Debbie F. Lew

Local variations in the epidemiology, microbiology, and outcome of necrotizing soft-tissue infections: a multicenter study.

BACKGROUND Necrotizing soft-tissue infections (NSTIs) are rare and highly lethal. METHODS A retrospective chart review of patients with NSTIs treated at 6 academic hospitals in Texas between January 1, 2004 and December 31, 2007. Patient demographics, presentation, microbiology, treatment, and outcome were recorded. Analysis of variance, chi-square test, and logistic regression analysis were performed. RESULTS Mortality rates varied between hospitals from 9% to 25% (n = 296). There was significant interhospital variation in patient characteristics, microbiology, and etiology of NSTIs. Despite hospital differences in treatment, primarily in critical care interventions, patient age and severity of disease (reflected by shock requiring vasopressors and renal failure postoperatively) were the main predictors of mortality. CONCLUSIONS Significant center differences occur in patient populations, etiology, and microbiology of NSTIs, even within a concentrated region. Management should be based on these characteristics given that adjunctive treatments are unproven and variations in outcome are likely because of patient disease at presentation.

Compliance with guidelines to prevent surgical site infections: As simple as 1-2-3?

BACKGROUND the purpose of this study was to assess predictive factors and compliance with surgical site infection (SSI) prevention guidelines at 2 county hospitals. DESIGN chart review and analysis of laparotomy patients undergoing colorectal, hysterectomy, or abdominal vascular procedures over two 6-month periods 1 year apart and evaluation of safety climate using the Safety Attitudes Questionnaire (SAQ). RESULTS overall compliance with all antibiotic prophylaxis guidelines was 62% (n = 442). Gynecologic surgery was an independent predictor of compliance with antibiotic prophylaxis guidelines in elective cases, and nonemergency status was an independent predictor when all cases were considered. Postoperative normothermia was predicted by hospital, procedure length, initial intraoperative temperature, and service. The SAQ had a 91% response rate. Contrary to expected, safety domain scores and agreement with statements on collaboration and teamwork were not predictive of compliance. CONCLUSION interventions to improve poor compliance with infection prevention guidelines must be multifaceted, hospital- and service-specific, and resilient during emergencies. Good safety and teamwork climate are not sufficient.

Is Nighttime the Right Time? Risk of Complications after Laparoscopic Cholecystectomy at Night

BACKGROUND Laparoscopic cholecystectomies can be performed at night in high-volume acute care hospitals. We hypothesized that nonelective nighttime laparoscopic cholecystectomies are associated with increased postoperative complications. STUDY DESIGN We conducted a single-center retrospective review of consecutive laparoscopic cholecystectomy patients between October 2010 and May 2011 at a safety-net hospital in Houston, Texas. Data were collected on demographics, operative time, time of incision, length of stay, 30-day postoperative complications (ie, bile leak/biloma, common bile duct injury, retained stone, superficial surgical site infection, organ space abscess, and bleeding) and death. Statistical analyses were performed using STATA software (version 12; Stata Corp). RESULTS During 8 months, 356 patients had nonelective laparoscopic cholecystectomies. A majority were female (n = 289 [81.1%]) and Hispanic (n = 299 [84%]). There were 108 (30%) nighttime operations. There were 29 complications in 18 patients; there were fewer daytime than nighttime patients who had at least 1 complication (4.0% vs 7.4%; p = 0.18). On multivariate analysis, age (odds ratio = 1.06 per year; 95% CI, 1.02-1.10; p = 0.002), case duration (odds ratio = 1.02 per minute; 95% CI, 1.01-1.02; p = 0.001), and nighttime surgery (odds ratio = 3.33; 95% CI, 1.14-9.74; p = 0.001) were associated with an increased risk of 30-day surgical complications. Length of stay was significantly longer for daytime than nighttime patients (median 3 vs 2 days; p < 0.001). CONCLUSIONS Age, case duration, and nighttime laparoscopic cholecystectomy were predictive of increased 30-day surgical complications at a high-volume safety-net hospital. The small but increased risk of complications with nighttime laparoscopic cholecystectomy must be balanced against improved efficiency at a high-volume, resource-poor hospital.

Defining risk for infectious complications on extracorporeal life support

BACKGROUND/PURPOSE Little is known about potentially modifiable risk factors associated with infectious complications (IC) acquired during extracorporeal life support (ECLS). PATIENTS AND METHODS The Extracorporeal Life Support Organization registry was accessed, and data on patient demographics, run characteristics, infections, and outcomes were collected. Patients who developed IC while on ECLS were compared to those that did not. Regression analysis was performed. Results are expressed as odds ratios, with P < .05 considered significant. RESULTS Infectious complications developed in 10.2% of 38,661 patients and was associated with increased odds of death. Risk factors for IC included increasing age, diagnosis, more remote decade, complications, presence of multiple complications, and ECLS mode. The risk of IC increased with the number of complications (P < .001). Patients with positive cultures before ECLS also had increased odds of IC (OR 2.12, 95% CI 1.92-2.34, P < .001). Those with IC were more likely to have cultures grow aggressive organisms (non-lactose fermenting gram negative rods, methicillin resistant Staphylococcus aureus, and fungi). CONCLUSIONS Strategies to reduce IC while on ECLS should be aimed at prevention of complications and treatment of pre-existing infections. Future studies should address whether broader spectrum antibiotic prophylaxis and/or empiric coverage for suspected sepsis is indicated in ECLS patients.

A tale of 2 hospitals: a staggered cohort study of targeted interventions to improve compliance with antibiotic prophylaxis guidelines.

BACKGROUND The purpose of this prospective study was to determine the effectiveness of targeted interventions to improve compliance with antibiotic prophylaxis guidelines (timing, spectrum, and discontinuation) at 2 university-affiliated hospitals. METHODS Based on barriers identified previously, hospital-specific interventions were developed such as educational conferences, standardized forms, an extended time-out, and feedback. Guideline compliance and surgical site infection (SSI) data were recorded on all patients who underwent elective laparotomies for colorectal procedures, vascular operations, and hysterectomies during four 6-month study periods. Prestudy data from July to December 2006 served as a baseline. One year later, a prospective cohort study was performed. The interventions were introduced to the 2 hospitals in a staggered fashion with 2-month implementation periods before reassessing compliance during the 6-month study periods. General linear modeling was performed (P < .05 significant). RESULTS Compliance with all 3 guidelines combined improved during the year preceding the study, after attention only, at both hospitals. Hospital-specific differences were found in the effectiveness of the intervention package on individual guidelines. Hospital 2 but not 1 improved in timing after the interventions; both hospitals improved in spectrum, and neither hospital improved in discontinuation. Overall compliance with all 3 antibiotic prophylactic measures was greater at hospital 1, but hospital 2 had lower SSI rates. CONCLUSION Simply increasing attention to a quality problem can result in a significant and sustained improvement. Quality improvement interventions should be evaluated rigorously for effectiveness given hospital-specific differences in effectiveness and for correlation of guideline compliance with outcome.

Abstract C41: Palliative care consults in terminal cancer patients dying in a safety-net hospital: Are they underutilized?

Introduction: Terminal patients with limited resources are more likely to die in the hospital which may be due in part to lack of access to palliative care. We hypothesized that the majority of terminal cancer patients who were treated and who died in a safety-net hospital did not receive a palliative care consult. Methods: A retrospective review of terminal cancer patients who were admitted and died at Lyndon Baines Johnson General Hospital, a safety-net hospital, from January through December 2012 was completed. Terminal cancer was defined as Stage IV or recurrent cancer with only palliative treatment options. Data was gathered on age, race/ethnicity, sex, length of stay (LOS) of final admission, underlying terminal cancer, insurance status, and receipt of a palliative consult. Univariate analysis was performed using chi-square and Kruskal-Wallis test. Results: Seventy-four patients with terminal cancer died in the hospital. The majority of patients were minorities: African Americans (n=28, 38%), Hispanics (n=27, 36%), Caucasians (n=14, 19%), and Asian/other ethnicities (n=5, 7%). Two-thirds of patients (n=49, 66%) received palliative consults. There was no difference in race/ethnicity, gender, or age between patients who did and did not receive palliative consults. Patients who received a palliative consult were more likely to be uninsured (90% vs. 56%, p=0.003). There was no difference in median LOS (interquartile range, days) of the final admission between patients who did and did not receive a palliative consult (7, 3-16 versus 6, 2-15 days; p=0.47). Conclusions: In a safety-net hospital, in-hospital deaths still occur among terminal cancer patients even when palliative care consults are received. Further studies are necessary to determine how palliative care can best address the needs of vulnerable patients in order to reduce in-hospital deaths and improve patient-centered outcomes. Citation Format: Rebecca L. Wiatrek, Zeinab I. Alawadi, Debbie F. Lew, Melanie E. Zuo, Jeanette G. Ferrer, Tien C. Ko, Lillian S. Kao, Curtis J. Wray. Palliative care consults in terminal cancer patients dying in a safety-net hospital: Are they underutilized?. [abstract]. In: Proceedings of the Sixth AACR Conference: The Science of Cancer Health Disparities; Dec 6–9, 2013; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2014;23(11 Suppl):Abstract nr C41. doi:10.1158/1538-7755.DISP13-C41