Timeliness and use of antibiotic prophylaxis in selected inpatient surgical procedures. The Antibiotic Prophylaxis Study Group.

BACKGROUND: Twenty-five percent of all nosocomial infections are wound infections. Professional guidelines support the timely use of preoperative prophylaxis for prevention of postoperative wound infections. Barriers exist in implementing this practice. IPRO, the New York State peer review organization, as part of the Health Care Financing Administration's Health Care Quality Improvement Program, sought to determine the proportion of patients receiving timely antibiotic prophylaxis for aortic grafts, hip replacements and colon resections in 44 hospitals in New York State. METHODS: IPRO conducted a retrospective medical record review of 44 hospitals through out New York State stratified for teaching, nonteaching status. A sample was drawn of 2651 patients, 2256 from Medicare and 395 from Medicaid, undergoing either abdominal aortic aneurysm repair, partial or total hip replacement or large bowel resection. The study determined the proportion of patients who had documentation of receiving antibiotics and those who received antibiotics timely, that is less than or equal to 2 hours preoperatively. RESULTS: Eighty-six percent of patients had documentation of receiving an antibiotic. Forty-six percent of aneurysm repairs and 60% of hip replacements had evidence of receiving timely antibiotic prophylaxis, that is within 2 hours prior to surgery. For colon resections, 73% of cases had either oral prophylaxis or timely parenteral therapy. An increased proportion of patients had received parenteral antibiotics prematurely as the surgical start time occurred later in the day. A total of 44 different antibiotics were recorded for prophylaxis. CONCLUSIONS: Antibiotic prophylaxis was performed in 81% to 94% of cases, however, anywhere from 27% to 54% of all cases did not receive antibiotics in a timely fashion. By delegating implementation of ordered antibiotic prophylaxis to the anesthesia team, timing may be improved and the incidence of postoperative wound infections may decrease.

The use of quality indicators for assessing radical prostatectomy specimens.

The information contained in pathology reports of radical prostatectomy specimens is critically important to treating physicians for selecting adjuvant therapy, evaluating therapy, estimating prognosis, and analyzing outcomes. This information is also of importance to patients and their families. In recent years, the Cancer Committee of the College of American Pathologists and the Association of Directors of Anatomic and Surgical Pathology developed suggested protocols for reporting the findings on radical prostatectomy specimens. The objectives of this study were to assess radical prostatectomy-specimen reports by using quality indicators derived from existing suggested protocols and to thereby assist pathologists in improving the quality of their reports on such specimens. A retrospective chart review of 554 cases for the second 6-month period of 1996 focused on 10 quality indicators: submission of a frozen section; location of the adenocarcinoma; proportion of the specimen involved by adenocarcinoma; perineural involvement; vascular involvement; seminal vesicle involvement; periprostatic fat status; number of nodes submitted; status of nodes; and prostate intraepithelial neoplasia (PIN). The findings of this study were shared with the pathology departments in all hospitals in New York State. In addition, the 113 hospitals from which the 554 cases were drawn were given their institution-specific data. Teleconferences were held with the 37 hospitals that accounted for 72.4% of all cases. These conferences included directors of pathology and laboratories and focused on the aggregate statewide findings. The presence of quality indicators in reports varied from a mean of 14.8% (periprostatic fat) to a mean of 85.9% (seminal vesicle involvement). For all hospitals, 4 indicators (proportion of the specimen involved by adenocarcinoma, vascular involvement, periprostatic fat status, and PIN) were included in fewer than 50% of cases. These 4 quality indicators and an additional 3 others (submission of a frozen section, perineural involvement, and the number of nodes submitted) were included in fewer than 70% of cases. Only 3 indicators (location of the adenocarcinoma, seminal vesicle involvement, and the status of nodes) were found in more than 70% of cases. Although the mean level of quality indicator inclusion ranged from 14.8% to 85.9% for all cases examined, the absolute range for any individual indicator was 0% to 100%. Thus, some hospitals included a given indicator 100% of the time; others never included it. This pattern held true for all 10 indicators. High-volume hospitals (10 or more cases) performed significantly better than low-volume hospitals (1-4 cases) on 5 indicators (P < .05), and better, but not significantly so, for an additional 2 indicators. Overall, the mean inclusion levels for all 10 indicators were 10% higher for high-volume hospitals compared with low-volume and medium-volume hospitals (5-9 cases). This study demonstrated wide variations in the inclusion of quality indicators by pathologists in their radical prostatectomy-pathology reports. Whereas some hospitals always include given indicators, others never mentioned them. These marked disparities point to the need for standardized reporting for radical prostatectomy specimens.

Effectiveness of a state law mandating use of bicycle helmets among children: an observational evaluation.

In spring 1999, the authors evaluated the effectiveness of a 1997 Florida law requiring helmet use by all bicyclists younger than age 16 years. Sixty-four counties in Florida had enacted the bicycle helmet-use law, while the other three counties had opted out. Using a cross-sectional study design, the authors conducted unobtrusive observations at bicycle racks at public elementary schools statewide. Florida children riding bicycles in counties where the state helmet-use law was in place were twice as likely to wear helmets as children in counties without the law. In counties where the state law was in place, 16,907 (79%) of 21,313 riders observed wore a helmet, compared with only 148 (33%) of 450 riders in counties where no such law was in place (crude prevalence ratio = 2.4, 95% confidence interval: 2.1, 2.8). Helmet use by children of all racial groups exceeded 60% under the law. No significant difference in use by gender was found. These data support the positive influence of a law on bicycle helmet use among children. The data reinforce the Healthy People 2010 objective that all 50 states adopt such a law for children in order to increase helmet use and consequently reduce brain injury.

Mycobacterium tuberculosis transmission in a health clinic.

Between January 1 and June 30, 1988, 30 (39.5%) of 76 staff members tested at a health clinic in Florida had positive tuberculin skin test reactions. This case-control study showed that people whose skin test converted were more likely than those whose skin test did not convert to have been present while patients were being treated with aerosolized pentamidine (odds ratio = 15.0; 95% confidence interval = 1.4 - 730.0) and to have worked on the first floor of the clinic (odds ratio = 9.3; 95% confidence interval = 1.1 - 420). The clinic building was poorly ventilated, and aerosolized pentamidine treatments were given in a room from which the air tended to flow into the hallway. Aerosolized pentamidine should be administered in a well-ventilated area from which the air is exhausted directly outside. All persons who are given such treatments should first be screened for tuberculosis. Use of trade names is for identification only and does not constitute endorsement by the Public Health Services or the U.S. Department of Health and Human Services.

Outbreak of Mycobacterium chelonae infection associated with use of jet injectors.

Between January 1 and May 15, 1988, foot infections due to Mycobacterium chelonae subspecies abscessus were diagnosed in eight persons who had undergone invasive procedures at a podiatry office. A cohort study was performed to evaluate risk factors for disease. Persons who underwent procedures before 10:30 AM were more likely to have developed infection than those with procedures after that time (relative risk, 5.6). In addition, procedures involving any of the second through fourth toes were more likely to have resulted in infection than procedures involving only the first and/or fifth toes (relative risk, 4.4). Persons with 0, 1, or 2 risk factors had attack rates of 5%, 14%, and 60%, respectively. Mycobacterium chelonae subspecies abscessus organisms of the same antimicrobial resistance pattern as the patients' strains were cultured from distilled water in a reusable, nonsterilized container. A jet injector used to administer lidocaine was held between procedures in a mixture of the distilled water and a disinfectant as recommended by the manufacturer. Inoculation of patients with mycobacteria by the jet injector may have only occurred early in the day due to slow killing of the bacteria by the disinfectant. The outbreak emphasizes the pathogenicity of this water-associated organism and the need for high-level disinfection of jet injectors.

Comparison of the in vitro and in vivo cardiovascular effects of two structurally distinct Ca++ channel activators, BAY K 8644 and FPL 64176.

We compared the cardiovascular effects of two structurally distinct L-type Ca++ channel activators, the 1,4-dihydropyridine Bay K 8644 and the benzoylpyrrole FPL 64176. Both compounds prolonged action potential duration and enhanced contractility in guinea pig papillary muscle with these responses being greater in the presence of FPL 64176 compared to (S)-Bay K 8644. (S)-Bay K 8644 (300 nM) and FPL 64176 (300 nM) increased whole-cell Ca++ channel current amplitude in neonatal rat ventricular cells by 249 +/- 14 and 484 +/- 100%, respectively. (S)-Bay K 8644 had little effect on Ca++ channel activation but significantly enhanced the rate of Ca++ channel current inactivation. FPL 64176 significantly slowed Ca++ channel current activation and inactivation. Tail current decay at -50 mV was monoexponential in the presence of (S)-Bay K 8644 and had a time constant of 4.59 +/- 0.16 msec. FPL 64176 produced biexponential tail current decays at -50 mV with fast and slow time constants of 4.30 +/- 0.30 and 44.52 +/- 4.56 msec, respectively. Intravenous administration (1-100 micrograms/kg) of Bay K 8644 and FPL 64176 produced large increases in cardiac contractile force and diastolic blood pressure in anesthetized dogs. Pretreatment with nifedipine attenuated the blood pressure response to FPL 64176 but not the effects on cardiac contractility. This study demonstrates that the benzoylpyrrole FPL 64176 defines a new and potent class of Ca++ channel agonist molecule and that this compound has pharmacological activity that differs, at least in some respects, from the 1,4-dihydropyridine group of agonists.