Mangla Gulati

An analysis of deep vein thrombosis in 1277 consecutive neurosurgical patients undergoing routine weekly ultrasonography

OBJECT Patients requiring neurosurgical intervention are known to be at increased risk for deep vein thrombosis (DVT) and attendant morbidity and mortality. Pulmonary embolism (PE) is the most catastrophic sequela of DVT and is the direct cause of death in 16% of all in-hospital mortalities. Protocols for DVT screening and early detection, as well as treatment paradigms to prevent PE in the acute postoperative period, are needed in neurosurgery. The authors analyzed the effectiveness of weekly lower-extremity venous duplex ultrasonography (LEVDU) in patients requiring surgical intervention for cranial or spinal pathology for detection of DVT and prevention of PE. METHODS Data obtained in 1277 consecutive patients admitted to a major tertiary care center requiring neurosurgical intervention were retrospectively reviewed. All patients underwent admission (within 1 week of neurosurgical intervention) LEVDU as well as weekly LEVDU surveillance if the initial study was normal. Additional LEVDU was ordered in any patient in whom DVT was suspected on daily clinical physical examination or in patients in whom chest CT angiography confirmed a pulmonary embolus. An electronic database was created and statistical analyses performed. RESULTS The overall incidence of acute DVT was 2.8% (36 patients). Of these cases of DVT, a statistically significant greater number (86%) were discovered on admission (within 1-7 days after admission) screening LEVDU (p < 0.05), whereas fewer were documented 8-14 days after admission (2.8%) or after 14 days (11.2%) postadmission. Additionally, for acute DVT detection in the present population, there were no underlying statistically significant risk factors regarding baseline physical examination, age, ambulatory status, or type of surgery. The overall incidence of acute symptomatic PE was 0.3% and the mortality rate was 0%. CONCLUSIONS Performed within 1 week of admission in patients who will undergo neurosurgical intervention, LEVDU is effective in screening for acute DVT and initiating treatment to prevent PE, thereby decreasing the overall mortality rate. Routine LEVDU beyond this time point may not be needed to detect DVT and prevent PE unless a change in the patients physical examination status is detected.

Hospital delirium treatment: Continuation of antipsychotic therapy from the intensive care unit to discharge

PURPOSE The rate of continuation of antipsychotics for the management of delirium during hospital transitions of care in a tertiary care medical center was investigated. METHODS A retrospective chart review was conducted for adult patients admitted to the medical intensive care unit (MICU) between June 1, 2011, and May 31, 2012, who were initiated on antipsychotic therapy at least 24 hours before transfer out of the MICU. The primary outcome evaluated was the percentage of patients initiated on an antipsychotic in the MICU who were continued on therapy after transfer to a medical ward. Secondary outcomes included the appropriateness of continuing antipsychotic therapy during transitions of care and the percentage of patients continued on an antipsychotic after hospital discharge. RESULTS Of the 87 patients who met the study inclusion criteria, 23 (26%) were continued on antipsychotic therapy after their transfer from the MICU to the medical ward. Of the 23 patients continued on antipsychotic therapy, 9 (39%) were discharged from the hospital with an antipsychotic. Fourteen of the 23 patients were eligible for assessment of inappropriate antipsychotic continuation upon transfer from the MICU. Of these 14 patients, 9 (64%) were inappropriately continued on an antipsychotic. Patients continued on antipsychotic therapy at hospital discharge were more likely to be discharged to a facility (rehabilitation, skilled nursing facility, or healthcare institution) (p = 0.049).Future areas for study should include (1) prospective analysis to understand the clinical decision-making of providers when treating delirium, (2) evaluation of the long-term impact of continuing antipsychotic therapy for delirium, and (3) ways to improve communication of medication regimens during transitions of care. Plans to reduce antipsychotic continuation could involve reassessing patients on the medical wards, improving documentation of the indication for use in the medical record, or developing protocols to taper off antipsychotics before patients are discharged from the hospital. CONCLUSION The continuation of antipsychotics for the management of delirium during transitions of care was a common practice at a tertiary care medical center. Patients receiving antipsychotics for treatment of delirium in the MICU were inappropriately continued on these agents when transferred from the MICU to the medical floor or discharged from the hospital.

Evaluation of Vancomycin Dosing and Monitoring in Adult Medicine Patients

Purpose To assess the clinical impact of a vancomycin dosing protocol and monitoring tool on initial dose, dosing interval, and trough concentrations in adult medicine patients. Methods This was a retrospective chart review of adult medicine patients who received at least one dose of vancomycin and were admitted during the pre-implementation period, February 1 to April 2009, or during the post-implementation period, June 1 to October 31, 2009. All outcomes for patients in the pre-implementation group were compared to those in the post-implementation group. The primary outcomes were frequency of appropriate initial vancomycin dose and dosing interval. The secondary outcomes included frequency of appropriate initial vancomycin trough concentrations, mean number of levels drawn per patient, and mean duration of therapy. Results A total of 450 patients were identified, with 225 patients in each study group. Patients with an appropriate initial vancomycin dose significantly increased in the post-implementation group (56% vs 40%; P < .001). The number of patients with an appropriate original dosing interval (67% vs 63%; P = 0.32), appropriate initial trough concentration (44% vs 45%; P = 0.89), mean number of levels drawn (1.9 vs 2.1; P = 0.56), and duration of therapy (4.9 vs 5.0; P = 0.77) was similar between the 2 groups. Conclusions The implementation of a vancomycin empiric dosing protocol and monitoring tool had a significant impact on the initial dose. Further education regarding vancomycin dosing and monitoring is warranted to improve initial dosing interval, initial trough concentration, number of levels drawn, and duration of therapy.

Routinization of HIV Testing in an Inpatient Setting: A Systematic Process for Organizational Change.

Abstract:In 2006, the U.S. Centers for Disease Control and Prevention released revised recommendations for routinization of HIV testing in healthcare settings. Health professionals have been challenged to incorporate these guidelines. In March 2013, a routine HIV testing initiative was launched at a large urban academic medical center in a high prevalence region. The goal was to routinize HIV testing by achieving a 75% offer and 75% acceptance rate and promoting linkage to care in the inpatient setting. A systematic six-step organizational change process included stakeholder buy-in, identification of an interdisciplinary leadership team, infrastructure development, staff education, implementation, and continuous quality improvement. Success was measured by monitoring the percentage of offered and accepted HIV tests from March to December 2013. The targeted offer rate was exceeded consistently once nurses became part of the consent process (September 2013). Fifteen persons were newly diagnosed with HIV. Seventy-eight persons were identified as previously diagnosed with HIV, but not engaged in care. Through this process, patients who may have remained undiagnosed or out-of-care were identified and linked to care. The authors propose that this process can be replicated in other settings. Increasing identification and treatment will improve the individual patients health and reduce community disease burden.

Impact of an Antipsychotic Discontinuation Bundle During Transitions of Care in Critically Ill Patients

Introduction: Delirium affects a large proportion of patients admitted to the intensive care unit (ICU) and is associated with increased morbidity and mortality. Antipsychotics have become frequently used agents for the treatment of delirium; however, they are often continued at transitions of care. This has potential negative short- and long-term health consequences that are preventable. We investigated the antipsychotic tapering bundle’s impact on the rate of antipsychotic continuation at transitions from the medical intensive care unit (MICU). Methods: This was a preretrospective and postretrospective chart review that included adult patients in the MICU initiated on antipsychotic therapy for ICU delirium. A bundled multidisciplinary education program and antipsychotic discontinuation algorithm were implemented in the MICU to provide recommendations for safe and effective use of antipsychotics for ICU delirium and minimize continuation of therapy at transitions of care. Rates of antipsychotic continuation at transition from the MICU were compared between the preintervention and postintervention groups with the χ2 test. Results: A total of 140 patients in the prebundle group and 141 patients in the postbundle group were enrolled. Overall, baseline characteristics were similar. After implementation of the discontinuation bundle, antipsychotic continuation at MICU discharge decreased (27.9% in the prebundle group vs 17.7% in the postbundle group; P < .05). In the multivariate analysis, patients were less likely to be continued on antipsychotic therapy at MICU discharge after implementation of the bundle (odds ratio [OR]: 0.47; 95% confidence interval [CI]: 0.26-0.86). There were also lower rates of overall antipsychotic continuation at hospital discharge (OR: 0.4; 95% CI: 0.18-0.89). Conclusion: This is the first study to demonstrate a reduction in antipsychotic continuation at transition from the MICU after implementation of an antipsychotic discontinuation bundle in ICU patients. We believe this bundle allows for safer transitions of care from the MICU and decreases unnecessary antipsychotic therapy.

Educating Residents Why Less Is More With Telemetry

tion. For example, Zuckerman et al1 included “special 510(k)s” intheiranalysis,whichbydefinitioncannotcontainperformance data, substantially diminishing the value of the study (refer to premarketnotificationnumbersK073703,K083495,andK113101, accessibleathttp://www.accessdata.fda.gov/scripts/cdrh/cfdocs /cfPMN/pmn.cfm). The value of the study is further eroded by the inclusion of 510(k)s for manufacturing changes based on internal quality control activities and acceptance criteria that are often confidential (refer to premarket notification number K113101 for the Exxcell ePTFE Vacular Graft by Boston Scientific, http://www.accessdata.fda.gov/cdrh_docs/pdf11/K113101 .pdf). A superior way to get insight into the substance of FDA decision making is through requests under the Freedom of Information Act; following such requests, the agency releases all the requested information, other than that which is deemed privileged or confidential. The FDA recently pledged to improve the quality of 510(k) summaries; this effort will have substantial costs. If summaries are not required for all 510(k) submissions, why should the agency spend resources carefully reviewing the summaries that it receives? Creating robust summaries may fend off some criticism but will inevitably detract from the FDA’s ability to engage in more meaningful public health activities.

Evaluating Transitions of Care of Hospitalized Medical Patients to Long-Term Care Facilities A Retrospective Review of Venous Thromboembolism Prophylaxis

Venous thromboembolism (VTE) is a significant but preventable cause of hospital-related morbidity and mortality. Prevention of in-hospital VTE, thus, has become a major quality improvement initiative within hospitals. However, addressing VTE prophylaxis rates and appropriateness on transition to other facilities has not been fully characterized to date. The authors of this study retrospectively evaluated VTE prophylaxis on transfer from medical inpatient settings to long-term care facilities. Analysis indicated that on transfer to other facilities, VTE prophylaxis recommendations were not routinely documented. Interfacility communication is crucial to ensure that appropriate prophylaxis recommendations are addressed during transitions of care. New processes evaluating VTE prophylaxis recommendations at the time of care transfer warrant further study.

Discharges Against Medical Advice: Prevalence, Predictors, and Populations

Discharge against medical advice (DAMA) is when a patient leaves a healthcare institution, typically a hospital where the patient is admitted, before it is deemed medically appropriate. DAMA constitutes approximately 1% of all US hospital discharges; however, the proportion of those leaving against medical advice may be higher in certain populations, and not all DAMA will be avoidable.

Financial and Regulatory Drivers in Health Care

The landscape of medicine in the United States is changing. The traditional concept of volume has shifted to one of improving quality of care with care being provided at the right time in the most cost-effective setting. A hospital stay is no longer an episode of care; rather it is part of the continuum of care for every patient. To help drive this change, many financial and regulatory incentives and penalty programs or “Pay for Performance programs” are being developed and implemented nationally. This chapter will review these changes and highlight how hospitalists are well positioned to help lead the change.

Introduction to Patient Safety and Quality

Healthcare is complicated. It is people working in a complex environment often with limited resources. The environment is complex as it involves the patient, the people, the technology, the policies—the system factors and the latent factors—the place the work occurs and the workload. This chapter will highlight some basic tools and examples of everyday scenarios that face a hospitalist.