Yosef Dlugacz

Using High-Technology to Enforce Low-Technology Safety Measures: The Use of Third-party Remote Video Auditing and Real-time Feedback in Healthcare

BACKGROUND Hand hygiene is a key measure in preventing infections. We evaluated healthcare worker (HCW) hand hygiene with the use of remote video auditing with and without feedback. METHODS The study was conducted in an 17-bed intensive care unit from June 2008 through June 2010. We placed cameras with views of every sink and hand sanitizer dispenser to record hand hygiene of HCWs. Sensors in doorways identified when an individual(s) entered/exited. When video auditors observed a HCW performing hand hygiene upon entering/exiting, they assigned a pass; if not, a fail was assigned. Hand hygiene was measured during a 16-week period of remote video auditing without feedback and a 91-week period with feedback of data. Performance feedback was continuously displayed on electronic boards mounted within the hallways, and summary reports were delivered to supervisors by electronic mail. RESULTS During the 16-week prefeedback period, hand hygiene rates were less than 10% (3933/60 542) and in the 16-week postfeedback period it was 81.6% (59 627/73 080). The increase was maintained through 75 weeks at 87.9% (262 826/298 860). CONCLUSIONS The data suggest that remote video auditing combined with feedback produced a significant and sustained improvement in hand hygiene.

Mechanisms of cerebellar tonsil herniation in patients with Chiari malformations as guide to clinical management

BackgroundThe pathogenesis of Chiari malformations is incompletely understood. We tested the hypothesis that different etiologies have different mechanisms of cerebellar tonsil herniation (CTH), as revealed by posterior cranial fossa (PCF) morphology.MethodsIn 741 patients with Chiari malformation type I (CM-I) and 11 patients with Chiari malformation type II (CM-II), the size of the occipital enchondrium and volume of the PCF (PCFV) were measured on reconstructed 2D-CT and MR images of the skull. Measurements were compared with those in 80 age- and sex-matched healthy control individuals, and the results were correlated with clinical findings.ResultsSignificant reductions of PCF size and volume were present in 388 patients with classical CM-I, 11 patients with CM-II, and five patients with CM-I and craniosynostosis. Occipital bone size and PCFV were normal in 225 patients with CM-I and occipitoatlantoaxial joint instability, 55 patients with CM-I and tethered cord syndrome (TCS), 30 patients with CM-I and intracranial mass lesions, and 28 patients with CM-I and lumboperitoneal shunts. Ten patients had miscellaneous etiologies. The size and area of the foramen magnum were significantly smaller in patients with classical CM-I and CM-I occurring with craniosynostosis and significantly larger in patients with CM-II and CM-I occurring with TCS.ConclusionsImportant clues concerning the pathogenesis of CTH were provided by morphometric measurements of the PCF. When these assessments were correlated with etiological factors, the following causal mechanisms were suggested: (1) cranial constriction; (2) cranial settling; (3) spinal cord tethering; (4) intracranial hypertension; and (5) intraspinal hypotension.

Diagnostic Value of Repeated Enzyme Immunoassays in Clostridium difficile Infection

OBJECTIVES:There has been a significant increase in the prevalence, severity, and mortality of Clostridium difficile infection (CDI), with an estimated three million new cases per year in the United States. Yet diagnosing CDI remains problematic. The most commonly used test is stool enzyme immunoassay (EIA) detecting toxin A and/or B, but there are no clear guidelines specifying the optimal number of tests to be ordered in the diagnostic workup, although multiple tests are frequently ordered. Thus, we designed a study with the primary objective of evaluating the diagnostic utility of repeat second and third tests of stool EIA detecting both toxins A and B (EIA (A&B)) in cases with negative initial samples, and sought to describe the physicians’ patterns of ordering this test in the workup of suspected CDI.METHODS:A retrospective study was carried out using a database of all stool EIA (A&B) tests ordered for a presumptive diagnosis of CDI. All patients were adults admitted to a major teaching hospital over a three-and-a-half-year period (tests completed within 5 days of ordering the first test were grouped into a single episode, and only the first three samples per episode were analyzed). Age, gender, and results of stool EIA were tabulated. In addition, physicians’ ordering patterns and proportion of positive stools relative to the number of tests ordered were also analyzed. A single positive EIA result was interpreted as evidence for the clinical presence of CDI.RESULTS:A total of 3,712 patients contributed to 5,865 separate diarrhea episodes (total stool EIA (A&B)=9,178), and 1,165 (19.9%) of these episodes were positive for CDI. Of the positive patients, 73.2% were over the age of 65 years and 54.2% of them were females. The most frequent ordering pattern for presumptive CDI was a single stool test (60.1%), followed by two more tests (23.2%). Three tests were still ordered in 16.6% of the cases. Of the 1,165 positive cases, 1,046 (89.8%) were diagnosed in the very first test, 95 (8.2%) in the second, and only 24 (2.0%) in the third test. In 1,934 instances, a second test was ordered after an initial negative result, of which 95 (4.91%) became positive. In 793 episodes, a third test was ordered after two negative samples, of which only 24 (3.03%) became positive.CONCLUSIONS:This study highlights the low diagnostic yield of repeat stool EIA (A&B) testing. Findings strongly support the utility of limiting the workup of suspected CDI to a single stool test with only one repeat test in cases of high clinical suspicion, and avoiding the routine ordering of multiple stool samples. As Clostridium difficile is becoming an endemic health-care problem resulting in major financial burdens for the US health-care system, clear guidelines specifying the optimal number of stool EIA (A&B) tests to be ordered in the diagnostic workup of suspected CDI must be established to assist physicians in the practice of evidence-based medicine.

Laboratory Surge Response to Pandemic (H1N1) 2009 Outbreak, New York City Metropolitan Area, USA

Emergency preparedness programs are critical.

2009 H1N1 vaccination by pregnant women during the 2009-10 H1N1 influenza pandemic

OBJECTIVE Pregnant women were identified at greater risk and given priority for 2009 H1N1 vaccination during the 2009 through 2010 H1N1 pandemic. We identified factors associated with acceptance or refusal of 2009 H1N1 vaccination during pregnancy. STUDY DESIGN We conducted an in-person survey of postpartum women on the labor and delivery service from June 17 through Aug. 13, 2010, at 4 New York hospitals. RESULTS Of 1325 survey respondents, 34.2% received 2009 H1N1 vaccination during pregnancy. A provider recommendation was most strongly associated with vaccine acceptance (odds ratio [OR], 19.4; 95% confidence interval [CI], 12.7-31.1). Also more likely to take vaccine were women indicating the vaccine was safe for the fetus (OR, 12.4; 95% CI, 8.3-19.0) and those who previously took seasonal flu vaccination (OR, 7.9; 95% CI, 5.8-10.7). Race, education, income, and age were less important in accepting vaccine. CONCLUSION Greater emphasis on vaccine safety and provider recommendation is needed to increase the number of women vaccinated during pregnancy.

Hand hygiene in long-term care facilities: a multicenter study of knowledge, attitudes, practices, and barriers.

An anonymous survey of 1143 employees in 17 nursing facilities assessed knowledge of, attitudes about, self-perceived compliance with, and barriers to implementing the 2002 Centers for Disease Control and Prevention hand hygiene guidelines. Overall, employees reported positive attitudes toward the guidelines but differed with regard to knowledge, compliance, and perceived barriers. These findings provide guidance for practice improvement programs in long-term care settings.

Expanding a performance improvement initiative in critical care from hospital to system.

BACKGROUND Concern about the expense and effects of intensive care prompted the development and implementation of a hospital-based performance improvement initiative in critical care at North Shore University Hospital, Manhasset, New York, a 730-bed acute care teaching hospital. THE HOSPITAL-BASED PERFORMANCE IMPROVEMENT INITIATIVE IN CRITICAL CARE: The initiative was intended to use a uniform set of measurements and guidelines to improve patient care and resource utilization in the intensive care units (ICUs), to establish and implement best practices (regarding admission and discharge criteria, nursing competency, unplanned extubations, and end-of-life care), and to improve performance in the other hospitals in the North Shore-Long Island Jewish Health System. In the medical ICU, the percentage of low-risk (low-acuity) patients was reduced from 42% to 22%. ICU length of stay was reduced from 4.6 days to 4.1 days. IMPLEMENTING THE CRITICAL CARE PROJECT SYSTEMWIDE A system-level critical care committee was convened in 1996 and charged with replicating the initiative. By and large, system efforts to integrate and implement policies have been successful. The critical care initiative has provided important comparative data and information from which to gauge individual hospital performance. DISCUSSION Changing the critical care delivered on multiple units at multiple hospitals required sensitivity to existing organizational cultures and leadership styles. Merging organizational cultures is most successful when senior leadership set clear expectations that support the need for change. The process of collecting, trending, and communicating quality data has been instrumental in improving care practices and fostering a culture of safety throughout the health care system.

Safety Strategies to Prevent Suicide in Multiple Health Care Environments

BACKGROUND Patient suicide is one of the primary sentinel events reported throughout the United States. North Shore-Long Island Jewish Health System undertook a series of performance improvement efforts to identify suicide risk factors and develop a series of strategies and tools to maximize the safety of all vulnerable patients. METHODOLOGY A multidisciplinary task force conducted root cause analyses of 17 attempted and completed suicides and targeted inadequate patient assessment, poor communication, and knowledge deficits. A protocol was designed to ensure appropriate assessment, monitoring, and treatment of patients at risk for alcohol withdrawal and suicide. Poor communication as patients moved throughout the continuum of care was addressed through targeted education, a centralized intake model, and an inter-institutional transfer summary form. A continuous suicide risk assessment tool was incorporated into the inpatient behavioral health rounds. SUMMARY AND CONCLUSIONS The new tools have raised awareness, improved accountability, and encouraged best practices throughout the health system.

UNDERDIAGNOSIS OF CHRONIC KIDNEY DISEASE IN THE NURSING HOME POPULATION

To the Editor: Chronic kidney disease (CKD) is present in more than 12% of Americans aged 65 and older. In the guidelines from the National Kidney Foundation (NKF) Kidney Disease Outcome Quality Initiative, age 60 and older is indeed considered to be a major risk factor for CKD. Among various complications, CKD appears to independently predict mortality and cardiovascular disease. 5 Readily available formulas for calculating glomerular filtration rates (GFRs), along with a staging system and CKD stage-dependent therapeutic guidelines, have simplified the ability to identify CKD, categorize its severity, and implement appropriate treatment. Nevertheless, several reports suggest that CKD is underdiagnosed and undertreated. The purpose of this study was to explore how frequently physicians of elderly nursing home residents, who have CKD based on NKF criteria, address this diagnosis. After institutional review board approval was obtained, a retrospective chart review was conducted of all long-term residents in a 672-bed facility aged 60 and older who had resided there for at least 6 months and whose records included at least two serum creatinine levels drawn at least 90 days apart from each other. Each subject’s monthly physician progress notes over the previous 6 months were reviewed to determine whether a diagnosis of CKD was recorded. The Modification of Diet in Renal Disease (MDRD) and Cockcroft-Gault (C-G) formulas were used to estimate subjects’ GFRs, with values less than 60 mL/min per 1.73 m of body surface area regarded as positive screening tests for CKD. Serum creatinine values recommended for identification of CKD ( 1.5 mg/dL for men, 1.3 mg/dL for women) were also used as screening criteria for CKD. Two hundred eighty patients met the criteria. Of those with CKD according to MDRD and C-G criteria, a diagnosis of CKD was not noted in 62% and 82%, respectively, of the charts. Of women with CKD according to MDRD and C-G criteria, 70.4% and 87%, respectively, had no notation of CKD in their charts. A diagnosis of CKD was omitted less often in men with CKD (35.3% and 62.9% when identified according to MDRD and C-G, respectively). A diagnosis of CKD was also frequently omitted from charts of patients with CKD based on aforementioned sex-based serum creatinine values as well. Using logistic regression analysis (P 5.02), when controlling for age, sex was found to significantly affect the likelihood of CKD being recognized. Men had only 0.25 odds of underdiagnosis of CKD when compared with women (P 5.049). When sex was controlled for, there was no significant relationship between age groups and underdiagnosis using the MDRD equation (Table 1). Using patients with CKD according to C-G, a similar effect of sex was observed using logistic regression (P 5.01), but when sex was controlled for, patients who were aged 71 to 80 had only a 0.23 odds of underdiagnosis when compared with those aged 90 and older (P 5.02). Delayed recognition and therapy of CKD may predispose patients to adverse outcomes, and these data suggest that CKD may be substantially underdiagnosed in the elderly nursing home population. Although CKD was addressed in only a minority of patients in whom it was evident using GFR estimations, the presence of CKD was documented more frequently when using the creatinine-based parameters described previously. Although there are a number of potential explanations why such a difference was observed, it may simply be that an overtly high serum creatinine level will be more likely to draw the physician’s attention than a relatively ‘‘normal’’ appearing serum creatinine level that nevertheless corresponds with a diminished GFR that has not been calculated. The NKF guidelines not only recommend use of GFR estimation equations, but also expressly declare use of serum creatinine alone not to be optimal in assessment of kidney function. Although GFR calculations and serum creatinine have limitations, these data nevertheless suggest substantial underdiagnosis of CKD, even with serum creatinine levels above 1.4 mg/dL. In summary, despite well-established criteria for the diagnosis of CKD, including simple methods to estimate GFR, CKD appears to be underdetected within the nursing home setting, potentially placing this community at risk for costly, avoidable outcomes. This study underlines the effect of age and sex on misdiagnosis of CKD. Further studies will

Journey to Top Performance: A Multipronged Quality Improvement Approach to Reducing Cardiac Surgery Mortality

BACKGROUND In 2006, leadership at Long Island Jewish Medical Center (New Hyde Park, New York) noted significantly higher cardiac surgery mortality rates for isolated valve and valve/coronary artery bypass graft procedures compared to the New York State Department of Healths Cardiac Surgery Reporting System statewide average. METHODS Long Island Jewish Medical Center, a 583-bed nonprofit, tertiary care teaching hospital, is one of the clinical and academic hubs of North Shore-LIJ Health System. Senior leadership launched an evaluation of the cardiac surgery program to determine why cardiac surgery mortality rates were higher than expected. As a result, the cardiac surgery program was redesigned, and interventions were implemented related to preoperative care, intraoperative monitoring, postoperative care, and the cardiac surgery quality management program. RESULTS According to the most recent New York State Department of Health reporting period (2009-2011), Long Island Jewish Medical Center had the lowest risk-adjusted mortality rate in New York State for adult patients undergoing surgeries to repair or replace heart valves and for adult patients in need of valve/coronary artery bypass graft surgery. The medical center has sustained significantly lower mortality rates compared to the statewide average for the past three cardiac surgery reporting periods. CONCLUSIONS Cardiac surgery mortality rates can be significantly reduced and sustained below comparative norms when the organization is committed to clinical excellence and quality and is involved in continuously assessing organizational performance. The evaluation launched at Long Island Jewish Medical Center led to the redesign of the cardiac surgery program and prompted widespread improvement efforts and cultural change across the entire organization.