Prevention of thromboembolic events in surgical patients through the creation and implementation of a computerized risk assessment program.

OBJECTIVES: Deep vein thrombosis (DVT) is a major source of postoperative morbidity and mortality and is currently a major quality improvement initiative. Mechanical and pharmacological prophylaxis is effective in preventing postoperative thromboembolic events, yet it remains underutilized in the clinical setting. Thus, the objective of this study was to develop and implement a computerized DVT risk assessment program in the electronic medical record and determine its effect on compliance with DVT prophylaxis guidelines. METHODS: A standardized DVT risk assessment program was developed and incorporated into the Computerized Patient Record System for all surgical patients at the Jesse Brown Veterans Affairs Medical Center. Four hundred consecutive surgical patients before and after implementation were evaluated for DVT risk, the prescription of pharmacological and mechanical DVT prophylaxis, and the development of thromboembolic events. RESULTS: With implementation of the DVT risk assessment program, the number of patients receiving the recommended pharmacological prophylaxis preoperatively more than doubled (14% to 36%) (P < .001), and use of sequential compression devices (SCD) increased 40% (P < .001). Overall, the percentage of at-risk patients receiving the recommended combined DVT prophylaxis of SCD and pharmacological prophylaxis increased nearly seven-fold (5% to 32%) (P < .001). The assessment also improved use of prophylaxis postoperatively, increasing SCD use by 27% (P < .001). With respect to DVT occurrence, there was an 80% decrease in the incidence of postoperative DVT at 30 days and a 36% decrease at 90 days; however, this did not reach statistical significance due to the low event rate. CONCLUSIONS: The creation and implementation of a standardized DVT risk assessment program in the electronic medical record significantly increased use of pharmacological and mechanical DVT prophylaxis before surgery in a Veterans Affairs Medical Center setting.

Academic institution pilot study shows far fewer diagnoses of sinusitis than reported nationally.

OBJECTIVE: To compare the prevalence of acute sinusitis (AS) and chronic sinusitis (CS) diagnosed by primary care and emergency medicine physicians in our academic institution to national data. STUDY DESIGN: Cross-sectional pilot study of institutional census data and a population-based national sample. The setting was primary care and emergency departments at an academic healthcare institution and community healthcare practices nationally. MATERIALS AND METHODS: We determined the proportion of adults visits at our institution for AS and CS from January 1, 2005, to December 31, 2010. We used the same parameters with the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey. As a control comparison, we determined the proportion of visits for epistaxis. RESULTS: The sinusitis prevalence was considerably lower at our academic institution: all sinusitis (AS and CS combined) ranged from 0.8% to 1.0% at our institution compared to 3.1% to 3.7% nationally. There were very small differences between AS rates at the academic institution (0.7%-0.8%) and nationally (0.8%-1.4%, P < 0.001) but very large differences between CS rates at the academic institution (0.1%) and national data (1.7%-2.9%, P < 0.001). Epistaxis rates were nearly identical in both datasets (0.1%-0.2%, P = 0.98-0.99). CONCLUSION: The prevalence of CS is much lower at our academic institution, but the prevalence of AS and epistaxis are similar to national data. This suggests CS is over-diagnosed by primary care and emergency medicine providers and that CS diagnosed outside of an academic institution or a specialty clinic may not hold up to diagnostic scrutiny. For this reason, diagnostic and treatment protocols for CS that have been developed in academic specialty clinics should not be extrapolated to patients diagnosed with CS in the community setting. The most appropriate intervention for the majority of patients diagnosed with CS in primary care and emergency medicine may be education of providers and patients about conditions that may be misdiagnosed as CS.

A diagnostic dilemma: chronic sinusitis diagnosed by non-otolaryngologists.

BACKGROUND: Ambulatory care visits for chronic sinusitis outnumber visits for acute sinusitis. The majority of these visits are with non-otolaryngologists. In order to better understand patients diagnosed with chronic sinusitis by non-otolaryngologists, we sought to determine if incident cases of chronic sinusitis diagnosed by primary care (PC) or emergency medicine (EM) providers meet diagnostic criteria. METHODS: This was a retrospective cohort study. Patients were identified using administrative data from 2005 to 2006. The dataset was then clinically annotated based on chart review. We excluded prevalent cases. RESULTS: We identified 114 patients with newly diagnosed chronic sinusitis in EM (75) or PC settings (39). Rhinorrhea (EM 61%, PC 59%) and nasal obstruction (EM 67%, PC 64%) were common in both settings but facial fullness (EM 80%, PC 39%) and pain (EM 40%, PC 18%) were more common in the EM setting. Few patients reported symptoms of 90 days or longer (EM 6.0%, PC 24%) and no patient had evidence of inflammation on physical examination. A minority of patients received a sinus computed tomography (CT) scan (22.8%) or nasal endoscopy (1.8%). In total, only 1 patient diagnosed with chronic sinusitis met the diagnostic criteria. CONCLUSION: Most patients diagnosed with chronic sinusitis by non-otolaryngologists do not have the condition. Caution should be used in studying chronic sinusitis using administrative data from non-otolaryngology providers because a large proportion of the patients may not actually have the disease.

Cervicofacial Rhytidectomy After Radiotherapy for Head and Neck Tumors.

IMPORTANCE: Whether undergoing cervicofacial rhytidectomy after radiotherapy for tumors of the head and neck is associated with increased complication rates and therefore should be avoided remains unknown. OBJECTIVE: To evaluate complication rates in patients who have undergone cervicofacial rhytidectomy after radiotherapy for head and neck tumors and compare these rates with those of patients who have not undergone radiotherapy. DESIGN, SETTING, AND PARTICIPANTS: Retrospective review of the medical records of 16 patients who underwent cervicofacial rhytidectomy after completing radiotherapy for head and neck tumors and those of 16 age-matched control participants who did not undergo radiotherapy. Patients underwent treatment from July 1, 2006, through February 28, 2014, with final follow-up on February 28, 2014. Complications after surgery were reviewed and data for surgery type, technique, radiation dose and delivery method, and time to surgery after radiotherapy were analyzed. Data were collected from June 1 through December 31, 2013, and analyzed from January 1, 2014, through June 1, 2015. MAIN OUTCOMES AND MEASURES: Rate of complications after surgery. RESULTS: The radiotherapy and control group patients were a mean of 62 years old. In the radiotherapy group, 8 of 16 were women; 14 of 16 were women in the control group. Two major complications, 1 hematoma and 1 perioperative stroke, occurred in the 16 patients who composed the study cohort. In the control group, there was 1 case of transient facial nerve weakness and 1 case of cellulitis that was successfully treated with antibiotics. Two patients experienced wound dehiscence, and no incidents of motor or sensory nerve injury occurred. Subcutaneous face-lift (3 of 3 patients [100%] vs 1 of 13 patients [8%] who underwent superficial musculoaponeurotic system and deep-plane face-lifts; P = .02) and the addition of chemotherapy (4 of 9 patients [44%] vs 0 of 7 patients who did not receive chemotherapy; P = .04) were associated with increased complications. Being older and the time from completion of radiotherapy and surgery did not show any correlation to complications. CONCLUSIONS AND RELEVANCE: Aesthetic facial surgery after radiotherapy has an increased risk for complication compared with facial surgery without radiotherapy. The incidence of wound dehiscence is elevated in the population undergoing radiotherapy but can be managed conservatively in most cases. Patients who undergo radiotherapy must be counseled on the increased risk for complications before proceeding with cervicofacial rhytidectomy. LEVEL OF EVIDENCE: 3.

Case Report: Neonate With Stridor and Subcutaneous Emphysema as the Only Signs of Physical Abuse.

A stridulous, dysphonic cry with no external signs of trauma is a unique and unusual presenting sign for physical abuse. We report a previously healthy neonate with unremarkable birth history and medical history who presented with stridor and hypopharyngeal perforation due to physical abuse. This case highlights the need for further evaluation for traumatic injuries in the setting of unexplained new-onset stridor and consideration of physical abuse in the differential diagnosis.

Trends in the management of pediatric peritonsillar abscess infections in the U.S., 2000-2009.

OBJECTIVES: To analyze temporal trends in the incidence and surgical management of children with peritonsillar abscesses (PTAs), and to examine whether there has been concurrent changes in hospital charges or length of stay. METHODS: The Kids' Inpatient Database (KID) from 2000 to 2009 was examined for children less than 18 years old with ICD-9-CM diagnostic codes for PTA (475). Survey weighted frequency and regression analyses were performed across the entire study period on variables of interest in order to determine estimates of national incidence, demographics and outcomes. RESULTS: A total of 20,546 weighted cases of PTA were identified during the study period. There was no significant change in the incidence of pediatric PTA across the study period (p=0.63) or in the rate of nonsurgical management (p=0.85). There was a significant increase in the rates of I&D from 26.4% to 33.7% (p<0.001) and a significant decrease in the rate of tonsillectomy from 13.0% to 7.8% (p<0.001). Mean inflation-adjusted charges significantly increased from approximately $8400 in 2000 to $13,300 in 2009 (p<0.001), and average length of stay was 2.15 days with no significant change during the study period (p=0.164). Mean inflation-adjusted charges for patients undergoing tonsillectomy alone were approximately $1800 greater than mean charges for those undergoing I&D alone (p=0.003) and length of stay was also significantly longer for tonsillectomy patients versus I&D patients [I&D 1.99 days versus tonsillectomy 2.23 days (p<0.001)]. CONCLUSIONS: There was no change in the incidence of pediatric PTAs from 2000 to 2009 but there was a change in surgical management, with a significant decrease in the rate of tonsillectomy and significant increase in the rate of incision and drainage procedures. Hospital charges during this period increased nearly 60% despite no change in rates of CT imaging, surgical intervention or length of stay.

Diagnosis and treatment of acute sinusitis in the primary care setting: A retrospective cohort.

OBJECTIVES AND HYPOTHESIS: Our objectives were to characterize the quality of acute sinusitis care and to identify nonclinical factors associated with antibiotic use for acute sinusitis. We hypothesized that we would identify provider-level factors associated with antibiotic use. STUDY DESIGN: Retrospective cohort at a single academic institution. METHODS: We developed and clinically annotated an administrative dataset of adult patients diagnosed with acute sinusitis between January 1, 2005, and December 31, 2006. We used identify factors associated with receipt of antibiotics. RESULTS: We find that 66.0% of patients with mild symptoms of short duration are given antibiotics, and that nonclinical factors, including the individual provider, the provider's specialty, and the presence of a medical trainee, significantly influence antibiotic use. Relative to internal medicine providers, family medicine providers use fewer antibiotics, and emergency medicine providers use more antibiotics for acute sinusitis. CONCLUSIONS: Antibiotics continue to be overused for patients with mild acute sinusitis of short duration. Nonclinical characteristics, including the individual provider, the provider's specialty, and the presence of a medical trainee, significantly influence use of antibiotics for acute sinusitis. LEVEL OF EVIDENCE: 4.

Pediatric deep space neck infections in U.S. children, 2000-2009.

OBJECTIVE: Deep space neck infections (DNI) are common pediatric illnesses, which can lead to significant morbidity and healthcare expenditures. Recent studies suggest that the incidence of pediatric DNI in the United States is increasing, but no nationally representative studies exist. This study sought to characterize pediatric DNI at the national level over the past decade and to determine whether U.S. incidence of pediatric DNI and associated resource utilization changed from 2000 to 2009. METHODS: The Kids' Inpatient Database (KID) was used to evaluate pediatric DNI incidence, demographics, and outcomes from 2000 to 2009. Cases were identified using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnostic codes for peritonsillar abscess (475), parapharyngeal abscess (478.22), and retropharyngeal abscess (478.24). Regression analyses within each year and across the entire study period were performed on variables of interest including performance of imaging studies, operative intervention, length of hospital stay and total hospital charges. RESULTS: The incidence of retropharyngeal abscess increased significantly from 0.10 cases per 10,000 in 2000 to 0.22 in 2009 (p=0.02). There was no significant change during this time period in the incidence of combined DNI (1.07-1.37 cases per 10,000, p=0.07), peritonsillar abscess (0.82-0.94 cases per 10,000, p=0.12) or parapharyngeal abscess (0.08-0.14 cases per 10,000, p=0.13). The percentage of retropharyngeal abscess patients managed surgically decreased (48-38%, p=0.04) and the average length of hospital stay also decreased during this time (4.6-3.9 days, p=0.03). There was a marked increase in the total inflation-corrected hospital charges per case for all DNI ($9,486-16,348, p=0.005). CONCLUSIONS: The incidence of pediatric retropharyngeal abscess has increased significantly from 2000 to 2009, without concurrent increases in the incidence of combined DNI, peritonsillar, or parapharyngeal abscesses. There has been a change in management of retropharyngeal abscesses during this time with a decrease in operative intervention and a decrease in the length of hospital stay. Hospital charges associated with all pediatric DNI have nearly doubled during this timeframe, warranting future epidemiologic resource utilization studies in this population.