Rapid implementation of blood culture stewardship: institutional response to an acute national blood culture bottle shortage.

We describe our approach to addressing a nation-wide supply issue for blood culture bottles. Aerobic blood culture bottles received from our distributor July 1-15, 2024 was <1% of typical usage. Through education and ordering restrictions blood culture designed to minimize risk, orders were reduced by 49% over a one-week period.

Decision Support to Improve Critical Care Services Documentation in an Academic Emergency Department.

OBJECTIVES: Critical care services (CCS) documentation affects billing, operations, and research. No studies exist on documentation decision support (DDS) for CCS in the emergency department (ED). We describe the design, implementation, and evaluation of a DDS tool built to improve CCS documentation at an academic ED. METHODS: This quality improvement study reports the prospective design, implementation, and evaluation of a novel DDS tool for CCS documentation at an academic ED. CCS-associated ED diagnoses triggered a message to appear within the physician note attestation workflow for any patient seen in the adult ED. The alert raised awareness of CCS-associated diagnoses without recommending specific documentation practices. The message disappeared from the note automatically once signed. We measured current procedural terminology (CPT) codes 99291 or 99292 (representing CCS rendered) for 8 months before and after deployment to identify CCS documentation rates. We performed state-space Bayesian time-series analysis to evaluate the causal effect of our intervention on CCS documentation capture. We used monthly ED volume and monthly admission rates as covariate time-series for model generation. RESULTS: The study included 92,350 ED patients with an observed mean proportion CCS of 3.9% before the intervention and 5.8% afterward. The counterfactual model predicted an average response of 3.9% [95% CI 3.5-4.3%]. The estimated absolute causal effect of the intervention was 2.0% [95% CI 1.5-2.4%] (p = 0.001). CONCLUSION: A DDS tool measurably increased ED CCS documentation. Attention to user workflows and collaboration with compliance and billing teams avoided alert fatigue and ensures compliance.

Adhesion and function of human endothelial cells co-cultured on smooth muscle cells.

To evaluate interactions between human endothelial cells (ECs) and smooth muscle cells (SMCs) for the development of tissue-engineered vessels, we examined the adhesion and key cell properties of human ECs grown on quiescent human aortic SMCs. ECs attached to SMCs spread more slowly than ECs attached to fibronectin surfaces, and ECs aligned along the direction of the SMCs. ECs attached firmly and less than 5% of the cells were removed by shear stresses as high as 300 dyn cm(-2). Unlike porcine SMCs and co-cultures, human SMCs or co-cultures do not contract under flow, and the human ECs and SMCs in co-culture align toward the direction of flow. A confluent endothelium could be maintained in co-culture for over 30 days, and some of the ECs reoriented perpendicular to the SMCs after 9 days in static culture. Surface tissue factor levels in ECs and SMCs were less in co-culture than in monoculture. Co-culture induced an increase in calponin expression in SMCs. These findings show that human co-cultures can be maintained for long culture periods, where the endothelium remains confluent and responds to long-term exposure to flow, and EC-SMC interactions lead to an increase in SMC differentiation and an EC surface that is less thrombotic.

Electrocardiographic manifestations of proximal left anterior descending artery occlusion.

We report the case of a 51-year-old woman who presents with a 2-week history of episodes of pressure like chest pain. The initial electrocardiogram was not indicative of myocardial ischemia or infarction and the cardiac enzymes remained normal during the initial hospital day. However, the precordial T waves inverted and progressively deepened on the second hospital day and the patient underwent cardiac catheterization with percutaneous coronary angioplasty and stent placement of the left anterior descending coronary artery with good results. The postprocedure electrocardiogram showed complete resolution of the inverted precordial T waves. The development of new T-wave inversions in the precordial leads of patients presenting with unstable angina is predictive of significant stenosis of the left anterior descending coronary artery. This subgroup of patients has a poor prognosis if medical therapy alone is instituted. Early cardiac catheterization and revascularization is recommended for these patients. Evidence has shown that 75% patients with these electrocardiogram changes who are not revascularized developed extensive anterior wall infarction within a few weeks.