Evaluating Adequacy of VTE Prophylaxis Dosing with Enoxaparin for Overweight and Obese Patients on an Orthopedic-Medical Trauma Comanagement Service.

OBJECTIVES: Venous thromboembolism (VTE) is a common nosocomial condition, developing frequently in overweight and obese patients. VTE prophylaxis with weight-based enoxaparin dosing may be more effective than the standard dosing regimen for overweight and obese patients; however, weight-based dosing is not practiced routinely. In this pilot study we sought to evaluate prophylactic anticoagulation regimens used for VTE prevention in overweight and obese patients on the Orthopedic-Medical Trauma (OMT) service to inform the need for modification of dosing practices. METHODS: This prospective, observational study evaluated the adequacy of current VTE prophylaxis practice at an academic tertiary center, including overweight and obese patients admitted during 2017-2018 to an OMT comanagement service. It included patients hospitalized for at least 3 days with a body mass index (BMI) of ≥25 and prescribed enoxaparin. Steady-state antifactor Xa trough and peak levels were monitored after three doses. Frequency of in prophylactic range (0.2-0.44) antifactor Xa levels and VTE events were compared by BMI groups and enoxaparin dosing using the χ2 test. RESULTS: There were 404 inpatients included: 41.1% were overweight (BMI 25-29), 43.4% were obese (BMI 30-39), and 15.6% were morbidly obese (BMI ≥40). A total of 351 patients (86.9%) received standard dose enoxaparin 30 mg 2 times per day (BID), and 53 patients received enoxaparin 40 mg BID or more. A number of patients (213; 52.7%) did not achieve prophylactic range antifactor Xa levels. A significantly higher number of patients in the overweight group achieved prophylactic range antifactor Xa compared with obese and morbidly obese groups (58.4% vs 41.7% and 33%, P = 0.002 and 0.0007, respectively). Morbidly obese patients treated with enoxaparin 40 mg BID or higher versus enoxaparin 30 mg BID had fewer VTE events (4% vs 10.8%, P = 0.18). CONCLUSIONS: The current practice of VTE enoxaparin prophylaxis may not be adequate for overweight and obese OMT patients. Further guidelines are needed to implement weight-based VTE prophylaxis in overweight and obese hospitalized patients.

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.

Outcomes of PD Patients at 6 Months.

The peritoneal dialysis (PD) patient population has grown rapidly in the past few years with concern over poor early outcomes. We report 6-month outcomes of incident PD patients in an experienced program with a strong focus on quality care. We analyzed data from an Institutional Review Board (IRB)- approved registry of all incident PD patients from January 1, 1991, to December 31, 2013, with follow-up to June 30, 2014. Time at risk began on the first day of training. Age, gender, race, diabetes mellitus (DM), Charlson comorbidity index (CCI), and albumin were collected at PD start. Exit-site infection (ESI), peritonitis, hospitalizations, and reasons for stopping PD were recorded. Multivariate analysis was done to examine outcomes.

Improvement in Herpes Zoster Vaccination in Patients with Rheumatoid Arthritis: A Quality Improvement Project.

OBJECTIVE: To improve herpes zoster (HZ) vaccination rates in high-risk patients with rheumatoid arthritis (RA) being treated with immunosuppressive therapy. METHODS: This quality improvement project was based on the pre- and post-intervention design. The project targeted all patients with RA over the age of 60 years while being treated with immunosuppressive therapy (not with biologics) seen in 13 rheumatology outpatient clinics. The study period was from July 2012 to June 2013 for the pre-intervention and February 2014 to January 2015 for the post-intervention phase. The electronic best practice alert (BPA) for HZ vaccination was developed; it appeared on electronic medical records during registration and medication reconciliation of the eligible patient by the medical assistant. The BPA was designed to electronically identify patient eligibility and to enable the physician to order the vaccine or to document refusal or deferral reason. Education regarding vaccine guidelines, BPA, vaccination process, and feedback were crucial components of the project interventions. The vaccination rates were compared using the chi-square test. RESULTS: We evaluated 1823 and 1554 eligible patients with RA during the pre-intervention and post-intervention phases, respectively. The HZ vaccination rates, reported as patients vaccinated among all eligible patients, improved significantly from the pre-intervention period of 10.1% (184/1823) to 51.7% (804/1554) during the intervention phase (p < 0.0001). The documentation rates (vaccine received, vaccine ordered, patient refusal, and deferral reasons) increased from 28% (510/1823) to 72.9% (1133/1554; p < 0.0001). The HZ infection rates decreased significantly from 2% to 0.3% (p = 0.002). CONCLUSION: Electronic identification of vaccine eligibility and BPA significantly improved HZ vaccination rates. The process required minimal modification of clinic work flow and did not burden the physician's time, and has the 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.

Long-Term Exit-Site Gentamicin Prophylaxis and Gentamicin Resistance in a Peritoneal Dialysis Program.

UNLABELLED: ♦ BACKGROUND: Daily gentamicin cream exit-site prophylaxis reduces peritoneal dialysis (PD)-related gram-negative infections. However, there is a concern about the potential for increasing gentamicin resistance with the long-term use of prophylactic gentamicin. This study evaluated the incidence of gentamicin-resistant PD-related infections over more than 2 decades. ♦ METHODS: Study data on prevalent PD patients were retrieved from a prospectively maintained institutional review board (IRB)-approved PD registry at a single center from January 1, 1991, to December 31, 2000, and January 1, 2004, to December 31, 2013. The rates of gram-negative infections, fungal infections and those infections with organisms resistant to gentamicin were examined for the 2 periods. Period 1 from 1991 to 2000 when S. aureus prophylaxis consisted initially of oral rifampin to treat nasal carriage with S. aureus, and was then daily exit-site mupirocin ointment for all PD patients, was compared to the period from 2004 to 2013 when daily exit-site gentamicin cream was prescribed as prophylaxis (Period 2). ♦ RESULTS: The study included a total of 444 PD patients (265 and 179 in Period 1 and Period 2, respectively). No significant difference was noted in demographics between the 2 periods except race. The gram-negative exit-site infection rates for Period 1 and Period 2 were 0.109 versus 0.027 (p < 0.0001). Gram-negative peritonitis rates were similar. There were 3 episodes of gentamicin-resistant infections in each period. Fungal infections remained consistently low. ♦ CONCLUSION: Despite a decade of exit-site gentamicin prophylaxis, gentamicin-resistant PD-related infections and fungal infections remained very low and similar to the prior period.

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.

Evaluation of a single-item screening question to detect limited health literacy in peritoneal dialysis patients.

Studies have shown that a single-item question might be useful in identifying patients with limited health literacy. However, the utility of the approach has not been studied in patients receiving maintenance peritoneal dialysis (PD). We assessed health literacy in a cohort of 31 PD patients by administering the Rapid Estimate of Adult Literacy in Medicine (REALM) and a single-item health literacy (SHL) screening question "How confident are you filling out medical forms by yourself?" (Extremely, Quite a bit, Somewhat, A little bit, or Not at all). To determine the accuracy of the single-item question for detecting limited health literacy, we performed sensitivity and specificity analyses of the SHL and plotted the area under the receiver operating characteristic (AUROC) curve using the REALM as a reference standard. Using a cut-off of "Somewhat" or less confident, the sensitivity of the SHL for detecting limited health literacy was 80%, and the specificity was 88%. The positive likelihood ratio was 6.9. The SHL had an AUROC of 0.79 (95% confidence interval: 0.52 to 1.00). Our results show that the SHL could be effective in detecting limited health literacy in PD patients.

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.

Examination of survival after transfer from peritoneal dialysis to hemodialysis.

Data on survival after transfer from peritoneal dialysis (PD) to hemodialysis (HD) is conflicting. We reviewed two decades of outcomes in a PD program to examine short-term survival after transfer from PD to HD. Of 379 patients on PD, 33% transferred to HD. The reasons for transfer were PD-related infections (340%), uremia or failure to thrive (26%), PD catheter problems or loss of mechanical skills (15%), dementia or unable to train (7%), noncompliant with PD (7%), other (10%, including gastrointestinal complications, hernia, encapsulating peritoneal sclerosis, preference, loss of ultrafiltration), and cardiac (2%). All of those transferring for "other" reasons survived 6 months, and as did all except 1 who transferred for uremia (p = 0.035). Overall survival was 92% at 3 months and 85% at 6 months. Using multivariate logistic regression analysis, only score on the Charlson comorbidity index at PD start was a risk factor for dying in the first 6 months on HD: for each 1 point increase in CCI score, the hazard ratio for death was 1.4 (95% confidence interval: 1.16 to 1.74; p = 0.005). To summarize, starting a patient on PD and waiting until uremia to transfer to HD does not have a negative impact on survival. In a program with relatively low PD-related infectious complications, such complications accounted for only one third of transfers to HD.

Peritonitis - does peritoneal dialysis modality make a difference?

BACKGROUND/AIMS: Peritonitis remains a significant problem for patients on peritoneal dialysis (PD). There is a certain amount of controversy as to whether peritoneal modality is itself a risk factor for peritonitis, with one modality higher than another. METHODS: A literature review was done (August 2009) searching under 'peritoneal dialysis', 'peritonitis' and 'modality' to find all articles related to the topic. The highest-quality articles were extracted for review. RESULTS: Two randomized controlled trials (RCTs) done with disconnect systems for continuous ambulatory PD (CAPD) and Luer lock connections for automated PD (APD) showed important decrements in peritonitis rate on APD compared to CAPD. The variation of peritonitis rates in studies comparing peritonitis on continuous cycling PD (CCPD) and CAPD may relate to the difference in connection type for APD in Europe (Luer lock) and North America (spike) and to differing prescriptions, including in some cases midday exchanges on APD and in other cases a dry abdomen on APD. The variation in peritonitis rates from center to center is marked. In many studies sufficient details regarding the connectology and the prescription, both of which may impact on peritonitis risk, are absent. CONCLUSION: At the present time, the best data suggest that use of APD with Luer lock connections versus CAPD with a disconnect system results in a reduction in peritonitis risk. More studies are needed on this important topic, particularly the possible advantage of initiating PD with a dry day in those with residual kidney function. This question would be best studied with an RCT comparing peritonitis rates in three groups of patients, i.e. those initiating dialysis on CCPD, CAPD and APD with a dry day.

Incidence of encapsulating peritoneal sclerosis at a single U.S. university center.

Encapsulating peritoneal sclerosis (EPS) is a life-threatening complication of peritoneal dialysis. Few data are available from the United States about the incidence of EPS over time. To examine that question, we retrospectively examined our PD registry, in existence for 30 years, to identify patients with EPS. All other data were collected prospectively. We asked a radiologist to review all computed tomography (CT) scans taken at the time of EPS diagnosis. Incidence of EPS in our 676 patients was 1.2%, but rose to 15% after 6 years, and 38% after 9 years on PD. Peritonitis rates were not high in patients that developed EPS. Scoring of CT scans confirmed the diagnosis of EPS in all patients. Treatment was variable, but in recent years, steroids and tamoxifen were generally used when EPS was recognized. Mortality related to EPS was 38%. Several years after diagnosis, 3 patients are still alive; none is on total parenteral nutrition. In summary, the risk of EPS is low early in the course of PD, but increases progressively at 6 years and beyond. Imaging by CT is useful for diagnosing EPS. Our preliminary results suggest that steroids and tamoxifen are beneficial. Multicenter studies on this serious problem are needed.

Clostridium difficile infections in outpatient dialysis cohort.

We examined the Clostridium difficile infection rate and risk factors in an outpatient dialysis cohort. The Cox proportional hazard for developing C. difficile infection was significantly higher with high comorbidity index and low serum albumin level. Conversely, it was lower for patients who had frequent bloodstream and dialysis access-related infections.