Heena Sheth

A prospective study of reasons for prolonged hospitalizations on a general medicine teaching service.

AbstractBACKGROUND: Delays in the care of hospitalized patients may lead to increased length of stay, iatrogenic complications, and costs. No study has characterized delays among general medicine inpatients in the current prospective payment era of care. OBJECTIVE: To quantify and characterize delays in care which prolong hospitalizations for general medicine inpatients. DESIGN: Prospective survey of senior residents. SETTING: Urban tertiary care university-affiliated teaching hospital. PARTICIPANTS: Sixteen senior residents were surveyed regarding 2,831 patient-days. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Data were collected on 97.6% (2,762) of patient-days eligible for evaluation. Three hundred seventy-three patient-days (13.5% of all hospital days) were judged unnecessary for acute inpatient care, and occurred because of delays in needed services. Sixty-three percent of these unnecessary days were due to nonmedical service delays and 37% were due to medical service delays. The vast majority of nonmedical service delays (84%) were due to difficulty finding a bed in a skilled nursing facility. Medical service delays were most often due to postponement of procedures (54%) and diagnostic test performance (21%) or interpretation (10%), and were significantly more common on weekend days (relative risk [RR], 1.49; P=.02). Indeed, nearly one fourth of unnecessary patient-days (24% overall, 88 patient-days) involved an inability to access medical services on a weekend day (Saturday or Sunday). CONCLUSIONS: At our institution, a substantial number of hospital days were judged unnecessary for acute inpatient care and were attributable to delays in medical and nonmedical services. Future work is needed to develop and investigate measures to decrease delays.

Promethazine Adverse Events after Implementation of a Medication Shortage Interchange

BACKGROUND: Prochlorperazine and droperidol were commonly used antiemetics at the University of Pittsburgh Medical Center– Presbyterian Hospital until a shortage of prochlorperazine occurred and a black box warning was added to droperidol prescribing information. Subsequently, promethazine was selected as the approved intravenous antiemetic for therapeutic interchange in December 2001. Promethazine use and adverse drug events (ADEs) were investigated following review of a serious ADE that identified promethazine use as a probable contributing factor. OBJECTIVE: To illustrate ADEs associated with promethazine and characterize high-risk patients. METHODS: An ADE database analysis identified promethazine ADEs reported from 2000 to 2003. Promethazine utilization and ADEs were compared with those of other antiemetics during the pre- and post-interchange periods. RESULTS: Promethazine utilization increased significantly during the post-interchange period compared with all other antiemetics (p < 0.001). Promethazine ADEs increased from one event during the pre-interchange period to 13 events during the post-interchange period. Causality assessment using the Naranjo algorithm ranged from possible to probable. The promethazine ADE rate per 10 000 doses was significantly higher than the combined ADE rate for all other antiemetics (p < 0.001; incident rate ratio [IRR] 4.32). Elderly patients (aged ≥65 y) experienced more promethazine ADEs than younger patients (p = 0.005; IRR 4.68). Concurrent use of opioids and/or sedating drugs contributed to promethazine ADEs in 11 of 14 (78.6%) patients. CONCLUSIONS: Geriatric status is a significant risk factor for promethazine ADEs. Concomitant use of sedating drugs may further increase the risk for ADEs. Therapeutic interchange programs should be monitored for both ADEs and utilization.

Peritonitis – Does Peritoneal Dialysis Modality Make a Difference?

Background/Aims: Peritonitis remains a significant problem for patients on peritoneal dialysis (PD). There is a certain amount of controversy as to whether peritoneal modality is itself a risk factor for peritonitis, with one modality higher than another. Methods: A literature review was done (August 2009) searching under ‘peritoneal dialysis’, ‘peritonitis’ and ‘modality’ to find all articles related to the topic. The highest-quality articles were extracted for review. Results: Two randomized controlled trials (RCTs) done with disconnect systems for continuous ambulatory PD (CAPD) and Luer lock connections for automated PD (APD) showed important decrements in peritonitis rate on APD compared to CAPD. The variation of peritonitis rates in studies comparing peritonitis on continuous cycling PD (CCPD) and CAPD may relate to the difference in connection type for APD in Europe (Luer lock) and North America (spike) and to differing prescriptions, including in some cases midday exchanges on APD and in other cases a dry abdomen on APD. The variation in peritonitis rates from center to center is marked. In many studies sufficient details regarding the connectology and the prescription, both of which may impact on peritonitis risk, are absent. Conclusion: At the present time, the best data suggest that use of APD with Luer lock connections versus CAPD with a disconnect system results in a reduction in peritonitis risk. More studies are needed on this important topic, particularly the possible advantage of initiating PD with a dry day in those with residual kidney function. This question would be best studied with an RCT comparing peritonitis rates in three groups of patients, i.e. those initiating dialysis on CCPD, CAPD and APD with a dry day.

Clostridium difficile Infections in Outpatient Dialysis Cohort

We examined the Clostridium difficile infection rate and risk factors in an outpatient dialysis cohort. The Cox proportional hazard for developing C. difficile infection was significantly higher with high comorbidity index and low serum albumin level. Conversely, it was lower for patients who had frequent bloodstream and dialysis access-related infections.

LONG-TERM EXIT-SITE GENTAMICIN PROPHYLAXIS AND GENTAMICIN RESISTANCE IN A PERITONEAL DIALYSIS PROGRAM

♦ Background: Daily gentamicin cream exit-site prophylaxis reduces peritoneal dialysis (PD)-related gram-negative infections. However, there is a concern about the potential for increasing gentamicin resistance with the long-term use of prophylactic gentamicin. This study evaluated the incidence of gentamicin-resistant PD-related infections over more than 2 decades. ♦ Methods: Study data on prevalent PD patients were retrieved from a prospectively maintained institutional review board (IRB)-approved PD registry at a single center from January 1, 1991, to December 31, 2000, and January 1, 2004, to December 31, 2013. The rates of gram-negative infections, fungal infections and those infections with organisms resistant to gentamicin were examined for the 2 periods. Period 1 from 1991 to 2000 when S. aureus prophylaxis consisted initially of oral rifampin to treat nasal carriage with S. aureus, and was then daily exit-site mupirocin ointment for all PD patients, was compared to the period from 2004 to 2013 when daily exit-site gentamicin cream was prescribed as prophylaxis (Period 2). ♦ Results: The study included a total of 444 PD patients (265 and 179 in Period 1 and Period 2, respectively). No significant difference was noted in demographics between the 2 periods except race. The gram-negative exit-site infection rates for Period 1 and Period 2 were 0.109 versus 0.027 (p < 0.0001). Gram-negative peritonitis rates were similar. There were 3 episodes of gentamicin-resistant infections in each period. Fungal infections remained consistently low. ♦ Conclusion: Despite a decade of exit-site gentamicin prophylaxis, gentamicin-resistant PD-related infections and fungal infections remained very low and similar to the prior period.

Evaluation of Risk Factors for Rectus Sheath Hematoma

Rectus sheath hematoma (RSH) develops due to rupture of epigastric arteries or the rectus muscle. Although RSH incidence rate is low, it poses a significant diagnostic dilemma. We evaluated the risk factors for RSH, its presentation, management, and outcomes for 115 patients hospitalized with confirmed RSH by computed tomography scan between January 2005 and June 2009. More than three-fourth (77.4%) of the patients were on anticoagulation therapy, 58.3% patients had chronic kidney disease (CKD) stage ≥3, 51.3% had abdominal injections, 41.7% were on steroids/immunosuppressant therapy, 37.4% had abdominal surgery/trauma, 33.9% had cough, femoral puncture was performed in 31.3% of patients, and 29.5% were on antiplatelet therapy. Rectus sheath hematoma was not an attributable cause in any of the 17 deaths. Mortality was significantly higher in patients with CKD stage ≥3 (P = .03) or who required transfusion (P = .007). Better understanding of RSH risk factors will facilitate early diagnoses and improve management.

Health literacy in patients on maintenance peritoneal dialysis: prevalence and outcomes.

6. Schaefer F, Borzych-Duzalka D, Azocar M, Munarriz RL, Sever L, Aksu N, et al. Impact of global economic disparities on practices and outcomes of chronic peritoneal dialysis in children: insights from the International Pediatric Peritoneal Dialysis Network Registry. Perit Dial Int 2012; 32:399–409. 7. Furth SL, Donaldson LA, Sullivan EK, Watkins SL. Peritoneal dialysis catheter infections and peritonitis in children: a report of the North American Pediatric Renal Transplant Cooperative Study. Pediatr Nephrol 2000; 15:179–82. 8. Abu-Aisha H, Elhassan EA, Khamis AH, Fedail H, Kaballo B, Abdelraheem MB, et al. Rates and causes of peritonitis in a National Multicenter Continuous Ambulatory Peritoneal Dialysis program in Sudan: first-year experience. Saudi J Kidney Dis Transpl 2007; 18:565–70. 9. Holloway M, Mujais S, Kandert M, Warady BA. Pediatric peritoneal dialysis training: characteristics and impact on peritonitis rates. Perit Dial Int 2001; 21:401–4. doi: 10.3747/pdi.2013.00342

Improvement in Herpes Zoster Vaccination in Patients with Rheumatoid Arthritis: A Quality Improvement Project

Objective. To improve herpes zoster (HZ) vaccination rates in high-risk patients with rheumatoid arthritis (RA) being treated with immunosuppressive therapy. Methods. This quality improvement project was based on the pre- and post-intervention design. The project targeted all patients with RA over the age of 60 years while being treated with immunosuppressive therapy (not with biologics) seen in 13 rheumatology outpatient clinics. The study period was from July 2012 to June 2013 for the pre-intervention and February 2014 to January 2015 for the post-intervention phase. The electronic best practice alert (BPA) for HZ vaccination was developed; it appeared on electronic medical records during registration and medication reconciliation of the eligible patient by the medical assistant. The BPA was designed to electronically identify patient eligibility and to enable the physician to order the vaccine or to document refusal or deferral reason. Education regarding vaccine guidelines, BPA, vaccination process, and feedback were crucial components of the project interventions. The vaccination rates were compared using the chi-square test. Results. We evaluated 1823 and 1554 eligible patients with RA during the pre-intervention and post-intervention phases, respectively. The HZ vaccination rates, reported as patients vaccinated among all eligible patients, improved significantly from the pre-intervention period of 10.1% (184/1823) to 51.7% (804/1554) during the intervention phase (p < 0.0001). The documentation rates (vaccine received, vaccine ordered, patient refusal, and deferral reasons) increased from 28% (510/1823) to 72.9% (1133/1554; p < 0.0001). The HZ infection rates decreased significantly from 2% to 0.3% (p = 0.002). Conclusion. Electronic identification of vaccine eligibility and BPA significantly improved HZ vaccination rates. The process required minimal modification of clinic work flow and did not burden the physician’s time, and has the potential for self-sustainability and generalizability.

Screening for injurious falls in acute care hospitals

Background Injurious fall is a serious hospital-acquired condition. Screening tools for injurious falls in hospitalized patients have received limited evaluation. Objective To compare operating characteristics of a succinct screening tool for injurious falls, the University of Pittsburgh Medical Center (UPMC) screening tool (based on mobility, fall history, and nursing judgment), with the ABCS injurious fall screening tool (based on Age, Bone, Coagulation, and recent Surgery). Design Case control study. Methods Hospitalized patients with injurious falls were identified from the UPMC adverse events database for 2007–2008 (N = 43). Controls (n = 86) matched for age, location, and period of fall event were selected from the hospital’s administrative database. Tools were evaluated independently by 2 screeners using electronic charts. Interrater agreement, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and c-statistics for the screening tools were calculated. Results Case and control groups were similar in age, sex, and race. Interrater agreement was 71% for ABCS and 72% for UPMC screens. ABCS and UPMC screens had sensitivity of 60.5% (95% CI, 52.0%–68.9%) and 62.8% (95% CI, 54.5%–71.1%), specificity of 41.9% (95% CI, 33.4%–50.4%) and 58.1% (95% CI 49.6%–66.7%), and c-statistics of 51.2% and 59.3%, respectively. With a 33% prevalence of injurious fall, the PPV was 34.2%, and NPV was 67.9% for ABCS, and the PPV was 42.9%, and NPV was 75.8% for UPMC. Operating characteristics were not statistically significantly different, although the UPMC screen was 8% more accurate in predicting injurious falls and had a lower false-positive rate (44.2% versus 65.1%). Conclusions Compared with the ABCS screen, the UPMC screen is a simple, practical tool. Prospective studies are needed to establish the UPMC tool’s predictive value in hospital practices with lower rates of injurious falls. In general, better screening tools for injurious falls should be developed to meet quality standards.

Evaluation of Upper Extremity Deep Vein Thrombosis Risk Factors and Management

Background: Upper extremity deep venous thrombosis (UEDVT) incidence and complications are increasing. We evaluated the risk factors and management for patients diagnosed with an UEDVT. Methods: All patients with an UEDVT in 2014 were evaluated for demographics, thrombosis characteristics, risk factors, PADUA risk score, outcomes and management. Results: Ninety UEDVT patients with mean age 57 years, 54.4% maleS, 31% obese (BMI ≥ 30 kg/m2), 26.7% prior VTE, 31.1% readmitted within 30 days. Median length of stay was 14 versus hospital’s 5-7days. 87.8% (n=79) were high risk on admission, 69.6% on anticoagulation when diagnosed. Risk factors: Immobility for 3 days 75 (83.3%), Age 50%) were decreased mobility, younger age, central venous catheters, males. UEDVT management was suboptimal and warrants standardization.