42%. Birth weight, Broviac catheter use and parenteral nutrition were significantly associated with NBSI (P < 0.05). When controlling for these variables interinstitutional variation in NBSI occurrence decreased but remained significant. CONCLUSIONS Neonatal NBSI incidence varies substantially among institutions despite adjustment for length of stay and some known risk factors. The uses of Broviac catheters and especially intravenous nutrition supplements were significant determinants of NBSI risk.
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Affiliation(s)
- S B Brodie
- Division of Infectious Disease, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA.
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Singer MV, Haft R, Barlam T, Aronson M, Shafer A, Sands KE. Vancomycin control measures at a tertiary-care hospital: impact of interventions on volume and patterns of use. Infect Control Hosp Epidemiol 1998; 19:248-53. [PMID: 9605273 DOI: 10.1086/647803] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Evaluate vancomycin prescribing patterns in a tertiary-care hospital before and after interventions to decrease vancomycin utilization. DESIGN Before/after analysis of interventions to limit vancomycin use. SETTING 420-bed academic tertiary-care center. INTERVENTIONS Educational efforts began August 10, 1994, and involved lectures to medical house staff followed by mailings to all physicians and posting of guidelines for vancomycin use on hospital information systems. Active interventions began November 15, 1994, and included automatic stop orders for vancomycin at 72 hours, alerts attached to the medical record, and, for 2 weeks only, computer alerts to physicians following each vancomycin order. Parenteral vancomycin use was estimated from the hospital pharmacy database of all medication orders. Records of a random sample of 344 patients receiving vancomycin between May 1, 1994, and April 30, 1995, were reviewed for an indication meeting published guidelines. RESULTS Vancomycin prescribing decreased by 22% following interventions, from 8.5 to 6.8 courses per 100 discharges (P<.05). The estimated proportion of vancomycin ordered for an indication meeting published guidelines was 36.6% overall, with no significant change following interventions. However, during the 2 weeks that computer alerts were in place, 60% of vancomycin use was for an approved indication. CONCLUSIONS Parenteral vancomycin prescribing decreased significantly following interventions, but the majority of orders still were not for an indication meeting published guidelines. Further improvement in the appropriateness of vancomycin prescribing potentially could be accomplished by more aggressive interventions, such as computer alerts, or by targeting specific aspects of prescribing patterns.
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Affiliation(s)
- M V Singer
- Division of Infectious Diseases, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
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Singer MV, Haft R, Barlam T, Aronson M, Shafer A, Sands KE. Vancomycin Control Measures at a Tertiary-Care Hospital: Impact of Interventions on Volume and Patterns of Use. Infect Control Hosp Epidemiol 1998. [DOI: 10.2307/30142415] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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35
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Sands KE, Bates DW, Lanken PN, Graman PS, Hibberd PL, Kahn KL, Parsonnet J, Panzer R, Orav EJ, Snydman DR, Black E, Schwartz JS, Moore R, Johnson BL, Platt R. Epidemiology of sepsis syndrome in 8 academic medical centers. JAMA 1997. [PMID: 9218672 DOI: 10.1001/jama.1997.03550030074038] [Citation(s) in RCA: 397] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CONTEXT Sepsis syndrome is a leading cause of mortality in hospitalized patients. However, few studies have described the epidemiology of sepsis syndrome in a hospitalwide population. OBJECTIVE To describe the epidemiology of sepsis syndrome in the tertiary care hospital setting. DESIGN Prospective, multi-institutional, observational study including 5-month follow-up. SETTING Eight academic tertiary care centers. METHODS Each center monitored a weighted random sample of intensive care unit (ICU) patients, non-ICU patients who had blood cultures drawn, and all patients who received a novel therapeutic agent or who died in an emergency department or ICU. Sepsis syndrome was defined as the presence of either a positive blood culture or the combination of fever, tachypnea, tachycardia, clinically suspected infection, and any 1 of 7 confirmatory criteria. Estimates of total cases expected annually were extrapolated from the number of cases, the period of observation, and the sampling fraction. RESULTS From January 4, 1993, to April 2, 1994, 12759 patients were monitored and 1342 episodes of sepsis syndrome were documented. The extrapolated, weighted estimate of hospitalwide incidence (mean+/-95% confidence limit) of sepsis syndrome was 2.0+/-0.16 cases per 100 admissions, or 2.8+/-0.17 per 1000 patient-days. The unadjusted attack rate for sepsis syndrome between individual centers differed by as much as 3-fold, but after adjustment for institutional differences in organ transplant populations, variation from the expected number of cases was reduced to 2-fold and was not statistically significant overall. Patients in ICUs accounted for 59% of total extrapolated cases, non-ICU patients with positive blood cultures for 11%, and non-ICU patients with negative blood cultures for 30%. Septic shock was present at onset of sepsis syndrome in 25% of patients. Bloodstream infection was documented in 28%, with gram-positive organisms being the most frequent isolates. Mortality was 34% at 28 days and 45% at 5 months. CONCLUSIONS Sepsis syndrome is common in academic hospitals, although the overall rates vary considerably with the patient population. A substantial fraction of cases occur outside ICUs. An understanding of the hospitalwide epidemiology of sepsis syndrome is vital for rational planning and treatment of hospitalized patients with sepsis syndrome, especially as new and expensive therapeutic agents become available.
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Affiliation(s)
- K E Sands
- Channing Laboratory, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Mass, USA.
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Abstract
Beat-to-beat heart rate variability was studied by power spectral analysis in 17 orthotopic cardiac transplant patients. Heart rate power spectra were calculated from eighty-four 256-second recordings and compared with those taken from six normal subjects. The power spectra from the control subjects resolved into discrete peaks at 0.04-0.12 Hz and 0.2-0.3 Hz, whereas those of heart transplant recipients resembled broad-band noise without peaks. Log total power in the 0.02-1.0 Hz range was greater in the control subjects (0.982 +/- 0.084 [0.206], mean +/- SEM [SD]) than in the transplanted subjects (-0.766 +/- 0.059 [0.541]), (p less than 0.0001). Fifty-five electrocardiographic recordings from transplant patients were done within 48 hours of an endomyocardial biopsy. When the power spectra of those patients whose endomyocardial biopsies showed evidence of myocardial rejection were compared with those from patients who were found to be free of rejection, a significant difference was found in log total power (-0.602 +/- 0.090 [0.525] vs. -0.909 +/- 0.136 [0.577], p less than 0.02). We conclude that denervation of the heart significantly reduces heart rate variability and abolishes the discrete spectral peaks seen in untransplanted control subjects and that the development of allograft rejection may significantly increase heart rate variability.
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Affiliation(s)
- K E Sands
- Harvard-Massachusetts Institute of Technology, Division of Health Sciences and Technology, Cambridge 02139
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