Rate and Risk Factors for Carbapenem Resistant Acinetobacter baumannii Clinical Infections in Colonized Patients.

BACKGROUND: Carbapenem-resistant Acinetobacter baumannii (CRAB) is an important cause of nosocomial infections. Active surveillance for CRAB carriage to identify and isolate colonized patients is used to reduce transmission. OBJECTIVES: To assess the rate and risks of clinical infection among CRAB-carrier and non-carrier patients. METHODS: Hospitalized patients from whom CRAB screening-cultures were obtained between January and June 2018 were identified retrospectively. All CRAB-carriers were compared to a convenient sample of non-carriers and were followed to detect development of CRAB clinical infection during admission. RESULTS: We compared 115 CRAB carriers to 166 non-carriers. The median age in the study group was 76 years (IQR 71-87) vs. 65 years (55-79) in the non-carriers group (P < 0.001). Residence in a nursing facility, debilitated state, and admission to medical wards vs. intensive care units were more frequent among CRAB-carriers (P < 0.001). Mechanically ventilated patients included 51 CRAB carriers (44%) and 102 non-carriers (61%). Clinical infection developed in 49 patients (17%), primarily CRAB pneumonia. Of the CRAB-carriers and non-carriers, 26/115 (23%) and 23/166 (14%), respectively, developed a clinical infection (P = 0.05). One-third of the ventilated patients were infected. Debilitated state and antibiotic treatment during hospitalization were linked to higher infection rates (P = 0.01). Adjusted analysis showed that mechanical ventilation and CRAB colonization were strongly associated with clinical infection (P < 0.05). CONCLUSIONS: The rate of CRAB infection among carriers was high. Mechanical ventilation and CRAB colonization were associated with CRAB clinical infection, primarily pneumonia.

The Timing of Limb Amputation in Nontraumatic Patients: Impact on Mortality and Postoperative Complication Rates.

Diabetes and peripheral vascular diseases are accompanied frequently by lower limb ischemia and in minority, need for amputation, as a treatment of last resort. Even after a decision has been made regarding amputation, the procedures are often repeatedly postponed due to more urgent surgeries and lack of operating room availability. This study assessed the possible relationship between the duration of time inpatients wait for semiurgent amputations and the incidence of postamputation complications. A retrospective cohort, including all 360 adult patients who underwent nontraumatic limb amputation due to an ischemic/gangrenous/infected foot in a single center during an 11-year period (2007-2017). Most (96%) of the procedures were major amputations. The mean waiting time until amputation was 3 ± 5 days. Mortality during hospitalization occurred in 101 (28%) patients and re-amputation in 38 (11%). The duration of antibiotic treatment was 11 ± 14 days. The rate of sepsis was 30% (107/360). There was no significant difference between the duration of time until amputation and mortality during hospitalization: among those who waited ≤48 hours, the mortality rate was 27% (60/224) and among those who waited >48 hours 30% (41/136) (p = .5). Patients waiting ≤48 hours had higher re-amputation rates than those waiting >48 (31/223 (14%) vs 7/136 (5%), p = .009). Mortality was associated significantly to patients' age and renal function. Correlation was found between the waiting time until amputation (≤48 or >48 hours) and the rates of in-hospital mortality, sepsis, duration of antibiotic treatment and overall duration of hospitalization. Re-amputation rate was higher in group with the shorter waiting time. This correlation may be explained by the fact that patients who needed urgent amputation had a more extensive and severe disease, and thus tended to require more re-amputation operations.

Prospective Audit of Empirical Antibiotic Therapy for Septic Patients.

BACKGROUND: Antibiotic stewardship programs are necessary to test the appropriateness of local guidelines for empirical antibiotic treatment by audits. OBJECTIVES: To assess whether compliance to local guidelines achieved a higher rate of appropriate antibiotic treatment and reduced morbidity and mortality, and whether infectious disease counseling improved the rate of appropriate treatment. METHODS: Our cohort comprised 294 patients with proven bacteremia. Data were retrieved from medical records including diagnosis, empiric antibiotic treatment, and outcomes. RESULTS: The empirical treatment was consistent with bacterial susceptibility in 227 patients (77%), and matched in 64% of the time to the first line, and another 24% to the second line of institutional guidelines. A strong correlation was found between appropriate empiric treatment according to bacterial susceptibility and reduced mortality (odds ratio [OR] 0.403, P = 0.007). A similar correlation was found with the choice of appropriate antibiotics according to local guidelines (OR 0.392, P = 0.005). Infectious disease consultation was related to an increase in the rate of appropriateness of treatment according to guidelines (85% vs.76%, P = 0.005). A tendency to increased appropriateness was related to microbial susceptibility (87% vs. 74%, P = 0.07). CONCLUSIONS: In this study, initiation of appropriate empiric antibiotic therapy, according to the hospital's guidelines, was found associated with reduced mortality in patients with bacteremia.

[PRINCIPLES OF APPROPRIATE ANTIBIOTIC USAGE IN ISRAELBY THE ISRAELI SOCIETY FOR INFECTIOUS DISEASES: TO WHOM ARE THEY DIRECTED?]

INTRODUCTION: In this issue of Harefuah Nesher and Strahilevitz discuss the principles of appropriate antibiotic guidelines based on a position paper by the Israeli Society for Infectious Diseases (ISID). This editiorial discusses for whom this position paper was intended. The first and most obvious target would be the Infectious Disease (ID) physicians themselves. Since the setup of ID units in Israeli hospitals in the 1970s and 1980s, all have engaged in antibiotic control and infection control. Antibiotic control in Israel has always consisted of antibiotic restriction, development of guidelines for the most commonly encountered infections, and oversight of adherence to guidelines (including computer applications). In comparison, antibiotic control was not an ID priority in US hospitals until the concept of antibiotic stewardship emerged in the last decade. Second, the position paper could have been intended for hospital managements, in order to provide the resources necessary to make appropriate antibiotic use an attainable goal, in particular: allocation of highly skilled manpower (physicians, clinical microbiologists, pharmacists) and development of relevant computer applications. Third, the position paper could have been intended as a response to the initiatives by Ministry of Health National Center for Infection Control and Antibiotic Use. The latter was set up more than a decade ago to deal with emerging multi-drug resistant pathogens and to provide professional leadership. Unfortunately, a professional conflict has emerged between the ISID and the National Center, when the latter was trying to impose professional guidelines regarding antibiotic stewardship unilaterally. While Nesher and Strahilevitz outline the ISID view on antibiotic stewardship in Israeli hospitals, they also call for cooperation and joining forces to combat the huge problem of antibiotic resistance in Israel. Forth, the position paper was probably also intended for all physicians who prescribe antimicrobials, to engage them in the responsibility of guarding antibiotics for us and the next generations.

[INTERVENTIONS TO IMPROVE THE QUALITY OF THE INTERNSHIP YEAR].

AIMS: To describe three interventions that have improved the quality of the internship. BACKGROUND: All medical school graduates are required to take a one year internship, rotating through various hospital departments. By various objective and subjective measures, the quality, benefit and efficacy of the internship varies significantly between departments and hospitals and also depends on where the interns studied. METHODS: The interventions were: First, all graduates of foreign medical schools (FMG) were required to interview and present a patient, demonstrating practical knowledge of spoken and written Hebrew and basic medical terminology prior to the start of the internship. Second, on the first day of their internship in internal medicine the new interns participate in an orientation day, addressing multiple clinical, administrative and other components. Third, upon the completion of their rotation in internal medicine, the interns participate in an interactive session to help them prepare for their future career. RESULTS: First, during the first 3 years after introducing the Hebrew test, 101 FMGs took the test, 89 (88%) passed the first time, the remainder passed the 2nd or 3rd test after another 1-3 months of studying Hebrew. Of 31 women, 30 (97%) passed the first time, compared to 59/70 (84%) of the men (p=0.065); 27/28 (96%) of Jewish interns passed the first time compared to 62/73 (85%) non-Jewish interns (p=0.99). Physicians report on the significantly increased ability of FMGs to participate in all activities from the onset of their internship. Second, upon completion of the orientation, 137 interns provided feedback of its 12 components; satisfaction was marked on a Likert scale (ranging from 1 [low] to 5 [high]) and ranged from 4.2±0.1 to 4.7±0.6; high/very high satisfaction with the various components ranged from 79% to 96%. Third, feedback was provided by 96 interns after participating in the interactive session helping to prepare for the future; satisfaction with the 5 components of the session ranged from 3.8±0.8 (on the acquired insight into the possibilities, scope and limitations regarding their future career) to 4.5±0.7 (regarding the relevance of such sessions). Sub-analysis revealed several statistically significant differences between male and female interns (male interns indicated these sessions to be more important to them than females, p<0.01), and FMG (as compared to graduates from Israeli medical schools) indicated that they had acquired relevant information more often (p<0.001). CONCLUSIONS: Various interventions positively impact the quality, benefit and efficacy of the internship as observed by physicians working with the residents, as well as perceived by the interns themselves.

[SELECTING A SPECIALTY BY INTERNS IN A CHANGING PERIOD: A MULTI-YEAR AND SINGLE-CENTER EXPERIENCE].

AIMS: To collect data on the expectations of interns at the onset of their internship regarding their professional future and the actual realization of these expectations of medical graduates who completed their internship in one medical center during the years 2010-2015. BACKGROUND: The internship year may have great importance in the decision-making process regarding selection of future residency. Previous research conducted 10-20 years ago involved graduates of Israeli medical schools. In the current era up to 50% of interns are foreign medical graduates (FMG), and it is not clear whether all of these professionals find a residency or employment according to their wishes. METHODS: Our hospital's database includes demographic details of all 237 graduates of the aforementioned years, according to gender (64% male); medical school (Israeli 50%); and ethnicity (Jewish, 66%). The aim of the study was to call all graduates according to the telephone numbers in the database and obtain relevant information on the basis of a pre-arranged script and with a standardized questionnaire to achieve uniform collection of data. RESULTS: Of 237 graduates, 151 (64%) responded, of whom 101 (64%) were male, 90 (60%) were Jewish, and 80 (54%) were FMG. Most interns had decided on a future career at the onset of their internship (114, 75%), but at its completion this rate had decreased to 88 (59%). Their preferences included surgical specialties 40 (36%), pediatrics 34 (30%), internal medicine 22 (19%), family practice 9 (8%), and other specialties 8 (7%). At the conclusion of the internship 108 (75%) immediately started a residency program; the remainder started employment in the community not within the context of a residency. A high degree of satisfaction was examined for three factors: personal relations and ethics - 114 (76%), professional learning - 108 (72%) and counseling regarding their professional future - 46 (31%). At the onset of their internship,) 75 77%( of the men and 46 )75%( of the women had decided upon their future career, without major change by the year's end. In reality, 43 (84%) of the women started a residency, but only 63 (65%) of the men (p=0.013). At the start of the year 67 (77%) of the Jewish interns and 46 (75%) of the Arab interns had decided on a future career; at the end of the year, the rate for Jewish interns had increased to 74 (85%) and it had decreased to 31 (67%) for Arab interns (p=0.026). Of the Jewish sector 74 (85%) had actually started a residency, as compared to 33 (54%) of the Arab sector (p<0.001) and 26 (43%) Arab graduates started work in the community not within the context of a residency. The rate of Israeli graduates who at onset of their internship had decided on their future choice was similar to that of FMG, 55 (82%) as compared to, respectively, 58 (73%) (Non significant), but at the end of the year a significant gap had opened up, 47 (86%) vs. 40 (52%), respectively (p=0.04). In addition, and not surprisingly, there were significant differences in the three measures of satisfaction between the Israeli and foreign graduates. CONCLUSIONS: During the internship year significant differences emerge between the interns, according to gender, ethnic background or the country they had studied medicine. Improved counseling could possibly help interns to secure optimal employment, especially for foreign medical graduates.

[AN EDUCATIONAL INTERVENTION TO REDUCE THE RATE OF CONTAMINANTS IN BLOOD CULTURES AND IMPROVE APPROPRIATE ANTIBIOTIC TREATMENT].

INTRODUCTION: Blood cultures' contamination (BCC) is associated with unnecessary processing of cultures, higher cost, and occasionally, unjustified antibiotic treatment. We aimed to reduce the rate of BCC by educational intervention. In parallel, we also strove to expand the use of aminoglycosides (AMG) and reduce the utilization of beta-lactam antibiotics. The rate of BCC was assessed prospectively in the study department - the Emergency Department (ED) and in control departments - Medical Departments A, B and Geriatrics. Data was collected continuously during the study period and educational interventions were performed in the ED but not in the control departments. The intervention included meetings with ED staff, emphasizing proper blood culture collection technique, and post-intervention result updates. The utilization of AMG was encouraged in cases of suspected gram-negative bacteremia. The empirical and definitive antibiotic regimen was assessed. During the study period, a 30% decrease in BCC rate [33/564 (5.9%) to 30/734 (4.1%), p=0.143] was noted in the study department whereas a small increase in BCC rate was noted in the control departments. Logistic regression analysis revealed significantly different trends in BCC rate between the study and control departments (p<0.001). Additionally, an increase in AMG utilization was observed (7% to 40%) in patients with suspected gram-negative bacteremia with normal renal function (p=0.16). Educational intervention was successful in reducing the rate of BCC and in parallel, increasing the utilization of AMG. Repeat and frequent interventions are required to maintain such achievements.

[PREVALENCE OF AND POSSIBLE RISK FACTORS FOR PROLONGED HOSPITAL STAY IN DEPARTMENTS OF INTERNAL MEDICINE].

BACKGROUND: Prolonged hospitalization (PH) is associated with increasing rates of complications and cost. OBJECTIVES: To detect and quantify causes and predictors for PH in current practice. METHODS: PH was defined as higher than the 70th percentile of the mean hospitalization duration for each department (two medical departments and one acute geriatric ward). Demographic and clinical data were collected on admission in order to determine predictive factors for PH. Actual causes for PH were tested on the 4th day of hospitalization for all patients by: (1) questioning the patients' attending physicians using a structured questionnaire; (2) assessing the patients' charts using a validated tool. RESULTS: Data were collected during a 5-month study period for all 1092 consecutively admitted patients hospitalized in the three departments in the study of whom 337 (30%) had a PH. In the multivariate analysis we detected the following independent predictors for PH: (1) unmarried patients; (2) dependent-patients; (3) hospitalization in the geriatric versus medical department; (4) an expected high mortality rate according to a validated prediction score; (5) renal failure on admission; (6) prior admission in the previous 6 months. The disease leading to the current admissions was the reason for continued admission on day 4 in the patients with eventual PH in 85% of the cases, as compared to 93% in the control group with regular-duration of hospitalization (p=0.014). On day 4, non-medical reasons for prolonged duration were detected in 7% of those with eventual PH as compared to 1% in the control group (p=0.018). CONCLUSIONS: We already detected demographic and clinical predictors for PH on admission, some of which may be amenable to intervention.

Spondylodiskitis and endocarditis due to Streptococcus gordonii.

BACKGROUND: Streptococcus gordonii is an infrequent cause of infective endocarditis (IE); associated spondylodiskitis has not yet been described in the literature. PURPOSE: We describe 2 patients who presented with new-onset, severe back pain; blood cultures revealed S. gordonii bacteremia, which led to the diagnosis of spondylodiskitis and IE. We review our 2-decade experience with S. gordonii bacteremia to describe the clinical and epidemiological characteristics of these patients. RESULTS: In our hospital over the last 20 years (1998-2017), a total of 15 patients with S. gordonii bacteremia were diagnosed, including 11 men and 4 women, and the mean age was 65 ± 22 (range 23-95). The most common diagnosis was IE (9 patients), spondylodiskitis (the presented 2 patients, who in addition were diagnosed with endocarditis), necrotizing fasciitis (1), sternitis (1), septic arthritis (1) and pneumonia (1). The 11 patients with IE were treated with penicillin ± gentamicin, or ceftriaxone for 6 weeks, 5 required valve surgery and 10/11 (91%) attained complete cure. The 2 patients with diskitis required 2-3 months of intravenous antibiotics to achieve complete cure. CONCLUSION: Spondylodiskitis was the presenting symptom of 2/11 (18%) patients with S. gordonii endocarditis. Spondylodiskitis should probably be looked for in patients diagnosed with S. gordonii endocarditis and back pain as duration of antibiotic treatment to achieve complete cure may be considerably longer.

Can Procalcitonin Contribute to the Diagnosis of Clostridium difficile Colitis?

BACKGROUND: It is a challenge to diagnosis Clostridium difficile colitis. OBJECTIVES: To determine, among patients who developed nosocomial diarrhea, whether serum procalcitonin (PCT) can distinguish between C. difficile toxin (CDT)-positive and CDT-negative patients. METHODS: This prospective study included 50 adults (>18 years) who developed diarrhea during hospitalization, 25 with a positive fecal test for CDT (study group) and 25 CDT negative (control group). RESULTS: Baseline demographic and underlying illnesses were similar in both groups. Duration of diarrhea was 6 ± 4 days and 3 ± 1 in the study and control groups, respectively (P = 0.001). Mean blood count was 20 ± 15 and 9.9 ± 4, respectively (P = 0.04). CRP level was higher in the study than in the control group (10.9 ± 7.4 and 6.6 ± 4.8, P = 0.028). PCT level was higher in the study group (4.4 ± 4.9) than the control group (0.3 ± 0.5, P = 0.102). A PCT level > 2 ng/ml was found in 7/25 patients (28%) and 1/25 (4%), respectively [odds ratio 9.33, 95% confidence interval (0.98 to 220), P = 0.049]. Multivariate analysis showed that only duration of diarrhea and left shift of peripheral leucocytes were significant indicators of CDT (P = 0.014 and P = 0.019, respectively). The mortality rate was 12/25 (48%) vs. 5/25 (20%), respectively (P = 0.04). CONCLUSIONS: We found a non-significant tendency to higher PCT levels in patients with CDT-positive vs. CDT-negative nosocomial diarrhea. However, a PCT level > 2 ng/ml may help distinguish between these patients.

[MONITORING UNITS IN DEPARTMENTS OF INTERNAL MEDICINE: FREQUENCY, IMPACT AND SATISFACTION].

BACKGROUND: Due to increasing numbers of elderly, seriously ill patients and shortage of ICU beds, many hospitals have established monitoring units (MU) in their medical departments. OBJECTIVES: (1) To assess the national prevalence of MUs in medical departments; (2) to determine the outcome of consecutively admitted MU patients; (3) to evaluate patient/ family satisfaction with care. METHODS: The case control study included all 123 patients hospitalized in the MU during a 5-month period, compared with two control groups: (1) 123 patients admitted to medical departments, matched at a ratio of 1:1 by gender, age±10 years and mechanical ventilation; (2) all 52 medical patients treated in the ICU. The main endpoint was 28-day survival. RESULTS: A total of 76/99 (77%) directors of medical departments in Israel responded: 70 (92%) reported the presence of a MU, 64 (92%) have 5-7 beds and 47 (67%) have one nurse per shift. Baseline characteristics of enrolled MU and medical department patients were similar, although 52 medical ICU patients were younger (56±21 vs. 73±14, p<0.001) and had a lower incidence of kidney failure (11.5% vs. 41.5%, p<0.001). The predicted mortality rates were higher for MU patients compared to medical department patients, but 28-day survival rates were similar (64-70%, NS). The questionnaire showed high rates of satisfaction (from 0=low to 5=high): highest with MU care: (4.79±0.48), followed by ICU (4.41±1.06) and lowest for medical department nursing care (4.27±0.84)(p=0.017). CONCLUSIONS: Monitoring units are ubiquitous in Israeli hospitals and contribute to survival and satisfaction with care.

Mortality due to blaKPC Klebsiella pneumoniae bacteraemia.

OBJECTIVES: To determine the mortality rate secondary to blaKPC Klebsiella pneumoniae (KPC/Kp) bacteraemia, compared with that from ESBL-producing K. pneumoniae (ESBL/Kp) bacteraemia, and to determine associated risk factors. METHODS: This was a retrospective case-control study of all 68 KPC/Kp bacteraemia patients diagnosed since 2006, matched by year of isolation, gender and age, at a ratio of 1:2, to 136 ESBL/Kp bacteraemia patients. RESULTS: There were no demographic differences between the two groups, but there were minor clinical differences. Fewer KPC/Kp study patients than ESBL/Kp control patients had a systolic blood pressure <90 mmHg (32/68, 47% versus 86/136, 63%, respectively, P = 0.02) or urinary catheterization (32/68, 47% versus 90/136, 66%, respectively, P = 0.005), while the KPC/Kp bacteraemia group had a greater incidence of acute renal failure (45/68, 66% versus 67/136, 49%, respectively, P = 0.02). There was no difference between the two groups in duration of hospitalization. The mortality rate of the KPC/Kp bacteraemia group was 44/68 (65%) compared with 54/136 (40%) in the ESBL/Kp bacteraemia control group (P = 0.008), which in the multivariate analysis remained highly significant (P < 0.001). Only 11/68 (16%) of KPC/Kp patients were functionally independent at discharge compared with 43/136 (32%) ESBL/Kp patients (P = 0.012). CONCLUSIONS: The selection of an ESBL/Kp control cohort with a ratio of 1:2 (study versus control group) helped resolve an as yet insufficiently settled question: bacteraemia with KPC/Kp is an independent risk factor for death, justifying the strict adherence to cohorting and isolation procedures.

Assessment and Improvement of Medical Histories: Impact of Focused Feedback.

BACKGROUND: Medical history-taking is an essential component of medical care. OBJECTIVES: To assess and improve history taking, physical examination and management plan for hospitalized patients. METHODS: The study consisted of two phases, pre- and post- intervention. During phase I, 10 histories were evaluated for each of 10 residents, a total of 100 histories. The assessment was done with a validated tool, evaluating history-taking (maximum 23 points), physical examination (23 points), assessment and plan (14 points) (total 60 points). Subsequently, half of these residents were informed that they were assessed; they received their scores and were advised regarding areas needing improvement. Phase II was identical to phase I. The primary endpoint was a statistically significant increase in score. RESULTS: In the study group (receiving feedback after phase I) the physical examination improved from 9.3 ± 2.4 in phase I to 10.8 ± 2.2 in phase II (P < 0.001), while in the control group there was no change (11.3 ± 1.9 to 11.5 ± 1.8 respectively, P = 0.59). The assessment and plan component improved in the study group from 6.4 ± 2.7 in phase I to 7.4 ± 2.6 in phase II (P = 0.05), while no change was observed in the control group (8.2 ± 2.7 and 7.8 ± 2.3, P = 0.43). Overall performance improved in the study group from 30.4 ± 5.1 in phase I to 32.9 ± 4.5 in phase II (P = 0.01), a 10% improvement, while no change was observed in the control group (35.5 ± 6.0 to 34.6 ± 4.1, P = 0.4). CONCLUSIONS: A review of medical histories obtained by residents, assessed against a validated score and accompanied by structured feedback may lead to significant improvement.

[Effect of a computer application on appropriate use and control of broad spectrum antibiotics].

BACKGROUND: Antibiotics are among the greatest contributions of modern medicine. However, since the onset of the antibiotic age, resistance has emerged, threatening the future usability of these drugs. The complexity of antibiotic prescribing and associated expense has led to the development of infectious disease (ID) expert stewardship programs. PURPOSE: To describe an in-house created computer application, in use since 2005 with which all restricted antimicrobials are ordered and approved by ID physicians before being supplied by the pharmacy. RESULTS: In the nine years since the application was adopted by the entire hospital, 173,436 prescriptions for restricted antibiotics have been ordered through the application, of which 52% were for male patients, 8% for children ≤ 20 years, 31% for adults 21-70 years old and 61% for patients > 70. All prescriptions were reviewed by ID physicians; their response included approval (mean 87%, range 82-92%), rejection (7%, 3-12%), or change (6%, 4-18%). The latter two decisions always involved written and/or oral interaction with the prescribing physicians. The result analysis showed that: by clinical diagnoses, the approval rate ranged from 82% (for central line associated infection) to 94% (for tuberculosis); by class of antimicrobial, the approval rate ranged from 71% (IV ciprofloxacin) to 95% (IV amoxicillin-calvulanate). Overall hospital expenditure on antimicrobials, corrected by 100 admissions and 100 admission days, did not change significantly. CONCLUSIONS: During the nine years of its use, the described computer program has significantly contributed to physician awareness of appropriate antibiotic use, provided tools to assist physicians in their choice of antimicrobial treatment, allowed ID supervision with unprecedented scope and depth and has significantly contributed to cost control.

[Shaare Zedek Medical Center's model of an integrated division of internal medicine].

BACKGROUND: The specialty and practice of internal medicine have been subject to serious challenges in the last two decades. METHODS: We describe the integrative model of internal medicine as developed in our hospital, providing solutions to some major challenges. RESULTS: Major components include: (1) Senior physicians and residents are employed by the Division rather than individual Departments of Medicine, allowing for balanced distribution of professional capabilities. (2) Two medical departments specialize in geriatric medicine, while the other departments take care of younger, more intellectually challenging patients. Senior and junior staff members rotate through these departments, allowing for exposure to different patient populations and professional expertise. (3) The backbone of senior physicians is rewarded by a set of incentives, including dedicated time for research. (4) Senior staff from the subspecialties contributes annually 1-2 months as senior physicians in the departments and receive academic and other compensation for their efforts. (5) In cases where medical departments elsewhere are flooded with corridor admissions (a source of frustration and burnout), a short admission unit in the emergency department relieves internal medicine pressures and shortens evaluation and therapy for many patients. CONCLUSION: Our integrative model of internal medicine allows for improved patient and staff distribution, greater satisfaction among patients and family members, greater professional satisfaction among physicians, while resident vacancies are filled with competent residents.

How effective are monthly departmental tracer surveys? A 5-year retrospective study of 138 surveys in 96 departments.

BACKGROUND: Repeat department-wide surveys are commonly employed for infection control. There remains debate concerning their cost-effectivess. The aim of the study was to measure the impact of repeat department-wide surveys in major in-patient departments (IPDs) and ambulatory facilities (AFs) in a tertiary care hospital. This was a retrospective study of 138 surveys condcuted in 96 departments over a 5-year period. METHODS: Two itemized questionnaires were designed to assess the most frequently inadequately adhered to infection control measures: one for IPD (with 21 items) and the other for AF (with 17 items). RESULTS: A total of 72 surveys were conducted in 49 IPDs, of which 39 (54%) were repeat surveys, and 66 surveys in 47 AFs, of which 33 (50%) were repeat surveys. The baseline rate of adherence/department was 71% ± 14 for the IPD, with an increase from the first to the last survey to 82% ± 13 (P = .037). In 15/21 measured infection control items, adherence improved. Adherence to infection control items was lower at baseline in the AFs than in the IPDs (63 ± 27), with an increase to 76 ± 20 (non significant). Although adherence improved for 9 items, it deteriorated in another 8, producing an overall statistically unchanged outcome. CONCLUSION: Repeat whole-department surveys contribute moderately to increased adherence to infection control guidelines. AFs demonstrate lower rates of adherence to infection control guidelines and are less receptive to educational measures.

[Impact of a monitoring unit in the medical department on patient outcome].

PURPOSE: Many hospitals have established monitoring units (MU) in their medical departments, with operating costs that are significantly lower than Intensive Care Units, but with no data on their effectiveness. We determined the outcome of patients, who were treated in a new MU during their hospitalization, compared with that of a control group. METHODS: We included all patients, who were admitted to the MU during a five months period. The control group consisted of patients, who were admitted to medical departments and did not stay in the MU during their hospitalization. Patients and controls were matched according to gender, age +/- 10 years, and need for mechanical ventilation. The main endpoint was the 28-day survival rate. RESULTS: There were minor differences between baseline characteristics of patients and controls. The patient cohort included a higher rate of acute renal failure (20/100, 20%) and chronic renal failure (23/100, 23%), compared to the control group (respectively, 10/100, 10%, p < 0.05 and 8/100, 8%, p < 0.05), and a higher rate of respiratory support (83/94, 82% and 72/99, 72%, p < 0.05). Contrarily, a GLasgow coma scale of 3-5 was found in 10/100 (10%) of MU patients and in 20/100 (20%) of control patients (p < 0.05). Despite these differences, there was no difference in predicted mortality score. Nevertheless, the observed survival rate of patients who stayed in the monitoring unit (76/100, 76%) was higher than that of the control group (64/100, 64%) (p < 0.05). CONCLUSIONS: The results of this pilot study indicate that a monitoring unit may contribute to improved survival.

The use of a diversion tube to reduce blood culture contamination: A "real-life" quality improvement intervention study.

BACKGROUND: Blood culture contamination is associated with health care costs and potential patient harm. Diversion of the initial blood specimen reduces blood culture contamination. We report results of the "real-life" clinical implementation of this technique. METHODS: Following an educational campaign, use of a dedicated diversion tube was recommended prior to all blood cultures. Blood culture sets taken from adults using a diversion tube were defined as "diversion sets," those without, "non-diversion" sets. Blood culture contamination and true positive rates were compared for diversion and nondiversion sets and to nondiversion historical controls. A secondary analysis investigated efficacy of diversion by patient age. RESULTS: Out of 20,107 blood culture sets drawn, the diversion group included 12,774 (60.5%) and the nondiversion group 8,333 (39.5%) sets. The historical control group included 32,472 sets. Comparing nondiversion to diversion, contamination decreased by 31% (5.5% [461/8333] to 3.8% [489/12744], P < .0001]. Contamination was also 12% lower in diversion than historical controls [3.8% (489/12744) vs 4.3% (1,396/33,174) P = .02)]. The rate of true bacteremia was similar. In older patients, contamination rate was higher, and the relative reduction associated with diversion decreased (54.3% amongst 20-40-year-olds vs 14.5% amongst >80-year-olds). CONCLUSIONS: Use of a diversion tube in the ED reduced blood culture contamination in this large real life observational study. Efficacy decreased with increasing age, which requires further investigation.

Mixed effect of increasing outflow of medical patients from an emergency department.

BACKGROUND AND AIM: Since 2014, the annual number of patients entering our emergency department (ED) has increased significantly. These were primarily Internal Medicine (IM) patients, and of these, 25-30% were admitted. The present governmental policy presents a deterrent to adding IM beds for these patients, and Emergency and IM departments cope with ever-increasing number of IM patients. We describe a quality improvement intervention to increase outflow of IM patients from the ED to the IM departments. METHODS: We conducted a quality improvement intervention at the Shaare Zedek Medical Center from 2014 to 2018. The first stage consisted of an effort to increase morning discharges from the IM departments. The second stage consisted of establishing a process to increase the number of admissions to the IM departments from the ED. RESULTS: Implementation of the first stage led to an increased morning discharge rate from a baseline of 2-4 to 18%. The second stage led to an immediate mean (± SD) morning transfer of 35 ± 7 patients to the medical departments (8-12 per department), providing significant relief for the ED. However, the additional workload for the IM departments' medical and nursing staff led to a rapid decrease in morning discharges, returning to pre-intervention rates. Throughout the period of the new throughput intervention, morning admissions increased from 30 to > 70%, and were sustained. The number of patients in each department increased from 36 to 38 to a new steady state of 42-44, included constant hallway housing, and often midday peaks of 48-50 patients. Mean length of stay did not change. IM physician and nurse dissatisfaction led to increased number of patients being admitted during the evening and night hours and fewer during the morning. CONCLUSION: We describe a quality improvement intervention to improve outflow of medical patients from the ED in the morning hours. The new ED practices had mixed effects. They led to less ED crowding in the morning hours but increased dissatisfaction among the IM department medical and nursing staff due to an increased number of admissions in a limited number of hours. The present governmental reimbursement policy needs to address hospital overcrowding as it relates to limited community healthcare beds and an aging population.