Enhancing hospitalists smoking cessation counseling and billing compliance by education intervention: a quality improvement project.

Smoking causes an estimated 480,000 deaths every year. At our institute, tobacco treatment services (TTS) provide inpatient counseling and hospitalists have an essential role in providing education and replacement medications at discharge. Our project focused on increasing knowledge among hospitalists to improve the frequency of smoking cessation consultation and utilization of pharmacotherapy, accompanied by appropriate documentation and billing. We used baseline data from March 2018 to February 2019. Educational intervention was implemented from March 2019 to June 2019. Post-intervention results are reported from July 2019 to February 2020. Pre- and post-intervention periods' results were compared. A significantly higher number of patients received TTS counseling during the post-intervention phase compared to pre-intervention (54 vs. 41%, p < 0.0001). A significantly higher number of patients were prescribed inpatient medications (42% to 48%, p = 0.004) and at the time of discharge (22% to 31%, p < 0.0001). However, there was a significant decrease in physician billing from pre-intervention to post-intervention, dropping from 19.5% to 16.2% (p = 0.012). Physicians' gender, experience level, and loss of incentives impacted their consultation and billing behaviors. Future studies should continue to address the importance of TTS and physician behavior on increasing inpatient smoking cessation counseling and treatment.

Improving Pneumococcal Vaccination Rates in Rheumatology Patients by Using Best Practice Alerts in the Electronic Health Records.

OBJECTIVE: To improve pneumococcal vaccination (PV) rates among rheumatology clinic patients on immunosuppressive therapy in the outpatient settings. METHODS: This quality improvement project was based on the pre-post intervention design. Phase I of the project targeted patients with rheumatoid arthritis from 13 rheumatology clinics (January 2013-July 2015) on immunosuppressive therapy to receive the pneumococcal polysaccharide vaccine (PPSV23). In the Phase II study (January 2016-October 2017), all patients on immunosuppressive medications regardless of diagnosis were targeted to receive PPSV23 and the pneumococcal conjugate vaccine (PCV13). The best practice alerts (BPAs) for both PVs were developed based on the Centers for Disease Control and Prevention guidelines, which appeared on electronic medical records for eligible patients at the time of assessment by the medical assistant. The BPA was designed to inform the vaccination status and enable the physician to order the PV, or to document refusal or deferral reasons. Education regarding vaccine guidelines, BPAs, vaccination process, and regular feedback of results were important project interventions. The vaccination rates during pre-post intervention for each study phase were compared using chi-square test. RESULTS: During phase I, PPSV23 vaccination rates improved from a 28% preintervention rate to 61.5% (P < 0.0001). During phase II, 77.4% of patients had received either PPSV23, PCV13, or both, compared to 49.6% of patients in the preintervention period (P < 0.0001). The documentation rates (vaccine received, ordered, patient refusal and deferral reasons) increased significantly in both phases. CONCLUSION: Electronic identification of vaccine eligibility and implementation of BPAs with capabilities to order and document resulted in significantly improved PV rates. The process has potential for self-sustainability and generalizability.

Organism-specific bacteremia by hemodialysis access.

BACKGROUND: Data on hemodialysis (HD)-related organism specific bacteremia rates by type of access over an extended period are scant in the literature. Using a registry data base we examined all positive blood cultures by organisms for each type of HD access over 14 years. METHODS: The IRB-approved registry data collection of prevalent patients at our HD unit from 1/1/1999 through 12/31/2012 was analyzed. All positive blood cultures were recorded and expressed as episodes/1,000 days by access type: arteriovenous fistula (AVF), arteriovenous graft (AVG), and central venous catheter (CVC). RESULTS: The rate of positive blood cultures in patients with CVCs was 1.86/1,000 days and was much higher than in patients with an AVF (0.08/1,000 days, p < 0.001) or an AVG (0.31/1,000 days, p < 0.002). There was considerable fluctuation in the bacteremia rate in CVCs with a spike during 2004 - 2008, due predominately to coagulase-negative staphylococcus (CNS) bacteremia. The rate subsequently decreased after retraining of staff. The exit site infection (ESI) rate of CVCs was low, suggesting this was not contributing to the cause of the increase rate of CNS bacteremia. Those patients using a CVC had a markedly increased risk of multiple episodes compared to those using an AVF. Bacteremia with Pseudomonas, polymicrobial, and fungal organisms occurred only in those with a CVC. CONCLUSIONS: The frequency and type of positive blood culture in HD patients are highly associated with type of access used. The high rate of CNS bacteremia with CVC in conjunction with low ESI rate suggests that contamination at the time of accessing the catheter may be the problem. Staff training was followed by a decrease in infection rates. Trending organism-specific bacteremia infection rates in HD units may provide important clues to bacteremia causality and thus prevention.

Evaluation of Risk Factors for Rectus Sheath Hematoma.

Rectus sheath hematoma (RSH) develops due to rupture of epigastric arteries or the rectus muscle. Although RSH incidence rate is low, it poses a significant diagnostic dilemma. We evaluated the risk factors for RSH, its presentation, management, and outcomes for 115 patients hospitalized with confirmed RSH by computed tomography scan between January 2005 and June 2009. More than three-fourth (77.4%) of the patients were on anticoagulation therapy, 58.3% patients had chronic kidney disease (CKD) stage ≥3, 51.3% had abdominal injections, 41.7% were on steroids/immunosuppressant therapy, 37.4% had abdominal surgery/trauma, 33.9% had cough, femoral puncture was performed in 31.3% of patients, and 29.5% were on antiplatelet therapy. Rectus sheath hematoma was not an attributable cause in any of the 17 deaths. Mortality was significantly higher in patients with CKD stage ≥3 (P = .03) or who required transfusion (P = .007). Better understanding of RSH risk factors will facilitate early diagnoses and improve management.

A new tool to asses risk of wandering in hospitalized patients.

This article describes the development and implementation of a wandering screening and intervention program based on identifying hospitalized patients with impaired cognition and mobility. A wandering screening tool developed by a multidisciplinary team was linked to appropriate levels of interventions available in the electronic health record. Advanced practice nurses (APNs) confirmed the accuracy of screening and interventions by bedside nurses for all patients who screened positive. Of 1,528 patients hospitalized during a 3-week period, 48 (3.1%) screened positive for wandering. At-risk patients were older (age ≥ 65) (66.7%), those admitted to surgical units (41.7%), Caucasian (89.6%), and men (58.3%). Thirteen (27.1%) had dementia and 45 (93.8%) had impaired cognition. Of those patients who screened positive for wandering, the APNs agreed with the bedside nurses' assessment in 79.2% of cases (38/48) about wandering risk and 89.5% (34/38 true positives) for the interventions. A two-item wandering screening tool and intervention was feasible for use by bedside nurses. Further studies are needed to determine whether this tool is effective in preventing wandering.

Screening for injurious falls in acute care hospitals.

BACKGROUND: Injurious fall is a serious hospital-acquired condition. Screening tools for injurious falls in hospitalized patients have received limited evaluation. OBJECTIVE: To compare operating characteristics of a succinct screening tool for injurious falls, the University of Pittsburgh Medical Center (UPMC) screening tool (based on mobility, fall history, and nursing judgment), with the ABCS injurious fall screening tool (based on Age, Bone, Coagulation, and recent Surgery). DESIGN: Case control study. METHODS: Hospitalized patients with injurious falls were identified from the UPMC adverse events database for 2007-2008 (N = 43). Controls (n = 86) matched for age, location, and period of fall event were selected from the hospital's administrative database. Tools were evaluated independently by 2 screeners using electronic charts. Interrater agreement, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and c-statistics for the screening tools were calculated. RESULTS: Case and control groups were similar in age, sex, and race. Interrater agreement was 71% for ABCS and 72% for UPMC screens. ABCS and UPMC screens had sensitivity of 60.5% (95% CI, 52.0%-68.9%) and 62.8% (95% CI, 54.5%-71.1%), specificity of 41.9% (95% CI, 33.4%-50.4%) and 58.1% (95% CI 49.6%-66.7%), and c-statistics of 51.2% and 59.3%, respectively. With a 33% prevalence of injurious fall, the PPV was 34.2%, and NPV was 67.9% for ABCS, and the PPV was 42.9%, and NPV was 75.8% for UPMC. Operating characteristics were not statistically significantly different, although the UPMC screen was 8% more accurate in predicting injurious falls and had a lower false-positive rate (44.2% versus 65.1%). CONCLUSIONS: Compared with the ABCS screen, the UPMC screen is a simple, practical tool. Prospective studies are needed to establish the UPMC tool's predictive value in hospital practices with lower rates of injurious falls. In general, better screening tools for injurious falls should be developed to meet quality standards.

Promethazine adverse events after implementation of a medication shortage interchange.

BACKGROUND: Prochlorperazine and droperidol were commonly used antiemetics at the University of Pittsburgh Medical Center-Presbyterian Hospital until a shortage of prochlorperazine occurred and a black box warning was added to droperidol prescribing information. Subsequently, promethazine was selected as the approved intravenous antiemetic for therapeutic interchange in December 2001. Promethazine use and adverse drug events (ADEs) were investigated following review of a serious ADE that identified promethazine use as a probable contributing factor. OBJECTIVE: To illustrate ADEs associated with promethazine and characterize high-risk patients. METHODS: An ADE database analysis identified promethazine ADEs reported from 2000 to 2003. Promethazine utilization and ADEs were compared with those of other antiemetics during the pre- and post-interchange periods. RESULTS: Promethazine utilization increased significantly during the post-interchange period compared with all other antiemetics (p < 0.001). Promethazine ADEs increased from one event during the pre-interchange period to 13 events during the post-interchange period. Causality assessment using the Naranjo algorithm ranged from possible to probable. The promethazine ADE rate per 10 000 doses was significantly higher than the combined ADE rate for all other antiemetics (p < 0.001; incident rate ratio [IRR] 4.32). Elderly patients (aged > or =65 y) experienced more promethazine ADEs than younger patients (p = 0.005; IRR 4.68). Concurrent use of opioids and/or sedating drugs contributed to promethazine ADEs in 11 of 14 (78.6%) patients. CONCLUSIONS: Geriatric status is a significant risk factor for promethazine ADEs. Concomitant use of sedating drugs may further increase the risk for ADEs. Therapeutic interchange programs should be monitored for both ADEs and utilization.