Comparing physicians and PAs as solo providers in a rural ED: A pilot study.

OBJECTIVE: To examine the use of physician assistants (PAs) as solo providers in rural EDs. METHODS: This study compared ED metrics and patient characteristics between physicians and PAs at a critical access hospital in Arizona. RESULTS: Nearly 26,000 patient encounters from the ED of the host institution were analyzed. Although minor variances in metrics were appreciated, transfers, 72-hour returns, and death rates were all similar among provider types. Results from this work do not demonstrate a clinically meaningful difference among ED metrics between physicians and PAs. CONCLUSIONS: Results from this study suggest that an appropriately trained and experienced PA can meet commonly used metrics in the care of patients presenting to this rural ED.

Failure of outpatient antibiotics among patients hospitalized for acute bacterial skin infections: What is the clinical relevance?

BACKGROUND: Infectious Diseases Society of America guidelines recommend that patients hospitalized for acute bacterial skin infections after failure of outpatient antibiotic therapy be managed as "severe" infections; however, the clinical relevance of apparent failure of outpatient therapy is not clear. METHODS: This was a secondary analysis of a multicenter, retrospective cohort of adults and children hospitalized for cellulitis, abscess, or wound infection. We compared clinical features, laboratory and microbiology findings, antibiotic treatment, and outcomes among patients who received outpatient antibiotics prior to admission and those who did not. RESULTS: Of 533 patients, 179 (34%) received outpatient antibiotics prior to admission. Compared with those who did not, patients who received antibiotics prior to admission less frequently had fever (18% vs 26%, P=.04) and leukocytosis (33% vs 51%, P<.001). In the 202 cases where a microorganism was identified, Staphylococcus aureus was more common among those who received antibiotics prior to admission (75% vs 58%, P=.02), particularly methicillin-resistant S aureus (41% vs 27%, P=.049), whereas aerobic gram-negative bacilli were less common (3% vs 13%, P=.03). After hospitalization, clinical failure occurred with similar frequency between the 2 groups (12% vs 11%, P=.73). CONCLUSIONS: Patients hospitalized with skin infections after apparently failing outpatient therapy had clinical features suggestive of less severe infection and similar outcomes compared with patients who did not receive antibiotics prior to admission. Our results suggest that inpatient treatment for patients not responding to outpatient therapy should focus on methicillin-resistant S aureus, not gram-negative pathogens.

Antibiotic prescribing practices in a multicenter cohort of patients hospitalized for acute bacterial skin and skin structure infection.

OBJECTIVE: Hospitalizations for acute bacterial skin and skin structure infection (ABSSSI) are common. Optimizing antibiotic use for ABSSSIs requires an understanding of current management. The objective of this study was to evaluate antibiotic prescribing practices and factors affecting prescribing in a diverse group of hospitals. DESIGN: Multicenter, retrospective cohort study. SETTING: Seven community and academic hospitals. METHODS: Children and adults hospitalized between June 2010 and May 2012 for cellulitis, wound infection, or cutaneous abscess were eligible. The primary endpoint was a composite of 2 prescribing practices representing potentially avoidable antibiotic exposure: (1) use of antibiotics with a broad spectrum of activity against gram-negative bacteria or (2) treatment duration greater than 10 days. RESULTS: A total of 533 cases were included: 320 with nonpurulent cellulitis, 44 with wound infection or purulent cellulitis, and 169 with abscess. Of 492 cases with complete prescribing data, the primary endpoint occurred in 394 (80%) cases and varied significantly across hospitals (64%-97%; P < .001). By logistic regression, independent predictors of the primary endpoint included wound infection or purulent cellulitis (odds ratio [OR], 5.12 [95% confidence interval (CI)], 1.46-17.88), head or neck involvement (OR, 2.83 [95% CI, 1.17-6.82]), adult cases (OR, 2.20 [95% CI, 1.18-4.11]), and admission to a community hospital (OR, 1.90 [95% CI, 1.05-3.44]). CONCLUSIONS: Among patients hospitalized for ABSSSI, use of antibiotics with broad gram-negative activity or treatment courses longer than 10 days were common. There may be substantial opportunity to reduce antibiotic exposure through shorter courses of therapy targeting gram-positive bacteria.

Clinical characteristics and antibiotic utilization in pediatric patients hospitalized with acute bacterial skin and skin structure infection.

BACKGROUND: Hospitalizations for acute bacterial skin and skin structure infection (ABSSSI) in children are increasingly frequent, but little is known about antibiotic utilization. In adults, recent studies suggest substantial opportunity to reduce broad-spectrum antibiotic use and shorten therapy. We sought to determine whether similar opportunity exists in children. METHODS: This was a planned secondary analysis of a pediatric cohort taken from a multicenter, retrospective cohort of patients hospitalized for ABSSSI between June 1, 2010, and May 31, 2012. The prespecified primary endpoint was a composite of 2 prescribing practices: (1) use of antibiotics with broad Gram-negative activity or (2) treatment duration >10 days. RESULTS: One-hundred and two patients ≤ 18 years old were included: 43 had non-purulent cellulitis, 19 had wound infection or purulent cellulitis and 40 had cutaneous abscess. The median age was 5 years (range 45 days to 18 years). Clindamycin was the most frequently prescribed antibiotic during hospitalization (67% of cases) and at discharge (66% of cases). The median duration of therapy was 11 days (interquartile range 10-12) and was similar for all 3 types of ABSSSI. The primary endpoint occurred in 67% of cases, including broad Gram-negative therapy in 25% and treatment duration >10 days in 61%. By multivariate logistic regression, admission through an emergency department and management by a medical (vs. surgical) service were independently associated with the primary endpoint. CONCLUSIONS: Children hospitalized for ABSSSI are frequently exposed to antibiotics with broad Gram-negative activity or treated longer than 10 days suggesting opportunity to reduce antibiotic use.

Let it snow: how snowfall and injury mechanism affect ski and snowboard injuries in Vail, Colorado, 2011-2012.

BACKGROUND: Current research examining the impact of mechanism of injury and daily snowfall amounts on injury severity among skiers and snowboarders is limited. The purpose of this study was to define correlations between injury mechanism and daily snowfall on injury patterns and severity among skiers and snowboarders. METHODS: This observational study analyzed daily snowfall measurements coupled with trauma admissions during the 2011 and 2012 ski seasons from a Level III trauma center servicing a large North American ski resort. Post hoc adjusted analyses and multivariate modeling was used to determine independent predictors of increased injury severity. RESULTS: Six hundred forty-four trauma admissions were analyzed, with primary research considerations detailing the variances in injury severity resulting from collisions with other skiers or snowboarders and daily total snowfall. Findings demonstrated that collisions were independently associated with increased (1) injury severity (Injury Severity Score [ISS ≥ 16]) (odds ratio [OR], 3.9; 95% confidence interval [CI], 2.0-7.6; p < 0.001), (2) thoracic injury severity (Abbreviated Injury Scale [AIS] score ≥ 3) (OR, 7.5; 95% CI, 3.7-15.0; p < 0.001), and (3) renal injuries (OR, 3.2; 95% CI, 1.2-8.1; p = 0.017) as well as and axial skeleton fractures (OR, 4.5; 95% CI, 2.6-7.7; p < 0.001). In addition, mean ISS was significantly higher in the setting of a collision when compared with a fall (8.6 vs. 5.8; p < 0.001). Findings regarding total snowfall demonstrate a negative correlation between snowfall and injury severity (r = -0.08, p = 0.05); the majority (65.5%) of injuries were sustained when there was 1 inch or less of recent snowfall, and a snowfall total of 2 inches or less was independently associated with increased injury severity (ISS ≥ 16) (OR, 3.1; 95% CI, 1.1-9.1; p = 0.036). CONCLUSION: Collisions between snowsport enthusiasts and total trace snowfall predict an increase in injury severity among alpine skiers and snowboarders. Findings from this project may lead to an increased understanding of predictive factors contributing to injury, alter the diagnostic evaluation of patients, provide educational opportunities for alpine enthusiasts, and enhance resort safety initiatives tailored to ambient conditions.