Development and validation of a pulmonary function test data extraction tool for the US department of veterans affairs electronic health record.

OBJECTIVE: Pulmonary function test (PFT) results are recorded variably across hospitals in the Department of Veterans Affairs (VA) electronic health record (EHR), using both unstructured and semi-structured notes. We developed and validated a hospital-specific code to extract pre-bronchodilator measures of obstruction (ratio of forced expiratory volume in one second [FEV1] to forced vital capacity [FVC]) and severity of obstruction (percent predicted of FEV1). RESULTS: Among 36 VA facilities with the most PFTs completed between 2018 and 2022 from a parent cohort of veterans receiving long-acting controller inhalers, 12 had a consistent syntactical convention or template for reporting PFT data in the EHR. Of the 42,718 PFTs identified from these 12 facilities, the hospital-specific text processing pipeline yielded 24,860 values for the FEV1:FVC ratio and 23,729 values for FEV1. A ratio of FEV1:FVC less than 0.7 was identified in 17,615 of 24,922 studies (70.7%); 8864 of 24,922 (35.6%) had a severe or very severe reduction in FEV1 (< 50% of the predicted value). Among 100 randomly selected PFT reports reviewed by two pulmonary physicians, the coding solution correctly identified the presence of obstruction in 99 out of 100 studies and the degree of obstruction in 96 out of 100 studies.

Impact of Reducing Time-to-Antibiotics on Sepsis Mortality, Antibiotic Use, and Adverse Events.

Rationale: Shorter time-to-antibiotics is lifesaving in sepsis, but programs to hasten antibiotic delivery may increase unnecessary antibiotic use and adverse events. Objectives: We sought to estimate both the benefits and harms of shortening time-to-antibiotics for sepsis. Methods: We conducted a simulation study using a cohort of 1,559,523 hospitalized patients admitted through the emergency department with meeting two or more systemic inflammatory response syndrome criteria (2013-2018). Reasons for hospitalization were classified as septic shock, sepsis, infection, antibiotics stopped early, and never treated (no antibiotics within 48 h). We simulated the impact of a 50% reduction in time-to-antibiotics for sepsis across 12 hospital scenarios defined by sepsis prevalence (low, medium, or high) and magnitude of "spillover" antibiotic prescribing to patients without infection (low, medium, high, or very high). Outcomes included mortality and adverse events potentially attributable to antibiotics (e.g., allergy, organ dysfunction, Clostridiodes difficile infection, and culture with multidrug-resistant organism). Results: A total of 933,458 (59.9%) hospitalized patients received antimicrobial therapy within 48 hours of presentation, including 38,572 (2.5%) with septic shock, 276,082 (17.7%) with sepsis, 370,705 (23.8%) with infection, and 248,099 (15.9%) with antibiotics stopped early. A total of 199,937 (12.8%) hospitalized patients experienced an adverse event; most commonly, acute liver injury (5.6%), new MDRO (3.5%), and Clostridiodes difficile infection (1.7%). Across the scenarios, a 50% reduction in time-to-antibiotics for sepsis was associated with a median of 1 to 180 additional antibiotic-treated patients and zero to seven additional adverse events per death averted from sepsis. Conclusions: The impacts of faster time-to-antibiotics for sepsis vary markedly across simulated hospital types. However, even in the worst-case scenario, new antibiotic-associated adverse events were rare.

A Multi-Hospital Survey of Current Practices for Supporting Recovery From Sepsis.

Sepsis survivors are at increased risk for morbidity and functional impairment. There are recommended practices to support recovery after sepsis, but it is unclear how often they are implemented. We sought to assess the current use of recovery-based practices across hospitals. DESIGN: Electronic survey assessing the use of best practices for recovery from COVID-related and non-COVID-related sepsis. Questions included four-point Likert responses of "never" to "always/nearly always." SETTING: Twenty-six veterans affairs hospitals with the highest (n = 13) and lowest (n = 13) risk-adjusted 90-day sepsis survival. SUBJECTS: Inpatient and outpatient clinician leaders. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: For each domain, we calculated the proportion of "always/nearly always" responses and mean Likert scores. We assessed for differences by hospital survival, COVID versus non-COVID sepsis, and sepsis case volume. Across eight domains of care, the proportion "always/nearly always" responses ranged from: 80.7% (social support) and 69.8% (medication management) to 22.5% (physical recovery and adaptation) and 0.0% (emotional support). Higher-survival hospitals more often performed screening for new symptoms/limitations (49.2% vs 35.1% "always/nearly always," p = 0.02) compared with lower-survival hospitals. There was no difference in "always/nearly always" responses for COVID-related versus non-COVID-related sepsis, but small differences in mean Likert score in four domains: care coordination (3.34 vs 3.48, p = 0.01), medication management (3.59 vs 3.65, p = 0.04), screening for new symptoms/limitations (3.13 vs 3.20, p = 0.02), and anticipatory guidance and education (2.97 vs 2.84, p < 0.001). Lower case volume hospitals more often performed care coordination (72.7% vs 43.8% "always/nearly always," p = 0.02), screening for new symptoms/limitations (60.6% vs 35.8%, p < 0.001), and social support (100% vs 74.2%, p = 0.01). CONCLUSIONS: Our findings show variable adoption of practices for sepsis recovery. Future work is needed to understand why some practice domains are employed more frequently than others, and how to facilitate practice implementation, particularly within rarely adopted domains such as emotional support.

Inpatient and Discharge Fluoroquinolone Prescribing in Veterans Affairs Hospitals Between 2014 and 2017.

BACKGROUND: Between 2007 and 2015, inpatient fluoroquinolone use declined in US Veterans Affairs (VA) hospitals. Whether fluoroquinolone use at discharge also declined, in particular since antibiotic stewardship programs became mandated at VA hospitals in 2014, is unknown. METHODS: In this retrospective cohort study of hospitalizations with infection between January 1, 2014, and December 31, 2017, at 125 VA hospitals, we assessed inpatient and discharge fluoroquinolone (ciprofloxacin, levofloxacin, moxifloxacin) use as (a) proportion of hospitalizations with a fluoroquinolone prescribed and (b) fluoroquinolone-days per 1000 hospitalizations. After adjusting for illness severity, comorbidities, and age, we used multilevel logit and negative binomial models to assess for hospital-level variation and longitudinal prescribing trends. RESULTS: Of 560219 hospitalizations meeting inclusion criteria as hospitalizations with infection, 37.4% (209602/560219) had a fluoroquinolone prescribed either during hospitalization (32.5%, 182337/560219) or at discharge (19.6%, 110003/560219). Hospitals varied appreciably in inpatient, discharge, and total fluoroquinolone use, with 71% of hospitals in the highest prescribing quartile located in the Southern United States. Nearly all measures of fluoroquinolone use decreased between 2014 and 2017, with the largest decreases found in inpatient fluoroquinolone and ciprofloxacin use. In contrast, there was minimal decline in fluoroquinolone use at discharge, which accounted for a growing percentage of hospitalization-related fluoroquinolone-days (52.0% in 2014; 61.3% by 2017). CONCLUSIONS: Between 2014 and 2017, fluoroquinolone use decreased in VA hospitals, largely driven by decreased inpatient fluoroquinolone (especially ciprofloxacin) use. Fluoroquinolone prescribing at discharge, as well as levofloxacin prescribing overall, is a growing target for stewardship.