Clinical Pharmacist Transition of Care Model Improves Hospital System Practice by Reducing Readmissions.

PURPOSE: A primary cause of hospital readmission is medication-related problems (MRPs). Polypharmacy patients taking multiple medications concurrently experience an increased likelihood of MRPs and high occurrence of readmissions to the hospital within 30 days. This study assessed the ability of a pharmacist-led transition of care program to decrease readmissions in polypharmacy patients by evaluating and rectifying MRPs. METHODS: Over 16 months, patients admitted onto the medicine ward service with ≥10 home medications ( n = 536) received medication management interventions from a clinical pharmacist including admission interview, medication reconciliation and consultation, and postdischarge phone follow-up. Admitted patients taking fewer than 10 home medications during the same time served as the control group and received routine standard of care ( n = 2317). RESULTS: The polypharmacy group who received the pharmacist-led intervention had a statistically significantly lower 30-day readmission rate (8.8%) compared with patients in the control group (12.4%; X 2 = 5.63, p = .01). Patients receiving pharmacist intervention were 33% less likely to be readmitted within 30 days of discharge compared with the control group (odds ratio = 0.67, 95% CI = 0.49-0.94). All patients had at least one medication-related discrepancy. CONCLUSION: This pharmacy-led transition of care program can effectively reduce readmission rates through resolution of medication-related problems.

Real-World Application of Oral Therapy for Infective Endocarditis: A Multicenter, Retrospective, Cohort Study.

BACKGROUND: We sought to compare the outcomes of patients treated with intravenous (IV)-only vs oral transitional antimicrobial therapy for infective endocarditis (IE) after implementing a new expected practice within the Los Angeles County Department of Health Services (LAC DHS). METHODS: We conducted a multicentered, retrospective cohort study of adults with definite or possible IE treated with IV-only vs oral therapy at the 3 acute care public hospitals in the LAC DHS system between December 2018 and June 2022. The primary outcome was clinical success at 90 days, defined as being alive and without recurrence of bacteremia or treatment-emergent infectious complications. RESULTS: We identified 257 patients with IE treated with IV-only (n = 211) or oral transitional (n = 46) therapy who met study inclusion criteria. Study arms were similar for many demographics; however, the IV cohort was older, had more aortic valve involvement, were hemodialysis patients, and had central venous catheters present. In contrast, the oral cohort had a higher percentage of IE caused by methicillin-resistant Staphylococcus aureus. There was no significant difference between the groups in clinical success at 90 days or last follow-up. There was no difference in recurrence of bacteremia or readmission rates. However, patients treated with oral therapy had significantly fewer adverse events. Multivariable regression adjustments did not find significant associations between any selected variables and clinical success across treatment groups. CONCLUSIONS: These results demonstrate similar outcomes of real-world use of oral vs IV-only therapy for IE, in accord with prior randomized, controlled trials and meta-analyses.

Assessing the Effectiveness Between Nurse Educator and Clinical Coach Critical Care Training Programs for New Graduate Nurses in the ICU.

OBJECTIVE: The aim of this study was to assess the differences in effectiveness between nurse educator-led and clinical coach-led intensive care unit (ICU) training programs for new graduate nurses. BACKGROUND: New graduate ICU nurses require substantial clinical training, which is often provided by peers serving as clinical coaches who have not been formally trained for an educator role. Our medical center successfully transitioned from a nurse educator-led to clinical coach-led model for initial ICU education after formally training the clinical coaches. METHODS: Nurses enrolled in nurse educator-led (n = 114) or clinical coach-led (n = 166) ICU clinical training programs were compared on program pass rate, satisfaction, preparedness, turnover, and competence. RESULTS: There were no statistically significant differences between the groups on any of the identified measures of program effectiveness. CONCLUSIONS: Both educator-led and clinical coach-led models, with appropriate training, effectively prepared ICU nurses in this setting. Implementing a clinical coaching model for ICU training of new graduate nurses could assuage common resource issues, such as a shortage of nurse educators, as well as address the increasing demand for well-trained ICU nurses.

Fosfomycin vs Ertapenem for Outpatient Treatment of Complicated Urinary Tract Infections: A Multicenter, Retrospective Cohort Study.

BACKGROUND: We sought to determine the comparative efficacy of fosfomycin vs ertapenem for outpatient treatment of complicated urinary tract infections (cUTIs). METHODS: We conducted a multicenter, retrospective cohort study involving patients with cUTI treated with outpatient oral fosfomycin vs intravenous ertapenem at 3 public hospitals in Los Angeles County between January 2018 and September 2020. The primary outcome was resolution of clinical symptoms 30 days after diagnosis. RESULTS: We identified 322 patients with cUTI treated with fosfomycin (n = 110) or ertapenem (n = 212) meeting study criteria. The study arms had similar demographics, although patients treated with ertapenem more frequently had pyelonephritis or bacteremia while fosfomycin-treated patients had more retained catheters, nephrolithiasis, or urinary obstruction. Most infections were due to extended-spectrum ß-lactamase-producing E. coli and Klebsiella pneumoniae, 80%-90% of which were resistant to other oral options. Adjusted odds ratios for clinical success at 30 days, clinical success at last follow-up, and relapse were 1.21 (95% CI, 0.68-2.16), 0.84 (95% CI, 0.46-1.52), and 0.94 (95% CI, 0.52-1.70) for fosfomycin vs ertapenem, respectively. Patients treated with fosfomycin had significant reductions in length of hospital stay and length of antimicrobial therapy and fewer adverse events (1 vs 10). Fosfomycin outcomes were similar irrespective of duration of lead-in intravenous (IV) therapy or fosfomycin dosing interval (daily, every other day, every third day). CONCLUSIONS: These results would support the conduct of a randomized controlled trial to verify efficacy. In the meantime, they suggest that fosfomycin may be a reasonable stepdown from IV antibiotics for cUTI.

Mortality and Readmission Rates Among Patients With COVID-19 After Discharge From Acute Care Setting With Supplemental Oxygen.

Importance: To optimize patient outcomes and preserve critical acute care access during the COVID-19 pandemic, the Los Angeles County Department of Health Services developed the SAFE @ HOME O2 Expected Practice (expected practice), enabling ambulatory oxygen management for COVID-19. Objective: To assess outcomes of patients with COVID-19 pneumonia discharged via the expected practice approach to home or quarantine housing with supplemental home oxygen. Design, Setting, and Participants: This retrospective cohort study included 621 adult patients with COVID-19 pneumonia who were discharged from 2 large urban public hospitals caring primarily for patients receiving Medicaid from March 20 to August 19, 2020. Patients were included in the analysis cohort if they received emergency or inpatient care for COVID-19 and were discharged with home oxygen. Interventions: Patients receiving at least 3 L per minute of oxygen, stable without other indication for inpatient care, were discharged from either emergency or inpatient encounters with home oxygen equipment, educational resources, and nursing telephone follow-up within 12 to 18 hours of discharge. Nurses provided continued telephone follow up as indicated, always with physician back-up. Main Outcomes and Measures: All-cause mortality and all-cause 30-day return admission. Results: A total of 621 patients with COVID-19 pneumonia (404 male [65.1%] and 217 female [34.9%]) were discharged with home oxygen. Median age of these patients was 51 years (interquartile range, 45-61 years), with 149 (24.0%) discharged from the emergency department and 472 (76%) discharged from inpatient encounters. The all-cause mortality rate was 1.3% (95% CI, 0.6%-2.5%) and the 30-day return hospital admission rate was 8.5% (95% CI, 6.2%-10.7%) with a median follow-up time of 26 days (interquartile range, 15-55 days). No deaths occurred in the ambulatory setting. Conclusions and Relevance: In this cohort study, patients with COVID-19 pneumonia discharged on home oxygen had low rates of mortality and return admission within 30 days of discharge. Ambulatory management of COVID-19 with home oxygen has an acceptable safety profile, and the expected practice approach may help optimize outcomes, by ensuring right care in the right place at the right time and preserving access to acute care during the COVID-19 pandemic.

Zero Staff Assaults in the Psychiatric Emergency Room: Impact of a Multifaceted Performance Improvement Project.

INTRODUCTION: Our psychiatric emergency room (ER) averages 18 patient-to-staff physical assaults annually, with some incidents resulting in multiple injuries. AIMS: The purpose of this performance improvement project was to develop, implement, and evaluate a multifaceted approach to reducing the number of physical assaults on staff. METHODS: We assessed the impact of these bundled interventions on staff assault rate: (1) increasing behavioral response team drills, (2) implementing shift doses, (3) screening for patients' risk for violence, (4) posting signage to communicate patients' violence propensity (Golden Hand), (5) implementing mitigating countermeasure interventions, (6) conducting postassault debriefing, and (7) providing postassault support. Psychiatric ER nurses completed questionnaires measuring their perceived self-efficacy in managing patients with a propensity for violence before, during, and after the bundled interventions. Physical assaults on staff were recorded and tracked monthly from May 2016 to September 2018 through a retrospective review of the hospital's online incident report system. RESULTS: Staff perceived self-efficacy increased from 78% to 95% after attending at least two behavioral response team drills. The Golden Hand signage was rated useful as it flagged and communicated the presence of high-risk patients. Shift dose was evaluated as an informative tool and manageable at ≤5 minutes. The violence-screening tool was considered more accurate in identifying patients with violent tendencies than standard assaultive precautions. Physical assaults on staff by patients decreased to zero in our psychiatric ER, which was sustained for a year. CONCLUSIONS: This innovative, multifaceted, bundled approach provides an opportunity for nurse leaders to promote workplace safety while improving staff engagement and empowerment.

Evaluation of the efficacy of commercial and noncommercial tourniquets for extremity hemorrhage control in a perfused cadaver model.

BACKGROUND: Tourniquets are a critical tool in the immediate response to life-threatening extremity hemorrhage; however, the optimal tourniquet type and effectiveness of noncommercial devices remain unclear. Our aim was to evaluate the efficacy of five tourniquets in a perfused-cadaver model. METHODS: This prospective study used a perfused-cadaver model with standardized superficial femoral artery injury bleeding at 700 mL/min. Five tourniquets were tested: combat application tourniquet; rapid application tourniquet system; Stretch, Wrap, And Tuck Tourniquet; an improvised triangle bandage windlass; and a leather belt. Forty-eight medical students underwent a practical hands-on demonstration of each tourniquet. Using a random number generator, they placed the tourniquets on the bleeding cadaver in random order. Time to hemostasis, time to secure devices, estimated blood loss, and difficulty rating were assessed. A one-way repeated measures analysis of variance was used to compare efficacy between the tourniquets in achieving the outcomes. RESULTS: The mean ± SD participant age was 25 ± 2.6 years, and 29 (60%) were male. All but one tourniquet was able to stop bleeding, but the rapid application tourniquet system had a 4% failure rate. Time to hemostasis and estimated blood loss did not differ significantly (p > 0.05). Stretch, Wrap, And Tuck Tourniquet required the longest time to be secured (47.8 ± 17.0 seconds), whereas the belt was the fastest (15.2 ± 6.5 seconds; p < 0.001). The improvised windlass was rated easiest to learn and apply, with 22 participants (46%) assigning a score of 1. CONCLUSION: Four of five tourniquets evaluated, including both noncommercial devices, effectively achieved hemostasis. A standard leather belt was the fastest to place and was able to stop the bleeding. However, it required continuous pressure to maintain hemostasis. The improvised windlass was as effective as the commercial devices and was the easiest to apply. In an emergency setting where commercial devices are not available, improvised tourniquets may be an effective bridge to definitive care.

Reducing Catheter-associated Urinary Tract Infections via Cost-saving Diagnostic Stewardship.

We conducted a quality improvement project at our large, public, tertiary-care, academic hospital to reduce the standardized infection ratio (SIR) of hospital-acquired catheter-associated urinary tract infections (CAUTIs). Our diagnostic stewardship program, based on education and audit and feedback, significantly reduced inpatient urine culture orders and CAUTI SIR.

The Discharge Lounge: A Patient Flow Process Solution.

BACKGROUND: Patient flow, from emergency department admission through to discharge, influences hospital overcrowding. We aimed to improve patient flow by increasing discharge lounge (DL) usage. LOCAL PROBLEM: Patients need to receive a continuum of nursing care to encourage compliance with follow-up care after discharge from the acute care setting. METHODS: Baseline data revealed inefficient use of the DL. We targeted the medical-surgical unit with the lowest DL use and trialed interventions over sequential Plan-Do-Study-Act cycles. INTERVENTIONS: After surveying the nursing staff, we assessed the influence of 3 interventions on DL usage: educating staff on patient eligibility, engaging a recruitment scout, and displaying a visual cue notifying staff when a patient's discharge order was written. RESULTS: The unit's average DL use increased from 18% to 36%, while hospital overcrowding and discharge turnaround time decreased. CONCLUSION: The DL is an effective tool to improve patient flow and decrease hospital overcrowding.

Buprenorphine/naloxone and methadone maintenance treatment outcomes for opioid analgesic, heroin, and combined users: findings from starting treatment with agonist replacement therapies (START).

OBJECTIVE: The objective of this secondary analysis was to explore differences in baseline clinical characteristics and opioid replacement therapy treatment outcomes by type (heroin, opioid analgesic [OA], or combined [heroin and OA]) and route (injector or non-injector) of opioid use. METHOD: A total of 1,269 participants (32.2% female) were randomized to receive one of two study medications (methadone or buprenorphine/naloxone [BUP]). Of these, 731 participants completed the 24-week active medication phase. Treatment outcomes were opioid use during the final 30 days of treatment (among treatment completers) and treatment attrition. RESULTS: Non-opioid substance dependence diagnoses and injecting differentiated heroin and combined users from OA users. Non-opioid substance dependence diagnoses and greater heroin use differentiated injectors from non-injectors. Further, injectors were more likely to be using at end of treatment compared with non-injectors. OA users were more likely to complete treatment compared with heroin users and combined users. Non-injectors were more likely than injectors to complete treatment. There were no interactions between type of opioid used or injection status and treatment assignment (methadone or BUP) on either opioid use or treatment attrition. CONCLUSIONS: Findings indicate that substance use severity differentiates heroin users from OA users and injectors from non-injectors. Irrespective of medication, heroin use and injecting are associated with treatment attrition and opioid misuse during treatment. These results have particular clinical interest, as there is no evidence of superiority of BUP over methadone for treating OA users versus heroin users.

Predictors of outcome after short-term stabilization with buprenorphine.

Using buprenorphine as a medication to treat opioid dependence is becoming more prevalent as illicit opiate use increases. Identifying the characteristics of opiate dependent individuals best suited to benefit from buprenorphine would improve guidelines for its administration. This study evaluates baseline and treatment participation variables for predicting positive response to short-term stabilization with buprenorphine. Data include demographic, drug use, and other variables collected from participants undergoing stabilization over a 4-week period before being tapered off buprenorphine in a short-term detoxification process. Outcome variables include opioid use and retention. Logistic regression results indicate several characteristics associated with opioid use at the end of the stabilization period. These include being older, having no criminal history, and less opiate use. Criminal activity and opioid use in the last 30 days were significantly associated with shorter treatment stays. The benefits of identifying individual characteristics that may predict treatment response are discussed.

Hyperalgesia in heroin dependent patients and the effects of opioid substitution therapy.

UNLABELLED: Evidence suggests that patients on opiate maintenance therapy for the treatment of addiction present with opioid-induced hyperalgesia. This study compared the experimental (cold-pressor, electrical stimulation) pain responses of 82 treatment-seeking heroin-dependent adults, randomized to methadone (METH, n = 11) or buprenorphine (BUP, n = 64) therapy, with matched drug free controls (n = 21). Heroin-dependent participants were evaluated at baseline (treatment entry), medication (METH or BUP) stabilization (4-8 weeks), and chronic administration (12-18 weeks), at trough (just prior to dosing) and peak (3 hours after dosing) plasma levels. Collection of the control group's pain responses occurred twice during a single session, 3 hours apart. Baseline comparisons indicate that heroin-dependent individuals demonstrate significantly shorter latencies to threshold and tolerance for cold-pressor pain than the control group. Across pain stimuli and time points, little change in pain responses was found over time, the exception being cold pressor pain tolerance, for which hyperalgesia significantly increased at trough METH/BUP levels in both groups as they stabilized in treatment. We conclude that heroin-dependent individuals are hyperalgesic, and that once stabilized in treatment, are not different in pain responses regardless of treatment agent. The effects of nonpharmacologic therapy and previous heroin use may explain increased hyperalgesia found with treatment. PERSPECTIVE: To better understand the clinical phenomenon of opioid-induced hyperalgesia, this article describes experimental pain responses of heroin-dependent participants both prior to and over the course of maintenance therapy with methadone or buprenorphine. Hyperalgesia is present with illicit and treatment opioid use, and does not appear to appreciably improve over the course of treatment.

Acute cigarette smoking reduces latencies on a Smoking Stroop test.

RATIONALE: Sensitivity to addiction-related cues, a type of attentional bias, may interfere with executive functions that are important in sustaining abstinence from drug abuse. Assessments of attentional bias in research participants who smoke cigarettes have used Smoking Stroop tasks, which are variations of emotional Stroop tasks in which the stimuli are smoking-related and neutral words. OBJECTIVES: We aimed to determine the effect of resumption of smoking by deprived cigarette smokers on attentional bias. METHODS: Testing occurred twice on each of two test days. One test day began after overnight abstinence (13-16h) and the other after <1h of abstinence. The participants (n=51) smoked a cigarette between the two test sessions on each test day. RESULTS: Smokers exhibited attentional bias for smoking-related words and had longer response times after overnight abstinence than after brief abstinence. Cigarette smoking between sessions reduced response times on both test days with no interaction by stimulus type. CONCLUSIONS: Smoking-related cues have distracting effects in smokers, and smoking reduces response latency, with no specific effect on attentional bias. The increase in response speed may contribute to a smoker's impression that abstinence hinders performance and that smoking reverses impairment.

Participant characteristics and buprenorphine dose.

BACKGROUND: Clinical parameters for determining buprenorphine dose have not been adequately examined in treatment outcome research. OBJECTIVES: This study is a secondary analysis of data collected in a recently completed comparison of buprenorphine taper schedules conducted as part of the National Institute on Drug Abuse's Clinical Trials Network to assess whether participant baseline characteristics are associated with buprenorphine dose. METHODS: After 3 weeks of flexible dosing, 516 participants were categorized by dose provided in the final dosing week (9.3% received a final week dose of 8 mg buprenorphine, 27.3% received 16 mg, and 63.4% received 24 mg). RESULTS: Findings show that final week dose groups differed in baseline demographic and drug use characteristics including education, heroin use, route of drug administration, withdrawal symptoms, and craving. These groups also differed in opioid use during the four dosing weeks, with the lowest use in the 8 mg group and highest use in the 24 mg group (p < .0001). Additional analyses address withdrawal symptoms and craving. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: Final week dose groups differed in demographic and drug use characteristics, and the group receiving the largest final week dose had the highest rate of continued opioid use. These findings may contribute to the development of clinical guidelines regarding buprenorphine dose in the treatment of opioid dependence; however, further investigations that include random assignment to dose by baseline characteristics are needed.