Ann Eichorn

Timeliness and use of antibiotic prophylaxis in selected inpatient surgical procedures

BACKGROUND Twenty-five percent of all nosocomial infections are wound infections. Professional guidelines support the timely use of preoperative prophylaxis for prevention of postoperative wound infections. Barriers exist in implementing this practice. IPRO, the New York State peer review organization, as part of the Health Care Financing Administrations Health Care Quality Improvement Program, sought to determine the proportion of patients receiving timely antibiotic prophylaxis for aortic grafts, hip replacements and colon resections in 44 hospitals in New York State. METHODS IPRO conducted a retrospective medical record review of 44 hospitals through out New York State stratified for teaching, nonteaching status. A sample was drawn of 2651 patients, 2256 from Medicare and 395 from Medicaid, undergoing either abdominal aortic aneurysm repair, partial or total hip replacement or large bowel resection. The study determined the proportion of patients who had documentation of receiving antibiotics and those who received antibiotics timely, that is less than or equal to 2 hours preoperatively. RESULTS Eighty-six percent of patients had documentation of receiving an antibiotic. Forty-six percent of aneurysm repairs and 60% of hip replacements had evidence of receiving timely antibiotic prophylaxis, that is within 2 hours prior to surgery. For colon resections, 73% of cases had either oral prophylaxis or timely parenteral therapy. An increased proportion of patients had received parenteral antibiotics prematurely as the surgical start time occurred later in the day. A total of 44 different antibiotics were recorded for prophylaxis. CONCLUSIONS Antibiotic prophylaxis was performed in 81% to 94% of cases, however, anywhere from 27% to 54% of all cases did not receive antibiotics in a timely fashion. By delegating implementation of ordered antibiotic prophylaxis to the anesthesia team, timing may be improved and the incidence of postoperative wound infections may decrease.

Using High-Technology to Enforce Low-Technology Safety Measures: The Use of Third-party Remote Video Auditing and Real-time Feedback in Healthcare

BACKGROUND Hand hygiene is a key measure in preventing infections. We evaluated healthcare worker (HCW) hand hygiene with the use of remote video auditing with and without feedback. METHODS The study was conducted in an 17-bed intensive care unit from June 2008 through June 2010. We placed cameras with views of every sink and hand sanitizer dispenser to record hand hygiene of HCWs. Sensors in doorways identified when an individual(s) entered/exited. When video auditors observed a HCW performing hand hygiene upon entering/exiting, they assigned a pass; if not, a fail was assigned. Hand hygiene was measured during a 16-week period of remote video auditing without feedback and a 91-week period with feedback of data. Performance feedback was continuously displayed on electronic boards mounted within the hallways, and summary reports were delivered to supervisors by electronic mail. RESULTS During the 16-week prefeedback period, hand hygiene rates were less than 10% (3933/60 542) and in the 16-week postfeedback period it was 81.6% (59 627/73 080). The increase was maintained through 75 weeks at 87.9% (262 826/298 860). CONCLUSIONS The data suggest that remote video auditing combined with feedback produced a significant and sustained improvement in hand hygiene.

The impact of do-not-resuscitate order on triage decisions to a medical intensive care unit

PURPOSE To determine whether the presence of a do-not-resuscitate (DNR) order impacts on triage decisions to a medical intensive care unit (MICU) of an academic medical center. METHODS Data were collected on 179 patients in whom MICU consultation was sought and included demographic, clinical information, diagnoses, ICU admission decision, Acute Physiological and Chronic Health Evaluation II (APACHE II) score, and the presence of DNR order. Functional status was determined retrospectively using the Modified Rankin Score. RESULTS The only factor that influenced MICU admission was the presence of DNR order at the time of MICU consultation (odds ratio, 0.25; 95% confidence interval, 0.09-0.71, P < .006). There was no difference between the age, APACHE II scores, or functional status between admitted or refused. Medical intensive care unit admission was associated with increased length of stay without difference in mortality. CONCLUSION The presence of a DNR order at the time of MICU consultation was significantly associated with the decision to refuse a patient to the MICU.

Hand hygiene in long-term care facilities: a multicenter study of knowledge, attitudes, practices, and barriers.

An anonymous survey of 1143 employees in 17 nursing facilities assessed knowledge of, attitudes about, self-perceived compliance with, and barriers to implementing the 2002 Centers for Disease Control and Prevention hand hygiene guidelines. Overall, employees reported positive attitudes toward the guidelines but differed with regard to knowledge, compliance, and perceived barriers. These findings provide guidance for practice improvement programs in long-term care settings.

External validation of the risk assessment model of the International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) for medical patients in a tertiary health system.

Background Hospitalized medical patients are at risk for venous thromboembolism (VTE). Universal application of pharmacological thromboprophylaxis has the potential to place a large number of patients at increased bleeding risk. In this study, we aimed to externally validate the International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) VTE risk assessment model in a hospitalized general medical population. Methods and Results We identified medical discharges that met the IMPROVE protocol. Cases were defined as hospital‐acquired VTE and confirmed by diagnostic study within 90 days of index hospitalization; matched controls were also identified. Risk factors for VTE were based on the IMPROVE risk assessment model (aged >60 years, prior VTE, intensive care unit or coronary care unit stay, lower limb paralysis, immobility, known thrombophilia, and cancer) and were measured and assessed. A total of 19 217 patients met the inclusion criteria. The overall VTE event rate was 0.7%. The IMPROVE risk assessment model identified 2 groups of the cohort by VTE incidence rate: The low‐risk group had a VTE event rate of 0.42 (95% CI 0.31 to 0.53), corresponding to a score of 0 to 2, and the at‐risk group had a VTE event rate of 1.29 (95% CI 1.01 to 1.57), corresponding to a score of ≥3. Low‐risk status for VTE encompassed 68% of the patient cohort. The area under the receiver operating characteristic curve was 0.702, which was in line with the derivation cohort findings. Conclusions The IMPROVE VTE risk assessment model validation cohort revealed good discrimination and calibration for both the overall VTE risk model and the identification of low‐risk and at‐risk medical patient groups, using a risk score of ≥3. More than two thirds of the entire cohort had a score ≤2.

Modifying the risk: Once-a-day bathing "at risk" patients in the intensive care unit with chlorhexidine gluconate

Chlorhexidine gluconate (CHG) decreases hospital-acquired methicillin-resistant Staphylococcus aureus (MRSA) that can cause colonization and infection. A standard approach is the bathing of all patients with CHG to prevent MRSA transmission. To decrease CHG utilization, this study assessed selective daily administration of CHG bathing to intensive care unit patients who had an MRSA-positive result or a central venous catheter. This risk-based approach was associated with a 72% decrease in hospital-acquired MRSA transmission rate.

Medical intensive care unit consults occurring within 48 hours of admission: A prospective study

RATIONALE Critical care consults requested shortly after admission could represent a triage error. This consult process has not been adequately assessed, and data are retrospective relying on discharge diagnoses. OBJECTIVES The aims of this study were to identify reasons for medical Intensive care unit (MICU) consultations within 48 hours of admission and to detect differences between those accepted and those denied MICU admission. METHODS Data were prospectively collected including demographics, reason for consultation, Acute Physiology and Chronic Health Evaluation II score, Elixhauser comorbidity measure, functional status, need for assisted ventilation or vasopressor, presence of do-not-resuscitate (DNR) order, and whether a DNR order was obtained after MICU consultation. RESULTS Ninety-four percent of patients consulted were not initially evaluated in the emergency department, half of whom were accepted. Respiratory failure, sepsis, and alcohol withdrawal were the most frequent reasons for MICU transfers. Factors predicting MICU admission included respiratory illness, better baseline functional status, and less comorbidity, whereas DNR predicted rejection. We did not find differences in hospital mortality; but hospital length of stay was longer. CONCLUSIONS Prospective examination of the consult process suggests that disease progression rather than triage error accounted for most unplanned transfers. Functional status and comorbidity predicted MICU admission rather than illness severity. Goals of care were not being discussed adequately. We did not detect differences in mortality although hospital length of stay was increased.