Jerome A. Leis

Reducing Antimicrobial Therapy for Asymptomatic Bacteriuria Among Noncatheterized Inpatients: A Proof-of-Concept Study

This proof-of-concept study demonstrates that no longer routinely reporting urine culture results from noncatheterized medical and surgical inpatients can greatly reduce unnecessary antimicrobial therapy for asymptomatic bacteriuria without significant additional laboratory workload. Larger studies are needed to confirm the generalizability, safety, and sustainability of this model of care.

Explanation and elaboration of the SQUIRE (Standards for Quality Improvement Reporting Excellence) Guidelines, V.2.0: examples of SQUIRE elements in the healthcare improvement literature

Since its publication in 2008, SQUIRE (Standards for Quality Improvement Reporting Excellence) has contributed to the completeness and transparency of reporting of quality improvement work, providing guidance to authors and reviewers of reports on healthcare improvement work. In the interim, enormous growth has occurred in understanding factors that influence the success, and failure, of healthcare improvement efforts. Progress has been particularly strong in three areas: the understanding of the theoretical basis for improvement work; the impact of contextual factors on outcomes; and the development of methodologies for studying improvement work. Consequently, there is now a need to revise the original publication guidelines. To reflect the breadth of knowledge and experience in the field, we solicited input from a wide variety of authors, editors and improvement professionals during the guideline revision process. This Explanation and Elaboration document (E&E) is a companion to the revised SQUIRE guidelines, SQUIRE 2.0. The product of collaboration by an international and interprofessional group of authors, this document provides examples from the published literature, and an explanation of how each reflects the intent of a specific item in SQUIRE. The purpose of the guidelines is to assist authors in writing clearly, precisely and completely about systematic efforts to improve the quality, safety and value of healthcare services. Authors can explore the SQUIRE statement, this E&E and related documents in detail at http://www.squire-statement.org.

Impact of Reported Beta-Lactam Allergy on Inpatient Outcomes: A Multicenter Prospective Cohort Study

BACKGROUND Reported allergy to beta-lactam antibiotics is common and often leads to unnecessary avoidance in patients who could tolerate these antibiotics. We prospectively evaluated the impact of these reported allergies on clinical outcomes. METHODS We conducted a trainee-led prospective cohort study to determine the burden and clinical impact of reported beta-lactam allergy on patients seen by infectious diseases consultation services at 3 academic hospitals. The primary outcome was a composite measure of readmission for the same infection, acute kidney injury, Clostridium difficile infection, or drug-related adverse reactions requiring discontinuation. Predictors of interest were history of beta-lactam allergy and receipt of preferred beta-lactam therapy. RESULTS Among 507 patients, 95 (19%) reported beta-lactam allergy; preferred therapy was a beta-lactam in 72 (76%). When beta-lactam therapy was preferred, 25 (35%) did not receive preferred therapy due to their report of allergy even though 13 (52%) reported non-severe prior reactions. After adjustment for confounders, patients who did not receive preferred beta-lactam therapy were at greater risk of adverse events (adjusted odds ratio [aOR], 3.1; 95% confidence interval [CI], 1.28-7.89) compared with those without reported allergy. In contrast, patients who received preferred beta-lactam therapy had a similar risk of adverse events compared with patients not reporting allergy (aOR, 1.33; 95% CI, .62-2.87). CONCLUSIONS Avoidance of preferred beta-lactam therapy in patients who report allergy is associated with an increased risk of adverse events. Development of inpatient programs aimed at accurately identifying beta-lactam allergies to safely promote beta-lactam administration among these patients is warranted.

Downstream impact of urine cultures ordered without indication at two acute care teaching hospitals.

Antimicrobial therapy for asymptomatic bacteriuria (ASB) is recommended for pregnant patients and those undergoing genitourinary procedures. In other populations, treatment has not been demonstrated to confer benefit and is associated with adverse drug reactions, selection for infection with increasingly drug-resistant bacteria, and Clostridium difficile infection. We undertook a prospective audit of urine culture ordering practices among medical and surgical inpatients at 2 acute care teaching hospitals to identify the proportion of urine cultures ordered without clinical indication that lead to antimicrobial therapy for ASB. During August and September 2012, consecutive urine cultures from nonpregnant ward patients were identified within 24 hours of culture ordering. Each patient was interviewed by the study team to determine the presence of urinary tract infection (UTI) using standard surveillance criteria. Non-catheterized patients met clinical indications for UTI if they had fever (temperature >38°C) without another explanation or at least 1 urinary symptom (dysuria, urgency, frequency, costovertebral angle tenderness, or suprapubic pain or tenderness). Catheterized patients met clinical indications for UTI if they had fever, suprapubic pain, or costovertebral angle tenderness. Other reasons for ordering cultures were documented on the basis of care provider interviews before culture results were known. Culture results and antimicrobial prescriptions were documented 72 hours later. The study was approved by the research ethics boards of Mount Sinai Hospital (472 beds) and University Health Network (408 beds; Toronto General Hospital site).

A primer on PDSA: executing plan–do–study–act cycles in practice, not just in name

Plan-do–study–act (PDSA) cycles are the building blocks of iterative healthcare improvement.1 Although frequently regarded as separate from research,2 this quality improvement method remains rooted in the scientific method. The P in PDSA usually stands for ‘plan’ but could just as easily refer to ‘predict’. Each cycle combines prediction with a test of change (in effect, hypothesis testing), analysis and a conclusion regarding the best step forward—usually a prediction of what to do for the next PDSA cycle.3 Too often, however, improvement teams go through the motions of PDSA cycles without really embracing its spirit or applying its scientific method. For example, an improvement team might talk about having used PDSA when in reality the original change idea remained roughly unchanged throughout the project, with no refinements to the intervention or the plan to implement it. Quality improvement rarely works out so smoothly. Even among published studies, which presumably include better than average projects, the application of PDSA falls short, with less than half of studies meeting minimum characteristics of PDSA.4 Sometimes PDSA seems more like a quality improvement catch phrase than it does a recognisable scientific process. In this paper, we review a recent improvement project5 to draw examples of real-world application of PDSA. This project was not chosen to place it on a pedestal in terms of the improvements achieved but rather to demonstrate PDSA methodology and highlight the benefits of putting it into practice. Urinary catheter overuse contributes to unnecessary patient harms including local trauma, decreased mobility, delirium and infection.6 As in many institutions, the practice at our tertiary care hospital in Toronto had been to leave decisions about insertion and removal of urinary catheters to the discretion of individual physicians without any systematic process to reassess them. Clinicians and infection control …

Medical Directive for Urinary Catheter Removal by Nurses on General Medical Wards

LESS IS MORE Medical Directive for Urinary Catheter Removal by Nurses on General Medical Wards Leaving a urinary catheter (UC) in place without indication has been identified as one of “Five Things Physicians and Patients Should Question” by the Society of Hospital Medicine and the Canadian Society of Internal Medicine.1,2 On a busy general medical (GM) ward, delays in reassessment of UCs can lead to catheter-associated urinary tract infection (CAUTI).3 Interventions aimed at physicians reduce unnecessary UC use,4 but empowering nurses to remove UCs through the use of medical directives remains an underused strategy.5

Aminoglycoside-induced ototoxicity

Aminoglycosides cause toxicity of the vestibular (balance) or cochlear (hearing) systems of the inner ear in up to 10% of patients receiving these drugs intravenously.[1][1] Frequently permanent, toxicity can result in failure to return to work and diminished quality of life. Gentamicin, tobramycin

Do physicians clean their hands? Insights from a covert observational study

Physicians are notorious for poor hand hygiene (HH) compliance. We wondered if lower performance by physicians compared with other health professionals might reflect differences in the Hawthorne effect. We introduced covert HH observers to see if performance differences between physicians and nurses decreased and to gain further insights into physician HH behaviors. Following training and validation with a hospital HH auditor, 2 students covertly measured HH during clinical rotations. Students rotated off clinical services every week to increase exposure to different providers and minimize risk of exposing the covert observation. We compared covertly measured HH compliance with data from overt observation by hospital auditors during the same time period. Covert observation produced much lower HH compliance than recorded by hospital auditors during the same time period: 50.0% (799/1597) versus 83.7% (2769/3309) (P < 0.0002). The difference in physician compliance between hospital auditors and covert observers was 19.0% (73.2% vs 54.2%); for nurses this difference was much higher at 40.7% (85.8% vs 45.1%) (P < 0.0001). Physician trainees showed markedly better compliance when attending staff cleaned their hands compared with encounters when attending did not (79.5% vs 18.9%; P < 0.0002). Our study suggests that traditional HH audits not only overstate HH performance overall, but can lead to inaccurate inferences about performance by professional groupings due to relative differences in the Hawthorne effect. We suggest that future improvement efforts will rely on more accurate HH monitoring systems and strong attending physician leadership to set an example for trainees. Journal of Hospital Medicine 2015;11:862-864.

Elimination of screening urine cultures prior to elective joint arthroplasty

Discontinuing routine processing of screening urine cultures prior to elective joint arthroplasty resulted in substantial reduction in urine cultures ordered and antimicrobial prescriptions for asymptomatic bacteriuria, without any significant impact on incidence of prosthetic joint infection. This simple change would be scalable across institutions with potential for significant healthcare savings.

Antibiotics "Just-In-Case" in a Patient With Aspiration Pneumonitis

Story From the Front Lines A 50-year-old man with cerebral palsy presented to the emergency department with a witnessed generalized tonic-clonic seizure. He had a known seizure disorder that previously had been well controlled with valproate sodium. On transfer, he had multiple seizures, which eventually terminated with intravenous lorazepam in the emergency department. His blood pressure was 70/40 mm Hg, and his Glasgow Coma Scale was 6. He was intubated to protect his airway. A chest radiograph demonstrated extensive airspace opacities at the bases bilaterally, causing concern for aspiration, and he was started on treatment with piperacillin-tazobactam. The following day, he was more alert, his blood pressure improved to 110/70 mm Hg, and he remained afebrile. He required minimal pressure support ventilation. His valproic acid dose was increased, and he completed 7 days of treatment with piperacillintazobactam for the possibility of aspiration pneumonia. He was extubated and transferred to the medical unit in stable condition and ultimately back to his chronic care home 10 days later. A week later, he presented again to the hospital with a 2-day history of lethargy, decreased oral intake, and frequent watery bowel movements. He was tachycardic, hypotensive, and had a serum white blood cell count of 30 400/μL (30.4 × 109/L). A computed tomographic scan of the abdomen revealed pancolitis, and a stool specimen was positive for Clostridium difficile. He was treated with oral vancomycin and intravenous metronidazole for severe C difficile infection. His substitute decision maker, in discussion with the general surgery team, declined a colectomy. Despite medical treatment, he experienced persistent diarrhea and progressive anasarca with hypoalbuminemia level as low as 16 g/L. On day 18 of hospitalization he died of unresolving C difficile colitis.