Impact of Povidone Application to Nares in Addition to Chlorhexidine Bath in Critically Ill Patients on Nosocomial Bacteremia and Central Line Blood Stream Infection.

Nosocomial Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia results in a significant increase in morbidity and mortality in hospitalized patients. We aimed to analyze the impact of applying 10% povidone iodine (PI) twice daily to both nares in addition to chlorhexidine (CHG) bathing on nosocomial (MRSA) bacteremia in critically ill patients. A quality improvement study was completed with pre and post-design. The study period was from January 2018 until February 2020 and February 2021 and June 2021. The control period (from January 2018 to May 2019) consisted of CHG bathing alone, and in the intervention period, we added 10% PI to the nares of critically ill patients. Our primary outcome is rates of nosocomial MRSA bacteremia, and our secondary outcome is central line associated blood stream infection (CLABSI) and potential cost savings. There were no significant differences in rates of MRSA bacteremia in critically ill patients. Nosocomial MRSA bacteremia was significantly lower during the intervention period on medical/surgical areas (MSA). CLABSIs were significantly lower during the intervention period in critically ill patients. There were no Staphylococcus aureus CLABSIs in critical care area (CCA)during the intervention period. The intervention showed potential significant cost savings. The application of 10% povidone iodine twice a day in addition to CHG bathing resulted in a significant decrease in CLABSIs in critically ill patients and a reduction in nosocomial MRSA in the non-intervention areas. Further trials are needed to tease out individual patients who will benefit from the intervention.

Association of Emergency Department Waiting Times With Patient Experience in Admitted and Discharged Patients.

Prolonged waiting times are associated with worse patient experience in patients discharged from the emergency department (ED). However, it is unclear which component of the waiting times is most impactful to the patient experience and the impact on hospitalized patients. We performed a retrospective analysis of ED patients between July 2018 and March 30, 2020. In all, 3278 patients were included: 1477 patients were discharged from the ED, and 1680 were admitted. Discharged patients had a longer door-to-first provider and door-to-doctor time, but a shorter doctor-to-disposition, disposition-to-departure, and total ED time when compared to admitted patients. Some, but not all, components of waiting times were significantly higher in patients with suboptimal experience (<100th percentile). Prolonged door-to-doctor time was significantly associated with worse patient experience in discharged patients and in patients with hospital length of stay ≤4 days. Prolonged ED waiting times were significantly associated with worse patient experience in patients who were discharged from the ED and in inpatients with short length of stay. Door-to-doctor time seems to have the highest impact on the patient's experience of these 2 groups.

Impact of Length of Stay on Readmission in Hospitalized Patients.

Background Readmission and length of stay (LOS) are two hospital-level metrics commonly used to assess the performance of hospitalist groups. Healthcare systems implement strategies aimed at reducing both. It is possible that tactics aimed at improving one measure in individual patients may adversely impact the other.  Objective We sought to analyze the impact of length of stay on readmission risk in an inpatient general medical population to assess whether patients with a lower length of stays were readmitted more frequently to the hospital. Methods We performed a retrospective analysis of inpatient adult patients admitted to our institution between January 2016 and December 2019. We recorded demographic variables and the outcomes of LOS and 30-day readmission. We excluded patients who expired, left against medical advice, or were transferred to other hospitals. We performed both univariate and multivariate analyses. Results There were 91,723 patients included in the study of which 10,598 (11.6%) were readmitted. The geometric LOS for all patients was 5.37 days and was higher in readmitted patients (6.87 vs 5.18 days, respectively, p < 0.001). Patients with higher readmission rates were older, had a higher proportion of male gender, African-American ethnicity, and were more likely to have Medicare or Medicaid payors. After performing a multivariate regression analysis, we found that a high LOS was associated with a higher likelihood of readmission (P < 0.001). Conclusion Contrary to our initial hypothesis, we found that general medical patients with a higher LOS had a higher likelihood of being readmitted to the hospital after adjusting for other variables. It is possible that factors not captured in the current dataset may help explain both the increase in LOS and readmission risk.

Discharge before noon: is the sun half up or half down?

OBJECTIVES: To analyze the impact of discharge before noon (DBN) on length of stay (LOS) and readmission of adult inpatients. STUDY DESIGN: Retrospective analysis of 78,826 patients from a single tertiary care center between January 1, 2016, and December 31, 2018. METHODS: The patient population was divided between patients discharged before and after noon. Outcomes were analyzed with univariate and multivariate analyses. RESULTS: DBN was independently associated with higher likelihood of LOS above the median (odds ratio [OR], 1.26; 95% CI, 1.18-1.35; P < .001) among medical patients. This association was not seen among surgical patients, in whom DBN was associated with a shorter LOS (OR, 0.78; 95% CI, 0.71-0.86; P < .001). Factors associated with higher LOS in both medical and surgical groups included higher case mix index, Medicaid payer, weekday discharges, and discharge to skilled nursing or rehabilitation facilities. For the variable of readmission, DBN in surgical patients was associated with a lower readmission rate (OR, 0.81; 95% CI, 0.69-0.95; P = .008). CONCLUSIONS: The finding that DBN was associated with higher LOS among medical patients suggests that some patients may have been able to be safely discharged the evening prior. In patients with surgical diagnoses, DBN was associated with a lower LOS and a lower risk of readmission. Patients with later discharges were more likely to be sent to a rehabilitation center or skilled nursing facility and were more frequently discharged during a weekday. Identification of these factors may help health systems transition patients safely and efficiently out of the hospital.

Optimization of the Order Menu in the Electronic Health Record Facilitates Test Patterns Consistent With Recommendations in the Choosing Wisely Initiative.

OBJECTIVES: Thyroid and rheumatologic autoimmune testing are areas where evidence-based guidance from specialty organizations and Choosing Wisely support utilizing screening tests for autoimmune and thyroid disorders prior to more specialized testing. Adjustment of the orderable options in the electronic health record (EHR) can influence ordering patterns without requiring manual review or additional effort by the clinician. METHODS: The menu was adjusted to reflect recommendations from Choosing Wisely to favor screening tests that automatically reflex to specialized testing on primary care providers' preference lists. Effectiveness was evaluated by reviewing total orders for individual tests. RESULTS: Shifts in ordering from individual screening tests (antinuclear antibody and thyrotropin) to ones that reflexed to specialized testing were observed in parallel with significant reductions in the corresponding specialized testing. CONCLUSIONS: Optimization of the EHR laboratory ordering menu can be used to shift ordering patterns toward Choosing Wisely recommendations.

Implementation of Laboratory Review of Test Builds Within the Electronic Health Record Reduces Errors.

CONTEXT.­: As electronic health records (EHRs) become more ubiquitous, physicians have come to expect that laboratory data from a variety of sources will be incorporated into the EHR in a structured format. The Clinical Laboratory Improvement Amendments have standards for data transmission traditionally met by pathologist review of their own hospital laboratory information system transmissions. However, with third-party laboratory data now being sent through external (nonhospital laboratory) interfaces, ownership of this review is less clear. Lack of an expert laboratory review process prior to changes being implemented can result in mapping and interfacing errors that could lead to misinterpretation and diagnostic errors. OBJECTIVE.­: To determine the impact of retrospective and prospective laboratorian-assisted review on the volume of interface errors and new builds. DESIGN.­: A seminal event led to a restructuring of the process for review of EHR laboratory builds, using laboratory expertise. RESULTS.­: A review of 26 500 test result fields found 61 of 4282 (1.4%) unique codes that could have led to misinterpretation. These were corrected and a process for proactive review and maintenance by laboratory experts was implemented. This resulted in monthly decreases in outbound error message from 4270 to 1820 (57.4%), in new test builds from 586 to 274 (53.2%), and in new result builds from 1116 to 552 (50.5%). CONCLUSIONS.­: Regular review and maintenance of external laboratory test builds in EHRs by a laboratory review team reduces interface error messages and reduces the number of new builds required for results to file into the EHR.

Implementation of a multicenter performance improvement program for early detection and treatment of severe sepsis in general medical-surgical wards.

Sepsis is a leading cause of in-hospital death, and evidence suggests a higher mortality in patients presenting with sepsis on the ward compared to those presenting to the emergency department. Ward patients who develop severe sepsis may have poor outcomes for a variety of reasons, including delayed diagnosis, lack of readily available staffing, and delayed treatment. We report on a multihospital quality improvement program for early detection and treatment of sepsis on general medical-surgical wards. We describe a multipronged approach to improve severe sepsis outcomes using the Institute for Healthcare Improvement's Plan-Do-Study-Act model. Sixty sites engaged in a collaborative implementation process that aligned people, process, and technology. Based on our experience, we recommend a stepwise approach to implement such a program: (1) both administrative and clinical leadership commit to a common goal; (2) appoint clinical champions and give them authority to engage other clinicians to improve timeliness of interventions; (3) map workflows and processes to rely heavily on the nursing staff's ability to evaluate and report severe sepsis screening results; (4) if available, design and deploy technology with the assistance of clinical informaticians (eg, to enable electronic health records-based continuous screening); (5) to determine success, consider tracking screening compliance and process, and outcome measures such as length of stay and mortality. Journal of Hospital Medicine 2016;S11:32-S39. © 2016 Society of Hospital Medicine.