Susan Szpunar

Peripherally inserted central venous catheters in the acute care setting: A safe alternative to high-risk short-term central venous catheters.

BACKGROUND Peripherally inserted central venous catheters (PICCs) serve as an alternative to short-term central venous catheters (CVCs) for providing intravenous (IV) access in the hospital. It is not clear which device has a lower risk of central line-associated bloodstream infection (CLABSI). We compared CVC- and PICC-related CLABSI rates in the setting of an intervention to remove high-risk CVCs. METHODS We prospectively followed patients with CVCs in the non-intensive care units (ICUs) and those with PICCs hospital-wide. A team evaluated the need for the CVC and the risk of infection, recommended the discontinuation of unnecessary or high-risk CVCs, and suggested PICC insertion for patients requiring prolonged access. Data on age, gender, type of catheter, duration of catheter utilization, and the development of CLABSIs were obtained. RESULTS A total of 638 CVCs were placed for 4917 catheter-days, during which 12 patients had a CLABSI, for a rate of 2.4 per 1000 catheter-days. A total of 622 PICCs were placed for 5703 catheter-days, during which 13 patients had a CLABSI, for a rate of 2.3 per 1000 catheter-days. The median time to development of infection was significantly longer in the patients with a PICC (23 vs 13 days; P=.03). CONCLUSION In the presence of active surveillance and intervention to remove unnecessary or high-risk CVCs, CVCs and PICCs had similar rates of CLABSIs. Given their longer time to the development of infection, PICCs may be a safe alternative for prolonged inpatient IV access.

Effect of establishing guidelines on appropriate urinary catheter placement.

OBJECTIVES Avoiding placement of unnecessary urinary catheters (UCs) in the emergency department (ED) affects UC utilization during hospitalization. The authors sought to evaluate the effect of establishing institutional guidelines for appropriate UC placement coupled with emergency physician (EP) education on UC utilization. METHODS Urinary catheter utilization was measured before and after the establishment of guidelines and EP education. Data collected included the presence of a UC on ED arrival, placement of a UC in the ED, documentation of a physician order for UC placement, reasons for placement, and compliance with the guidelines. Chi-square analyses were used to study the association between pre- and postintervention time periods and catheter use. RESULTS A total of 377 (15%) patients had UCs; only 151 (47%) UCs initially placed in the ED had a physician order documented. UC placement was appropriately indicated in 75.5% of patients with a documented physician order, but in only 52% of cases without a documented physician order (p<0.001). The physician intervention was associated with an overall reduction in UC utilization from 16.4% to 13% (p=0.018). Physicians ordered 40% fewer UCs postintervention compared to preintervention. Preintervention, a physician order for UC placement was found indicated in 72.6% patients, compared to 82.2% patients with UC placed postintervention (p=0.21). CONCLUSIONS Establishing guidelines for UC placement and physician education in the ED were associated with a marked reduction in utilization. However, addressing appropriate UC utilization may require evaluating other factors such as nursing influence on utilization.

Effect of race and insurance on outcome of pediatric trauma

OBJECTIVES This study sought to determine if insurance or race status affect trauma outcomes in pediatric trauma patients. METHODS Using the National Trauma Data Bank (NTDB; v6.2), the following variables were extracted: age (0-17 years), payment type (insured, Medicaid/Medicare, or self-pay), race (white, Black/African American, or Hispanic), Injury Severity Score (ISS > 8), type of trauma (blunt or penetrating), and discharge status (alive or dead). Data were analyzed using logistic regression. RESULTS Of the 70,781 patient visits analyzed, 67% were insured, 23% were Medicaid/Medicare, and 10% were self-pay. Self-pay patients had higher mortality (11%, compared to Medicaid/Medicare at 5% and insured at 4%; p < 0.001). African Americans and Hispanics also had higher mortality (7 and 6%) compared to whites (4%; p < 0.001). Self-pay patients more likely suffered penetrating trauma than insured patients (12% vs. 4%; p < 0.001), and mortality for penetrating trauma self-pay patients was 29%, compared to only 11% for penetrating trauma insured patients (p < 0.001). The mortality rate varied from a low of 3% for insured whites, to 18% for self-pay African Americans. Logistic regression (including race, insurance status, injury type, and ISS) revealed that African Americans and Hispanics both had an increased risk of death compared to whites (African American odds ratio [OR] = 1.37, Hispanic OR = 1.20). Medicaid/Medicare patients had a slightly increased risk of death with OR = 1.14, but self-pay patients were almost three times more likely to die (adjusted OR = 2.92). CONCLUSIONS After controlling for ISS and type of injury, mortality disparity exists for uninsured, African American, and Hispanic pediatric trauma patients. Although the reasons for this are unclear, efforts to decrease these disparities are needed.

Relationship Between Carotid Disease on Ultrasound and Coronary Disease on CT Angiography

OBJECTIVES The purpose of this study was to assess the relationship between carotid artery disease by ultrasound and coronary artery disease by coronary computed tomography angiography (CTA) and to identify carotid ultrasound parameters predictive of coronary artery disease. BACKGROUND Carotid ultrasound and CTA are noninvasive modalities used to image atherosclerosis. Studies examining the relationship between the 2 tests, however, are lacking. METHODS We performed carotid ultrasound on predominantly nondiabetic subjects referred for CTA. Carotid intima media thickness (IMT) and plaque were assessed and compared with coronary artery calcification and the number of coronary arteries with any evidence of atherosclerosis on CTA. RESULTS A total of 150 subjects underwent both CTA and carotid ultrasound on the same day. Carotid plaque was present in 71.3% (n = 107), whereas the presence of at least 1 coronary artery with disease on CTA was present in 57.1% (n = 84). Carotid plaque was present in 47.6% (30 of 63) of subjects with a calcium score of 0 and 88.5% (77 of 87) of subjects with a calcium score >0 (p = 0.0001). Similarly carotid plaque was present in 52.4% (33 of 63) of subjects with no CTA evidence of atherosclerosis versus 85.7% (72 of 84) of subjects with any CTA evidence of atherosclerosis (p < 0.0001). Carotid plaque, IMT ≥ 1.5 mm, or averaged mean IMT >0.75 mm were associated with a calcium score >0 (odds ratio: 5.4, p < 0.0001, 2.7, p < 0.001; 2.9, p = 0.011, respectively) and disease in at least 1 vessel on CTA (odds ratio: 2.8, p = 0.03, 2.19, p = 0.073; 2.22, p = 0.058, respectively) independent of age and sex. CONCLUSIONS Carotid plaque and increased carotid IMT are associated with the presence and severity of coronary calcification and disease on CTA in ambulatory subjects.

Urinary catheters in the emergency department: Very elderly women are at high risk for unnecessary utilization

BACKGROUND Many of the urinary catheters (UCs) placed in the emergency department (ED) might not be necessary. We evaluated compliance with our institutional UC utilization guidelines and assessed factors influencing utilization. METHODS We conducted a 12-week retrospective observational study evaluating UC utilization in all admissions from the ED. Data included reason for placement, presence of a physicians order for placement, resident physician involvement, and patient age and sex. RESULTS Out of 4521 patients evaluated, 532 (11.8%) had a UC placed. Of these UCs, 371 (69.7%) were indicated, and 312 (58.6%) had a physicians order documented. The mean age of the patients who had a UC placed without an indication was 71.3 ± 18.8 years, that of patients with an indication was 60.0 ± 22.4 years (P < .0001), and that of patients who did not have a UC placed was 56.2 ± 22.6 years (P < .0001). Half of the women aged ≥80 years who had a UC placed did not have an indication according to our institutional guidelines. Multivariate logistic regression showed that women were 1.9 times more likely than men, and those age ≥80 years were 2.9 times more likely than those age ≤50 years, to have a UC placed without an indication. CONCLUSION Very elderly women are at high risk for inappropriate UC utilization in the ED. Interventions are needed to address this vulnerable population.

The effect of resident peer-to-peer education on compliance with urinary catheter placement indications in the emergency department.

Objective This study aims to evaluate the effect of resident peer-to-peer education on knowledge of appropriate urinary catheter (UC) placement in the emergency department (ED) and to determine if this translates into further reduction in UC utilisation. Background Instituting guidelines for appropriate UC placement reduces UC utilisation in the ED. No study has explored if resident education in a teaching hospital would further reduce UC utilisation. Methods An educational intervention implemented in February 2009 consisted of a lecture, distribution of pocket cards and a peer-administered weekly review of institutional UC guidelines. A 12-question multiple-choice test was given to residents prelecture and postlecture, and the 12-question test was repeated 3 months later. Retrospective chart review was performed to evaluate UC utilisation before, immediately after and 3 months after the educational intervention. Results 30 residents completed all three tests. Significant differences were found between the mean test score pre-education and the mean test score immediately after education (9.43±1.17 vs 10.87±1.46, p<0.001) and between the mean test score pre-education and the mean test score 3 months posteducation (9.43±1.17 vs 10.43±1.28, p<0.001). There was no significant difference in UC utilisation or in the proportion of indicated UCs placed by residents within the three study periods. Conclusions Resident peer-to-peer education was associated with improvement of knowledge but did not result in decreased UC utilisation. A more active approach must be taken and other factors need to be further explored to reduce unnecessary placement of UC by residents in the ED.

Validating Severity of Illness Scoring Systems in the Prediction of Outcomes in Staphylococcus aureus Bacteremia

Background:Severity of illness scores are helpful in predicting mortality; however, no standardized scoring system has been validated in patients with Staphylococcus aureus bacteremia (SAB). The modified Rapid Emergency Medicine Score (REMS), the CURB-65 (confusion, urea, respiratory rate, blood pressure and age 65) and the Charlson weighted index of comorbidity (CWIC) were compared in predicting outcomes at the onset of SAB. Methods:All adult inpatients with SAB from July 15, 2008, to December 31, 2009, were prospectively assessed. The 3 scoring systems were applied: REMS, CURB-65 and CWIC. The end points were attributable and overall mortality. Results:A total of 241 patients with SAB were reviewed during the study period. The all-cause mortality rate was 22.8% and attributable mortality 14.1%. Patients who died had higher mean CURB-65 score and REMS than those who lived, whereas the difference in the CWIC score was not significant. Two logistic regression models based on CURB-65 score or REMS, after controlling for CWIC, revealed that both scores were independent predictors of mortality, with an odds ratio of 3.38 (P < 0.0001) and 1.45 (P < 0.0001) for CURB-65 and REMS, respectively. Receiver operating characteristic analysis revealed that a cutoff point of 3.0 (CURB-65) and 6.0 (REMS) provided the highest sensitivity and specificity. The area under the curves for all-cause mortality were 0.832 and 0.806, and for attributable mortality 0.845 and 0.819, for CURB-65 and REMS, respectively. Conclusions:REMS and CURB-65 scores outperformed CWIC as predictors of mortality in SAB and may be effective in predicting the severity of illness at the onset of bacteremia.

Routine HIV testing in primary care clinics: a study evaluating patient and provider acceptance.

Sharon E. Valenti, MSN, ACNP, BC, CNP, AACRN, is an HIV Research Coordinator, Department of Internal Medicine, Division of Infectious Diseases, St. John Hospital & Medical Center, Detroit, Michigan. Susan M. Szpunar, PhD, is a Senior Medical Researcher, Department of Medical Education, St. John Hospital & Medical Center, Detroit, Michigan. Louis D. Saravolatz, MD, is a Department Chair, Department of Internal Medicine, Division of Infectious Diseases, St. John Hospital & Medical Center and Wayne State School of Medicine, Detroit, Michigan. Leonard B. Johnson, MD, is a Vice Chair, Department of Internal Medicine, Program Director, Division of Infectious Diseases, St. John Hospital & Medical Center and Wayne State School of Medicine, Detroit, Michigan, USA.

Decreasing troponin turnaround time in the emergency department using the central laboratory: A process improvement study.

OBJECTIVES To implement collaborative process improvement measures to reduce emergency department (ED) troponin turnaround time (TAT) to less than 60min using central laboratory. DESIGN AND METHODS This was an observational, retrospective data study. A multidisciplinary team from the ED and laboratory identified opportunities and developed a new workflow model. Process changes were implemented in ED patient triage, staffing, lab collection and processing. Data collected included TAT of door-to-order, order-to-collect, collect-to-received, received-to-result, door-to-result, ED length of stay, and hemolysis rate before (January-August, 2011) and after (September 2011-June 2013) process improvement. RESULTS After process improvement and implementation of the new workflow model, decreased median TAT (in min) was seen in door-to-order (54 [IQR43] vs. 11 [IQR20]), order-to-collect (15 [IQR 23] vs. 10 [IQR12]), collect-to-received (6 [IQR8] vs. 5 [IQR5]), received-to-result (30 [IQR12] vs. 24 [IQR11]), and overall door-to-result (117 [IQR60] vs. 60 [IQR40]). A troponin TAT of <60min was realized beginning in May 2012 (59 [IQR39]). Hemolysis rates decreased (14.63±0.74 vs. 3.36±1.99, p<0.0001), as did ED length of stay (5.87±2.73h vs. 5.15±2.34h, p<0.0001). Conclusion Troponin TAT of <60min using a central laboratory was achieved with collaboration between the ED and the laboratory; additional findings include a decreased ED length of stay.

Use of portable electronic devices in a hospital setting and their potential for bacterial colonization

Portable electronic devices are increasingly being used in the hospital setting. As with other fomites, these devices represent a potential reservoir for the transmission of pathogens. We conducted a convenience sampling of devices in 2 large medical centers to identify bacterial colonization rates and potential risk factors.