Clinical Characteristics of Pediatric Patients With Carbon Monoxide Poisoning.

OBJECTIVES: Carbon monoxide (CO) poisoning is a common and deadly form of poisoning that is often treated with hyperbaric oxygen. The characteristics of children exposed to CO and then treated with hyperbaric oxygen have not been delineated. The purpose of this study was to describe the clinical characteristics of children treated with hyperbaric oxygen therapy for CO poisoning at a regional hyperbaric referral center. METHODS: The study is based on a retrospective review of data extracted from the medical records of children (age <19 years) who were referred to our center for hyperbaric oxygen therapy for CO poisoning between 2008 and 2013. Inferential analyses were used to compare demographic characteristics, serum carboxyhemoglobin (COHb) levels, and presenting symptoms. RESULTS: Forty-seven children met our study criteria. Their mean age was 8.9 years, and their mean COHb level was 14.3% (range, 3.4%-30.1%). Severity of symptoms did not correlate with serum COHb levels; however, neurologic symptoms at presentation were more common in patients with a COHb level greater than 25%. There was a correlation between increasing age and higher COHb levels and between COHb and lactate levels. CONCLUSIONS: Our retrospective review of patients' records showed no correlation of serum COHb levels with symptoms on presentation; however, a correlation was found between increasing age and COHb level as well as lactate level and COHb level.

Repeat lactate level predicts mortality better than rate of clearance.

BACKGROUND: Lactate clearance has been developed into a marker of resuscitation in trauma, but no study has compared the predictive power of the various clearance calculations. Our objective was to determine which method of calculating lactate clearance best predicted 24-hour and in-hospital mortality after injury. STUDY DESIGN: Retrospective chart review of patients admitted to a Level-1 trauma center directly from the scene of injury from 2010 to 2013 who survived >15min, had an elevated lactate at admission (≥3mmol/L), followed by another measurement within 24h of admission. Lactate clearance was calculated using five models: actual value of the repeat level, absolute clearance, relative clearance, absolute rate, and relative rate. Models were compared using the areas under the respective receiver operating curves (AUCs), with an endpoint of death at 24h and in-hospital mortality. RESULTS: 3910 patients had an elevated admission lactate concentration on admission (mean=5.6±3.0mmol/L) followed by a second measurement (2.7±1.8mmol/L). Repeat absolute measurement best predicted 24-hour (AUC=0.85, 95% CI: 0.84-0.86) and in-hospital death (AUC=0.77; 95% CI, 0.76-0.78). Relative clearance was the best model of lactate clearance (AUC=0.77, 95% CI: 0.75-0.78 and AUC=0.705, 95% CI: 0.69-72, respectively) (p<0.0001 for each). A sensitivity analysis using a range of initial lactate measures yielded similar results. CONCLUSIONS: The absolute value of the repeat lactate measurement had the greatest ability to predict mortality in injured patients undergoing resuscitation.

Evaluating Barriers to Bystander CPR among Laypersons before and after Compression-only CPR Training.

OBJECTIVE: Bystander CPR is an essential part of out-of-hospital cardiac arrest (OHCA) survival. EMS and public safety jurisdictions have embraced initiatives to teach compression-only CPR to laypersons in order to increase rates of bystander CPR. We examined barriers to bystander CPR amongst laypersons participating in community compression-only CPR training and the ability of the training to alleviate these barriers. The barriers analyzed include fear of litigation, risk of disease transmission, fear of hurting someone as a result of doing CPR when unnecessary, and fear of hurting someone as a result of doing CPR incorrectly. METHODS: Laypersons attending community compression-only CPR training were administered surveys before and after community CPR training. Data were analyzed via standard statistical analyses. RESULTS: A total of 238 surveys were collected and analyzed between September 2015 and January 2016. The most common reported motivation for attending CPR training was "to be prepared/just in case" followed by "infant or child at home." Respondents reported that they were significantly more likely to perform CPR on a family member than a stranger in both pre-and post-training responses. Nevertheless, reported self-confidence in and likelihood of doing CPR on both family and strangers increased from pre-training to post-training. There was a statistically significant decrease in reported likelihood of all four barriers to prevent respondents from performing bystander CPR when pre-training responses were compared to post-training responses. Previous CPR training and history of having witnessed a sudden cardiac arrest (SCA) were both associated with decreased barriers to CPR, but previous training had no effect on reported likelihood of or confidence in performing CPR. CONCLUSION: The training initiative studied significantly reduced the reported likelihood of all barriers studied to prevent respondents from performing bystander CPR and also increased the reported confidence in doing CPR and likelihood of doing CPR on both strangers and family. However, it did not alleviate the pre-training discrepancy between likelihood of performing CPR on strangers versus family. Previous CPR training or certification had no impact on likelihood of or confidence in performing CPR.

The impact of a freestanding ED on a regional emergency medical services system.

OBJECTIVE: The objective of the study is to examine the effect of the opening of a freestanding emergency department (FED) on the surrounding emergency medical services (EMS) system through an examination of EMS system metrics such as ambulance call volume, ambulance response times, and turnaround times. METHODS: This study is based on data from the county's computer-aided dispatch center, the FED, and the Maryland Health Services Cost Review Commission. The analysis involved a pre/post design, with a 6-month washout period. The preintervention period was April to October 2010, and the postintervention period was April to October 2011. Data were analyzed using standard t tests. RESULTS: The average daily number of EMS-related calls received in the computer-aided dispatch center was lower after the FED opened (16.3 [95% confidence interval {CI}, 15.7-16.9] vs 15.8 [95% CI, 14.9-16.9]). One-fourth of all patients were transported by ambulance to the FED after it opened. Use of the FED and adjacent hospitals increased by 8647 visits (15.8%) during the study period. Turnaround time for the county's ALS units decreased from 26.8 (95% CI, 26.2-27.5) to 25.1 (95% CI, 24.3-25.8) minutes. The ambulance out-of-service interval decreased from 87.3 (95% CI, 86.0-88.5) to 81.1 (95% CI, 79.7-82.4) minutes. Based on change in out-of-service this study had a small effect size (Cohen's d = 0.33). CONCLUSIONS: The opening of an FED was associated with a modest improvement in time-specific EMS system metrics: a decrease in ambulance turnaround time and shorter out-of-service intervals.

The Severity of Bleeding and Mortality in Trauma Patients Taking Dabigatran.

BACKGROUND: Dabigatran, a direct thrombin inhibitor, has been shown to be more effective than warfarin in the prevention of stroke in patients with atrial fibrillation. Until recently, it lacked a reversal agent, and its contribution to the risk of transfusion in injured patients is unknown. OBJECTIVE: We sought to determine whether patients who sustain traumatic injuries while taking dabigatran receive more blood transfusions than matched patients taking warfarin, aspirin, clopidogrel, or controls. METHODS: This retrospective, single-center cohort consisted of injured patients who were taking dabigatran before admission to a major trauma center (January 2010-December 2013) who were compared with cohorts of patients taking warfarin, clopidogrel, or aspirin and a control group. The outcome was bleeding risk as measured by the use of blood products, with mortality as a secondary outcome. Outcomes were controlled for by age, sex, injury severity, and blunt mechanism. RESULTS: Thirty-eight patients were taking dabigatran. Compared with the general trauma population, patients taking dabigatran were more likely to be male, older, and to have higher injury severity. Patients taking dabigatran received transfusions (odds ratio [OR] 1.31 [95% confidence interval {CI} 0.56-3.04]), packed red blood cells (OR 1.43 [95% CI 0.54-3.77]), frozen plasma (OR 1.20 [95% CI 0.42-3.49]), and platelets (OR 2.01 [95% CI 0.63-6.37]) as often as matched controls. The mortality rate among patients on dabigatran was 12.5% (OR 1.51 [95% CI 0.39-5.89]) compared with 9.1% in matched controls. None of these results was statistically significant. CONCLUSIONS: In this small study, injured patients taking dabigatran were transfused as often and had similar in-hospital mortality as matched controls who were not taking anticoagulants.

Association of Direct Oral Anticoagulation Management Strategies With Clinical Outcomes for Adults With Atrial Fibrillation.

Importance: Anticoagulation management services (AMSs; ie, warfarin clinics) have evolved to include patients treated with direct oral anticoagulants (DOACs), but it is unknown whether DOAC therapy management services improve outcomes for patients with atrial fibrillation (AF). Objective: To compare outcomes associated with 3 DOAC care models for preventing adverse anticoagulation-related outcomes among patients with AF. Design, Setting, and Participants: This retrospective cohort study included 44 746 adult patients with a diagnosis of AF who initiated oral anticoagulation (DOAC or warfarin) between August 1, 2016, and December 31, 2019, in 3 Kaiser Permanente (KP) regions. Statistical analysis was conducted from August 2021 through May 2023. Exposures: Each KP region used an AMS to manage warfarin but used distinct approaches to DOAC care: (1) usual care (UC) by the prescribing clinician, (2) UC plus an automated population management tool (PMT), or (3) pharmacist-managed AMS care. Propensity scores and inverse probability of treatment weights (IPTWs) were estimated. Direct oral anticoagulant care models were first indirectly compared using warfarin as a common comparator within each region and then directly compared across regions. Main Outcomes and Measures: Patients were followed up until the first occurrence of an outcome (composite of thromboembolic stroke, intracranial hemorrhage, other major bleeding, or death), discontinuation of KP membership, or December 31, 2020. Results: Overall, 44 746 patients were included: 6182 in the UC care model (3297 DOAC; 2885 warfarin), 33 625 in the UC plus PMT care model (21 891 DOAC; 11 734 warfarin), and 4939 in the AMS care model (2089 DOAC; 2850 warfarin). Baseline characteristics (mean [SD] age, 73.1 [10.6] years, 56.1% male, 67.2% non-Hispanic White, median CHA2DS2-VASc [congestive heart failure, hypertension, age ≥75 years, diabetes, stroke, vascular disease, age 65-74 years, female sex] score of 3 [IQR, 2-5]) were well balanced after IPTW. Over a median follow-up of 2 years, patients who received the UC plus PMT or AMS care model did not have significantly better outcomes than those who received UC. The incidence rate of the composite outcome was 5.4% per year for DOAC and 9.1% per year for warfarin for those in the UC group, 6.1% per year for DOAC and 10.5% per year for those in the UC plus PMT group, and 5.1% per year for DOAC and 8.0% per year for those in the AMS group. The IPTW-adjusted hazard ratios (HRs) for the composite outcome comparing DOAC vs warfarin were 0.91 (95% CI, 0.79-1.05) in the UC group, 0.85 (95% CI, 0.79-0.90) in the UC plus PMT group, and 0.84 (95% CI, 0.72-0.99) in the AMS group (P = .62 for heterogeneity across care models). When directly comparing patients receiving DOAC, the IPTW-adjusted HR was 1.06 (95% CI, 0.85-1.34) for the UC plus PMT group vs the UC group and 0.85 (95% CI, 0.71-1.02) for the AMS group vs the UC group. Conclusions and Relevance: This cohort study did not find appreciably better outcomes for patients receiving DOAC who were managed by either a UC plus PMT or AMS care model compared with UC.

Factors Associated With Opting Out of Automated Text and Telephone Messages Among Adult Members of an Integrated Health Care System.

Importance: Health care systems deliver automated text or telephone messages to remind patients of appointments and to provide health information. Patients who receive multiple messages may demonstrate message fatigue by opting out of future messages. Objective: To assess whether the volume of automated text or interactive voice response (IVR) telephone messages is associated with the likelihood of patients requesting to opt out of future messages. Design, Setting, and Participants: This retrospective cohort study was conducted at Kaiser Permanente Colorado (KPCO), an integrated health care system. All adult members who received 1 or more automated text or IVR message between October 1, 2018, and September 30, 2019, were included. Exposures: Receipt of automated text or IVR messages. Main Outcomes and Measures: Message volume and opt-out rates obtained from messaging systems over 1 year. Results: Of the 428 242 adults included in this study, 59.7% were women, and 66.5% were White; the mean (SD) age was 52.3 (17.7) years. During the study period, 84.1% received 1 or more text messages (median, 4 messages; interquartile range, 2-8 messages) and 67.8% received 1 or more IVR messages (median, 3 messages; interquartile range, 1-6 messages). A total of 8929 individuals (2.5%) opted out of text messages, and 4392 (1.5%) opted out of IVR messages. In multivariable analyses, individuals who received 10 to 19.9 or 20 or more text messages per year had higher opt-out rates for text messages compared with those who received fewer than 2 messages per year (adjusted odds ratio [aOR]: 10-19.9 vs <2 messages, 1.27 [95% CI, 1.17-1.38]; ≥20 vs <2 messages, 3.58 [95% CI, 3.28-3.91]), whereas opt-out rates increased progressively in association with IVR message volume, with the highest rates among individuals who received 10.0 to 19.9 messages (aOR, 11.11; 95% CI, 9.43-13.08) or 20.0 messages or more (aOR, 49.84; 95% CI, 42.33-58.70). Individuals opting out of text messages were more likely to opt out of IVR messages (aOR, 4.07; 95% CI, 3.65-4.55), and those opting out of IVR messages were more likely to opt out of text messages (aOR, 5.92; 95% CI, 5.29-6.61). Conclusions and Relevance: In this cohort study among adult members of an integrated health care system, requests to discontinue messages were associated with greater message volume. These findings suggest that, to preserve the benefits of automated outreach, health care systems should use these messages judiciously to reduce message fatigue.

Mass-Gathering Medical Care in Electronic Dance Music Festivals.

Introduction Electronic dance music (EDM) festivals represent a unique subset of mass-gathering events with limited guidance through literature or legislation to guide mass-gathering medical care at these events. Hypothesis/Problem Electronic dance music festivals pose unique challenges with increased patient encounters and heightened patient acuity under-estimated by current validated casualty predication models. METHODS: This was a retrospective review of three separate EDM festivals with analysis of patient encounters and patient transport rates. Data obtained were inserted into the predictive Arbon and Hartman models to determine estimated patient presentation rate and patient transport rates. RESULTS: The Arbon model under-predicted the number of patient encounters and the number of patient transports for all three festivals, while the Hartman model under-predicted the number of patient encounters at one festival and over-predicted the number of encounters at the other two festivals. The Hartman model over-predicted patient transport rates for two of the three festivals. CONCLUSION: Electronic dance music festivals often involve distinct challenges and current predictive models are inaccurate for planning these events. The formation of a cohesive incident action plan will assist in addressing these challenges and lead to the collection of more uniform data metrics. FitzGibbon KM , Nable JV , Ayd B , Lawner BJ , Comer AC , Lichenstein R , Levy MJ , Seaman KG , Bussey I . Mass-gathering medical care in electronic dance music festivals. Prehosp Disaster Med. 2017;32(5):563-567.

The Decline in Hydrocodone/Acetaminophen Prescriptions in Emergency Departments in the Veterans Health Administration Between 2009 to 2015.

INTRODUCTION: The purpose of the study was to measure national prescribing patterns for hydrocodone/acetaminophen among veterans seeking emergency medical care, and to see if patterns have changed since this medication became a Schedule II controlled substance. METHODS: We conducted a retrospective cohort study of emergency department (ED) visits within the Veterans Health Administration (VA) between January 2009 and June 2015. We looked at demographics, comorbidities, utilization measures, diagnoses, and prescriptions. RESULTS: During the study period, 1,709,545 individuals participated in 6,270,742 ED visits and received 471,221 prescriptions for hydrocodone/acetaminophen (7.5% of all visits). The most common diagnosis associated with a prescription was back pain. Prescriptions peaked at 80,776 in 2011 (8.7% of visits), and declined to 35,031 (5.6%) during the first half of 2015 (r=-0.99, p<0.001). The percentage of hydrocodone/acetaminophen prescriptions limited to 12 pills increased from 22% (13,949) in 2009 to 31% (11,026) in the first half of 2015. A prescription was more likely written for patients with a pain score≥7 (OR 3.199, CI [3.192-3.205]), a musculoskeletal (OR 1.622, CI [1.615-1.630]) or soft tissue (OR 1.656, CI [1.649-1.664]) diagnosis, and those below the first quartile for total ED visits (OR 1.282, CI [1.271-1.293]) and total outpatient ICD 9 codes (OR 1.843, CI [1.833-1.853]). CONCLUSION: Hydrocodone/acetaminophen is the most frequently prescribed ED medication in the VA. The rate of prescribing has decreased since 2011, with the rate of decline remaining unchanged after it was classified as a Schedule II controlled substance. The proportion of prescriptions falling within designated guidelines has increased but is not at goal.

The Medical Duty Officer: An Attempt to Mitigate the Ambulance At-Hospital Interval.

INTRODUCTION: A lack of coordination between emergency medical services (EMS), emergency departments (ED) and systemwide management has contributed to extended ambulance at-hospital times at local EDs. In an effort to improve communication within the local EMS system, the Baltimore City Fire Department (BCFD) placed a medical duty officer (MDO) in the fire communications bureau. It was hypothesized that any real-time intervention suggested by the MDO would be manifested in a decrease in the EMS at-hospital time. METHODS: The MDO was implemented on November 11, 2013. A senior EMS paramedic was assigned to the position and was placed in the fire communication bureau from 9 a.m. to 9 p.m., seven days a week. We defined the pre-intervention period as August 2013 - October 2013 and the post-intervention period as December 2013 - February 2014. We also compared the post-intervention period to the "seasonal match control" one year earlier to adjust for seasonal variation in EMS volume. The MDO was tasked with the prospective management of city EMS resources through intensive monitoring of unit availability and hospital ED traffic. The MDO could suggest alternative transport destinations in the event of ED crowding. We collected and analyzed data from BCFD computer-aided dispatch (CAD) system for the following: ambulance response times, ambulance at-hospital interval, hospital diversion and alert status, and "suppression wait time" (defined as the total time suppression units remained on scene until ambulance arrival). The data analysis used a pre/post intervention design to examine the MDO impact on the BCFD EMS system. RESULTS: There were a total of 15,567 EMS calls during the pre-intervention period, 13,921 in the post-intervention period and 14,699 in the seasonal match control period one year earlier. The average at-hospital time decreased by 1.35 minutes from pre- to post-intervention periods and 4.53 minutes from the pre- to seasonal match control, representing a statistically significant decrease in this interval. There was also a statistically significant decrease in hospital alert time (approximately 1,700 hour decrease pre- to post-intervention periods) and suppression wait time (less than one minute decrease from pre- to post- and pre- to seasonal match control periods). The decrease in ambulance response time was not statistically significant. CONCLUSION: Proactive deployment of a designated MDO was associated with a small, contemporaneous reduction in at-hospital time within an urban EMS jurisdiction. This project emphasized the importance of better communication between EMS systems and area hospitals as well as uniform reporting of variables for future iterations of this and similar projects.

Alcohol consumption decreases lactate clearance in acutely injured patients.

INTRODUCTION: Alcohol, a common risk factor for injury, has direct toxic effects on the liver. The use of lactate clearance has been well described as an indicator of the adequacy of resuscitation in injured patients. We investigated whether acutely injured patients with positive blood alcohol content (+BAC) had less lactate clearance than sober patients. METHODS: We conducted a retrospective cohort study of acutely injured patients treated at an urban Level 1 trauma centre between January 2010 and December 2012. Blood alcohol and venous lactate levels were measured on all patients at the time of arrival. Study subjects were patients transported directly from the scene of injury, who had an elevated lactate concentration on arrival (≥3.0mmol/L) and at least one subsequent lactate measurement within 24h after admission. Lactate clearance ([Lactate1-Lactate2]/Lactate1) was calculated for all patients. Chi-squared tests were used to compare values from sober and intoxicated subjects. Lactate clearance was plotted against alcohol levels and stratified by age and Injury Severity Score (ISS). RESULTS: Serial lactate concentration measurements were obtained in 3910 patients; 1674 of them had +BAC. Patients with +BAC were younger (mean age: 36.6 [SD 14.7] vs 41.0 [SD 19.9] years [p=0.0001]), were more often male (83.4% vs 75.9% [p=0.0001]), had more minor injuries (ISS<9) (33.8% vs 27.1% [p=0.0001]), had a lower in-hospital mortality rate (1.4% vs 3.9% [p=0.0001]), but also had lower average lactate clearance (37.8% vs 47.6% [p=0.0001]). The lactate clearance of the sober patients (47.6 [SD 33.5]) was twice that of those with +BAC >400 (23.5 [SD 6.5]). Lactate clearance decreased with increasing BAC irrespective of age and ISS. CONCLUSIONS: In a large group of acutely injured patients, a dose-dependent decrease in lactate clearance was seen in those with elevated BAC. This relationship will cause a falsely elevated lactate reading or prolong lactate clearance and should be taken into account when evaluating patients with +BAC.

Patients without ST elevation after return of spontaneous circulation may benefit from emergent percutaneous intervention: A systematic review and meta-analysis.

INTRODUCTION: The American Heart Association recommends that post-arrest patients with evidence of ST elevation myocardial infarction (STEMI) on electrocardiogram (ECG) be emergently taken to the catheterization lab for percutaneous coronary intervention (PCI). However, recommendations regarding the utility of emergent PCI for patients without ST elevation are less specific. This review examined the literature on the utility of PCI in post-arrest patients without ST elevation compared to patients with STEMI. METHODS: A systematic review of the English language literature was performed for all years to March 1, 2015 to examine the hypothesis that a percentage of post-cardiac arrest patients without ST elevation will benefit from emergent PCI as defined by evidence of an acute culprit coronary lesion. RESULTS: Out of 1067 articles reviewed, 11 articles were identified that allowed for analysis of data to examine our study hypothesis. These studies show that patients presenting post cardiac arrest with STEMI are thirteen times more likely to be emergently taken to the catheterization lab than patients without STEMI; OR 13.8 (95% CI 4.9-39.0). Most importantly, the cumulative data show that when taken to the catheterization lab as much as 32.2% of patients without ST elevation had an acute culprit lesion requiring intervention, compared to 71.9% of patients with STEMI; OR 0.15 (95% CI 0.06-0.34). CONCLUSION: The results of this systematic review demonstrate that nearly one third of patients who have been successfully resuscitated from cardiopulmonary arrest without ST elevation on ECG have an acute lesion that would benefit from emergent percutaneous coronary intervention.

Using Big Data to Evaluate the Association between Periodontal Disease and Rheumatoid Arthritis.

An association between periodontal disease and rheumatoid arthritis is believed to exist. Most investigations into a possible relationship have been case-control studies with relatively low sample sizes. The advent of very large clinical repositories has created new opportunities for data-driven research. We conducted a retrospective cohort study to measure the association between periodontal disease and rheumatoid arthritis in a population of 25 million patients. We demonstrated that subjects with periodontal disease were roughly 1.4 times more likely to have rheumatoid arthritis. These results compare favorably with those of previous studies on smaller cohorts. Additional work is needed to identify the mechanisms behind this association and to determine if aggressive treatment of periodontal disease can alter the course of rheumatoid arthritis.

Failure to clear elevated lactate predicts 24-hour mortality in trauma patients.

BACKGROUND: Lactate clearance is a standard resuscitation goal in patients in nontraumatic shock but has not been investigated adequately as a tool to identify trauma patients at risk of dying. Our objective was to determine if trauma patients with impaired lactate clearance have a higher 24-hour mortality rate than patients whose lactate concentration normalizes. METHODS: A retrospective chart review identified patients who were admitted directly from the scene of injury to an urban trauma center between 2010 and 2013 and who had at least one lactate concentration measurement within 24 hours. Transfers, patients without lactate measurement, and those who were dead on arrival were excluded. Of the 26,545 screened patients, 18,304 constituted the initial lactate measurement population, and 3,887 were the lactate clearance cohorts. RESULTS: Initial lactate had an area under the receiver operating characteristic curve of 0.86 and 0.73 for mortality at 24 hours and in the hospital, respectively. An initial concentration of 3 mmol/L or greater had a sensitivity of 0.86 and a specificity of 0.73 for mortality at 24 hours. The mortality rate among patients with elevated lactate concentrations (n = 2,381; 5.6 [2.8] mmol/L) that did not decline to less than 2.0 mmol/L in response to resuscitative efforts (mean [SD] second measurement, 3.7 [1.9] mmol/L) was nearly seven times higher (4.1% vs. 0.6%, p < 0.001) than among those with an elevated concentration (n = 1,506, 5.3 [2.7] mmol/L) that normalized (1.4 [0.4] mmol/L). Logistic regression analysis showed that failure to clear lactate was associated with death more than any other feature (odds ratio, 7.4; 95% confidence interval, 1.5-35.5), except having an Injury Severity Score (ISS) greater than 25 (odds ratio, 8.2; 95% confidence interval, 2.7-25.2). CONCLUSION: Failure to clear lactate is a strong negative prognostic marker after injury. An initial lactate measurement combined with a second measurement for high-risk individuals might constitute a useful method of risk stratifying injured patients. LEVEL OF EVIDENCE: Prognostic study, level III.

Depressive symptoms and hospital readmission in older adults.

OBJECTIVES: To quantify the risk of 30-day unplanned hospital readmission in adults aged 65 and older with depressive symptoms. DESIGN: Prospective cohort study. SETTING: University of Maryland Medical Center. PARTICIPANTS: Individuals aged 65 and older admitted between July 1, 2011, and August 9, 2012, to the general medical and surgical units and followed for 31 days after hospital discharge (N = 750). MEASUREMENTS: Primary exposure was depressive symptoms at admission, defined as a score of 6 or more on the 15-item Geriatric Depression Scale. Primary outcome was unplanned 30-day hospital readmission, defined as an unscheduled overnight stay at any inpatient facility not occurring in the emergency department. RESULTS: Prevalence of depressive symptoms was 19% and incidence of 30-day unplanned hospital readmission was 19%. Depressive symptoms were not significantly associated with hospital readmission (relative risk (RR) = 1.20, 95% confidence interval (CI) = 0.83-1.72). Age, Charlson Comorbidity Index score, and number of hospitalizations within the past 6 months were significant predictors of unplanned 30-day hospital readmission. CONCLUSION: Although not associated with hospital readmission, depressive symptoms were associated with other poor outcomes and may be underdiagnosed in hospitalized older adults. Hospitals interested in reducing readmission should focus on older adults with more comorbid illness and recent hospitalizations.

Using antibiograms to improve antibiotic prescribing in skilled nursing facilities.

BACKGROUND: Antibiograms have effectively improved antibiotic prescribing in acute-care settings; however, their effectiveness in skilled nursing facilities (SNFs) is currently unknown. OBJECTIVE: To develop SNF-specific antibiograms and identify opportunities to improve antibiotic prescribing. DESIGN AND SETTING: Cross-sectional and pretest-posttest study among residents of 3 Maryland SNFs. METHODS: Antibiograms were created using clinical culture data from a 6-month period in each SNF. We also used admission clinical culture data from the acute care facility primarily associated with each SNF for transferred residents. We manually collected all data from medical charts, and antibiograms were created using WHONET software. We then used a pretest-posttest study to evaluate the effectiveness of an antibiogram on changing antibiotic prescribing practices in a single SNF. Appropriate empirical antibiotic therapy was defined as an empirical antibiotic choice that sufficiently covered the infecting organism, considering antibiotic susceptibilities. RESULTS: We reviewed 839 patient charts from SNF and acute care facilities. During the initial assessment period, 85% of initial antibiotic use in the SNFs was empirical, and thus only 15% of initial antibiotics were based on culture results. Fluoroquinolones were the most frequently used empirical antibiotics, accounting for 54.5% of initial prescribing instances. Among patients with available culture data, only 35% of empirical antibiotic prescribing was determined to be appropriate. In the single SNF in which we evaluated antibiogram effectiveness, prevalence of appropriate antibiotic prescribing increased from 32% to 45% after antibiogram implementation; however, this was not statistically significant ([Formula: see text]). CONCLUSIONS: Implementation of antibiograms may be effective in improving empirical antibiotic prescribing in SNFs.

Antimicrobial use for symptom management in patients receiving hospice and palliative care: a systematic review.

BACKGROUND: Patients receiving hospice or palliative care often receive antimicrobial therapy; however the effectiveness of antimicrobial therapy for symptom management in these patients is unknown. OBJECTIVE: The study's objective was to systematically review and summarize existing data on the prevalence and effectiveness of antimicrobial therapy to improve symptom burden among hospice or palliative care patients. DESIGN: Systematic review of articles on microbial use in hospice and palliative care patients published from January 1, 2001 through June 30, 2011. MEASUREMENTS: We extracted data on patients' underlying chronic condition and health care setting, study design, prevalence of antimicrobial use, whether symptom response following antimicrobial use was measured, and the method for measuring symptom response. RESULTS: Eleven studies met our inclusion criteria in which prevalence of antimicrobial use ranged from 4% to 84%. Eight studies measured symptom response following antimicrobial therapy. Methods of symptom assessment were highly variable and ranged from clinical assessment from patients' charts to the Edmonton Symptom Assessment Scale. Symptom improvement varied by indication, and patients with urinary tract infections (two studies) appeared to experience the greatest improvement following antimicrobial therapy (range 67% to 92%). CONCLUSION: Limited data are available on the use of antimicrobial therapy for symptom management among patients receiving palliative or hospice care. Future studies should systematically measure symptom response and control for important confounders to provide useful data to guide antimicrobial use in this population.

Healthcare-associated infection and hospital readmission.

OBJECTIVE: Hospital readmissions are a current target of initiatives to reduce healthcare costs. This study quantified the association between having a clinical culture positive for 1 of 3 prevalent hospital-associated organisms and time to hospital readmission. DESIGN: Retrospective cohort study. PATIENTS AND SETTING: Adults admitted to an academic, tertiary care referral center from January 1, 2001, through December 31, 2008. METHODS: The primary exposure of interest was a clinical culture positive for methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), or Clostridium difficile obtained more than 48 hours after hospital admission during the index hospital stay. The primary outcome of interest was time to readmission to the index facility. Multivariable Cox proportional hazards models were used to model the adjusted association between positive clinical culture result and time to readmission and to calculate hazard ratios (HRs) and 95% confidence intervals (CIs). RESULTS: Among 136,513 index admissions, the prevalence of hospital-associated positive clinical culture result for 1 of the 3 organisms of interest was 3%, and 35% of patients were readmitted to the index facility within 1 year after discharge. Patients with a positive clinical culture obtained more than 48 hours after hospital admission had an increased hazard of readmission (HR, 1.40; 95% CI, 1.33-1.46) after adjusting for age, sex, index admission length of stay, intensive care unit stay, Charlson comorbidity index, and year of hospital admission. CONCLUSIONS: Patients with healthcare-associated infections may be at increased risk of hospital readmission. These findings may be used to impact health outcomes after discharge from the hospital and to encourage better infection prevention efforts.

Serious mental illness and acute hospital readmission in diabetic patients.

Patients with serious mental illness (SMI), particularly those with other chronic illnesses, may be vulnerable to unplanned hospital readmission. The authors hypothesized that SMI would be associated with increased 30-day hospital readmission in a cohort of adult patients with comorbid diabetes admitted to a tertiary care facility from 2005 to 2009. SMI was defined by International Classification of Diseases, Ninth Revision, discharge diagnosis codes for schizophrenia, schizoaffective, bipolar, manic, or major depressive disorders, or other psychosis. The primary outcome was 30-day readmission to the index hospital. Among 26 878 eligible admissions, the prevalence of SMI was 6% and the incidence of 30-day hospital admission was 16%. Among patients aged <35 years, SMI was significantly associated with decreased odds of 30-day hospital readmission (odds ratio [OR] = 0.39; 95% confidence interval [CI] = 0.17, 0.91). However, among patients ≥35 years, SMI was not significantly associated with 30-day hospital readmission (OR = 1.11; 95% CI = 0.86, 1.42). SMI may not be associated with increased odds of 30-day hospital readmission in this population.