Accuracy of Tongue Swab Testing Using Xpert MTB-RIF Ultra for Tuberculosis Diagnosis.

Tongue dorsum swabs have shown promise as alternatives to sputum for detecting Mycobacterium tuberculosis (MTB) in patients with pulmonary tuberculosis (TB). Some of the most encouraging results have come from studies that used manual quantitative PCR (qPCR) to analyze swabs. Studies using the automated Cepheid Xpert MTB/RIF Ultra qPCR test (Xpert Ultra) have exhibited less sensitivity with tongue swabs, possibly because Xpert Ultra is optimized for testing sputum, not tongue swab samples. Using two new sample preprocessing methods that demonstrated good sensitivity in preliminary experiments, we assessed diagnostic accuracy and semi-quantitative signals of Xpert Ultra performed on tongue swabs collected from 183 adults with presumed TB in Kampala, Uganda. Relative to a sputum Xpert Ultra reference standard, the sensitivity of tongue swab Xpert Ultra was 77.8% (95% confidence interval [CI] 64.4-88.0) and specificity was 100.0% (95% CI, 97.2-100.0). When compared to a microbiological reference standard (MRS) incorporating both sputum Xpert Ultra and sputum mycobacterial culture, sensitivity was 72.4% (95% CI, 59.1-83.3) and specificity remained the same. Semi-quantitative Xpert Ultra results were generally lower with tongue swabs than with sputum, and cycle threshold values were higher. None of the eight sputum Xpert Ultra "trace" or "very low" results were detected using tongue swabs. Tongue swabs should be considered when sputum cannot be collected for Xpert Ultra testing, or in certain mass-screening settings. Further optimization of tongue swab analysis is needed to achieve parity with sputum-based molecular testing for TB.

Staffing and pattern of mechanical restraint use across a multiple hospital system.

BACKGROUND: In an effort to enhance patient safety in acute care settings, governmental and regulatory agencies have established initiatives aimed at limiting the use of mechanical restraints. Concurrently, hospital staffing levels are undergoing changes raising concerns about the impact these changes may have on restraint use. No studies to date have described the impact these two initiatives have had on restraint use in acute care hospitals. OBJECTIVES: To determine across a multiple hospital system: (a) the rates, frequencies, duration, and timing of restraint use, and (b) the relationship between restraint use and staffing. METHODS: This was a secondary analysis of prospective, observational data from a large outcomes database for 10 acute care hospitals. Monthly data were obtained from 94 patient care units for periods ranging from 1-12 months for a total of 566 cumulative months during 1999. RESULTS: The system restraint application duration rate (total restraint hours/total possible hours) was 2.8% (hospital ranges: 0.3-4.4%). More restraints were applied on night shifts (48.8%; n = 5,296) than on day (33.5%; n = 3,634) or evening shifts (17.7%; n = 1,926) (p < .0001) and most applied at midnight (31.7%; n = 3,441) followed by 0600-0900 (33.3%; n = 3,614). There was a weak positive relationship between staffing and restraint use (r = 0.276, p = .0001) at the system level and units with higher staffing levels also had higher baseline restraint use (p < .0001). CONCLUSIONS: Restraint frequency, duration, and timing may have been altered by recent initiatives, and there is beginning evidence that differences exist between community, rural, and tertiary hospitals. While there is a weak positive relationship between higher staffing and restraint use at the system and unit level, further exploration of the influence of other factors, specifically patient acuity, are in order. The finding of unit variability and consistent restraint application times provides a starting point for further quality initiatives or research interventions aimed at restraint reduction.

Atrial fibrillation: prevalence after minimally invasive direct and standard coronary artery bypass.

BACKGROUND: This study identified and compared the prevalence of new-onset atrial fibrillation (AFIB) following standard coronary artery bypass grafting (SCABG) with cardiopulmonary bypass (CPB) and minimally invasive direct vision coronary artery bypass grafting (MIDCAB) without CPB. A further comparison was made between AFIB prevalence in SCABG and MIDCAB subjects with two or fewer bypasses. METHODS: This is a retrospective, comparative survey. Patients with new-onset AFIB who underwent SCABG or MIDCAB alone were identified electronically using a triangulated method (International Classification of Diseases, 9th revision, Clinical Modification [ICD-9 CM] code; clinical database word search; and pharmacy database drug search). RESULTS: The total sample (n = 814; 94 MIDCAB, 720 SCABG) exhibited a trend toward lower AFIB prevalence in MIDCAB (23.4%) versus SCABG (33.1%) subjects (p = 0.059). AFIB prevalence in the SCABG subset with two or less vessel bypasses (n = 98; n = 18 single vessel, n = 80 double vessels) and MIDCAB subjects (n = 94; n = 90 single vessels, n = 4 double vessels) was almost identical (SCABG subset 24.5% versus MIDCAB 23.4%, p = 0.860). Slightly more than half (56.9%) of new-onset AFIB subjects were identified by ICD-9 CM codes, with the remainder by word search (37.7%) or procainamide query (5.4%). CONCLUSIONS: In this sample, the number of vessels bypassed seemed to have a greater influence on AFIB prevalence than the application of CPB or the surgical approach. Retrospective identification of AFIB cases by ICD-9 CM code grossly underestimated AFIB prevalence.

Benchmarking patient outcomes.

PURPOSE: To examine the usefulness of three types of benchmarking for interpreting patient outcome data. DESIGN: This study was part of a multiyear, multihospital longitudinal survey of 10 patient outcomes. The patient outcome used for this methodologic presentation was central line infections (CLI). The sample included eight hospitals in an integrated healthcare system, with a range in size from 144 to 861 beds. The unit of analysis for CLI was the number of line days, with the CLI rate defined as the number of infections per 1,000 patient-line days per month. METHODS: Data on each outcome were collected at the unit level according to standardized protocols. Results were submitted via standardized electronic forms to a central data management center. Data for this presentation were analyzed using a Bayesian hierarchical Poisson model. Results are presented for each hospital and the system as a whole. FINDINGS: In comparison to published benchmarks, hospital performances were mixed with regard to CLI. Five of the 8 hospitals exceeded 2.2 infections per 1,000 patient-line days. When benchmarks were established for each hospital using 95% credible intervals, hospitals did reasonably well with only isolated months reaching or going beyond the benchmark limits. When the entire system was used to establish benchmarks with the 95% credible intervals, the hospitals that reached or exceeded the benchmark limits remained the same, but some hospitals had CLI rates more frequently in the upper 50% of the benchmarking limits. CONCLUSIONS: Benchmarking of quality indicators can be accomplished in a variety of ways as a means to quantify patient care and identify areas needing attention and improvement. Hospital-specific and system-wide benchmarks provide relevant feedback for improving performance at individual hospitals.

Developing a multi-institutional nursing report card.

As regulatory and public interest groups demand information on the quality of patient care outcomes produced by their hospitals and care providers, nurse administrators are establishing processes for the effective and efficient definition, retrieval, and reporting of patient outcomes thought to be nursing-sensitive. The authors describe the administrative infrastructure and the data management processes used by one large integrated healthcare system to establish a nursing report card and maintain it for several years.

Practice patterns related to mechanical restraint use across a multi-institutional health care system.

In recent years, regulatory and governmental initiatives have focused increased scrutiny on the use and practices associated with mechanical restraints. Consequently, hospitals are increasingly measuring and comparing both internally and externally their restraint practices as they strive to optimize their use and assure the safe care of patients being restrained. This study analyzes 12,860 restraint episodes from 10 acute care hospitals in a single health care system. Overall findings support many previously identified trends related to the types of restraints used and reasons for application. However, findings from this study also suggest that there are differences among rural, community, and tertiary hospitals. This study also provides the first widespread documentation of rates and types of alternative methods attempted and common patient care practices carried out during restraint application. These results can serve as external comparisons for other acute care settings as they strive to minimize and assure safety in restraint application.

Hypertension and hypothermia in the acute postoperative period.

The past decade has witnessed the addition of newer and more sophisticated pharmacologic agents and technologies into the treatment regimes for postoperative hypertension and hypothermia. Although these additions have resulted in improved patient outcomes and understanding of physiologic principles in some areas they have also assisted in highlighting many new areas where nursing and medical research is further required.

Complications after cardiac transplantation. The role of immunosuppression.

Increased numbers of cardiac transplantations are being performed as a therapeutic option for end-stage cardiac disease. Immunosuppressive therapy combining multiple drugs to prevent rejection is essential to the success of this procedure. Although the patient's primary problem of heart failure is alleviated by a successful transplant, the secondary effect of immunosuppression causes many potential problems for this patient population. Infection from common pathogens or opportunistic microorganisms is the primary complication causing death in the post-transplant patient. Bacterial, viral, fungal, or parasitic infection may ensue during the postoperative period. Life-long immunosuppressive therapy places the patient at continuous risk for the development of infection. Nurses play an important role in the management of the cardiac transplant patient. A thorough knowledge of normal immune system function and the specific actions of each immunosuppressive drug on the immune system function is a prerequisite for providing care for these patients. Continuous monitoring of the patient to detect the signs and symptoms of infection or other side effects of the drugs is part of the nurse's role in caring for these patients. Maintenance of the patient's nonspecific host defenses is supported by specific nursing actions. In preparation for the life-long effects of the drugs, education of the patient and family regarding the implications of therapy with immunosuppressive agents is a crucial nursing function for the successful management of the cardiac transplant patient.

Traumatic popliteal and trifurcation vascular injuries: determinants of functional limb salvage.

Forty-seven patients with 64 popliteal or trifurcation arterial injuries were analyzed to elucidate the influence of associated limb trauma on ultimate functional recovery. Nerve, bone, and soft tissue injuries appeared to be critical risk factors. Two or more risk factors were present in 60 percent of 30 blunt injuries, compared with 17 percent of 18 penetrating injuries. All limbs with less than two of these risk factors recovered to a functional state, whereas none of the limbs with all three risk factors had a good outcome, and 7 of 13 limbs (54 percent) were amputated. Vascular reconstruction was successful in 90 percent of the 48 limbs, and patency was 100 percent among the 27 limbs with less than two risk factors. Patients with all three risk factors should be considered for early amputation. We believe reports of peripheral vascular trauma must delineate associated limb injuries to facilitate analysis of patients stratified by relative risk.