Noreen H. Chan-Tompkins

Feasibility of integrating a clinical decision support tool into an existing computerized physician order entry system to increase seasonal influenza vaccination in the emergency department

While emergency department (ED) seasonal influenza vaccination programs are feasible, reported implementation barriers include added staffing requirements to identify eligible patients and getting busy ED personnel to order and provide vaccination. We present a prospective, observational trial of integrating a clinical decision support tool into an existing ED computerized physician order entry (CPOE) system to increase ED seasonal influenza vaccination without added staffing resources, the operational barriers identified to program implementation, the revenue generated and data on opportunities for future quality improvement. Compared to the comparable pre-protocol period, ED influenza vaccination rose by 17.5% with a resultant profit margin of 34.5%.

Appropriateness of antibiotic management of uncomplicated skin and soft tissue infections in hospitalized adult patients

BackgroundSkin and soft tissue infections (SSTIs) are a leading cause for hospitalizations in the United States. Few studies have addressed the appropriateness of antibiotic therapy in the management of SSTIs without complicating factors. We aimed to determine the appropriateness of antibiotic treatment duration for hospitalized adult patients with uncomplicated SSTIs.MethodsThis was a retrospective analysis performed at two academic medical centers in Pittsburgh, Pennsylvania on patients aged 18 years and older with primary ICD-9 code for SSTIs admitted August 1st, 2014–March 31st, 2015. The primary outcome was the appropriateness of antibiotic treatment duration for uncomplicated SSTIs. Secondary objectives included the appropriateness of antibiotic agent spectrum, duration of inpatient length of stay (LOS), utilization of blood cultures and advanced imaging modalities, and re-hospitalization for SSTI within 30 days of discharge from the index admission.ResultsA total of 163 episodes were included in the cohort. The mean duration of total antibiotic therapy was 12.6 days. Appropriate duration was defined as receipt of total antibiotic duration of less than 10 days and occurred in 20.2% of patients. Twenty eight percent of patients received antibiotics for greater than 14 days. Seventy three (44.8%) patients received greater than 24 h of inappropriate extended spectrum gram-negative coverage; 65 (39.9%) received anaerobic coverage.ConclusionsIn the majority of patients, treatment duration was excessive. Inappropriate broad spectrum antibiotic selection was utilized with regularity for SSTIs without complicating factors. The management of uncomplicated SSTIs represents a significant opportunity for antimicrobial stewardship.

Fever of unknown origin: a case of cardiac myxoma infected with Staphylococcus lugdunensis.

Infected cardiac myxoma is a rare entity. It poses a diagnostic challenge as clinical presentation may reflect an underlying infectious, immune, or a neoplastic disease process. To the best of our knowledge, the first case of a cardiac myxoma infected with Staphylococcus lugdunensis is reported in a 54-year-old man with fever of unknown origin for 4 months. Successful excision of the tumor was performed and was followed by an uneventful recovery. Clinical presentation, diagnosis, and management of infected cardiac myxomas are discussed.

Perceptions of Participating Emergency Nurses Regarding an ED Seasonal Influenza Vaccination Program

INTRODUCTION Numerous professional organizations have recommended that emergency departments provide influenza vaccine to patients. However, no study has reported on the perceptions of participating emergency nurses regarding ED influenza vaccination programs. METHODS We conducted an anonymous Web-based survey to assess the post-participation perceptions of emergency nurses regarding an ED influenza vaccination protocol. The vaccination protocol occurred at an urban, academic emergency department and was designed to be performed by emergency nurses without added staffing resources by using ED Electronic Medical Record technology. Data from the Web-based survey were analyzed using descriptive statistics and χ(2) analysis to assess significant associations of where emergency nurses believed the protocol was time inefficient. RESULTS The ED influenza vaccination protocol was in effect from October 1-25, 2009, with 3091 eligible ED visits and 613 patients receiving ED seasonal influenza vaccination. Fifty-eight of 59 participating emergency nurses (98%) responded to the survey. Significant findings were that 59% of responding emergency nurses found the protocol too time consuming and believed it was inappropriate in the ED setting. Responding emergency nurses reported that protocol efficiency could be improved by adding staff, simplifying screening and vaccination documentation requirements, and improving vaccine supply and stocking procedures in the emergency department. CONCLUSION A majority of surveyed emergency nurses who had participated in an ED influenza vaccination program reported that the protocol was too time consuming and inappropriate for the ED setting. Surveyed emergency nurses expressed the opinion that such protocols required added staff, simplified patient consent/vaccination documentation requirements, and improved vaccine supply and stocking processes.

Employee thoughts on influenza vaccine: here we go again.

Author(s): Noreen H. Chan‐Tompkins , PharmD; Andrew Sahud , MD; Deborah Pucci , RN, BSN, CCM; Cheryl Herbert , RN, CIC Source: Infection Control and Hospital Epidemiology, Vol. 29, No. 2 (February 2008), pp. 186187 Published by: The University of Chicago Press on behalf of The Society for Healthcare Epidemiology of America Stable URL: http://www.jstor.org/stable/10.1086/524913 . Accessed: 16/05/2014 04:48

Delays in the administration of antimicrobials in the emergency department and the impact of an educational intervention to improve this administration.

Objectives The aim of the study was to assess the factors associated with delays in emergency department (ED) antimicrobial administration and to determine whether an educational intervention would reduce the incidence of such delays. Methods We carried out a retrospective observational cohort study of patients aged 18–89 years who received intravenous antimicrobial(s) in a single ED and were subsequently admitted (March 2011). Using multivariable logistic regression, we analyzed whether demographic and operational factors were significantly associated with delayed ED antimicrobial administration (>30 min from physician order to nurse initiation time). We then conducted an educational intervention with ED/hospital staff to disseminate knowledge of these identified factors. After the intervention, we carried out a prospective observational cohort study of participants with the same inclusion criteria (March 2012), using the large sample z-test to analyze whether the incidence of such delays was significantly reduced. Results A total of 575 ED antimicrobial orders (302 patients) before the intervention and 493 antimicrobial orders (275 patients) after the intervention fulfilled the inclusion criteria. The median time to antimicrobial administration (interquartile) was 48 min (17–130 min) before the intervention and 49 min (17–156 min) after the intervention. Variables significantly increasing or decreasing the odds of delayed ED antimicrobial administration were older age [OR: 1.01, 95% confidence interval (CI) 1.003–1.03], one-time dosing (OR: 0.53, 95% CI 0.31–0.92), and second (OR: 2.40, 95% CI 1.39–4.14), and third (OR: 3.66, 95% CI 1.69–7.92) antimicrobial administration (multiple agents ordered). The incidence of antimicrobial administration was 35.8% within 30 min before the intervention and 34.7% after the intervention (z-test: 0.39, P=0.70). Conclusion Older age, multiple agent orders, and dosing ordering pattern showed a significant association with delays in ED antimicrobial administration. An educational intervention to disseminate knowledge of these factors did not result in a reduction in such delays.

Impact of Procalcitonin Guidance on the Management of Adults Hospitalized with Pneumonia

Abstract Background Community-acquired pneumonia and healthcare-associated pneumonia are often treated with prolonged antibiotic therapy. Procalcitonin (PCT) has effectively and safely reduced antibiotic use for pneumonia in controlled studies. However, limited data exist regarding PCT guidance in real-world settings for management of pneumonia. Methods A retrospective, preintervention/postintervention quality improvement study was conducted to compare management for patients admitted with pneumonia before and after implementation of PCT guidance at two teaching hospitals in Pittsburgh, Pennsylvania. The preintervention period was March 1, 2014 through October 31, 2014, and the post-intervention period was March, 1 2015 through October 31, 2015. Results A total of 152 and 232 patients were included in the preintervention and postintervention cohorts, respectively. When compared with the preintervention group, the mean duration of therapy decreased (9.9 vs. 6.1 days; P < 0.001). More patients received an appropriate duration of 7 days or less (26.9% vs. 66.4%; P < 0.001). Additionally, mean hospital length of stay decreased in the postintervention group (4.9 vs. 3.5 days; P = 0.006). Pneumonia-related 30-day readmission rates (7.2% vs. 4.3%; P = 0.99) were unaffected. In the postintervention group, patients with PCT levels < 0.25 µg/l received shorter mean duration of therapy compared with patients with levels >0.25 µg/l (8.0 vs. 4.6 days; P < 0.001) as well as reduced hospital length of stay (3.9 vs. 3.2 days; P = 0.02). Conclusion In this real-world practice study, PCT guidance led to shorter durations of total antibiotic therapy and abridged inpatient length of stay without affecting hospital re-admissions. Disclosures All authors: No reported disclosures.

Screening for Methicillin-Resistant Staphylococcus aureus: Reliability and Accuracy

To the Editor—We read with great interest the article by Lucet and Regnier in Clinical Infectious Diseases that discussed the controversy regarding screening and decolonization for methicillin-resistant Staphylococcus aureus (MRSA). Whether screening effectively detects a significant proportion of patients colonized with MRSA and whether decolonization is effective for the prevention of infection are matters of debate. We would like to briefly report a study conducted in a 706bed tertiary care hospital, the results of which may add to the current data that exist on screening for MRSA. In our institution, screening for MRSA is performed by culturing samples obtained from the anterior nares alone. Although some have found swab samples of the nares to be of sufficient utility, others assert that cultures of samples obtained from a combination of sites are necessary for adequate levels of detection. To assess the effectiveness of the nares swab as a screening tool, we conducted a retrospective analysis of cultures of nares specimens at our institution and compared the rates of concordance and discordance with the results of concomitantly performed clinical cultures. We searched our Web-based infection prevention database for all nares swab samples tested for patients hospitalized at our institution during the calendar year 2008. Another query was performed to detect all clinical cultures with positive results for MRSA during the same time period. A clinical culture was defined as any culture not originating from a screening test of nares samples. We paired the 2 data sets and proceeded to exclude all patients for whom only nares screening tests or only clinical cultures were performed. Of the remaining data, we included only those patients for whom samples were obtained for both a nares screen and a clinical culture within 48 hours. Concordance was defined as the presence of both a nares screen and a clinical culture result positive for MRSA within 48 hours. Similarly, discordance was defined as a negative nares screen result but a positive clinical culture result for MRSA within 48 hours. A total of 630 events met the inclusion criteria for analysis. Of these, only 206 (32.7%) fulfilled the definition of concordance, whereas 114 (18.1%) fulfilled the definition of discordance. Of 320 clinical cultures with positive results for MRSA, only 206 of the matching nares screen culture results were also positive for MRSA. This yielded a sensitivity of 64.4% for the nares screen. The specificity, negative predictive value, and positive predictive value TABLE i. Concordance and Discordance between Cultures of Nares Samples and Clinical Cultures for Methicillin-Resistant Staphylococcus aureus