Decreasing Hospital Readmissions Utilizing an Evidence-Based COPD Care Bundle.

PURPOSE: Chronic obstructive pulmonary disease (COPD) is a chronic condition that leads to significant morbidity and mortality. Management of COPD hospitalizations utilizing an evidence-based care bundle can provide consistent quality of care and may reduce readmissions. METHODS: This single-center retrospective cohort study evaluated readmission rates in patients hospitalized with a COPD exacerbation. Patients in the pre-intervention cohort received usual care, while patients in the post-intervention cohort received an innovative inpatient COPD care bundle. The bundle focused on optimizing care in five areas: consults, inpatient interventions, education, transitions of care, and after discharge care. RESULTS: In this study, 149 subjects were included in the pre-intervention cohort and 214 subjects were included in the post-intervention cohort. Thirty-day readmission rates were lower in the post-intervention cohort compared to the pre-intervention cohort, 22.4% vs. 38.3% (p = 0.001). A reduction in 60-day and 90-day readmission rates was also observed, 13.7% vs. 40.3% (p < 0.001) and 10.1% vs. 32.2% (p < 0.001), respectively. CONCLUSION: Bundled care is an effective and inexpensive method for institutions to provide consistent and quality care. The findings of this study demonstrate that the implementation of a COPD care bundle is an effective strategy to decrease hospital readmissions.

Current directions in military health-care provider resilience.

After more than a decade of war, the US military continues to place significant emphasis on psychological health and resilience. While research and programs that focus on the broader military community's resilience continue to emerge, less is known about and until recently little focus has been placed on military medical provider resilience. In this article, we review the literature on military medical provider resilience, provide an overview of the programmatic and technological advances designed to sustain and develop military medical provider resilience, and finally offer recommendations for future research.

Intestinal toxemia botulism in 3 adults, Ontario, Canada, 2006-2008.

Five cases of intestinal toxemia botulism in adults were identified within an 18-month period in or near Toronto, Ontario, Canada. We describe findings for 3 of the 5 case-patients. Clinical samples contained Clostridium botulinum spores and botulinum neurotoxins (types A and B) for extended periods (range 41-61 days), indicative of intestinal toxemia botulism. Patients' clinical signs improved with supportive care and administration of botulinum antitoxin. Peanut butter from the residence of 1 case-patient yielded C. botulinum type A, which corresponded with type A spores found in the patient's feces. The food and clinical isolates from this case-patient could not be distinguished by pulsed-field gel electrophoresis. Two of the case-patients had Crohn disease and had undergone previous bowel surgery, which may have contributed to infection with C. botulinum. These cases reinforce the view that an underlying gastrointestinal condition is a risk factor for adult intestinal toxemia botulism.

Screening policies for daycare attendees: lessons learned from an outbreak of E. coli O157:H7 in a daycare in Waterloo, Ontario.

OBJECTIVES: Control measures for enteric outbreaks in child care settings frequently include screening by stool cultures from symptomatic children only. We present evidence from an investigation of Escherichia coli (E. coli) O157:H7 in a daycare in Waterloo, Ontario to support implementation of a mandatory screening policy for all children during an outbreak. METHODS: In addition to routine outbreak control measures employed by the health unit, stool samples from all children and staff were collected, with positive E. coli cultures typed by pulsed field gel electrophoresis (PFGE). We conducted a cohort study, using data from the environmental investigation and questionnaires administered to parents and staff, to look for risk factors for infection and to survey parent/staff knowledge regarding appropriate management of diarrhea. RESULTS: Overall 11 E. coli O157:H7 cases were identified (7 lab-confirmed); 9 were children. No common source of infection was identified. Factors identified as possibly contributing to person-to-person transmission within the daycare included: i) the underreporting and possible attendance of symptomatic children despite alerting parents to the outbreak and requirements to keep symptomatic children at home, ii) possible transmission from an asymptomatic infected child, and iii) inconsistent understanding among parents and staff regarding diarrhea and appropriate management of a child with diarrhea. DISCUSSION/CONCLUSION: This investigation reveals that in child care settings, E. coli O157:H7 outbreak screening policies based on reported symptoms only may be insufficient. We recommend that such policies be amended to include the collection of at least one stool culture from all children in attendance, regardless of symptom history.

Difficulty in defecation in infants with gastroesophageal reflux treated with smaller volume feeds thickened with rice cereal.

We prospectively evaluated the incidence of difficulty in defecation in infants with gastroesophageal reflux who were treated with smaller volume feeds thickened with rice cereal and also assessed the effect of changing the cereal to oatmeal. We evaluated 53 thriving infants with uncomplicated gastroesophageal reflux who were treated with smaller volume feeds thickened with rice cereal. Parents maintained records of bowel movements for 7 days. Rice was substituted by oatmeal cereal in those infants developing difficulty in defecation and another 7 days' record was kept. Of the 53 infants enrolled, 34 (64%) reported no difficulty in defecation, 8 (15%) reported mild difficulty, and 11 (21%) reported severe difficulty in defecation during rice-based feedings. In these symptomatic 19 infants, after rice was substituted by oatmeal cereal, 10 infants (52.6%) reported no symptoms, 6 (31.6%) had mild symptoms, and 3 (15.8%) continued to have severe symptoms. We conclude that difficulty in defecation is common during treatment of infants with gastroesophageal reflux with smaller volume feeds thickened with rice cereal. Substitution of rice with oatmeal cereal results in partial or complete resolution of symptoms in most of these infants.

Propofol versus midazolam plus meperidine for sedation during ambulatory esophagogastroduodenoscopy.

OBJECTIVE: To evaluate the efficacy and safety of propofol and meperidine plus midazolam for sedation during esophagogastroduodenoscopy (EGD) in children. METHODS: Data were collected prospectively and retrospectively from neurologically intact children (0.2-17.7 years of age) who underwent ambulatory diagnostic EGD during a 4-year period. Data were included from 155 consecutive patients receiving propofol with or without premedication with midazolam (PM group). One hundred five consecutive patients who received sedation with a midazolam plus meperidine combination served as a comparison (MM group). Outcome variables were: time required for induction of sedation, length of procedure, time for recovery, need for additional supportive measures, and need for physical restraint. RESULTS: The onset of sedation was faster and the length of procedure and recovery were significantly shorter in the PM group as compared with the MM group (P < 0.01). Patients in the MM group required restraint more often than in the PM group. A higher dose of meperidine and midazolam was used in the prospective study. This led to deeper sedation but increased need for additional support. CONCLUSIONS: Propofol is safe and effective for facilitating EGD in children.

Role of gastroesophageal reflux in older children with persistent asthma.

BACKGROUND: Gastroesophageal reflux (GER) plays a role in inducing or exacerbating asthma. METHODS: We evaluated asthma outcome before and after anti-GER treatment in older children (age range, 5 to 10.5 years) who had persistent moderate asthma and were being treated with short- and long-acting bronchodilators, inhaled corticosteroids, and leukotriene antagonists. Forty-six such consecutive children underwent extended esophageal pH monitoring. Of the 27 patients (59%) who had evidence of GER disease, 18 patients underwent medical treatment (lifestyle changes, proton pump inhibitors, and prokinetics) and 9 patients opted for surgical treatment (Nissen fundoplication) of GER. Of the 19 patients with normal pH study findings, 8 patients underwent empiric medical anti-GER treatment and the remaining 11 patients served as a control group. Data on all patients were collected from 6 months prior to performing the pH studies and for 12 months after initiation of anti-GER treatment. The frequency of oral and inhaled corticosteroids, short- and long-acting bronchodilators, and leukotriene antagonists was prospectively recorded. RESULTS: There was a significant reduction in the use of short- and long-acting bronchodilators as well as inhaled corticosteroids after anti-GER treatment was instituted in patients with GER disease (p < 0.05). Two patients (25%) without evidence of GER disease showed significant reduction in need for asthma medication after anti-GER treatment, but none of the patients without GER disease and no GER treatment showed any significant reduction in the need for asthma medications. CONCLUSIONS: Anti-GER treatment in patients with GER disease and asthma results in a significant reduction in the requirement of asthma medications.