Neonatal Peripherally Inserted Central Catheter Practices and Providers: Results From the Neonatal PICC1 Survey.

BACKGROUND: Neonatal intensive care units (NICUs) commonly utilize peripherally inserted central catheters (PICCs) to provide nutrition and long-term medications to premature and full-term infants. However, little is known about PICC practices in these settings. PURPOSE: To assess PICC practices, policies, and providers in NICUs. METHODS: The Neonatal PICC1 Survey was conducted through the use of the electronic mailing list of a national neonatal professional organization's electronic membership community. Questions addressed PICC-related policies, monitoring, practices, and providers. Descriptive statistics were used to assess results. RESULTS: Of the 156 respondents accessing the survey, 115 (73.7%) indicated that they placed PICCs as part of their daily occupation. Of these, 110 responded to at least one question (70.5%) and were included in the study. Reported use of evidence-based practices by NICU providers varied. For example, routine use of maximum sterile barriers was reported by 90.4% of respondents; however, the use of chlorhexidine gluconate for skin disinfection was reported only by 49.4% of respondents. A majority of respondents indicated that trained PICC nurses were largely responsible for routine PICC dressing changes (61.0%). Normal saline was reported as the most frequently used flushing solution (46.3%). The most common PICC-related complications in neonates were catheter migration and occlusion. IMPLICATIONS FOR PRACTICE: Variable practices, including the use of chlorhexidine-based solutions for skin disinfection and inconsistent flushing, exist. There is a need for development of consistent monitoring to improve patient outcomes. IMPLICATIONS FOR RESEARCH: Future research should include exploration of specific PICC practices, associated conditions, and outcomes.

Longitudinal Study of Transfusion Utilization in Hospitalized Veterans.

OBJECTIVE: Although transfusion guidelines have changed considerably over the past two decades, the adoption of patient blood management programs has not been fully realized across hospitals in the United States. PATIENTS AND METHODS: We evaluated trends in red blood cell (RBC), platelet and plasma transfusion at three Veterans Health Administration (VHA) hospitals from 2000 through 2010. RESULTS: There were 176,521 hospitalizations in 69,621 patients; of these, 13.6% of hospitalizations involved transfusion of blood products (12.7% RBCs, 1.4% platelets, 3.0% plasma). Transfusion occurred in 25.2% of surgical and 5.3% of medical hospitalizations. Transfusion use peaked in 2002 for surgical hospitalizations and declined afterwards (p<0.001). There was no significant change in transfusion use over time (p=0.126) for medical hospitalizations. In hospitalizations that involved transfusions, there was a 20.3% reduction in the proportion of hospitalizations in which ≥3 units of RBCs were given (from 51.7% to 41.1%; p<0.001) and a 73.6% increase when one RBC unit was given (from 8.0% to 13.8%; p<0.001) from 2000-2010. Of the hospitalizations with RBC transfusion, 9.6% involved the use of one unit over the entire study period. The most common principal diagnoses for medical patients receiving transfusion were anemia, malignancy, heart failure, pneumonia and renal failure. Over time, transfusion utilization increased in patients who were admitted for infection (p=0.009). CONCLUSION: Blood transfusions in three VHA hospitals have decreased over time for surgical patients but remained the same for medical patients. Further study examining appropriateness of blood products in medical patients appears necessary.

Do clinicians know which of their patients have central venous catheters?: a multicenter observational study.

BACKGROUND: Complications associated with central venous catheters (CVCs) increase over time. Although early removal of unnecessary CVCs is important to prevent complications, the extent to which clinicians are aware that their patients have a CVC is unknown. OBJECTIVE: To assess how often clinicians were unaware of the presence of triple-lumen catheters or peripherally inserted central catheters (PICCs) in hospitalized patients. DESIGN: Multicenter, cross-sectional study. SETTING: 3 academic medical centers in the United States. PATIENTS: Hospitalized medical patients in intensive care unit (ICU) and non-ICU settings. MEASUREMENTS: To ascertain awareness of CVCs, whether a PICC or triple-lumen catheter was present was determined; clinicians were then queried about device presence. Differences in device awareness among clinicians were assessed by chi-square tests. RESULTS: 990 patients were evaluated, and 1881 clinician assessments were done. The overall prevalence of CVCs was 21.1% (n=209), of which 60.3% (126 of 209) were PICCs. A total of 21.2% (90 of 425) of clinicians interviewed were unaware of the presence of a CVC. Unawareness was greatest among patients with PICCs, where 25.1% (60 of 239) of clinicians were unaware of PICC presence. Teaching attendings and hospitalists were more frequently unaware of the presence of CVCs than interns and residents (25.8% and 30.5%, respectively, vs. 16.4%). Critical care physicians were more likely to be aware of CVC presence than general medicine physicians (12.6% vs. 26.2%; P=0.003). LIMITATIONS: Awareness was determined at 1 point in time and was not linked to outcomes. Patient length of stay and indication for CVC were not recorded. CONCLUSION: Clinicians are frequently unaware of the presence of PICCs and triple-lumen catheters in hospitalized patients. Further study of mechanisms that ensure that clinicians are aware of these devices so that they may assess their necessity seems warranted. PRIMARY FUNDING SOURCE: None.

The use of multiple qualitative methods to characterize communication events between physicians and nurses.

Despite the importance of communication to patient safety in hospital settings, we know surprisingly little about communication patterns between physicians and nurses, particularly on general medical-surgical units. Poor communication is the leading cause of preventable adverse events in hospitals, as well as a major root cause of sentinel events. The literature provides little guidance on what qualitative methods are best for capturing different types of communication events and patterns. The purpose of this study was to develop a methodology for identifying and characterizing communication events between physicians and nurses to better understand communication patterns on general medical-surgical units. We used a sequential qualitative mixed method design beginning with general observation, progressing to shadowing and focus groups of physicians and nurses who worked on two medical-surgical units at one academically affiliated U.S. Department of Veterans Affairs (VA) hospital. Each data collection method (observation, shadowing, and focus groups) had its own advantages and disadvantages for capturing communication events and patterns. Through observation we were able to see the "what": communication activities. Shadowing was most useful for understanding "how" physicians and nurses communicated. Focus groups helped answer "why" certain patterns emerged and allowed us to further explore communication events within a group setting. By using all three methods we were able to more thoroughly characterize communication events than by using a single method alone, providing a more holistic picture of how communication occurs on an inpatient medical-surgical unit.

Identifying patients with severe sepsis using administrative claims: patient-level validation of the angus implementation of the international consensus conference definition of severe sepsis.

BACKGROUND: Severe sepsis is a common and costly problem. Although consistently defined clinically by consensus conference since 1991, there have been several different implementations of the severe sepsis definition using ICD-9-CM codes for research. We conducted a single center, patient-level validation of 1 common implementation of the severe sepsis definition, the so-called "Angus" implementation. METHODS: Administrative claims for all hospitalizations for patients initially admitted to general medical services from an academic medical center in 2009-2010 were reviewed. On the basis of ICD-9-CM codes, hospitalizations were sampled for review by 3 internal medicine-trained hospitalists. Chart reviews were conducted with a structured instrument, and the gold standard was the hospitalists' summary clinical judgment on whether the patient had severe sepsis. RESULTS: Three thousand one hundred forty-six (13.5%) hospitalizations met ICD-9-CM criteria for severe sepsis by the Angus implementation (Angus-positive) and 20,142 (86.5%) were Angus-negative. Chart reviews were performed for 92 randomly selected Angus-positive and 19 randomly-selected Angus-negative hospitalizations. Reviewers had a κ of 0.70. The Angus implementation's positive predictive value was 70.7% [95% confidence interval (CI): 51.2%, 90.5%]. The negative predictive value was 91.5% (95% CI: 79.0%, 100%). The sensitivity was 50.4% (95% CI: 14.8%, 85.7%). Specificity was 96.3% (95% CI: 92.4%, 100%). Two alternative ICD-9-CM implementations had high positive predictive values but sensitivities of <20%. CONCLUSIONS: The Angus implementation of the international consensus conference definition of severe sepsis offers a reasonable but imperfect approach to identifying patients with severe sepsis when compared with a gold standard of structured review of the medical chart by trained hospitalists.

Determining the noninfectious complications of indwelling urethral catheters: a systematic review and meta-analysis.

BACKGROUND: Although the epidemiology of catheter-associated urinary tract infection is well-described, little is known about noninfectious complications resulting from urethral catheter use. PURPOSE: To determine the frequency of noninfectious complications after catheterization. DATA SOURCES: MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, CINAHL, Conference Papers Index, BIOSIS Previews, Scopus, and ClinicalTrials.gov were searched for human studies without any language limits and through 30 July 2012. STUDY SELECTION: Clinical trials and observational studies assessing noninfectious complications of indwelling urethral catheters in adults. DATA EXTRACTION: Relevant studies were sorted into 3 categories: short-term catheterization in patients without spinal cord injury (SCI), long-term catheterization in patients without SCI, and catheterization in patients with SCI. The proportion of patients who had bladder cancer, bladder stones, blockage, false passage, gross hematuria, accidental removal, urine leakage, or urethral stricture was then pooled using random-effects models. DATA SYNTHESIS: Thirty-seven studies (2868 patients) were pooled. Minor complications were common. For example, the pooled frequency of urine leakage ranged from 10.6% (95% CI, 2.4% to 17.7%) in short-term catheterization cohorts to 52.1% (CI, 28.6% to 69.5%) among outpatients with long-term indwelling catheters. Serious complications were also noted, including urethral strictures, which occurred in 3.4% (CI, 1.0% to 7.0%) of patients with short-term catheterization. For patients with SCI, 13.5% (CI, 3.4% to 21.9%) had gross hematuria and 1.0% (CI, 0.0% to 5.0%) developed bladder cancer. LIMITATIONS: Although heterogeneity existed across studies for several outcomes, most could be accounted for by differences between studies with respect to quality and sex composition. Evidence published after 30 July 2012 is not included. CONCLUSION: Many noninfectious catheter-associated complications are at least as common as clinically significant urinary tract infections. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality.

Health care-associated infection after red blood cell transfusion: a systematic review and meta-analysis.

IMPORTANCE: The association between red blood cell (RBC) transfusion strategies and health care-associated infection is not fully understood. OBJECTIVE: To evaluate whether RBC transfusion thresholds are associated with the risk of infection and whether risk is independent of leukocyte reduction. DATA SOURCES: MEDLINE, EMBASE, Web of Science Core Collection, Cochrane Central Register of Controlled Trials, Cochrane Database of Sytematic Reviews, ClinicalTrials.gov, International Clinical Trials Registry, and the International Standard Randomized Controlled Trial Number register were searched through January 22, 2014. STUDY SELECTION: Randomized clinical trials with restrictive vs liberal RBC transfusion strategies. DATA EXTRACTION AND SYNTHESIS: Twenty-one randomized trials with 8735 patients met eligibility criteria, of which 18 trials (n = 7593 patients) contained sufficient information for meta-analyses. DerSimonian and Laird random-effects models were used to report pooled risk ratios. Absolute risks of infection were calculated using the profile likelihood random-effects method. MAIN OUTCOMES AND MEASURES: Incidence of health care-associated infection such as pneumonia, mediastinitis, wound infection, and sepsis. RESULTS: The pooled risk of all serious infections was 11.8% (95% CI, 7.0%-16.7%) in the restrictive group and 16.9% (95% CI, 8.9%-25.4%) in the liberal group. The risk ratio (RR) for the association between transfusion strategies and serious infection was 0.82 (95% CI, 0.72-0.95) with little heterogeneity (I2 = 0%; τ2 <.0001). The number needed to treat (NNT) with restrictive strategies to prevent serious infection was 38 (95% CI, 24-122). The risk of infection remained reduced with a restrictive strategy, even with leukocyte reduction (RR, 0.80 [95% CI, 0.67-0.95]). For trials with a restrictive hemoglobin threshold of <7.0 g/dL, the RR was 0.82 (95% CI, 0.70-0.97) with NNT of 20 (95% CI, 12-133). With stratification by patient type, the RR was 0.70 (95% CI, 0.54-0.91) in patients undergoing orthopedic surgery and 0.51 (95% CI, 0.28-0.95) in patients presenting with sepsis. There were no significant differences in the incidence of infection by RBC threshold for patients with cardiac disease, the critically ill, those with acute upper gastrointestinal bleeding, or for infants with low birth weight. CONCLUSIONS AND RELEVANCE: Among hospitalized patients, a restrictive RBC transfusion strategy was associated with a reduced risk of health care-associated infection compared with a liberal transfusion strategy. Implementing restrictive strategies may have the potential to lower the incidence of health care-associated infection.

Committed to Success: A Structured Mentoring Program for Clinically Oriented Physicians.

Objective: To examine impacts of a structured mentorship committee program on academic promotion and participant perceptions because impacts of formal mentorship programs for clinical faculty are unknown. Participants and Methods: This prospective cohort study at a Midwestern Veterans Affairs tertiary care system from December 17, 2019 to December 31, 2022 included clinical track faculty in the Medicine Service below the rank of Clinical Associate Professor. Mentoring meetings (mentee, committee chair, and mentors) were generally held twice annually. All participants were surveyed after each meeting (response rate: 100%). Results: All 23 of 23 (100%) eligible faculty were enrolled as mentees, and 49 distinct meetings occurred. Three (13%) mentees were promoted, and the remaining 20 (87%) continued in the program. Mean scores (SD), scaled 1 (strongly disagree) to 5 (strongly agree), for mentors and mentees were 4.71 (0.51) and 4.80 (0.54) for "effective use of my time"; 4.58 (0.64) and 4.37 (0.49) for "appropriate progress since last meeting"; 4.52 (0.66) and 4.31 (0.64) for "program increased my work satisfaction"; and 4.07 (0.96) and 3.75 (0.92) for "program reduced my work burnout," respectively. Conclusion: Clinically oriented physicians viewed the program positively. It appeared to help junior faculty get promoted and led to improved work satisfaction and reduced burnout.

Awareness of peripheral IV catheters among nurses, physicians, and trainees: A prospective cohort study.

BACKGROUND: Peripheral intravenous catheters (PIVs) are the most frequently used invasive device in hospitalized patients. These devices are not benign and are associated with complications. However, clinician awareness of them is variable and poorly understood. METHODS: We conducted a prospective, multicenter, observational point prevalence study to assess awareness of PIV presence among clinicians caring for hospitalized patients in 4 hospitals between May 2018 and February 2019 located in Michigan, USA. We first assessed patients for the presence of a PIV then interviewed their providers. Differences in awareness by provider type were assessed via χ² tests; P < .05 was considered statistically significant. Analyses were performed on Stata MP v16. RESULTS: A total of 1,385 patients and 4,003 providers were interviewed. Nurses had the greatest awareness of overall PIV presence, 98.6%, while attendings were correct 88.1% of the time. Nurses were more likely to correctly assess PIV presence and exact location than physicians (67.7% vs <30% for all others). Awareness of PIV presence did not significantly vary in patients on contact precautions or those receiving infusions. CONCLUSIONS: Given the ubiquity of PIVs and known complications, methods to increase awareness to ensure appropriate care and removal are necessary.

Functional outcomes of general medical patients with severe sepsis.

BACKGROUND: Severe sepsis is a common cause for admission to the general medical ward. Previous work has demonstrated substantial new long-term disability in patients with severe sepsis, but the short-term functional outcomes of patients admitted to the general medical floor -- where the majority of severe sepsis is treated -- are largely unknown. METHODS: A retrospective cohort study was performed of patients initially admitted to non-ICU medical wards at a tertiary care academic medical center. Severe sepsis was confirmed by three physician reviewers, using the International Consensus Conference definition of sepsis. Baseline functional status, disposition location, and receipt of post-acute skilled care were recorded using a structured abstraction instrument. RESULTS: 3,146 discharges had severe sepsis by coding algorithm; from a random sample of 111 patients, 64 had the diagnosis of severe sepsis confirmed by reviewers. The mean age of the 64 patients was 63.5 years +/- 18.0. Prior to admission, 80% of patients lived at home and 50.8% of patients were functionally independent. Inpatient mortality was 12.5% and 37.5% of patients were discharged to a nursing facility. Of all patients in the cohort, 50.0% were discharged home, and 66.7% of patients who were functionally independent at baseline were discharged to home. CONCLUSIONS: New physical debility is a common feature of severe sepsis in patients initially cared for on the general medical floor. Debility occurs even in those with good baseline physical function. Interventions to improve the poor functional outcomes of this population are urgently needed.

International patient preferences for physician attire: results from cross-sectional studies in four countries across three continents.

OBJECTIVE: The patient-physician relationship impacts patients' experiences and health outcomes. Physician attire is a form of nonverbal communication that influences this relationship. Prior studies examining attire preferences suffered from heterogeneous measurement and limited context. We thus performed a multicentre, cross-sectional study using a standardised survey instrument to compare patient preferences for physician dress in international settings. SETTING: 20 hospitals and healthcare practices in Italy, Japan, Switzerland and the USA. PARTICIPANTS: Convenience sample of 9171 adult patients receiving care in academic hospitals, general medicine clinics, specialty clinics and ophthalmology practices. PRIMARY AND SECONDARY OUTCOME MEASURES: The survey was randomised and included photographs of a male or female physician dressed in assorted forms of attire. The primary outcome measure was attire preference, comprised of composite ratings across five domains: how knowledgeable, trustworthy, caring and approachable the physician appeared, and how comfortable the respondent felt. Secondary outcome measures included variation in preferences by country, physician type and respondent characteristics. RESULTS: The highest rated forms of attire differed by country, although each most preferred attire with white coat. Low ratings were conferred on attire extremes (casual and business suit). Preferences were more uniform for certain physician types. For example, among all respondents, scrubs garnered the highest rating for emergency department physicians (44.2%) and surgeons (42.4%). However, attire preferences diverged for primary care and hospital physicians. All types of formal attire were more strongly preferred in the USA than elsewhere. Respondent age influenced preferences in Japan and the USA only. CONCLUSIONS: Patients across a myriad of geographies, settings and demographics harbour specific preferences for physician attire. Some preferences are nearly universal, whereas others vary substantially. As a one-size-fits-all dress policy is unlikely to reflect patient desires and expectations, a tailored approach should be sought that attempts to match attire to clinical context.

Knowledge of hepatocellular carcinoma screening guidelines and clinical practices among gastroenterologists.

BACKGROUND: Screening of high-risk patients for hepatocellular carcinoma (HCC) may result in early diagnosis and improved outcomes. Our aim was to assess gastroenterologists' knowledge of HCC management guidelines established by the American Association for the Study of Liver Diseases (AASLD) and usual clinical practice. METHODS: We surveyed gastroenterologists attending two gastroenterology board review courses regarding their knowledge of HCC screening guidelines and usual practice of screening for HCC. Practices were compared and adherence to the 2005 published HCC guidelines was assessed. RESULTS: The median age of gastroenterology attending physicians (n = 160) was 41 years, and 75% were men with a median of 11.5 years of practice. A total of 79% of respondents correctly identified the high-risk patients who qualify for HCC screening. Most gastroenterologists correctly identified the screening methods (88.5%) and screening interval (98%). Among those who knew guideline recommendations (i.e., correct identification and certainty of guideline recommendations), 100% reported that they followed the guideline recommendation in their own practices. Regarding the management of abnormal test, 31% of gastroenterologists did not identify that referral for liver transplantation is the recommended management strategy for small HCC in a Child B patient with cirrhosis. The number of years in clinical practice (p = 0.30) and involvement in a malpractice suit (p = 0.34) did not affect the practice patterns. CONCLUSIONS: Most gastroenterologists correctly identified the common high-risk scenarios, methods, and interval of HCC screening as recommended by AASLD. Gastroenterologists who knew the HCC guidelines applied them in their own practice. However, approximately one-quarter do not know the appropriate management of a positive result, thereby likely hampering the overall effectiveness of screening.

Randomized trial using hair stylists as lay health advisors to increase donation in African Americans.

OBJECTIVE: To test the efficacy of using hair stylists as lay health advisors to increase organ donation among African American clients. DESIGN: This study was a randomized, controlled intervention trial where we randomized 52 salons (2,789 clients) to receive a 4 session, stylist-delivered health education program (comparison) or a four session brief motivational intervention that encouraged organ donation (intervention). Intervention stylists received a four-hour training in organ donation education and counseling. Organ donation was measured by self-report questionnaire at 4-month posttest as well as by verified enrollment in the Michigan Organ Donor Registry. SETTING: Hair salons in Michigan urban areas. PARTICIPANTS: Blacks (n = 2,449), non-Blacks (n = 261) in Michigan. MAIN OUTCOME MEASURES: Self-reported donation status, registration in Michigan Organ Donor Registry. RESULTS: At posttest, rates of self-reported positive donation status were 19.8% in the intervention group and 16.0% in the comparison group. In multivariate analyses, intervention participants were 1.7 times (95% Cl = 0.98-2.8) more likely than comparison participants to report positive donation status at posttest. Based on verified organ registry data, enrollment rates were 4.8% and 2%, respectively for the intervention and comparison groups. In multivariate analyses, intervention group members were 4.4 (95% CI = 1.3-15.3) more likely to submit an enrollment card than comparison participants. CONCLUSION: Clients of hair stylists trained to provide brief motivational intervention for organ donation were approximately twice as likely to enroll in the donor registry as comparison clients. Use of lay health advisors appears to be a promising approach to increase donation among African Americans.

Patient Preferences for Physician Attire: A Multicenter Study in Japan.

BACKGROUND: Previous studies have shown that patients have specific expectations regarding physician dress. Japan has a cultural background that is in many ways distinct from western countries. Thus, physician attire may have a different impact in Japan. METHODS: We conducted a multicenter, cross-sectional study to examine patients' preferences for and perceptions of physician attire in Japan. The questionnaire was developed using photographs of either a male or female physician dressed in seven different forms of attire, and it was randomly distributed to inpatients and outpatients. Respondents were asked to rate the provider pictured; they were also asked to provide preferences for different forms of attire in varied clinical settings. Preference was evaluated for five domains (knowledgeable, trustworthy, caring, approachable, and comfortable). We also assessed variation in preferences for attire by respondent characteristics. RESULTS: A total of 1,233 (61%) patients indicated that physician dress was important, and 950 (47%) patients agreed that it influenced their satisfaction with care. Compared with all forms, casual attire with a white coat was the most preferred dress. Older patients more often preferred formal attire with a white coat in primary care and hospital settings. In addition, physician attire had a greater impact on older respondents' satisfaction and experience. CONCLUSION: The majority of Japanese patients indicated that physician attire is important and influenced their satisfaction with care. Geography, settings of care, and patient age appear to play a role in patient preferences.

Why don't gastroenterologists follow colon polyp surveillance guidelines?: results of a national survey.

GOALS: To measure knowledge and acceptance of colon polyp surveillance guidelines among gastroenterologists. BACKGROUND: Gastroenterologists often perform surveillance colonoscopy sooner than recommended by guidelines. Lack of knowledge may be an important factor, but gastroenterologists could also simply disagree with guideline recommendations. STUDY: A 24-item multiple-choice survey was developed from the 2003 multisociety colorectal cancer screening and surveillance guideline. The survey was distributed to practicing gastroenterologists preparing for the gastroenterology board recertification examination at 2 major national gastroenterology board review courses. For each question, subjects were given a clinical scenario and asked: (1) the guideline recommendation for the scenario; (2) their usual practice in the scenario; and, (3) if they definitely knew the recommendation or were simply guessing at the correct answer. If a respondent knew the recommendation but differed in their usual practice, this was considered disagreement with the recommendation. RESULTS: The survey was completed by 57.1% (116/203) of gastroenterologists preparing for 2004 recertification. Seventy-eight percent reported that they were familiar with the 2003 guideline, though only 57% reported that guidelines were "very influential" in their practice. Many did not correctly answer questions on the recommended interval for hyperplastic polyps (12%), 2 small adenomas (36%), 3 small adenomas (49%), and adenoma with high-grade dysplasia (41%). Of gastroenterologists who knew the guideline recommendations, up to 76% disagreed with the recommendations and chose to perform surveillance sooner than recommended. CONCLUSIONS: Though many gastroenterologists lack knowledge about guideline recommendations for colon polyp surveillance, even those who know the recommendations often ignore them and perform surveillance colonoscopy sooner than recommended.

Use of Designated Nurse PICC Teams and CLABSI Prevention Practices Among U.S. Hospitals: A Survey-Based Study.

OBJECTIVES: The use of peripherally inserted central catheters (PICCs) has increased substantially within hospitals during the past several years. Yet, the prevalence and practices of designated nurse PICC teams (i.e., specially trained nurses who are responsible for PICC insertions at a hospital) are unknown. We, therefore, identified the prevalence of and factors associated with having a designated nurse PICC team among U.S. acute care hospitals. METHODS: We conducted a survey of infection preventionists at a random sample of U.S. hospitals in May 2013, which asked about personnel who insert PICCs and the use of practices to prevent device-associated infections, including central line-associated bloodstream infection. We compared practice use between hospitals that have a designated nurse PICC team versus those that do not. RESULTS: Survey response rate was 70% (403/575). According to the respondents, nurse PICC teams inserted PICCs in more than 60% of U.S. hospitals in 2013. Moreover, certain practices to prevent central line-associated bloodstream infection, including maximum sterile barrier precautions (93% versus 88%, P = 0.06), chlorhexidine gluconate for insertion site antisepsis (96% versus 87%, P = .003) and facility-wide insertion checklists (95% versus 87%, P = 0.02) were regularly used by a higher percentage of hospitals with nurse PICC teams compared with those without. CONCLUSIONS: These data suggest that nurse PICC teams play an integral role in PICC use at many hospitals and that use of such teams may promote key practices to prevent complications. Better understanding of the role, composition, and practice of such teams is an important area for future study.

Patient Preferences for Telemedicine Video Backgrounds.

This cross-sectional study assesses patient preferences for various visual backgrounds during telemedicine video visits.

Role of transfusions in the development of hospital-acquired urinary tract-related bloodstream infection among United States Veterans.

BACKGROUND: Urinary tract-related bloodstream infection (BSI) is associated with substantial morbidity, mortality, and financial costs. We examined the role of red blood cell (RBC) transfusions on developing this condition among US Veterans. METHODS: We conducted a matched case-control study among adult inpatients admitted to 4 Veterans Affairs hospitals. Cases were patients with a positive urine culture result obtained 48hours or longer after admission and a blood culture obtained within 14days of the urine culture, which grew the same organism. Controls included patients with a positive urine culture result who were at risk for but did not develop BSI (control group 1) and patients without a positive urine culture result who were present in the facility at the time of case diagnosis (control group 2). RESULTS: Compared with the findings in control group 1, receipt of RBCs was not significantly associated with urinary tract-related BSI (odds ratio, 1.03; 95% confidence interval, 1.00-1.07; P = .07). However, we found increased odds of urinary tract-related BSI compared with the results in patients without infection (control group 2) (odds ratio, 1.11; 95% confidence interval, 1.06-1.17; P < .001). CONCLUSIONS: Given the heightened risk of urinary tract-related BSI associated with receiving a greater number of RBC transfusions, adhering to recommendations to transfuse the minimum amount of blood products necessary may minimize the risk of this infection among Veterans.

Patient-reported complications related to peripherally inserted central catheters: a multicentre prospective cohort study.

OBJECTIVE: Peripherally inserted central catheters (PICC) are frequently used to deliver medical therapies, but our knowledge regarding PICC-related complications remains incomplete. The objective of this study was to systematically elicit and characterise PICC-related complications as experienced by patients during and after hospitalisation. DESIGN: Prospective cohort study. SETTING: Inpatient medical units at four US hospitals in two states. PARTICIPANTS: Consecutive sample of patients who had a new PICC placed during a hospital stay between August 2015 and May 2017. MAIN OUTCOMES: Patient-reported signs and symptoms of a possible PICC-related complication or functional issues. RESULTS: Of the 438 patients in the analytic cohort (91.4% of those consented), two-thirds were male with a mean age of 56 years. The most common reason for PICC placement was long-term antibiotic therapy (43.4%). During the 70-day follow-up period, 61.4% of patients reported signs of at least one complication, including potentially serious complications, such as bloodstream infection (17.6%) and deep vein thrombosis (30.6%). Correspondence of these reported events with medical record documentation of the complication was generally low. More than one-quarter (27.9%) of patients reported minor complications, such as insertion site redness, discomfort or difficult removal. While the PICC was in place, 26.0% reported restrictions in activities of daily living, 14.4% social activity restrictions and 19.2% had difficulty with flushing or operating the PICC. CONCLUSION: Over 60% of patients report signs or symptoms of a possible complication or adverse effect after PICC placement. Bothersome complications from the patient perspective are clearly more common than those that typically rise to the level of healthcare provider attention or concern. Understanding the patient experience is critical for providing safe and effective care.

Patient Preferences for Physician Attire in Ophthalmology Practices.

IMPORTANCE: Interest is growing in targeting physician attire to improve the patient experience. Few studies in ophthalmology have examined patient preferences for physician attire. OBJECTIVE: To understand patient preferences for physician attire in ophthalmology practices in the United States. DESIGN: Survey-based, cohort study. SETTING: Two private and two academic ophthalmology practices. PARTICIPANTS: A convenience sample of patients receiving ophthalmic care between June 1, 2015 and October 31, 2016. METHODS: A questionnaire containing 22 questions and photographs of a male and female physician in seven forms of attire were presented to patients; 14 unique questionnaires were randomly distributed. Patient preference for physician attire was the primary outcome determined by summing ratings of how knowledgeable, trustworthy, caring, approachable, and comfortable the pictured physician made the respondent feel. One-way ANOVA assessed differences in mean composite scores. Comparisons between respondent demographics, practice type, and attire preferences were assessed by chi-square tests. Patient satisfaction was assessed by agreement with questions about importance of physician attire and whether this influences happiness with care. RESULTS: In total, 1,297 of 1,826 (71.0%) questionnaires were completed. Physician attire was rated as "important" by 62.9% of participants. A total of 43.6% of participants indicated that physician attire influenced how happy they were with their care. Overall, formal attire with white coat was preferred to casual, formal, and business attire (all comparisons, p < 0.05). No differences in composite scores between formal attire with white coat, scrubs alone, scrubs with white coat, or casual attire with white coat were observed. However, compared with formal attire with white coat, physicians wearing scrubs without white coat appeared less knowledgeable (mean [standard deviation]: 8.2 [1.8] vs. 7.4 [2.1]; p < 0.05) and trustworthy (8.3 [1.8] vs. 7.6 [2.1]; p < 0.05). Additionally, casual attire with white coat was rated as less knowledgeable compared with formal attire with white coat (7.4 [2.0] vs. 8.2 [1.8]; p < 0.05). Preferences for attire varied by clinical setting: patients preferred surgeons (45.2%) and physicians in emergency rooms (41.7%) in scrubs rather than formal attire with white coat. CONCLUSIONS: Physician attire is important to patients receiving ophthalmic care. Policies aimed at physician attire in ophthalmology practices should be considered.