2011 December 30

Impact of inappropriate empirical antibiotic therapy on outcome of bacteremic adults visiting the ED.

Dec 302011

Impact of inappropriate empirical antibiotic therapy on outcome of bacteremic adults visiting the ED.

Am J Emerg Med. 2011 Dec 26;

Authors: Lee CC, Lee CH, Chuang MC, Hong MY, Hsu HC, Ko WC

Abstract
OBJECTIVES: To investigate the clinical impact of inappropriate empirical antibiotics on patient outcome and determine the risk factors for mortality in bacteremic adults who visited the emergency department (ED). METHODS: Bacteremic adults visiting the ED from January 2007 to June 2008 were identified retrospectively. Demographic characteristics, clinical conditions, bacteremic pathogens, antimicrobial agents, and outcomes were determined from chart records. RESULTS: The total of 454 eligible bacteremic adults were included in the analysis; excluded from the study were another 261 patients with contaminated blood cultures and 64 patients with ED stays of less than 24 hours. Among the included individuals, the mean age was 64.6 years, with a small predominance of males (230 patients, 50.7%). Of a total 494 bacteremic isolates, Escherichia coli (206, 41.7%) and Klebsiella species (81, 16.4%) were the most frequently encountered microorganisms. A lower 28-day mortality rate was demonstrated in bacteremic patients treated with appropriate antibiotics than that in those with inappropriate antibiotics or that in those with no antibiotic therapy, as judged by Kaplan-Meier survival curves (P = .01). Moreover, the differences among these three groups achieved higher significance (P = .002) in critically ill patients (Pittsburgh bacteremia scores of ?4 points). In multivariate analyses, inappropriate antibiotic therapy in the ED was associated independently with mortality at 28 days (odds ratio, 2.26; 95% confidence interval, 1.01-5.13; P = .04). CONCLUSIONS: For bacteremic adults visiting the ED, their outcomes were favorable following appropriate antibiotics, compared to treatment with inappropriate antibiotics or no antibiotics.

PMID: 22205015 [PubMed - as supplied by publisher]

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Hospital-level variation in the percentage of admissions originating in the emergency department.

Am J Emerg Med Start a Discussion »

Dec 302011

Hospital-level variation in the percentage of admissions originating in the emergency department.

Am J Emerg Med. 2011 Dec 26;

Authors: Studnicki J, Platonova EA, Fisher JW

Abstract
PURPOSE: Well over half of all US hospital patients are now admitted directly through the emergency department (ED) rather than scheduled through the admissions department by a referring member of the medical staff. This study sought to understand hospital-level variation in the percentage of admissions originating in the ED. BASIC PROCEDURES: This was a retrospective, cross-sectional analysis of 5 748 375 ED visits and 2 265 478 inpatient discharge occurring in 192 short-term acute Florida hospitals in calendar year 2005. MAIN FINDINGS: Hospitals with increasing percentages of patients admitted through the ED are smaller in scale with fewer admissions, beds, and smaller medical staffs but admit a higher percentage of their ED visits to the hospital. Patients in these hospitals are increasingly Hispanic, older, Medicare insured, and likely to represent a preventable ambulatory sensitive condition. CONCLUSIONS: The increasing rate of admissions from the ED department is a national trend, but there is substantial variation at the hospital level. In Florida, measures of hospital scale and an older population with some limitations in access to, or the quality of, primary care are the factors influencing hospital-level variation. Factors implicated in increased ED use such as ED visit acuity, lack of insurance, and race are not important contributory variables. The process of admission and, particularly, the role of the organized medical staff in this process are evolving, and the consequences of these changes require further research.

PMID: 22205007 [PubMed - as supplied by publisher]

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Validation of a novel risk score for severity of illness in acute exacerbations of COPD.

Chest Start a Discussion »

Dec 302011

Validation of a novel risk score for severity of illness in acute exacerbations of COPD.

Chest. 2011 Nov;140(5):1177-83

Authors: Shorr AF, Sun X, Johannes RS, Yaitanes A, Tabak YP

Abstract
BACKGROUND: Clinicians lack a validated tool for risk stratification in acute exacerbations of COPD (AECOPD). We sought to validate the BAP-65 (elevated BUN, altered mental status, pulse > 109 beats/min, age > 65 years) score for this purpose.
METHODS: We analyzed 34,699 admissions to 177 US hospitals (2007) with either a principal diagnosis of AECOPD or acute respiratory failure with a secondary diagnosis of AECOPD. Hospital mortality and need for mechanical ventilation (MV) served as co-primary end points. Length of stay (LOS) and costs represented secondary end points. We assessed the accuracy of BAP-65 via the area under the receiver operating characteristic curve (AUROC).
RESULTS: Nearly 4% of subjects died while hospitalized and approximately 9% required MV. Mortality increased with increasing BAP-65 class, ranging from < 1% in subjects in class I (score of 0) to > 25% in those meeting all BAP-65 criteria (Cochran-Armitage trend test z = -38.48, P < .001). The need for MV also increased with escalating score (2% in the lowest risk cohort vs 55% in the highest risk group, Cochran-Armitage trend test z = -58.89, P < .001). The AUROC for BAP-65 for hospital mortality and/or need for MV measured 0.79 (95% CI, 0.78-0.80). The median LOS was 4 days, and mean hospital costs equaled $5,357. These also varied linearly with increasing BAP-65 score.
CONCLUSIONS: The BAP-65 system captures severity of illness and represents a simple tool to categorize patients with AECOPD as to their risk for adverse outcomes. BAP-65 also correlates with measures of resource use. BAP-65 may represent a useful adjunct in the initial assessment of AECOPDs.

PMID: 21527510 [PubMed - indexed for MEDLINE]

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Early ICU energy deficit is a risk factor for Staphylococcus aureus ventilator-associated pneumonia.

Chest Start a Discussion »

Dec 302011

Early ICU energy deficit is a risk factor for Staphylococcus aureus ventilator-associated pneumonia.

Chest. 2011 Nov;140(5):1254-60

Authors: Faisy C, Candela Llerena M, Savalle M, Mainardi JL, Fagon JY

Abstract
BACKGROUND: Caloric insufficiency during the first week of ICU stay has been associated with increased infection rates. The connection between specific pathogens and host nutritional status in the ICU is not well known. This study was undertaken to determine the impact of patients' early in-ICU energy balance on the pathogens responsible for ventilator-associated pneumonia (VAP).
METHODS: In this prospective, observational, cohort study conducted in a teaching hospital ICU, energy balance (energy delivered - calculated resting energy expenditure) was compared according to the microbiologic results of the fiber-optic BAL cultures of 76 consecutive patients receiving acute prolonged (? 96 h) mechanical ventilation who developed VAP during their ICU stay.
RESULTS: Among the 76 BAL cultures, 22 contained significant Staphylococcus aureus concentrations. The cumulated energy deficit of patients with S aureus VAP was greater than those with VAP caused by other pathogens (-10,275 ± 4,211 kcal vs -7,376 ± 4,013 kcal from ICU admission to day of BAL, P < .01). ICU admission, nutritional status, and conditions potentially limiting feeding did not differ significantly between the two groups. Patients with S aureus VAP had lower prescribed and delivered energy, causing higher energy deficits. Multivariate analysis identified energy deficit as being independently associated with S aureus VAP. More-severe energy deficit and higher rate of S aureus-positive BAL cultures (P = .01 comparing quartiles) were observed.
CONCLUSIONS: Early ICU energy deficit is an independent determinant for acquiring S aureus VAP in patients on acute prolonged mechanical ventilation.

PMID: 21903738 [PubMed - indexed for MEDLINE]

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Experiences with hospital care: perspectives of black and Hispanic patients.

J Gen Intern Med Start a Discussion »

Dec 302011

Experiences with hospital care: perspectives of black and Hispanic patients.

J Gen Intern Med. 2008 Aug;23(8):1234-40

Authors: Hicks LS, Tovar DA, Orav EJ, Johnson PA

Abstract
BACKGROUND: Significant racial and ethnic differences along several dimensions of patients'experiences with hospital care have been previously documented. However, the relationship between these differences and possible differences in processes of care has not been well described.
METHODS: We conducted focus groups with 37 black and Hispanic men and women who had recently been discharged from either medical or obstetrical services at an urban academic medical center to assess which dimensions of these patients' experiences with care were most important in determining overall levels of satisfaction.
RESULTS: Differences were found between Hispanics and blacks in the factors that influence their overall positive and negative experiences. Participants identified two themes that influence experiences with hospital care that are not commonly examined in many patient satisfaction instruments: availability and quality of translators, and attitudes of social workers and nursing staff.
CONCLUSIONS: Our findings suggest that hospitals should pursue hiring a culturally diverse work force and should collect racial and ethnically specific data about satisfaction with care including satisfaction with availability of social workers and interpreters.

PMID: 18414953 [PubMed - indexed for MEDLINE]

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Patient safety stories: a project utilizing narratives in resident training.

Acad Med Start a Discussion »

Dec 302011

Patient safety stories: a project utilizing narratives in resident training.

Acad Med. 2011 Nov;86(11):1473-8

Authors: Cox LM, Logio LS

Abstract
Incident reports have traditionally been the vehicle for identifying, assessing, and responding to quality gaps in hospitals. Yet because of a variety of barriers, residents often fail to participate in this formal process. The authors created a project to engage residents in incident reporting through the use of an online, anonymous narrative format, faculty-facilitated discussion groups, and involvement of patient safety officers in the educational process. During three months, 36 residents submitted a total of 79 stories about patient care that did not "go as intended." The authors reviewed and scored each story for contributing factors and outcomes. The residents met monthly in small groups with trained faculty facilitators to analyze the stories, which were also shared with the patient safety officers. The stories, narratives of both personal involvement and observed events, ranged from near-misses to sentinel events. Key contributing factors included lapses of professionalism, decision errors, communication/information mishaps, transition mix-ups, and workload difficulties. The narrative format proved a feasible tool for collecting significant, previously unrecognized patient safety issues. Internal medicine residents were willing to discuss gaps in care when given the tools and opportunity for anonymous storytelling and blame-free dialogue.

PMID: 21952066 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

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