Prevalence of Discordant Procalcitonin Use at an Academic Medical Center.

OBJECTIVES: Despite multiple trials demonstrating that procalcitonin (PCT) is an effective tool for antibiotic stewardship, inconsistent application in real-world settings continues to fuel controversy regarding its clinical utility. We sought to determine rates of concordance between PCT results and antibiotic prescribing in hospitalized patients. METHODS: We performed a retrospective review of all inpatient encounters at an academic tertiary care health system with a PCT result between February 2017 and October 2019. Concordant prescribing was defined as starting or continuing antibiotics following an elevated PCT (>0.5 ng/mL) finding and withholding or stopping antibiotics following a low PCT (< 0.1 ng/mL) finding. RESULTS: Antibiotic prescribing decisions were discordant from the PCT level in 32.5% of our sample. Among patients not receiving antibiotics at the time of testing, 25.9% (430 of 1,662) were prescribed antibiotics despite a low PCT result. Among patients already receiving antibiotics, treatment was continued despite a low PCT level in 80.4% (728 of 906) of cases. Enhanced decision support tools introduced during the study period had no impact on PCT use for antibiotic decisions. CONCLUSIONS: Overall concordance between PCT results and antibiotic use is relatively low in a real-world setting. The potential value of PCT for antibiotic stewardship may not be fully realized.

Diagnostic Value of Procalcitonin in Transplant Patients Receiving Immunosuppressant Drugs: A Retrospective Electronic Medical Record-Based Analysis.

OBJECTIVES: To evaluate concentrations of procalcitonin (PCT) in transplant recipients receiving immunosuppressive therapy compared with nonimmunosuppressed patients. METHODS: We analyzed a data set of 9,500 inpatient encounters to compare levels of PCT and other biomarkers of infection (C-reactive protein [CRP], WBC count, and absolute neutrophil count [ANC]) between immunosuppressed and nonimmunosuppressed cohorts. We also assessed the correlation between PCT and clinical variables in immunosuppressed patients. RESULTS: Patients receiving immunosuppressive drugs had significantly higher levels of maximal and minimal PCT compared with the nonimmunosuppressed patients (P < .0001 and P = .0019, respectively). However, CRP levels, WBC count, and ANC were significantly lower in immunosuppressed patients compared with the nonimmunosuppressed patients (P = .0003, P < .0019, and P = .0001, respectively). CONCLUSIONS: Our results from real-world data demonstrated that PCT dynamics remain intact despite immunosuppressive therapy, in contrast to other biomarkers such as CRP, WBC, and ANC. In addition, higher PCT levels are associated with systemic infections and reflect disease severity.

The Effect of Clostridioides difficile Diagnostic Stewardship Interventions on the Diagnosis of Hospital-Onset Clostridioides difficile Infections.

BACKGROUND: Public reporting of Clostridioides difficile infection (CDI) using laboratory-identified events has led some institutions to revert from molecular-based tests to less sensitive testing modalities. At one academic medical center, researchers chose to use nucleic acid amplification test alone in CDI diagnosis with institutional protocols aimed at diagnostic stewardship. METHODS: A single-center, quasi-experimental study was conducted to introduce and analyze the effects of various diagnostic stewardship interventions. In April 2017 an order report was created to inform providers of patients' recent bowel movements, laxative use, and prior Clostridioides difficile (CD) testing (Intervention 1). In November 2017 nursing staff were empowered to not send nondiarrheal stools for testing (Intervention 2). In February 2019, an interruptive alert was implemented to prevent testing that was not indicated (Intervention 3). CD testing rates and healthcare facility-onset CDI (HO-CDI) rates were compared before and after the interventions using one-way analysis of variance (ANOVA). RESULTS: At baseline, testing for CD after 3 days of admission was performed at mean ± standard deviation of 15.9 ± 1.7 tests/1,000 patient-days. After Intervention 1, it decreased to 12.1 ± 1.1 tests. This further decreased to 10.6 ± 0.8 after Intervention 2 and to 8.1 ± 0.1 after Intervention 3 (p < 0.001). HO-CDI cases per 10,000 patient-days declined from 12.7 ± 1.4 cases at baseline to 10.7 ± 1.2 after Intervention 1, to 8.7 ± 2.4 after Intervention 2, and to 5.8 ± 0.2 after Intervention 3 (p = 0.03). CONCLUSION: A multidisciplinary approach optimizing electronic health record support tools and leveraging nursing education can reduce both testing and HO-CDI rates while using the most sensitive testing modality.

The HCAP gap: differences between self-reported practice patterns and published guidelines for health care-associated pneumonia.

BACKGROUND: Health care-associated pneumonia (HCAP) is prevalent among hospitalized patients. In contrast to community-acquired pneumonia (CAP), patients with HCAP are at increased risk for multidrug-resistant organisms, and appropriate initial antibiotic therapy is associated with reduced mortality. METHODS: An online survey was distributed to faculty and housestaff at 4 academic medical centers. The survey required respondents to choose initial antibiotic therapy for 9 hypothetical pneumonia cases (7 cases of HCAP and 2 cases of CAP). Answers were considered correct if the antibiotic regimen chosen was consistent with published guidelines. In addition, physicians rated their knowledge of current guidelines, as well as their level of agreement with guideline recommendations. RESULTS: Surveys were sent to 1313 physicians with a response rate of 65% (n = 855). Respondents included physicians in the following categories: hospital medicine/internal medicine, 60%; emergency medicine, 25%; and critical care, 13%. Respondents selected guideline-concordant antibiotic regimens 78% of the time for CAP, but only 9% of the time for HCAP. Because mean scores for HCAP questions were extremely low (mean, 0.63 correct answers out of 7), differences in performance between groups were too small to be meaningful. Despite their poor performance, 71% of the respondents stated that they are aware of published guidelines for HCAP, and 79% stated that they agree with and practice according to the guidelines. CONCLUSIONS: In this survey, physicians reported they were aware of, agreed with, and practiced according to published pneumonia guidelines; however, the overwhelming majority did not choose guideline-concordant therapy when tested.

The many faces of error disclosure: a common set of elements and a definition.

BACKGROUND: Patients want to know when errors happen in their care. Professional associations, ethicists, and patient safety experts endorse disclosure of medical error to patients. Surveys of physicians show that they believe harmful errors should be disclosed to patients, yet errors are often not disclosed. OBJECTIVE: To understand the discrepancy between patients' expectations and physicians' behavior concerning error disclosure. DESIGN, SETTING, AND PARTICIPANTS: We conducted focus groups to determine what constitutes disclosure of medical error. Twenty focus groups, 4 at each of 5 academic centers, included 204 hospital administrators, physicians, residents, and nurses. APPROACH: Qualitative analysis of the focus group transcripts with attention to examples of error disclosure by clinicians and hospital administrators. RESULTS: Clinicians and administrators considered various forms of communication about errors to be error disclosure. Six elements of disclosure identified from focus group transcripts characterized disclosures ranging from Full disclosure (including admission of a mistake, discussion of the error, and a link from the error to harm) to Partial disclosures, which included deferral, misleading statements, and inadequate information to "connect the dots." Descriptions involving nondisclosure of harmful errors were uncommon. CONCLUSIONS: Error disclosure may mean different things to clinicians than it does to patients. The various forms of communication deemed error disclosure by clinicians may explain the discrepancy between error disclosure beliefs and behaviors. We suggest a definition of error disclosure to inform practical policies and interventions.

Features of successful academic hospitalist programs: Insights from the SCHOLAR (SuCcessful HOspitaLists in academics and research) project.

BACKGROUND: As clinical demands increase, understanding the features that allow academic hospital medicine programs (AHPs) to thrive has become increasingly important. OBJECTIVE: To develop and validate a quantifiable definition of academic success for AHPs. METHODS: A working group of academic hospitalists was formed. The group identified grant funding, academic promotion, and scholarship as key domains reflective of success, and specific metrics and approaches to assess these domains were developed. Self-reported data on funding and promotion were available from a preexisting survey of AHP leaders, including total funding/group, funding/full-time equivalent (FTE), and number of faculty at each academic rank. Scholarship was defined in terms of research abstracts presented over a 2-year period. Lists of top performers in each of the 3 domains were constructed. Programs appearing on at least 1 list (the SCHOLAR cohort [SuCcessful HOspitaLists in Academics and Research]) were examined. We compared grant funding and proportion of promoted faculty within the SCHOLAR cohort to a sample of other AHPs identified in the preexisting survey. RESULTS: Seventeen SCHOLAR programs were identified, with a mean age of 13.2 years (range, 6-18 years) and mean size of 36 faculty (range, 18-95). The mean total grant funding/program was $4 million (range, $0-$15 million), with mean funding/FTE of $364,000 (range, $0-$1.4 million); both were significantly higher than the comparison sample. The majority of SCHOLAR faculty (82%) were junior, a lower percentage than the comparison sample. The mean number of research abstracts presented over 2 years was 10.8 (range, 9-23). DISCUSSION: Our approach effectively identified a subset of successful AHPs. Despite the relative maturity and large size of the programs in the SCHOLAR cohort, they were comprised of relatively few senior faculty members and varied widely in the quantity of funded research and scholarship. Journal of Hospital Medicine 2016;11:708-713. © 2016 Society of Hospital Medicine.

Helping Hospitalized Smokers: A Factorial RCT of Nicotine Patches and Counseling.

INTRODUCTION: Most smokers abstain from smoking during hospitalization but relapse upon discharge. This study tests the effectiveness of two proven treatments (i.e., nicotine patches and telephone counseling) in helping these patients stay quit after discharge from the hospital, and assesses a model of hospital-quitline partnership. STUDY DESIGN: This study had a 2×2 factorial design in which participants were stratified by recruitment site and smoking rate and randomly assigned to usual care, nicotine patches only, counseling only, or patches plus counseling. They were evaluated at 2 and 6 months post-randomization. SETTING/PARTICIPANTS: A total of 1,270 hospitalized adult smokers were recruited from August 2011 to November 2013 from five hospitals within three healthcare systems. INTERVENTION: Participants in the patch condition were provided 8 weeks of nicotine patches at discharge (or were mailed them post-discharge). Quitline staff started proactively calling participants in the counseling condition 3 days post-discharge to provide standard quitline counseling. MAIN OUTCOME MEASURES: The primary outcome measure was self-reported 30-day abstinence at 6 months using an intention-to-treat analysis. Data were analyzed from September 2015 to May 2016. RESULTS: The 30-day abstinence rate at 6 months was 22.8% for the nicotine patch condition and 18.3% for the no-patch condition (p=0.051). Nearly all participants (99%) in the patch condition were provided nicotine patches, although 36% were sent post-discharge. The abstinence rates were 20.0% and 21.1% for counseling and no counseling conditions, respectively (p=0.651). Fewer than half of the participants in the counseling condition (47%) received counseling (mean follow-up sessions, 3.6). CONCLUSIONS: Provision of nicotine patches proved feasible, although their effectiveness in helping discharged patients stay quit was not significant. Telephone counseling was not effective, in large part because of low rates of engagement. Future interventions will need to be more immediate to be effective. TRIAL REGISTRATION: This study is registered at www.clinicaltrials.gov NCT01289275.

Community-acquired pneumonia: defining quality care.

BACKGROUND: Community-acquired pneumonia (CAP) is one of 3 initial conditions for which the Joint Commission for Accreditation of Healthcare Organizations and the Centers for Medicare & Medicaid Services have defined quality measures. Eight "core measures" of pneumonia care have been targeted for reporting by U.S. hospitals to facilitate performance monitoring. METHODS: A review of the literature supporting the core measures was performed. RESULTS: Indicators encouraging influenza vaccination and appropriate antibiotic selection had the most robust evidence. Rapid delivery of antibiotics also showed significant reduction in mortality, though the actual timing (4 versus 8 hours) varied between studies. Other measures, such as performance of blood cultures, pneumococcal vaccination, smoking cessation, and oxygenation assessment, demonstrated less obvious clinical benefit. CONCLUSIONS: There is inherent value in setting standards of care for high-impact conditions such as CAP, but these standards should be chosen on the basis of high-quality research. Public reporting of the current measures is problematic, as it implies they represent best practices for CAP despite relatively weak evidence.