Risk factors for 30-day readmission in patients with congestive heart failure.

BACKGROUND: Risk of readmission is elevated in patients congestive heart failure (CHF), and clinical decision makers need to better understand risk factors for 30-day readmissions. OBJECTIVE: To identify risk factors for readmission in patients with CHF. METHODS: We studied all admissions for patients with CHF during 2011 using a statewide discharge data set from Pennsylvania. The primary outcome was readmission to any Pennsylvania hospital within 30 days of discharge. RESULTS: Of 155,146 CHF patients admitted, 35,294 (22.8%) were readmitted within 30 days. Male sex, black race, coverage by Medicare, comorbidities, discharge to a skilled nursing facility or with a home nurse, a longer length of stay (LOS), admission from another facility, and emergent admission (all p < 0.001) were significant risk factors. CONCLUSIONS: Comorbidities, sociodemographic factors including male sex, age, black race and Medicare coverage, and prolonged length of stay are associated with increased risk of readmission in patients with CHF.

Reduction of central venous catheter associated blood stream infections following implementation of a resident oversight and credentialing policy.

BACKGROUND: This study assesses the impact that a resident oversight and credentialing policy for central venous catheter (CVC) placement had on institution-wide central line associated bloodstream infections (CLABSI). We therefore investigated the rate of CLABSI per 1,000 line days during the 12 months before and after implementation of the policy. METHODS: This is a retrospective analysis of prospectively collected data at an academic medical center with four adult ICUs and a pediatric ICU. All patients undergoing non-tunneled CVC placement were included in the study. Data was collected on CLABSI, line days, and serious adverse events in the year prior to and following policy implementation on 9/01/08. RESULTS: A total of 813 supervised central lines were self-reported by residents in four departments. Statistical analysis was performed using paired Wilcoxon signed rank tests. There were reductions in median CLABSI rate (3.52 vs. 2.26; p = 0.015), number of CLBSI per month (16.0 to 10.0; p = 0.012), and line days (4495 vs. 4193; p = 0.019). No serious adverse events reported to the Pennsylvania Patient Safety Authority. CONCLUSIONS: Implementation of a new CVC resident oversight and credentialing policy has been significantly associated with an institution-wide reduction in the rate of CLABSI per 1,000 central line days and total central line days. No serious adverse events were reported. Similar resident oversight policies may benefit other teaching institutions, and support concurrent organizational efforts to reduce hospital acquired infections.

Reporting quality data on your hospital website: what? why? how?

Explore the challenges in making performance improvement data publicly available on hospital websites, and consider some practical tips and suggestions for aligning organizational goals with community and consumer needs.

Foot problems in diabetes: an overview.

Diabetes is the leading cause of nontraumatic lower-extremity amputations in the United States. Most amputations are preceded by an ulcer, and ulcers are costly in their own right. Most ulcers are neuropathic in etiology and plantar in location. They occur typically at sites of high mechanical loading because of repetitive trauma in people with loss of pain sensation. In an adequately perfused limb, such ulcers are not difficult to heal. When they are properly mechanically off-loaded, approximately 90% of these wounds heal in approximately 6 weeks. The reference standard off-loading device is the total contact cast, but other reasonably efficacious methods exist. Screening and implementation of preventive measures in the high-risk patient are highly recommended and can reduce the incidence of ulceration. All patients with diabetes should be screened annually for loss of protective sensation, with the 10-g Semmes-Weinstein monofilament being the easiest tool to use. Education to prevent complications should be implemented for all patients with loss of protective sensation.

Evolving targets for risk reduction in diabetes.

Recent evidence shows that target low-density lipoprotein cholesterol should be less than 100 mg/dl in patients with diabetes, and that even those with initially low levels benefit from pharmacologic therapy. Recent studies document that blood pressures lower than the previous target of 140/90 mmHg are beneficial, in addition to providing observational evidence against a lower threshold of benefit. Evidence that addresses the effect of blood glucose on macrovascular disease risk in patients with diabetes is reviewed. Finally, recommendations are made regarding systematic changes in healthcare delivery that will facilitate risk reduction strategies in diabetes.