An Electronic Health Record-integrated Web Application Augments a QI-directed Morbidity & Mortality Conference and Improves Quality of Care.

BACKGROUND: In 2014, we developed a QI-directed Morbidity and Mortality (M&M) Conference, prioritizing discussion of individual and system failures, as well as development of action items to prevent failure recurrence. However, due to a reliance on individual electronic documents to store M&M data, our ability to assess trends in failures and action item implementation was hindered. To address this issue, in 2019, we created a secure electronic health record (EHR)-integrated web application (web app) to store M&M data. STUDY DESIGN: In this study, we assessed the impact of our web app on efficient review and tracking of M&M data, including system failure occurrence and closure of action items. Additionally, in 2021, it was discovered that a backlog of action items existed. To address this issue, we implemented a QI initiative to reduce the backlog, and used the web app to compare action item closure over time. RESULTS: Use of the web app dramatically improved review of M&M data. During the study period, there was a 67.0% reduction in the occurrence of the most common system failures. Additionally, our QI initiative resulted in a 97.7% reduction in the duration of time to complete a single action item and a 61.1% increase in the on-time closure rate for action items. CONCLUSIONS: Integration of a web app into a QI-directed M&M Conference enhanced our ability to track system level failures and action item closure over time. Using this web app, we demonstrated that our M&M Conference achieved its intended goal of improving the quality of patient care. LEVEL OF EVIDENCE: IV.

Superior performance of biofilm versus planktonic Limosilactobacillus reuteri in protection of the intestines and brain in a piglet model of necrotizing enterocolitis.

Necrotizing enterocolitis (NEC) is the leading cause of gastrointestinal-related death in premature infants. Its etiology is multifactorial, with intestinal dysbiosis playing a major role. Probiotics are a logical preventative therapy for NEC, however their benefits have been inconsistent. We previously developed a novel probiotic delivery system in which planktonic (free-living) Limosilactobacillus reuteri (Lr) is incubated with biocompatible dextranomer microspheres (DM) loaded with maltose (Lr-DM-maltose) to induce biofilm formation. Here we have investigated the effects of Lr-DM-maltose in an enteral feed-only piglet model of NEC. We found a significant decrease in the incidence of Definitive NEC (D-NEC), death associated with D-NEC, and activated microglia in the brains of piglets treated with Lr-DM-maltose compared to non-treated piglets. Microbiome analyses using 16S rRNA sequencing of colonic contents revealed a significantly different microbial community composition between piglets treated with Lr-DM-maltose compared to non-treated piglets, with an increase in Lactobacillaceae and a decrease in Clostridiaceae in Lr-DM-maltose-treated piglets. Furthermore, there was a significant decrease in the incidence of D-NEC between piglets treated with Lr-DM-maltose compared to planktonic Lr. These findings validate our previous results in rodents, and support future clinical trials of Lr in its biofilm state for the prevention of NEC in premature neonates.

Probiotics and novel probiotic delivery systems.

Necrotizing enterocolitis (NEC) is an infectious and inflammatory intestinal disease that is the most common surgical emergency in the premature patient population. Although the etiology of the disease is multifactorial, intestinal dysbiosis is a hallmark of this disease. Based on this, probiotics may play a therapeutic role in NEC by introducing beneficial bacteria with immunomodulating, antimicrobial, and anti-inflammatory functions into the gastrointestinal tract. Currently, there is no Food and Drug Administration (FDA)-approved probiotic for the prevention and treatment of NEC. All probiotic clinical studies to date have administered the bacteria in their planktonic (free-living) state. This review will discuss established probiotic delivery systems including planktonic probiotics, prebiotics, and synbiotics, as well as novel probiotic delivery systems such as biofilm-based and designer probiotics. We will also shed light on whether or not probiotic efficacy is influenced by administration with breast milk. Finally, we will consider the challenges associated with developing an FDA-approved probiotic for NEC.

Development of a novel definitive scoring system for an enteral feed-only model of necrotizing enterocolitis in piglets.

Introduction: Necrotizing enterocolitis (NEC) is a complex inflammatory disorder of the human intestine that most often occurs in premature newborns. Animal models of NEC typically use mice or rats; however, pigs have emerged as a viable alternative given their similar size, intestinal development, and physiology compared to humans. While most piglet NEC models initially administer total parenteral nutrition prior to enteral feeds, here we describe an enteral-feed only piglet model of NEC that recapitulates the microbiome abnormalities present in neonates that develop NEC and introduce a novel multifactorial definitive NEC (D-NEC) scoring system to assess disease severity. Methods: Premature piglets were delivered via Caesarean section. Piglets in the colostrum-fed group received bovine colostrum feeds only throughout the experiment. Piglets in the formula-fed group received colostrum for the first 24 h of life, followed by Neocate Junior to induce intestinal injury. The presence of at least 3 of the following 4 criteria were required to diagnose D-NEC: (1) gross injury score ≥4 of 6; (2) histologic injury score ≥3 of 5; (3) a newly developed clinical sickness score ≥5 of 8 within the last 12 h of life; and (4) bacterial translocation to ≥2 internal organs. Quantitative reverse transcription polymerase chain reaction was performed to confirm intestinal inflammation in the small intestine and colon. 16S rRNA sequencing was performed to evaluate the intestinal microbiome. Results: Compared to the colostrum-fed group, the formula-fed group had lower survival, higher clinical sickness scores, and more severe gross and histologic intestinal injury. There was significantly increased bacterial translocation, D-NEC, and expression of IL-1α and IL-10 in the colon of formula-fed compared to colostrum-fed piglets. Intestinal microbiome analysis of piglets with D-NEC demonstrated lower microbial diversity and increased Gammaproteobacteria and Enterobacteriaceae. Conclusions: We have developed a clinical sickness score and a new multifactorial D-NEC scoring system to accurately evaluate an enteral feed-only piglet model of NEC. Piglets with D-NEC had microbiome changes consistent with those seen in preterm infants with NEC. This model can be used to test future novel therapies to treat and prevent this devastating disease.

Current and future methods of probiotic therapy for necrotizing enterocolitis.

Necrotizing enterocolitis (NEC) is a complex intestinal disease that primarily affects premature neonates. Given its significant mortality and morbidity, there is an urgent need to develop improved prophylactic measures against the disease. One potential preventative strategy for NEC is the use of probiotics. Although there has been significant interest for decades in probiotics in neonatal care, no clear guidelines exist regarding which probiotic to use or for which patients, and no FDA-approved products exist on the market for NEC. In addition, there is lack of agreement regarding the benefits of probiotics in neonates, as well as some concerns about the safety and efficacy of available products. We discuss currently available probiotics as well as next-generation probiotics and novel delivery strategies which may offer an avenue to capitalize on the benefits of probiotics, while minimizing the risks. Thus, probiotics may still prove to be an effective prevention strategy for NEC, although further product development and research is needed to support use in the preterm population.

Approach to the Adult Colorectal Patient with a History of Pediatric Abdominal Surgery.

Children with colorectal diseases often undergo operative management in their youth. As these patients become adult, it is important for surgeons to understand their postoperative anatomy as well as the pathophysiology of their diseases. Here, we present a description of common colorectal diseases of childhood that may have significant impact on patients' presentations as adult. We also discuss the diagnosis and management of conditions that are usually seen early in life but may present during adulthood as well.

Pre-Operative Antibiotic Agents for Facial Fractures: Is More than One Day Necessary?

Background: Despite a paucity of evidence, patients with facial fractures often receive long courses of pre-operative antibiotic agents. This study compared the effect of a short versus long pre-operative antibiotic course on the development of post-operative head/neck infections in this population. Patients and Methods: All adult patients admitted between January 2010 and May 2015 to a level 1 trauma center with isolated head/neck injuries who underwent surgery for facial fracture(s) were included. Patients with infections prior to surgery were excluded. Our primary analysis compared head/neck infections between patients given a short (≤24 hours) versus long (>24 hours) course of pre-operative antibiotic agents. Bivariate analysis and multivariate logistic regression (MLR) were performed to identify risk factors for head/neck infections. Results: This study included 188 patients; median age was 38.5 years, 83% were male, 81% had blunt injuries, 51.6% had fractures in multiple facial thirds, and 48.9% required intensive care unit (ICU) admission. One hundred twenty-five (66.5%) patients received a short course and 63 (33.5%) received a long course of pre-operative antibiotic agents. Head/neck infections were higher in the long course group (28.6% vs 15.2%; p = 0.034), but median days to infection were similar. Factors associated with head/neck infections included penetrating injury, mandible fracture, involvement of multiple facial thirds, ICU admission, operative time, and receiving a long pre-operative antibiotic course. Multivariable logistic regression found mandible fracture (odds ratio [OR], 2.9; p = 0.01) and ICU admission (OR, 3.3; p = 0.003) to be independent predictors of head/neck infections (area under the curve [AUC] = 0.706), but pre-operative antibiotic course was not. Patients with isolated mandible fractures (n = 42) had higher rates of head/neck infections in the long course group (29.4% vs 4.0%; p = 0.032), despite similar demographics. Conclusion: Long (>24 hours) course of continuous pre-operative antibiotic prophylaxis before surgery for facial fractures did not reduce the development of head/neck infections.

Consequences of Implementing a "Better" Blood Culture System.

BACKGROUND: Blood cultures (BCx) are the gold standard for diagnosing blood stream infections. However, contamination remains a challenge and can increase cost, hospital days, and unnecessary antibiotic use. National goals are to keep overall BCx contamination rates to ≤3%. Our healthcare system recently moved to a BCx system with better organism recovery, especially for gram-negative, fastidious, and anaerobic bacteria. The study objectives were to determine the benefits/consequences of implementing a more sensitive blood culture system, specifically on contamination rates. METHODS: The electronic health record was queried for all BCx obtained within our tertiary-care health system from April 2015 to October 2016. Cultures were divided into those obtained 12 months before and six months after the new system was introduced. A positive BCx was defined as one with any growth. Contaminated BCx were defined as those showing coagulase-negative Staphylococcus, Corynebacterium, Bacillus, Micrococcus, or Propionibacterium acnes. Cultures with Staphylococcus aureus, Klebsiella pneumoniae, or Escherichia coli were said to contain a true pathogen. Results based on hospital location of blood drawing also were determined. RESULTS: A total of 20,978 blood cultures were included, 13,292 before and 7,686 after the new system was introduced. With the new system, positive BCx rates increased from 7.5% to 15.7% (p < 0.001). Contaminants increased from 2.3% to 5.4% (p < 0.001), and pathogens increased from 2.5% to 5.8% (p < 0.001). Contaminated BCx increased significantly in the surgical/trauma intensive care unit (STICU), emergency department (ED), and medical ICU (MICU), while pathogen BCx increased on the surgical floor, ED, and MICU. CONCLUSIONS: A new blood culture system resulted in significant increases in the rates of positive, contaminated, and pathogen BCx. After the new system, multiple hospital units had contamination rates >3%. These data suggest that a "better" BCx system may not be superior regarding overall infection rates. More research is needed to determine the impact of identifying more contaminants and pathogens with the new system.

Level I Trauma Centers: More Is Not Necessarily Better.

The optimal number of level I trauma centers (L1TCs) in a region has not been elucidated. To begin addressing this, we compared mortalities for patients treated in counties or regions with 1 L1TC to those with >1 L1TC across Ohio. Ohio Trauma Registry data from 2010 to 2012 were analyzed. Patients with age ≥15 from counties/regions with L1TC were included. Region was defined as a L1TC containing county and its neighboring counties. Two analyses were performed. In the county analysis, counties containing 1 L1TC were compared with counties with multiple L1TCs. This comparison is repeated on a regional level for the regional analysis. Subgroup analyses were performed. 38,661 and 55,064 patients were in the county and regional analysis, respectively. Patients treated in counties or regions with multiple L1TCs were significantly younger (P < 0.001). Despite this, the mortality was similar for the two groups in the county analysis and significantly higher for regions with multiple L1TCs (P < 0.001). Multivariate logistic regression demonstrated that having multiple L1TC coverage in a region was an independent predictor for death (odds ratios: 1.17; 1.07-1.28; P = 0.001). Subgroup analyses showed that mortality in counties and regions with multiple L1TCs was not lower in any subgroups but was higher in patients with age ≥65 and patients with blunt injuries (P < 0.05). Having multiple L1TCs in a county was associated with increased mortality in certain patient subgroups. Having multiple L1TCs in a region was an independent predictor for death. These results should be considered carefully when designing future regionalized trauma networks. More L1TCs is not necessarily better.

Statewide Analysis Shows Collaborative Regional Trauma Network Reduces Regional Mortality.

A Regional Trauma Network (RTN), composed of one level I and several lower-level trauma centers (TCs) across multiple hospital systems, was established in 2010. This collaborative network used a unified triage protocol and a single transfer center. The impact of this RTN was assessed by evaluating regional mortality changes before and after RTN establishment. Patients in the state trauma registry aged 15 and older from 2006 to 2012 were analyzed; 2006 to 2009 and 2010 to 2012 were designated as pre-RTN and RTN periods, respectively. The region was defined as a county containing L1TC and its adjacent counties. Any counties bordering multiple L1TC-containing counties were excluded from analysis. Mortality was compared for all regions before and after RTN implementation. The following subgroups were also included a priori for the comparison: Injury Severity Score ≥15, age ≥65, and trauma mechanisms. 121,448 patients were analyzed; 66,977 and 54,471 patients were in the pre-RTN and RTN groups, respectively. Mean age was 58; 90 per cent had blunt injuries. The overall mortality was 4.9 per cent. Mortality comparisons over time for all regions are presented. The RTN region was the only region in the state that had mortality reduction in all patient subgroups. After adjusting for age, Injury Severity Score, level of TC that performed treatment, and trauma mechanism, RTN implementation was an independent predictor of survival (odds ratio: 0.876; 95% CI: 0.771-0.995, P = 0.04, c-statistic: 0.84). These findings suggest that regional collaboration and network-wide, uniform triage practices should be key components in the development of regionalized trauma networks.

Utility of Sequential Organ Failure Assessment score in predicting bacteremia in critically ill burn patients.

BACKGROUND: We evaluated whether qSOFA ≥2 and an increase in SOFA (ΔSOFA) ≥2 can help predict bacteremia in a critically ill burn population. METHODS: Patients age ≥15 and TBSA ≥15% admitted between 2009 and 2015 were included. All blood cultures were recorded, and positive and negative blood culture days were defined based on the culture results. SOFA and qSOFA scores were compared between positive and negative blood culture days. RESULTS: There were 50 patients in our study with a mean age of 47yrs and mean TBSA burn of 37%. Bacteremic patients had larger TBSA and full thickness burns, higher revised Baux score, and longer hospital LOS, without a difference in mortality, compared to non-bacteremic patients. There was no difference in qSOFA and SOFA scores between positive and negative blood culture days. A ΔSOFA ≥5 was highly specific for positive blood culture days. CONCLUSIONS: SOFA and qSOFA have limited ability to predict bacteremia in critically ill burn patients.

Prehospital Assessment of Trauma.

The organization of prehospital care for trauma patients began in the military arena. At the urging of multiple stakeholders and providers, these lessons were applied to the civilian setting and emergency medical services were created across the nation. Advances have taken place in the triage, transport, and management of severely injured patients. Many issues remain in the care of trauma patients in the prehospital environment. Collaboration between stakeholders and providers, regionalization of trauma care, and protocol-driven care may be solutions to some of these issues. Further research is necessary to dictate standard of care in this early phase after injury.

Performance of a regional trauma network: A state-wide analysis.

BACKGROUND: The Northern Ohio Trauma System (NOTS), established in 2010, is a collaborative regional trauma system composed of one level I and several lower-level trauma centers (TCs) across multiple hospital systems. Mortalities between counties in NOTS and other Ohio counties were compared to assess NOTS performance. METHODS: State trauma registry was analyzed for patients 15 years or older from 2006 to 2012. Mortality change over time was assessed by comparing all counties before and after NOTS establishment. Two analyses were done in the post-NOTS period: (1) a county analysis, comparing Cuyahoga County, the county containing NOTS level I TC (L1TC), with other counties containing L1TCs and (2) a regional analysis, comparing Cuyahoga and its adjacent counties (i.e., the NOTS region) with other L1TC containing regions. The following subgroups were included a priori: Injury Severity Score 15 or greater, age 65 years or older, and trauma mechanism. RESULTS: A total of 178,143 patients were analyzed. Cuyahoga was the only county that had a decrease in mortality for both the overall group and all subgroups over time (all p < 0.05). Both the county and regional analyses showed that the overall NOTS patients were 1 to 4 years older (p < 0.05), had similar or higher Injury Severity Score (p < 0.05), and were treated more often at lower-level TCs (p < 0.001). County analysis demonstrated that Cuyahoga County had approximately 1% lower mortality in geriatrics patients compared with non-NOTS counties. Regional analysis showed lower mortality in the NOTS region for the overall patient group, as well as geriatric and blunt injuries subgroups. CONCLUSIONS: Cuyahoga was the only county in Ohio that had significant mortality reduction for all patient groups over time. Trauma system regionalization was associated with greater utilization of lower-level TCs and lower patient mortality. These findings suggest that a collaborative regional trauma system may be more important than the number of L1TC in an area. LEVEL OF EVIDENCE: Therapeutic/care management study, level IV.

Upcoming rules and benchmarks concerning the monitoring of and the payment for surgical infections.

There has been a good deal of dialogue about pay for performance and linking outcomes with reimbursement, especially given the recent national health care legislation. Many such concerns are caused by upcoming changes that have been outlined in the Affordable Care Act. This article discusses these upcoming changes and reviews some of the literature that supports them, specifically those related to surgical infections. Likewise, the lack of support for some of these changes in the academic literature is discussed. Finally, some of the proposed key benchmarks and the methodologies behind the design of those benchmarks are discussed.