Comparison of emergency department to hospital antibiograms: Influence of patient risk factors on susceptibility.

OBJECTIVES: Traditional antibiograms use local resistance patterns and susceptibility data to guide empiric antimicrobial therapy selection. However, antibiograms are rarely unit-specific and do not account for patient-specific risk factors. METHODS: This retrospective, single-center descriptive study used culture and susceptibility data from January 1 to December 31, 2016 to develop an Emergency Department (ED)-specific antibiogram and compare the antimicrobial susceptibilities of the most commonly identified organisms to the hospital antibiogram. All ED isolates were further stratified by the following risk factors that may influence antimicrobial susceptibility: age, disposition from ED, previous antimicrobial use and/or hospitalization within 30 days, and presenting location (i.e. healthcare facility residence versus community). RESULTS: A total of 2158 isolates from the ED were included: Escherichia coli (n = 1244), Klebsiella pneumoniae (n = 232), Proteus mirabilis (n = 131), Pseudomonas aeruginosa (n = 103), Staphylococcus aureus (n = 303), and Enterococcus faecalis (n = 145). There were no statistically significant differences between the ED and hospital antibiogram (n = 5739) with the exception of Escherichia coli. The hospital antibiogram overestimated Escherichia coli resistance rates for cefazolin (20% vs 15.6%, p = 0.049), ceftriaxone (9.6% vs 6.4%, p < 0.033), and ciprofloxacin (23.7% vs 15.4%, p < 0.006). There were significantly more risk factors present in patients admitted versus discharged from the ED (p < 0.001). Healthcare facility residence had the greatest influence on susceptibility, especially Escherichia coli (81.8% vs 34.9%, p < 0.001) and Proteus mirabilis (75.3% vs 33%, p < 0.001) ciprofloxacin susceptibility. CONCLUSIONS: There were no statistically significant differences between the ED and hospital antibiogram with the exception of Escherichia coli. However, development of an ED-specific antibiogram can aid physicians in prescribing appropriate empiric therapy when risk factors are included.

Similar health economic outcomes in low-risk and high-risk malnourished inpatients as screened by the Malnutrition Screening Tool after delivery of oral nutritional supplements.

OBJECTIVE: The aim of this study was to determine whether modified low- and high-risk Malnutrition Screening Tool (MST) scores (2 versus >2, respectively) were independently predictive of health economic outcomes. METHODS: We analyzed data from a recent nutrition-based quality improvement program (QIP) that prescribed daily oral nutritional supplements for all hospitalized adults at risk for malnutrition. In the original study, an electronic medical records-based MST was administered at the time of admission, and patients were classified as "low risk" or "high risk" for malnutrition based on MST scores (2 versus ≥2). We compared health economic outcomes for patients at low or high risk for malnutrition based on a modified score (MST = 2 versus >2, respectively), looking for between-group differences in length of stay (LOS) and unplanned 30-d readmissions. Analyses were additionally stratified by age (<65 versus ≥65 y of age). RESULTS: Of the 1269 patients enrolled in the QIP, 413 (32.5%) had MST of 2 and 856 (67.5%) had MST >2. Mean LOS was 5.19 d (±4.78) for patients with MST 2 and 4.49 d (±4.69) with MST >2 (non-statistically significant between-group difference; P = 0.277). There were no significant differences in unplanned 30-d readmission rates (14% for low-risk and 17.1% for high-risk patients; P = 0.171). These findings remained statistically insignificant when the low- and high-risk MST score groups were further stratified by age. CONCLUSIONS: Outcomes of hospitalized patients with MST 2 were not significantly different from those with an MST >2. This suggests that patients at both lower and higher risk for malnutrition (based on MST scores of 2 versus ≥3) were similar in terms of LOS and 30-d readmission rates. To avoid overlooking cases of malnutrition risk, the validated cutoff scores for the MST should be consistently implemented. Training that is consistent with the validated MST is recommended rather than attempting to reduce the case burden by "raising the bar" and attempting to classify patients with an MST = 2 as "low risk."

Factors Associated with Inpatient Thoracentesis Procedure Quality at University Hospitals.

BACKGROUND: Physicians increasingly refer thoracentesis procedures to interventional radiology (IR) rather than performing them at the bedside. Factors associated with thoracentesis procedures at university hospitals were studied to determine clinical outcomes by provider specialty. METHODS: An administrative database review was performed of patients who underwent an inpatient thoracentesis procedure in hospitals participating in the University HealthSystem Consortium (UHC) Database from January 2010 through September 2013. The incidence of iatrogenic pneumothorax, mean total hospital costs, and mean length of stay (LOS) were compared by clinical specialty. RESULTS: There were 113,860 admissions with 132,472 thoracentesis procedures performed on 99,509 patients at 234 UHC hospitals. IR performed 43,783 (33%) thoracentesis procedures; medicine, 22,243 (17%); and pulmonary, 26,887 (20%). The incidence of iatrogenic pneumothorax was 2.8% for IR, 2.9% for medicine, and 3.1% for pulmonary. Medicine and pulmonary had equivalent risk of iatrogenic pneumothorax compared to IR after controlling for clinical covariates. Admissions with medicine and pulmonary procedures were associated with significantly lower costs compared to IR admissions (p < 0.001) after controlling for clinical covariates. Admissions with IR procedures had a mean LOS of 14.1 days; medicine, 13.2 days; and pulmonary, 15.9 days. Admissions with medicine and pulmonary procedures were associated with fewer hospital days when compared to IR in the controlled model (p < 0.001). CONCLUSION: Admissions with medicine and pulmonary bedside thoracentesis procedures are as safe and less costly than IR procedures. Shifting IR thoracentesis procedures to the bedside might be a potential way to reduce hospital costs while still ensuring high-quality patient care, provided that portable ultrasound is used.

Defining a mismatch: differences in usage of social networking sites between medical students and the faculty who teach them.

BACKGROUND: Use of social networking sites (SNS) by medical students is increasing, and some students lack awareness of pitfalls arising from the intersection of social networking and medicine. Many institutions have developed guidelines on using SNS, but they are insufficient for students. Educators need new methods to train students on the appropriate use of this technology, but more information is needed before implementing change. PURPOSES: Differences in SNS usage between students and faculty were examined. The goal was to evaluate four content areas: SNS usage patterns, attitudes regarding activity on SNS, experience with patient interactions online, and awareness of institutional guidelines on use of SNS. METHODS: A cross-sectional survey took place at Feinberg School of Medicine, Northwestern University, in 2012. Participants included all students and a cohort of faculty who teach them in a class on professionalism. RESULTS: The response rate was 42% by students (300/711) and 78% by faculty (31/40). Of the students, 94% use SNS, compared to 48% of faculty. Students were more likely than faculty to display content they would not want patients to see (57% vs. 27%), report seeing inappropriate content on colleagues' SNS profiles (64% vs. 42%), and ignore harmful postings by colleagues (25% vs. 7%). Faculty were more likely than students to have been approached by patients on SNS (53% vs. 3%). Most participants were unlikely to conduct Internet searches on patients. CONCLUSIONS: Students are more likely than faculty to use SNS and use it very differently than faculty. Students would benefit from training on appropriate use of SNS. Topics that should be addressed include editing one's online presence, managing friend requests from patients, dealing with colleagues who post harmful content, conducting Internet searches on patients, and discussion of boundaries to identify potential harms associated with SNS usage. Differences in usage between students and faculty raise questions if faculty are well suited to provide this training.

Cost savings of performing paracentesis procedures at the bedside after simulation-based education.

INTRODUCTION: Paracentesis procedures are increasingly performed in interventional radiology (IR) rather than at the bedside, and there are few comparative effectiveness data on safety or cost. There is also no consensus about the need for blood product transfusions before the procedure. In a previous study, we reported that the selection of procedure location was largely discretionary and that bedside procedures had equal or better outcomes than IR procedures. Therefore, the aim of this study was to evaluate direct hospital costs of IR paracentesis procedures compared with procedures performed at the bedside by simulation-trained clinicians. METHODS: We performed an observational study of paracentesis procedures on a hepatology/liver transplant floor at a tertiary care hospital from July 2008 to December 2011. We modeled hospital costs for IR facility use and transfused blood products and calculated the cost of simulation training to compare costs between IR and bedside procedures. RESULTS: Five hundred eighty-eight patients underwent 764 paracentesis procedures (331 in IR and 433 at bedside). Fifty-one patients (15.4%) with IR procedures received platelet transfusions versus 16 patients (3.7%) with bedside procedures (P < 0.001). Forty-nine patients (14.8%) with IR procedures received fresh frozen plasma transfusions versus 24 patients (5.5%) with bedside procedures (P < 0.001). There were no clinical differences in platelet counts or coagulopathy between groups. In random-effects logistic regression, IR procedures had significantly higher likelihood of platelet (odds ratio, 6.36; 95% confidence interval, 3.28-12.35) and fresh frozen plasma (odds ratio, 3.41; 95% confidence interval, 1.95-5.95) transfusions. Total costs were $663.42 per case for IR and $134.01 per case for bedside procedures. CONCLUSIONS: Training residents to perform bedside paracentesis procedures was highly cost-effective. This approach should be considered as part of national efforts to reduce hospital costs while providing quality care.

Specialties performing paracentesis procedures at university hospitals: implications for training and certification.

BACKGROUND: Paracentesis procedure competency is not required for internal medicine or family medicine board certification, and national data show these procedures are increasingly referred to interventional radiology (IR). However, practice patterns at university hospitals are less clear. OBJECTIVE: To evaluate which specialties perform paracentesis procedures at university hospitals, compare characteristics of patients within each specialty, and evaluate length of stay (LOS) and hospital costs. DESIGN, SETTING, PATIENTS: Observational administrative database review of patients with liver disease who underwent paracentesis procedures in hospitals participating in the University HealthSystem Consortium (UHC) Database from January 2010 through December 2012. UHC is an alliance of 120 academic medical centers and their 290 affiliated hospitals. EXPOSURE: Patients with liver disease who underwent inpatient paracentesis procedures. MEASUREMENTS: We compared characteristics of patients who underwent paracentesis procedures by physician specialty, modeling the effects of patient characteristics on the likelihood of IR referral. We also analyzed LOS and hospital costs among patients with a >20% predicted probability of IR referral. RESULTS: There were 97,577 paracentesis procedures performed during 70,862 hospital stays in 204 hospitals. IR performed 29% of paracenteses versus 49% by medicine and medicine subspecialties including gastroenterology/hepatology. Patients who were female, obese, and those with lower severity of illness were more likely to be referred to IR. Patients with a medicine or gastroenterology/hepatology paracentesis had a similar LOS compared to IR. Hospital costs were an estimated as $1308 less for medicine and $803 less for gastroenterology/hepatology compared to admissions with IR procedures (both P = 0.0001). CONCLUSIONS: Internal medicine- and family medicine-trained clinicians frequently perform paracentesis procedures on complex inpatients but are not currently required to be competent in the procedure. Increasing bedside paracentesis procedures may reduce healthcare costs.