Antipsychotic prescribing patterns, and the factors and outcomes associated with their use, among patients requiring prolonged mechanical ventilation in the long-term acute care hospital setting.

BACKGROUND: Administration of scheduled antipsychotic therapy to mechanically ventilated patients to prevent or treat delirium is common, despite the lack of evidence to support its use. Among long-term acute care hospital (LTACH) patients requiring prolonged mechanical ventilation (PMV), the frequency of scheduled antipsychotic therapy use, and the factors and outcomes associated with it, have not been described. OBJECTIVE: To identify scheduled antipsychotic therapy prescribing practices, and the factors and outcomes associated with the use of antipsychotics, among LTACH patients requiring PMV. METHODS: Consecutive patients without major psychiatric disorders or dementia who were admitted to an LTACH for PMV over 1 year were categorized as those receiving scheduled antipsychotic therapy (≥24 hours of use) and those not receiving scheduled antipsychotic therapy. Presence of delirium, use of psychiatric evaluation, nonscheduled antipsychotic therapy, and scheduled antipsychotic therapy-related adverse effects were extracted and compared between the 2 groups and when significant (p ≤ 0.05), were entered into a regression analysis using generalized estimating equation techniques. RESULTS: Among 80 patients included, 39% (31) received scheduled antipsychotic therapy and 61% (49) did not. Baseline characteristics, including age, sex, illness severity, and medical history, were similar between the 2 groups. Scheduled antipsychotic therapy was administered on 52% of LTACH days for a median (interquartile range [IQR]) of 25 (6-38) days and, in the antipsychotic group, was initiated at an outside hospital (45%) or on day 2 (1-6; median [IQR]) of the LTACH stay (55%). Quetiapine was the most frequently administered scheduled antipsychotic (77%; median dose 50 [37-72] mg/day). Use of scheduled antipsychotic therapy was associated with a greater incidence of psychiatric evaluation (OR 5.7; p = 0.01), delirium (OR 2.4; p = 0.05), as-needed antipsychotic use (OR 4.1; p = 0.005) and 1:1 sitter use (OR 7.3; p = 0.001), but not benzodiazepine use (p = 0.19). CONCLUSIONS: Among LTACH patients requiring PMV, scheduled antipsychotic therapy is used frequently and is associated with a greater incidence of psychiatric evaluation, delirium, as-needed psychotic use, and sitter use. Although scheduled antipsychotic therapy-related adverse effects are uncommon, these effects are infrequently monitored.

Accidental decannulation following placement of a tracheostomy tube.

BACKGROUND: Accidental decannulation is a cause of substantial morbidity and mortality in patients in long-term acute care hospitals who require a tracheostomy tube. OBJECTIVE: To analyze features of accidental decannulation (AD) following placement of a tracheostomy tube, and to implement strategies to reduce the problem. METHODS: An analysis of data collected prospectively for quality management in a long-term acute care hospital was performed. RESULTS: AD occurred at a rate of 4.2 ± 0.9/1,000 tracheostomy days over a 7 month period. Factors associated with AD included mental status changes, increased secretions, and change of shift. Following the implementation of a series of interventions (staff education on risk factors for AD and best tracheostomy care practice; increased availability of telemetry and oximetry; and signage to identify patients at high risk of AD), the incidence of AD over a subsequent 7 month period was significantly reduced, to 2.7 ± 1.9/1,000 tracheostomy days. In addition the numbers of multiple, unmonitored, unreported, and night shift ADs were all significantly reduced. CONCLUSIONS: Targeted interventions can significantly reduce both the incidence of AD following tracheostomy and associated morbidity. Best practice guidelines to help minimize AD in patients with tracheostomy tubes are proposed.

Unplanned transfers following admission to a long-term acute care hospital: a quality issue.

The unplanned transfer of patients from long-term acute care hospitals (LTACHs) back to acute facilities disrupts the continuity of care, delays recovery and increases the cost of care. This study was performed to better understand the unplanned transfer of patients with pulmonary disease. A retrospective analysis of data obtained for quality management in a cohort of patients admitted to an LTACH system over a 3-year period. Of the 3506 patients admitted with a pulmonary diagnosis studied, 414 (12%) underwent 526 unplanned transfers back to an acute facility after a median LTACH length of stay (LOS) of 45 days. Mechanical ventilation via tracheostomy was used in 259 (63%) patients admitted to the LTACH with a pulmonary diagnosis. The commonest reasons for unplanned transfers included acute respiratory failure, cardiac decompensation, gastrointestinal bleed and possible sepsis. Over 50% of patients had LOS at the LTACH between 4 and 30 days prior to the unplanned transfer. Patients with an LOS <3 days prior to transfer were more likely to be transferred around the weekend. In all, 32% of patients died within a median of 7 days of transfer back to the acute facility. Thirty-day mortality following unplanned transfer appeared independent of organ system involved, attending physician specialty/coverage status, nursing shift or transferring LTACH unit. Unplanned transfers disrupting continuity of care remain a significant problem in patients admitted to an LTACH with a pulmonary diagnosis and are associated with significant mortality. Strategies designed to reduce cardiopulmonary decompensation, gastrointestinal bleeding and possible sepsis in the LTACH along with additional strategies implemented throughout the health care continuum will be needed to reduce this problem.

Beyond Initial Screening: One-Year Follow-up of Adolescents with Internalizing Problems on the Pediatric Symptom Checklist.

OBJECTIVE: Screening for adolescent depression is a quality indicator for pediatric care, and the parent-completed, 17-item Pediatric Symptom Checklist's internalizing (PSC-17P-INT) subscale has been validated for this purpose. The current study assessed the feasibility of PSC-17P-INT screening, the prevalence of risk on 2 consecutive PSC-17P-INTs, and rates of behavioral health (BH) service use before and after screening. METHODS: The parent-report PSC-17 was completed on tablet devices before well-child visits (WCVs) with results instantaneously available to clinicians in the electronic health record. Billing data were used to identify adolescents with 2 consecutive WCVs and possible BH service utilization 6 months before and after their first screen. RESULTS: In 2017, 1,068 adolescents (12-17 years old) were seen for a WCV, and 637 (59.6%) of them had one in 2018. Most (93.9%; N = 604) completed a PSC at both visits. Patients who scored positively on their first PSC-17P-INT were about 9 times more likely to receive subsequent BH services than patients who screened negative (24.3% vs 2.6%, χ2 = 59.65, p < 0.001). However, risk prevalence increased from the first (11.6%) to the second (14.9%) screen, and only 37.1% of at-risk patients remitted. CONCLUSION: The current study demonstrated that screening adolescents for depression using the PSC-17P-INT was feasible and associated with a significant increase in BH treatment rates. The study also demonstrated that the PSC could be used to track adolescents at risk for depression, found that most youth who screened positive remained at risk 1 year later, and supported recent quality guidelines calling for annual depression screening and follow-up for adolescents with depression.

Implementation of an Electronic Approach to Psychosocial Screening in a Network of Pediatric Practices.

OBJECTIVE: A network of 18 pediatric practice locations serving predominantly commercially insured patients implemented the electronic administration of the Pediatric Symptom Checklist-17 parent-report (PSC-17P) for all 5.50- to 17.99-year-old children seen for well child visits (WCVs) and wrote up the results as a quality improvement project. The current study investigated this screening over 2 years to assess its implementation and risk rates over time. METHODS: Parents completed the PSC-17P electronically before the visit and the scored data were immediately available in the patient's chart. Using billing and screening data, the study tracked rates of overall and positive screening during the first-year baseline (4 months) and full implementation phases of the project in the first (8 months) and second (12 months) year. RESULTS: A total of 35,237 patients completed a WCV in the first year. There was a significant improvement in PSC-17P screening rates from the first-year baseline (26.3%) to full implementation (89.3%; P < .001) phases. In the second year, a total of 40,969 patients completed a WCV and 77.9% (n = 31,901) were screened, including 18,024 patients with screens in both years. PSC-17P screening rates varied significantly across the 18 locations and rates of PSC-17P risk differed significantly by practice, insurance type, sex, and age. CONCLUSIONS: The current study demonstrated the feasibility of routine psychosocial screening over 2 years using the electronically administered PSC-17P in a network of pediatric practices. This study also corroborated past reports that PSC-17 risk rates differed significantly by insurance type (Medicaid vs commercial), sex, and age group.

How an Electronic Medical Record System Facilitates and Demonstrates Effective Psychosocial Screening in Pediatric Primary Care.

Using questionnaires, administrative claims, and chart review data, the current study explored the impact of using an electronic medical record system to administer, score, and store the Pediatric Symptom Checklist (PSC-17) during annual pediatric well-child visits. Within a sample of 1773 Medicaid-insured outpatients, the electronic system demonstrated that 90.5% of cases completed a PSC-17 screen electronically, billing codes indicating a screen was administered agreed with the existence of a questionnaire in the chart in 98.8% of cases, the classification of risk based on PSC-17 scores agreed with the classification of risk based on the Current Procedural Terminology code modifiers in 72.9% of cases, and 90.0% of clinicians' progress notes mentioned PSC-17 score in treatment planning. Using an electronic approach to psychosocial screening in pediatrics facilitated the use of screening information gathered during the clinical visit and allowed for enhanced tracking of outcomes and quality monitoring.

Factors Associated With Increased Collection of Patient-Reported Outcomes Within a Large Health Care System.

Importance: The collection of patient-reported outcomes (PROs) has garnered intense interest, but dissemination of PRO programs has been limited, as have analyses of the factors associated with successful programs. Objective: To identify factors associated with improving PRO collection rates within a large health care system using a centralized PRO infrastructure. Design, Setting, and Participants: This cohort study included 205 medical and surgical clinics in the Partners Healthcare system in Massachusetts that implemented a PRO program between March 15, 2014, and December 31, 2018, using a standardized centralized infrastructure. Data were analyzed from March to April 2019. Exposures: Relevant clinical characteristics were recorded for each clinic launching a PRO program. Main Outcomes and Measures: The primary outcome was the mean PRO collection rate during each clinic's most recent 6 months of collection prior to January 2019. Data were analyzed using a linear regression model with the 6-month PRO collection rate as the dependent variable and clinic characteristics as independent variables. Secondary analysis used a logistic regression model to assess clinical factors associated with successful clinics, defined as those that collected PROs at a rate greater than 50%. Results: Between March 2014 and December 2018, 205 Partners Healthcare clinics were available for analysis, and 4 061 205 PRO measures from 745 028 encounters were collected. Among these, 103 clinics (50.2%) collected at a rate greater than 50%. Increased collection rates were associated with more than 50% of physicians in a clinic trained on PROs (change, 19.6% [95% CI, 9.9%-29.4%]; P < .001), routine administrative oversight of collection rates (change, 16.0% [95% CI, 6.6%-25.5%]; P = .001), previous collection of PROs on paper (change, 12.5% [95% CI, 4.7%-20.3%]; P = .002), presence of a clinical champion (change, 11.2% [95% CI, 2.5%-20.0%]; P = .01) and payer incentive (change, 10.5% [95% CI, 2.0%-18.9%]; P = .02). Conclusions and Relevance: These findings suggest that training physicians on the use of PROs, administrative surveillance of collection rates, and the presence of a local clinical champion may be promising interventions for increasing PRO collection. Clinics that have previously collected PROs may have greater success in increasing collections. Payer incentive for collection was associated with improved collections, but not associated with successful programs.

Apomorphine prevents myocardial ischemia/reperfusion-induced oxidative stress in the rat heart.

This study examined the hypothesis that low-concentration apomorphine improves postischemic hemodynamic and mitochondrial function in the isolated rat heart model by attenuating oxidation of myocardial proteins. Control and apomorphine-treated hearts were subjected to 35 min of perfusion, 25 min of normothermic global ischemia, and 60 min of reperfusion. Apomorphine (2 microM) was introduced into the perfusate for 20 min starting from the onset of reperfusion. Apomorphine significantly (p <.05) improved postischemic hemodynamic function: work index of the heart (product of LVDP and heart rate) was twice as high in apomorphine-treated hearts compared to controls at the end of reperfusion (p <.01). After isolation of cardiac mitochondria, the respiratory control ratio (RCR) was calculated from the oxygen consumption rate of State 3 and State 4 respiration. Apomorphine significantly improved postischemic RCR (87% of preischemic value vs. 39% in control, p <.05). Using an immunoblot technique, carbonyl content of multiple unidentified myocardial proteins (mitochondrial and nonmitochondrial) was observed to be elevated after global ischemia and reperfusion. Apomorphine significantly attenuated the increased protein oxidation at the end of reperfusion. These results support the conclusion that apomorphine is capable of preventing ischemia/reperfusion-induced oxidative stress and thereby attenuating myocardial protein oxidation and preserving mitochondrial respiration function.

Regional distribution of mercury in sediments of the main rivers of French Guiana (Amazonian basin).

Use of mercury (Hg) for gold-mining in French Guiana (up until 2006) as well as the presence of naturally high background levels in soils, has led to locally high concentrations in soils and sediments. The present study maps the levels of Hg concentrations in river sediments from five main rivers of French Guiana (Approuague River, Comté River, Mana River, Maroni River and Oyapock River) and their tributaries, covering more than 5 450 km of river with 1 211 sampling points. The maximum geological background Hg concentration, estimated from 241 non-gold-mined streams across French Guiana was 150 ng g(-1). Significant differences were measured between the five main rivers as well as between all gold-mining and pristine areas, giving representative data of the Hg increase due to past gold-mining activities. These results give a unique large scale vision of Hg contamination in river sediments of French Guiana and provide fundamental data on Hg distribution in pristine and gold-mined areas.

Epidemiology of decompensated heart failure in a single community in the northeastern United States.

Limited data are available describing the clinical characteristics, hospital treatment practices, and hospital and long-term death rates of patients hospitalized with decompensated heart failure (HF). To examine the descriptive epidemiology of acute HF in residents of a large New England metropolitan area during the 2 study years of 1995 and 2000, we reviewed the medical records of patients hospitalized with acute HF at 11 medical centers in the Worcester, Massachusetts, metropolitan area during 1995 and 2000 for purposes of collecting information about patients' sociodemographic and clinical characteristics, hospital management approaches, and hospital and postdischarge mortalities. The mean age of 4,537 residents of the Worcester metropolitan area hospitalized with decompensated HF was 76 years, 57% were women, and most study patients had been previously diagnosed with several co-morbidities. The average duration of hospitalization was 6.3 days and 6.8% of patients died during hospitalization. Diuretics (98%) and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (54%) were the most common medications used to treat acutely ill patients. The 1- and 5-year death rates of hospital survivors were 39% and 77%, respectively, with no change observed in these death rates between our 2 study years. In conclusion, the results of this observational study in residents of a central New England metropolitan area provide insights into the characteristics, treatment practices, and short- and long-term death rates associated with this increasingly prevalent clinical syndrome.

Terminal withdrawal of mechanical ventilation at a long-term acute care hospital: comparison with a medical ICU.

BACKGROUND: Failure to wean from prolonged mechanical ventilation (MV) is common in long-term acute care hospitals (LTACHs), but the process of terminal withdrawal of MV in LTACHs is not well described. We compared terminal withdrawal of MV at an LTACH with that in a medical ICU (MICU). METHODS: A retrospective medical chart review was done of all patients undergoing terminal withdrawal of MV in an LTACH (n = 30) and in a MICU (n = 74) over a 2-year period. RESULTS: The decision to withdraw MV was more likely initiated by patient or family in the LTACH and by medical staff in the MICU (p < 0.0001). Social workers, pastoral care, and hospital administration were more likely to participate in the withdrawal process at the LTACH compared with the MICU (p < 0.05). Time from initiation of MV to orders for do not resuscitate, comfort measures only, or withdrawal of MV was significantly greater in the LTACH (weeks) compared with the MICU (days) (p < 0.05). The dose of benzodiazepines given during the final 24 h of life was greater in the MICU as compared with the LTACH (p < 0.05). Narcotic and benzodiazepine use in the hour before or after withdrawal of MV did not differ between the two groups. COPD and pneumonia were the most common causes of death among patients undergoing withdrawal of MV at the LTACH, as opposed to septic shock in the MICU (p < 0.05). CONCLUSIONS: Terminal withdrawal of MV in the LTACH differs from that in the MICU with regard to decision making, benzodiazepine use, and cause of death.