Estimated mortality with early empirical antibiotic coverage of methicillin-resistant Staphylococcus aureus in hospitalized patients with bacterial infections: a systematic review and meta-analysis.

OBJECTIVES: We performed a systematic review and meta-analysis to estimate the effect of early active empirical antibiotics for MRSA on mortality, both in patients admitted with MRSA infections and in patients admitted with common infectious syndromes, for whom the causative pathogen may not have been MRSA. METHODS: A systematic literature search was conducted using Embase, MEDLINE, PubMed, Web of Science, Cochrane, Scopus and Google Scholar from the earliest entry through to 26 April 2022. We included studies of patients hospitalized with culture-proven MRSA infections that compared mortality rates depending on whether patients received active empirical antibiotics. The primary outcome was the adjusted OR for mortality with early active empirical antibiotics. After performing random-effects meta-analysis, we estimated the absolute risk reduction in mortality with initial empirical MRSA coverage for common infectious syndromes based on the prevalence of MRSA and baseline mortality rate for each syndrome, as reported in the medical literature. RESULTS: Of an initial 2136 unique manuscripts, 37 studies (11 661 participants) met our inclusion criteria. Fifteen studies (6066 participants) reported adjusted OR of mortality. The pooled adjusted OR for mortality was 0.64 (95% CI, 0.48-0.84), favouring active empirical antibiotics. The estimated absolute mortality benefit was 0% for patients with pneumonia, 0.1% (95% CI, 0.04-0.2) for non-critically ill patients with soft tissue infections, 0.04% (95% CI, 0.01-0.05) for non-critically ill patients with urinary tract infections, 0.6% (95% CI, 0.2-1.0) for patients with septic shock, and 1.0% (95% CI, 0.3-1.4) for patients with catheter-related infections admitted to ICUs. CONCLUSIONS: For the three most common infections in the hospital, the absolute benefit on mortality of empirical antibiotics against MRSA is 0.1% or less. Meaningful benefit of empirical antimicrobials against MRSA is limited to patients with approximately 30% mortality and 10% prevalence of MRSA. Avoiding empirical antibiotics against MRSA for low-risk infections would substantially reduce the use of anti-MRSA therapy.

Reducing Nighttime Interruptions and Improving Sleep for Hospitalized Patients by Restructuring Nighttime Clinical Workflow.

BACKGROUND: Nighttime sleep disruptions negatively impact the experience of hospitalized patients. OBJECTIVE: To determine the impact of adopting a sleep-promoting nighttime clinical workflow for hospitalized patients on nocturnal disruptions and sleep. DESIGN: Survey-based pre- and post-intervention cross-sectional study using convenience samples. PARTICIPANTS: Hospitalized veterans on a 23-bed general medical ward at a tertiary Veterans Administration Hospital. INTERVENTIONS: Baseline sleep surveys (N=149) identified two major sources of interruptions: blood pressure checks at 4 am for telemetry patients and subcutaneous (SQ) heparin injections between 4:30 and 6 am for venous thromboembolism prophylaxis. Clinical workflow was restructured to eliminate these disruptions: moving 4 am blood pressure checks to 6 am and providing daily SQ enoxaparin at 9 am as an alternative to Q 8-h SQ heparin, which had prompted an injection between 4:30 and 6 am. The impact of these changes was assessed in a second round of surveys (N=99). MAIN MEASURES: Frequency and sources for nighttime sleep disruptions; percentage of patients reporting longer time to fall asleep, more interruptions, and worse sleep quality (vs. home) before and after restructuring nighttime clinical workflow. KEY RESULTS: After restructuring nighttime clinical workflow, medication administration as a source of nighttime disruption decreased from 40% (59/149) to 4% (4/99) (p<0.001). Blood pressure checks as a source of disruption decreased from 56% (84/149) to 42% (42/99) (p=0.033). Fewer patients reported taking longer to fall asleep in the hospital vs. home (39% pre-intervention vs. 25% post-intervention, p=0.021). Similarly, fewer patients experienced waking up more frequently in the hospital vs. home (46% pre-intervention vs. 32% post-intervention, p=0.036). Fewer patients reported sleeping worse in the hospital (44% pre-intervention vs. 39% post-intervention), though this trend was not statistically significant (p=0.54). CONCLUSIONS: Nighttime disruptions in hospitalized patients frequently interfere with sleep. Restructuring of the clinical workflow significantly reduced disruptions and improved sleep.

Providing Structured Real-Time Feedback on Postdischarge Outcomes Using Electronic Health Record Data.

OBJECTIVES: Most trainees do not receive information about postdischarge outcomes, despite the importance of external feedback for accurate self-assessment and improvement in discharge planning skills. We aimed to design an intervention to foster reflection and self-assessment by trainees regarding how they can improve transitions of care with minimal investment of program resources. METHODS: We developed a low-resource session delivered near the end of an internal medicine inpatient rotation. Faculty, medical students, and internal medicine residents reviewed and reacted to postdischarge outcomes of their patients, explored understanding of the reasons for these outcomes, and developed goals for future practice. The intervention required minimal resources given that it was conducted during scheduled teaching time, did not require additional staff, and used already available data. Forty internal medicine resident and medical student participants completed pre- and postintervention surveys that evaluated their understanding of causes for poor patient outcomes, sense of responsibility for postdischarge outcomes, degree of self-reflection, and goals for future practice. RESULTS: Trainee understanding of the causes for poor patient outcomes was significantly different in several areas after completing the session. Trainees were less likely to believe that their responsibility for patients ends at the time of discharge, indicating an increase in sense of responsibility for postdischarge outcomes. After the session, 52.6% of trainees planned to change their approach to discharge planning, and 57.1% of attending physicians planned to change their approach to discharge planning with trainees. Through free-text responses, trainees noted that the intervention facilitated reflection and discussion about discharge planning and led to the development of goals to adopt specific behaviors for future practice. CONCLUSIONS: Meaningful information about postdischarge outcomes from the electronic health record can be used to provide feedback to trainees in a brief, low-resource session during an inpatient rotation. This feedback significantly affects trainee sense of responsibility for and understanding of postdischarge outcomes, which may lead to improved trainee ability to orchestrate transitions of care.

Symptom-Triggered Therapy for Alcohol Withdrawal Syndrome: a Systematic Review and Meta-analysis of Randomized Controlled Trials.

BACKGROUND: Benzodiazepines are the standard medication class for treating alcohol withdrawal. Guidelines recommend dosing based on objectively measured symptoms (symptom-triggered therapy) rather than fixed dose regimens. However, the superiority of symptom-triggered therapy has been questioned, and concerns have been raised about its inappropriate use and safety. We aimed to assess whether symptom-triggered therapy is superior to fixed dose schedules in terms of mortality, delirium, seizures, total benzodiazepine dose, and duration of therapy. METHODS: A systematic literature search using Medline, Embase, and the Cochrane Registry through February 2018 was conducted for randomized controlled trials of patients with alcohol withdrawal syndrome comparing fixed dose benzodiazepine schedules to symptom-triggered therapy. Risk of bias was assessed using the Cochrane Risk of Bias Tool. Outcomes were pooled using random effects meta-analysis. Heterogeneity was estimated using the I2 statistic. Strength of evidence was assessed using methods outlined by the Agency for Healthcare Research and Quality. RESULTS: Six studies involving 664 patients were included. There were no deaths and only one seizure in each group. Four studies reported delirium, which occurred in 4 out of 164 patients randomized to symptom-triggered therapy compared to 6 out of 164 randomized to fixed dose therapy (odds ratio, 0.64 [95% CI, 0.17-2.47]). Three studies reported duration of therapy, which was 60.4 h less with symptom-triggered therapy (95% CI, 39.7-81.1 h; p < 0.001). Six studies reported total benzodiazepine dosage, which was 10.5 mg in lorazepam-equivalent dosing less with symptom-triggered therapy (95% CI, 7.1-13.9 mg; p = 0.011). DISCUSSION: Moderate strength evidence suggests that symptom-triggered therapy improved duration of therapy and total benzodiazepine dose in specialized detoxification settings of low-risk patients but the applicability of this evidence in general hospital settings is low. There was insufficient evidence for any conclusions about symptom-triggered therapy for the major outcomes of mortality, seizure, and delirium in any setting. PROSPERO REGISTRATION: CRD42017073426.

Native Joint Septic Arthritis: Comparison of Outcomes with Medical and Surgical Management.

OBJECTIVE: To determine whether there are differences in the outcomes of native joint septic arthritis (SA) in adults, based on medical versus surgical management. METHODS: A 10-year retrospective single-center study was conducted of patients admitted to a tertiary care hospital between January 1, 2006 and December 31, 2015 with a diagnosis of SA to compare outcomes based on the management approach taken: medical (bedside closed-needle joint aspiration) versus surgical (arthrotomy/arthroscopy). Evaluated outcomes included joint recovery, time to recovery, length of stay, disposition to home versus rehabilitation unit, recurrence of SA in the same joint, and mortality. RESULTS: Of 118 confirmed cases of SA, 48 were in prosthetic joints and 70 were in native joints, and 61 met our inclusion criteria. Forty-one (67%) patients received surgery, and 20 (33%) received closed-needle aspiration. There was no statistically significant difference in long-term outcomes between the two groups at 12 months. Patients managed medically were more likely to experience full recovery at 3 months and were less likely to need short-term rehabilitation. CONCLUSIONS: Medical management with closed-needle aspiration may be an adequate approach to the treatment of native joint infections.

The "Hand-in" Project: Jump-starting Communication Between Inpatient and Outpatient Providers.

OBJECTIVES: Communication between hospitalists and primary care providers (PCPs) upon discharge has been much discussed, but the transition from outpatient to inpatient has received less attention. We questioned whether a brief, standardized e-mail from the hospitalist to the PCP upon admission could facilitate information exchange, increase communication, elucidate PCP preferences, and improve outcomes. METHODS: This prospective single-center study with a preintervention-to-postintervention design involved 300 inpatient admissions from June 2015 through October 2015 in the Veterans Affairs Connecticut Healthcare System. Hospitalists e-mailed an encrypted notification of admission along with standardized questions to PCPs within 1 day of admission. Measurements included the number of communications between PCPs and hospitalists, length of stay (LOS), 30-day readmissions, 30-day emergency department (ED) utilization rates, PCP preferences with regard to communication, and follow-up. RESULTS: Preintervention data for 94 patients during a 6-week period revealed 0.11 communications per patient, an LOS of 4.18 days, 30-day readmissions of 28.7%, and 30-day ED visits of 32%. Postintervention data on 206 patients during the next 12 weeks showed statistically significant increased communications per patient (0.5), and a nonsignificant decrease in LOS (3.96 days), 30-day readmissions (22.3%), and 30-day ED visits (31%). P values were <0.001, 0.67, 0.4, and 0.79, respectively. PCPs preferred e-mail communication upon discharge (40%) to telephone (25%) or instant messaging (13%), and 39% wanted a follow-up appointment within 2 weeks, regardless of what transpired. CONCLUSIONS: A hospitalist-led transition-of-care intervention designed to improve communication and information exchange between PCPs and hospitalists at the time of admission demonstrated that encrypted e-mail could be used as a tool to obtain useful additional medical and psychosocial information and to better understand PCP attitudes and preferences. The increased level of communication did not yield statistically significant decreases in LOS, 30-day readmission rates, or 30-day post-discharge ED visits, however.

Number of Consults and Response Times to ED: Effects on Patient Flow and Outcomes.

OBJECTIVES: 'he number of consults and response times to our Emergency Department (ED) were tracked to understand the effects on patient flow and outcomes. STUDY DESIGN: We conducted a prospective observational study using convenience samples. METHODS: There were 992 requests for physician consultations or logistical services (bed manager, transport, or room cleaning) logged during ED shifts from January through July, 2014 at the VA CT Healthcare System West Haven Campus (VACHS). Services were paged every 15 minutes until a response was received; the total response time was then recorded. One-hundred-eighty-six requests were triggered by one author's cohort of 392 patients, for which age, disposition, and outcomes were also tracked. RESULTS: The median response times were one to six minutes depending on the service requested; outli- ers exceeded an hour. A patient's ED stay duration increased with the number of services paged. The number of services paged was associated with mortality despite adjusting for age, ED waiting time, ED total time, and disposition (odds ratio = 3.14, P = .02) although comorbidity scores were not tracked. CONCLUSIONS: Response time to ED pages varies widely. The number of services paged correlated with ED length of stay and possibly inpatient mortality.

Gender Disparity in Full Professor Rank Among Academic Physicians: A Systematic Review and Meta-Analysis.

PURPOSE: The gender gap in promotion in academic medicine is well established. However, few studies have reported gender differences in promotion adjusted for scholarly production and national or international reputation, namely, career duration, publications, grant funding, and leadership positions. The authors performed a systematic review and meta-analysis of the differences between men and women in achieving benchmarks for promotion and analyze where such differences lie geographically and within specialties. METHOD: A systematic search of Academic Search Premier, Business Source Complete, Cochrane Library, ERIC, GenderWatch, Google Scholar, Embase, MEDLINE, PubMed, Scopus, and Web of Science was conducted from inception to August 17, 2022. All studies that reported the number of male and female full professors on medical school faculty were included. The primary outcome was the adjusted odds ratio (AOR) for promotion to full professor for women compared with men. RESULTS: Two hundred forty-four studies met the inclusion criteria. The unadjusted OR for promotion to full professor for women was 0.38 (95% confidence interval [CI], 0.36-0.41). Sixteen studies reported an AOR. The pooled AOR of promotion for women to full professor was 0.60 (95% CI, 0.46-0.77). The AOR for promotion to full professor was 0.55 (95% CI, 0.34-0.88) in surgery and 0.80 (95% CI, 0.57-1.11) in internal medicine. Statistical heterogeneity was high ( Q = 66.6, I2 = 79.4%, P < .001). On meta-regression, 77% of the heterogeneity was from studies outside the United States, where more disparity was reported (AOR, 0.29; 95% CI, 0.22-0.38). CONCLUSIONS: Most studies continued to find decreased promotion of women. Gender disparity was particularly notable in surgery and in studies from outside the United States. The results suggest that differences in promotion were due to differences in productivity and leadership and to gender bias.

Risk of Intestinal Necrosis With Sodium Polystyrene Sulfonate: A Systematic Review and Meta-analysis.

BACKGROUND: Reports of severe gastrointestinal side effects associated with sodium polystyrene sulfonate (SPS), particularly intestinal necrosis, have led some to recommend costlier alternative medications. No prior systematic review has included studies with controls reporting intestinal necrosis rates associated with SPS. METHODS: A systematic literature search was conducted using Cochrane Library, Embase, Medline, Google Scholar, PubMed, Scopus, and Web of Science Core Collection from database inception through October 4, 2020. We included any clinical trial, cohort, or case-control study reporting an association between SPS and intestinal necrosis or severe gastrointestinal side effects. RESULTS: Six studies including 26,716 patients treated with SPS with controls met inclusion criteria. The pooled odds ratio (OR) of intestinal necrosis was 1.43 (95% CI, 0.39-5.20). The pooled hazard ratio (HR) for intestinal necrosis from the two studies that performed survival analysis was 2.00 (95% CI, 0.45-8.78). The pooled HR for the composite outcome of severe gastrointestinal adverse events was 1.46 (95% CI, 1.01-2.11). CONCLUSION: Based on our review of six studies, the risk of intestinal necrosis with SPS is not statistically greater than controls, although there was a statistically significantly increased risk for the composite outcome of severe gastrointestinal side effects based on two studies. Because of the risk of bias from potential confounding and selective reporting, the overall strength of evidence to support an association between SPS and intestinal necrosis or other severe gastrointestinal side effects is low. PROSPERO registration CRD42020213119.

Prevalence of harmful diagnostic errors in hospitalised adults: a systematic review and meta-analysis.

BACKGROUND: Diagnostic error is commonly defined as a missed, delayed or wrong diagnosis and has been described as among the most important patient safety hazards. Diagnostic errors also account for the largest category of medical malpractice high severity claims and total payouts. Despite a large literature on the incidence of inpatient adverse events, no systematic review has attempted to estimate the prevalence and nature of harmful diagnostic errors in hospitalised patients. METHODS: A systematic literature search was conducted using Medline, Embase, Web of Science and the Cochrane library from database inception through 9 July 2019. We included all studies of hospitalised adult patients that used physician review of case series of admissions and reported the frequency of diagnostic adverse events. Two reviewers independently screened studies for inclusion, extracted study characteristics and assessed risk of bias. Harmful diagnostic error rates were pooled using random-effects meta-analysis. RESULTS: Twenty-two studies including 80 026 patients and 760 harmful diagnostic errors from consecutive or randomly selected cohorts were pooled. The pooled rate was 0.7% (95% CI 0.5% to 1.1%). Of the 136 diagnostic errors that were described in detail, a wide range of diseases were missed, the most common being malignancy (n=15, 11%) and pulmonary embolism (n=13, 9.6%). In the USA, these estimates correspond to approximately 249 900 harmful diagnostic errors yearly. CONCLUSION: Based on physician review, at least 0.7% of adult admissions involve a harmful diagnostic error. A wide range of diseases are missed, including many common diseases. Fourteen diagnoses account for more than half of all diagnostic errors. The finding that a wide range of common diagnoses are missed implies that efforts to improve diagnosis must target the basic processes of diagnosis, including both cognitive and system-related factors. PROSPERO REGISTRATION NUMBER: CRD42018115186.

Stethoscope hygiene: Using cultures and real-time feedback with bioluminescence-based adenosine triphosphate technology to change behavior.

BACKGROUND: Stethoscope hygiene is rarely done despite guideline recommendations. We wanted to determine whether demonstrating what is growing on the stethoscopes of providers via culture or bioluminescence technology alters perceptions and improves compliance. METHODS: Providers were given the opportunity to (1) culture their stethoscopes before and after disinfection with alcohol pads, alcohol-based hand rub, or hydrogen peroxide disinfectant wipes and (2) swab stethoscopes for bioluminescence-based adenosine triphosphate testing before and after disinfection. Outcomes were observed for hand and stethoscope hygiene rates and before and after intervention survey responses. The bacteria that were isolated, colony-forming units (CFU), and bioluminescence scores were tracked. RESULTS: A total of 1,245 observed hand hygiene opportunities showed that compliance improved from 72.5%-82.3% (P < .001). In addition, 590 observed patient-provider encounters revealed no significant change in stethoscope hygiene rates of 10% initially and 5% afterward (P = .08), although self-reported rates trended from 56%- 67% postintervention (P = .06). Perceptions regarding stethoscope hygiene importance improved (8.5/10 to 9.3/10; P = .04). Disinfection with alcohol pads, alcohol-based hand rub, and hydrogen peroxide disinfectant wipes were equivalent in CFU reduction (P = .21). CONCLUSIONS: Showing providers what is growing on their stethoscopes via cultures and bioluminescence technology before and after disinfection improved "buy in" regarding stethoscope hygiene importance. Both methods were rated as having an equal impact, however, objective observations failed to show improvement.

Auricular Acupuncture and Skin-Cancer Detection: An Opportunity.

Background: Auricular acupuncture is effective for many patients with pain. Many skin malignancies and precancerous lesions are found on the head and neck. Practitioners of acupuncture are in a unique situation to detect cutaneous malignancy at an early state. Case: An 83-year-old man referred for Battlefield Acupuncture was found to have a scalp lesion suspicious for malignancy as well as several precancerous lesions. Results: Referral to a dermatologist led to excision of a basal-cell cancer and treatment of actinic keratoses. Conclusions: Practitioners of auricular acupuncture should be familiar with common skin cancers and precancerous lesions; these practitioners are in a unique situation to detect these common skin lesions.

Can education influence stethoscope hygiene?

The importance of stethoscope hygiene has been demonstrated in prior studies, and is acknowledged by guidelines, yet it is rarely done. We implemented a pilot project consisting of provider education, reminder flyers and provision of cleaning supplies at the start of clinical rotations for housestaff, medical students, and attending physicians. Hand hygiene rates did not change significantly with rates between 58% and 63% while stethoscope hygiene remained at zero.

Diagnostic accuracy of methicillin-resistant Staphylococcus aureus nasal colonization to predict methicillin-resistant S aureus soft tissue infections.

Nasal methicillin-resistant Staphylococcus aureus (MRSA) testing at admission to the hospital was found to have a positive likelihood ratio of 8.5 and a negative likelihood ratio of 0.41 for predicting MRSA soft tissue infections. The clinical utility of this test depends on the prevalence of MRSA infection. In high prevalence populations, nasal MRSA is useful to rule in MRSA infections. In low prevalence populations it may be useful to rule out infections.