Adult Tertiary Care Hospital Research Articles

Dizziness and Imbalance Across the Lifespan: Findings of a Pediatric and Adult Vestibular Clinic.

To evaluate diagnostic trends in pediatric and adult patients presenting for multidisciplinary subspecialty evaluation of dizziness and imbalance across the lifespan. Retrospective chart review. Single pediatric and single adult academic tertiary care hospital. Retrospective review of electronic health record for patients presenting to an adult or pediatric multidisciplinary vestibular clinic from 2017 to 2020, including clinical data, physical therapy evaluation, and audiovestibular testing. A total of 1934 patients aged 1 to 95 were evaluated. Most patients were female (n = 1188, 61%); the largest cohort was in the fifth decade of life (n = 321, 17%). Seventy-six percent of patients (n = 1470) were assigned a pathologic diagnosis. Central causes of dizziness were most common in children and young adults, comprising 38% to 54% of all diagnoses in ages 1 to 30. The proportion of peripheral vestibular disorders increased with age, peaking at 32% in ages 61 to70. Vestibular migraine was the most common pathologic diagnosis in ages 6 to 20 (n = 110, 39%) and 31 and 50 (n = 69, 17%) regardless of gender, but was more prevalent in females (21% vs 14%; P < .0001). The prevalence of benign paroxysmal positional vertigo (BPPV) increased throughout the lifespan, peaking at age 71 to 80. Meniere's disease (MD) did not occur within the first decade of life, but increased thereafter, peaking at ages 51 to 60. Multidisciplinary vestibular evaluation resulted in a diagnosis for the majority of patients. Vestibular diagnoses vary across the lifespan however among most age groups, central disorders, including migraine disorders, outnumber peripheral vestibulopathies. The prevalence of peripheral vestibular disorders such as BPPV and MD increased with age. Level IV.

Candida auris outbreak at a tertiary care hospital during the COVID-19 pandemic

Candida auris (C auris) is a fungal pathogen that has the potential for environmental persistence leading to outbreaks in health care settings. There has been a worldwide surge in C auris outbreaks during the COVID-19 pandemic. In this report, we describe an outbreak of C auris, its control, patient outcomes, and lessons learned. The outbreak occurred in a 600-bed adult academic tertiary care hospital. Contact tracing was initiated immediately after identification of the index case and surveillance testing for C auris was obtained from patients who were exposed to the index case. Infection prevention measures were closely followed. A total of 560 cultures were performed on 453 unique patients between August 2021 and December 2021. Of those, 31 cultures (5.5%) were positive for C auris; 27 (87.1%) were colonized with C auris, while 4 patients developed a clinical infection (12.9%). The secondary attack rate was 6.8% (31/453). The 30-day all-cause mortality rate for all patients who tested positive for C auris was 9.7%. C auris can cause protracted outbreaks that result in colonization and invasive infections. Multidisciplinary work to improve adherence to infection prevention measures as well as targeted admission screening are essential to limit outbreaks.

Integrating Google Trends Search Engine Query Data Into Adult Emergency Department Volume Forecasting: Infodemiology Study.

The search for health information from web-based resources raises opportunities to inform the service operations of health care systems. Google Trends search query data have been used to study public health topics, such as seasonal influenza, suicide, and prescription drug abuse; however, there is a paucity of literature using Google Trends data to improve emergency department patient-volume forecasting. We assessed the ability of Google Trends search query data to improve the performance of adult emergency department daily volume prediction models. Google Trends search query data related to chief complaints and health care facilities were collected from Chicago, Illinois (July 2015 to June 2017). We calculated correlations between Google Trends search query data and emergency department daily patient volumes from a tertiary care adult hospital in Chicago. A baseline multiple linear regression model of emergency department daily volume with traditional predictors was augmented with Google Trends search query data; model performance was measured using mean absolute error and mean absolute percentage error. There were substantial correlations between emergency department daily volume and Google Trends "hospital" (r=0.54), combined terms (r=0.50), and "Northwestern Memorial Hospital" (r=0.34) search query data. The final Google Trends data-augmented model included the predictors Combined 3-day moving average and Hospital 3-day moving average and performed better (mean absolute percentage error 6.42%) than the final baseline model (mean absolute percentage error 6.67%)-an improvement of 3.1%. The incorporation of Google Trends search query data into an adult tertiary care hospital emergency department daily volume prediction model modestly improved model performance. Further development of advanced models with comprehensive search query terms and complementary data sources may improve prediction performance and could be an avenue for further research.

Consultation Needs for Young Adults with Intellectual and Developmental Disabilities Admitted to an Adult Tertiary Care Hospital: Implications for Inpatient Practice

BackgroundChildren with intellectual and developmental disabilities (IDD), particularly those with medical complexity, account for a large proportion of pediatric inpatients and are increasingly surviving to adulthood. However, few studies have evaluated the inpatient care of this population after transition to adult hospitals. This paper describes a Med-Peds Hospitalist service providing inpatient consultation for young adults with childhood conditions and offers a window into issues likely to be faced by young adults with IDD as they face increased admissions to adult hospitals. MethodsA single center retrospective chart review was performed of adults with intellectual and developmental disabilities referred to the Med-Peds consult service at a large urban adult academic medical center. FindingsThe most common medical recommendations provided focused on diagnosis and management of gastrointestinal, neurologic, and respiratory issues. Coordination between pediatric and adult caregivers, disposition planning, communication and family support, and guidance on weight-based dosing were also commonly provided services. DiscussionYoung adults with IDD face new challenges when admitted to adult hospitals. In this single-center study, several areas were identified where expert consultation could be helpful. The need for structured coordination of care for this vulnerable patient population was highlighted. Knowledgeable consultative services may be an effective intervention to address the unique needs of hospitalized young adults with IDD. Application to practiceHospitals should consider structured inpatient programs, care-paths, or consultation from providers knowledgeable in the care of young adults with intellectual disabilities in order to improve the inpatient care of this population.

“A TRUE EXPERIMENTAL STUDY TO ASSESS THE EFFECTIVENESS OF XYLOCAINE 2% GEL ON PAIN INTENSITY DURING INTRAVENOUS CANNULATION AMONG PATIENTS AT SELECTED TERTIARY CARE HOSPITAL BELAGAVI”

A true experimental, post test only control group design was used to nd out the effectiveness of Xylocaine 2% gel on pain intensity reduction during intravenous cannulation among the adult patients tertiary care hospital of Belagavi, Karnataka. Quantitative approach was used for the study. The study was done on 80 adult patients using standardized pain numerical scale. (Based on pilot study the prevalence rates in both group calculated p1=82% p2=100%, q1=18 q2=0, d=18% , Z= 1.96 (at 5% α error), Z= 0.842 (at 80% power) n=38 40). Simple random (lottery method) technique was used .in this study the patients, who have a patent intravenous cannula in place and who are unable perceive and responds for pain (unconscious patient). Demographical variables analyzed for the study Age, Gender, Education, Occupation, Previous experience, duration of pain during intravenous cannulation, site of cannulation and size of intravenous Cannula (Variables Independent variable: Xylocaine 2% gel. Dependent variable: Pain intensity experience during intravenous cannulation). Total 21 reviews were taken under the title of the above study (Indian- 03, International- 18). The conceptual framework used for this study is based on General Systems Theory introduced by Ludwig Von Bertalanffy in 1968. The obtained data was analyzed by using descriptive and inferential statistics. The mean of post test pain intensity during IV cannulation in experimental group was 1.93 and 4.30 in control group and SD of 0.60 in experimental group, 0.61 in control group. In this study 62.50% of participants have mild pain and 15% have moderate pain in experimental group as compared to 55% have severe pain followed by 37.50% have worst pain in control group. The difference is found to be statistically signicant

A152 FOREIGN BODY INGESTIONS AT A TERTIARY CARE CENTRE - A QUALITY ASSURANCE STUDY

Abstract Background Foreign body ingestion and esophageal food bolus impaction are common emergencies encountered by gastroenterologists. If not treated in a timely fashion these can result in significant morbidity, or even mortality. The mainstay of diagnosis and therapy is endoscopy. Guidelines regarding timing of endoscopy have been published by both the American and European Societies of Gastrointestinal Endoscopy, and both suggest emergent endoscopy, meaning within 2 to 6 hours, for complete esophageal obstructions. There is relatively sparse data regarding the endoscopic techniques used in real world practice. Aims This is a quality assurance study looking at the endoscopic practices at an adult tertiary care hospital in Halifax, Nova Scotia with respect to foreign body and food impaction management. Methods The hospital records of all patients presenting with ingested foreign bodies or esophageal food bolus impactions between May 2018 and July 2019 were included. Patients were identified by searching the call-back forms used by our department which documents all on-call endoscopy cases. This was then cross-referenced by endoscopy nursing charting which documents every endoscopy performed. Information such as demographics, obstruction type, endoscopic method of removal, complications, time between consultation and endoscopy, underlying pathology, and others were analyzed. Results 70 cases were identified. Average patient age was 51.3 years old (range 16–96). 18 (25.7%) were female and 52 (74.3%) were male. 64 cases (91.4%) were esophageal food impactions and 6 (8.57%) were foreign body ingestions. Of the food impactions, 39 cases (60.9%) were cleared by the push/slide-by technique only and 10 (16.7%) were relieved using instruments such as snares, forceps, or nets. 15 (23.4%) passed spontaneously prior to scope, of which 7 received glucagon. An overtube was used in 1 case (0.16%). Complications occurred in 5 (7.8%) cases and included 3 mucosal tears, 2 of which required therapeutic interventions, and 2 episodes of oxygen desaturation in which the procedure was aborted. Complete obstructions occurred in 42 (65.6%) cases with average time of consultation to endoscopy of 2.4 hours. However, 3 (7.1%) cases exceeded 6 hours. The most common pathology was eosinophilic esophagitis with 20 cases (31.3%). Ingested foreign bodies included 2 long objects, 3 sharp objects, and a cylindrical battery, and all but one were in the stomach. 5 (83.3%) cases used an overtube. No complications occurred. Conclusions At our institution 67/70 (95.7%) cases were performed within the timelines recommended by society guidelines. No complications occurred in the cases not performed within those time limits. An overtube was used in only one case in which a food bolus was retrieved out of the esophagus. Overall this study suggests that our centre is meeting recommended targets, however there is room for improvement. Funding Agencies None

Factors influencing seasonal influenza vaccination uptake among health care workers in an adult tertiary care hospital in Singapore: A cross-sectional survey

This study aimed to evaluate the factors influencing seasonal influenza vaccination uptake among different health care professional groups. A single-center, cross-sectional survey using a standardized anonymous, self-administered questionnaire to assess knowledge, attitudes, and uptake of seasonal influenza vaccination was used. Associations between respective health care groups and vaccination acceptance were then assessed. In total, 3,873 health care workers completed the questionnaire. Of these, 7% were administrative staff, 17% were allied health staff, 7% were ancillary staff, 11% were medical staff, and 58% were nursing staff. The overall vaccination rate for the Southern Hemisphere 2015 influenza season was 82%. In a multivariate logistic regression model, after controlling for gender and presence of chronic disease, associated factors for accepting influenza vaccination were age, education level of bachelor degree or higher, preference for vaccination provided by mobile teams, having 1-50 patient contacts per week, and belief in the potential severity of influenza and vaccine safety (P < .05). In contrast, factors negatively associated with vaccination acceptance included being a medical staff member or allied health staff member, living with family members under the age of 16, fear of adverse reactions, and disbelief in vaccination effectiveness (P < .05). Although vaccine coverage in Singapore has been high, our findings provide guidance for the development of strategies to further improve vaccine coverage among different groups of health care workers.

Differences in psychosocial determinants of hand hygiene between health care professional groups: Insights from a mixed-methods analysis

Good hand hygiene (HH) prevents health care-associated infections. We compared psychosocial and organizational factors associated with HH compliance and perceived need for improvement among physicians, nurses, and allied health professionals (AHPs). We conducted a mixed-methods study in a 1,600-bed adult tertiary-care hospital in Singapore. Seven focus group discussions were conducted and data were analyzed using thematic analysis. The subsequent cross-sectional survey involved 1,064 staff members. Principal components analysis was performed to derive the latent factor structure that was applied in multivariable analyses. All staff members acknowledged that HH was an integral part of their work, but were noncompliant due to competing priorities. Physicians were forgetful but appreciated reminders. Nurses were intrinsically motivated for HH. After adjusting for gender, staff category, seniority, and dermatitis history, having positive knowledge-attitudes-behaviors (odds ratio [OR], 1.44; 95% confidence interval [CI], 1.23-1.69), personal motivators-enablers (OR, 1.60; 95% CI, 1.38-1.86), and emotional motivators (OR, 1.62; 95% CI 1.40-1.88) were positively associated with good HH compliance. Women (OR, 3.91; 95% CI, 1.37-11.11), seniors (OR, 2.88; 95% CI, 1.08-7.68), nurses (OR, 4.05; 95% CI, 1.51-10.87), and staff with personal motivators-enablers for HH (OR, 1.60; 95% CI, 1.08-2.37) were more likely to perceive a need for improvement. Factors influencing self-reported HH differed between health care professional groups. Group-specific interventions are needed to improve compliance.

Managing Incidentalomas Safely: Do Computed Tomography Requisitions Tell Us What We Need to Know?

PurposeTechnological advancements and the ever-increasing use of computed tomography (CT) have greatly increased the detection of incidental findings, including tiny pulmonary nodules. The management of many “incidentalomas” is significantly influenced by a patient's history of cancer. The study aim is to determine if CT requisitions include prior history of malignancy. MethodsRequisitions for chest CTs performed at our adult tertiary care hospital during April 2012 were compared to a cancer history questionnaire, administered to patients at the time of CT scan. Patients were excluded from the study if the patient questionnaire was incomplete or if the purpose of the CT was for cancer staging or cancer follow-up. ResultsA total of 569 CTs of the chest were performed. Of the 327 patients that met inclusion criteria, 79 reported a history of cancer. After excluding patients for whom a history of malignancy could not be confirmed through a chart review and excluding nonmelanoma skin cancer, dysplasia, and in situ neoplasm, 68 patients were identified as having a history of malignancy. We found 44% (95% confidence interval [0.32-0.57]) of the chest CT requisitions for these 68 patients did not include the patient's history of cancer. Of the malignancies that were identified by patient questionnaire but omitted from the clinical history provided on the requisitions, 47% were malignancies that commonly metastasize to the lung. ConclusionsA significant number of requisitions failed to disclose a history of cancer. Without knowledge of prior malignancy, radiologists cannot comply with current guidelines regarding the reporting and management of incidental findings.

Clinical features and risk factors predicting severe influenza: The experience of an adult tertiary care hospital in Singapore

Clinical features and risk factors predicting severe influenza: The experience of an adult tertiary care hospital in Singapore

Surveillance of Zika virus infection: The experience of an adult tertiary care hospital in Singapore

Surveillance of Zika virus infection: The experience of an adult tertiary care hospital in Singapore

Risk assessment and laboratory investigation of respiratory illness in travellers returning to Singapore 2012-2015: experience from the MERS-CoV Surveillance Programme.

Since the emergence of Middle East respiratory syndrome coronavirus (MERS-CoV), Singapore has enhanced its national surveillance system to detect the potential importation of this novel pathogen. Using the guidelines from the Singapore Ministry of Health, a suspect case was defined as a person with clinical signs and symptoms suggestive of pneumonia or severe respiratory infection with breathlessness, and with an epidemiological link to countries where MERS-CoV cases had been reported within the preceding 14 days. This report describes a retrospective review of 851 suspected MERS-CoV cases assessed at the adult tertiary-care hospital in Singapore between September 2012 and December 2015. In total, 262 patients (31%) were hospitalized. All had MERS-CoV infection ruled out by RT-PCR or clinical assessment. Two hundred and thirty (88%) of the hospitalized patients were also investigated for influenza virus by RT-PCR. Of these, 62 (27%) tested positive for seasonal influenza. None of the patients with positive influenza results had been vaccinated in the year prior to hospital admission. Ninety-three (36%) out of the 262 hospitalized patients had clinical and/or radiological evidence of pneumonia. This study demonstrates the potential benefits of pre-travel vaccination against influenza and pneumococcal disease.

Plasma cholesterol in adults with phenylketonuria

Phenylketonuria (PKU) is an autosomal recessive disorder of phenylalanine (Phe) catabolism resulting from a deficiency of L-phenylalanine hydroxylase (PAH). An association between hyperphenylalaninaemia (HPA) and hypocholesterolaemia has been reported in children. However, controversy exists as to whether this is due to the low protein diet or to a disruption to cholesterol biosynthesis inherent to those with PKU. We investigated the relationship between blood Phe and plasma cholesterol in 41 apparently healthy adults with PKU (26 female, 15 male, age 18-57 years, median age 26 years) attending a PKU outpatient clinic at an adult tertiary care hospital. Of these patients, 33 (80%) were compliant with a Phe-restricted diet with amino acid supplementation, whereas eight (20%) were not. The PKU subjects had a mean body mass index (BMI) of 30.3 ± 1.8 kg/m; 72% were obese, 14% overweight, with only 14% having normal BMI. The mean blood Phe was 1194 ± 522 μmol/L with plasma total cholesterol, triglyceride, HDL-cholesterol, LDL-cholesterol and apolipoprotein (apo) B concentrations of 4.3 ± 0.8 mmol/L, 1.6 ± 0.8 mmol/L, 1.2 ± 0.3 mmol/L, 2.3 ± 0.8 mmol/L, and 0.83 ± 0.21 g/L, respectively. The mean LDL-cholesterol was 19% lower in PKU females than that of 8944 age-matched females from a community population (2.5 ± 0.8 mmol/L vs. 3.1 ± 0.9 mmol/L, p < 0.001). Similarly, the mean LDL-cholesterol was 32% lower in PKU males than 3786 age-matched males (2.1 ± 0.7 mmol/L vs. 3.1 ± 1.0 mmol/L, p < 0.0001). No correlations were observed between Phe and total cholesterol, LDL-cholesterol or apoB in the PKU cohort. Adults with PKU had low-normal cholesterol concentrations, with no correlation observed between Phe and cholesterol levels. Our findings support the concept that the HPA found in PKU, rather than an effect of a low-protein diet, leads to hypocholesterolaemia. Studies are required to determine whether this cholesterol-lowering effect confers cardioprotection.

Psychosocial determinants of physicians’ acceptance of recommendations by antibiotic computerised decision support systems: A mixed methods study

Antibiotic computerised decision support systems (CDSSs) were developed to facilitate optimal prescribing, but acceptance of their recommendations has remained low. We aimed to evaluate physicians’ perceptions and attitudes toward antibiotic CDSSs and determine psychosocial factors associated with acceptance of CDSS recommendations for empirical therapy. A mixed methods study was conducted in an adult tertiary-care hospital in Singapore, with its in-house antibiotic CDSS that integrates antimicrobial stewardship with electronic prescribing. Focus group discussions were conducted among purposively sampled physicians and data were analysed using the framework approach. Emerging themes were included in the questionnaire with newly developed scales for the subsequent cross-sectional survey involving all physicians. Principal components analysis was performed to derive the latent factor structure that was later applied in multivariate analyses. Physicians expressed confidence in the credibility of CDSS recommendations. Junior physicians accepted CDSS recommendations most of the time, whilst senior physicians acknowledged overriding recommendations in complex patients with multiple infections or allergies. Willingness to consult the CDSS for common and complex infections (OR=1.68, 95% CI 1.16–2.44) and preference for personal or team decision (OR=0.61, 95% CI 0.43–0.85) were associated with acceptance of CDSS recommendations. Cronbach's α for scales measuring physicians’ attitudes and perceptions towards acceptance of CDSS recommendations ranged from 0.64 to 0.88. Physicians’ willingness to consult an antibiotic CDSS determined acceptance of its recommendations. Physicians would choose to exercise their own or clinical team's decision over CDSS recommendations in complex patient situations when the antibiotic prescribing needs were not met.

Outcomes of patients requiring insertion of an inferior vena cava filter

Data regarding inferior vena cava (IVC) filter use and complications are scarce. This study evaluates the safety and efficacy of IVC filters over a 4-year period at two adult tertiary care hospital sites. A retrospective observational study was conducted of consecutive admitted patients who underwent insertion of an IVC filter between 1 January 2007 and 31 December 2010. The main objective of the study was to evaluate the safety and efficacy of IVC filters. We identified 338 patients with an attempted filter insertion who were followed for a median 16.3 months. Ninety-one percent of filters inserted were for an appropriate indication. Sixty-eight patients (20% of all patients) had one or more filter-related complication. Despite a median time after filter insertion to start anticoagulation of 2 days (interquartile range 3 days) for prophylactic and 6 days (interquartile range 7 days) for full dose, 38 patients (11% of all patients) had one or more thrombotic complications during follow-up. In a subgroup of patients with complete anticoagulation information available, thrombotic complications occurred in 18, 16, and 8% of patients receiving no, prophylactic, or full dose anticoagulation after IVC filter insertion, respectively (NS; P = 0.13). IVC filter use in our study was associated with a substantial rate of complications including thrombotic complications. This study highlights the need for further research regarding the safety and efficacy of IVC filters and the role for early initiation of anticoagulation.

Correlations between first documented cardiac rhythms and preceding telemetry in patients with code blue events

Among in-hospital cardiac arrest (IHCA) patients, the first cardiac rhythm documented on resuscitation records (FDR) is often used as a surrogate for arrest etiology. Although the FDR generally represents the electrical activity at the time of cardiopulmonary resuscitation initiation, it may not be the ideal rhythm to infer the arrest etiology. We hypothesized that a rhythm present earlier-at the time of the code blue call-would frequently differ from the FDR, because the FDR might represent the later stage of a progressive cardiopulmonary process. To evaluate agreement between FDR and telemetry rhythm at the time of code blue call. Cross-sectional study. A 750-bed adult tertiary care hospital and a 240-bed adult inner city community hospital. Adult general ward patients monitored on the hospital's telemetry system during the 2 minutes prior to a code blue call for IHCA. None. Agreement between FDR and telemetry rhythm. Among 69 IHCAs, agreement between FDR and telemetry was 65% (kappa = 0.37). Among 17 events with FDRs of ventricular tachyarrhythmia (VTA), telemetry showed VTA in 12 (71%) and other organized rhythms in 5 (29%). Among 12 events with first documented rhythms of asystole, telemetry showed asystole in 3 (25%), VTA in 1 (8%), and other organized rhythms in 8 (67%). The FDR had only fair agreement with the telemetry rhythm at the time of code blue call. The telemetry rhythm may be a useful adjunct to the FDR when investigating arrest etiology.

Hardware Removal Rates for Mandibular Angle Fractures: Comparing the 8‐Hole Strut and Champy’s Plates

Objective: 1) Compare the rate of removal of Champy’s plates vs 8-hole strut plates used for repair of mandible angle fracture. 2) Determine the reason for removal of these plates. Method: A retrospective chart review was conducted from 2006 to 2010 comparing the removal rate between Champy’s plates and 8-hole strut plates for internal fixation of traumatic angle mandible fractures at a large adult tertiary care hospital. The reason for removal of each plate was then determined from the clinical record. Results: A total of 104 patients with a total of 106 angle fractures met the inclusion criteria for this study. A total of 73 angle fractures were treated with the 8-hole strut and 33 angle fractures were treated with Champy’s plates. There were 6 plates removed in both groups. This resulted in 8.2% of plates removed in the 8-hole strut plate group and 18.2% in the Champy’s group ( P = .133). Loose hardware was determined to be the cause of plate removal in 1 (2.7%) of the 8-hole strut plate group compared with all 6 (18.2%) of the Champy’s group ( P = .005). Conclusion: In our experience, the 8-hole strut plate has a lower rate of plate removal compared to the Champy’s plate in treating mandible angle fractures. The main reason for plate removal was loose hardware. The rate of removal for loose hardware was higher and statistically significant in the Champy’s group.

The Spectrum of Invasive Pneumococcal Disease at an Adult Tertiary Care Hospital in the Early 21st Century

Despite widespread pneumococcal vaccination of children and adults, invasive pneumococcal disease (IPD) remains prominent. Using our database of all Streptococcus pneumoniae infections at the Veterans Affairs Medical Center, Houston, Texas, since 2000, we reviewed cases of IPD, defined as the isolation of pneumococci from any normally sterile body site. In 136 cases, the mean age of patients was 63 years; 43% were African American, a higher proportion than the 30% served by our hospital. One hundred sixteen patients (85%) had pneumonia, of whom 3 also had empyema. Seven had bacteremia with no apparent source, 5 meningitis, 5 spontaneous bacterial peritonitis, 3 septic arthritis, 2 endocarditis, and individual patients had osteomyelitis and/or localized abscesses. One hundred twenty-one patients (89%) had > or =1 underlying condition associated with susceptibility to pneumococcal infection, and another 8 (6%) were aged >65 years old. Thus only 5% of patients lacked a condition for which 23-valent pneumococcal polysaccharide vaccine (PPV23) is recommended. Fifty-five percent had been vaccinated; similar proportions of vaccine serotypes infected previously vaccinated and nonvaccinated patients. All but 2 isolates were fully susceptible to penicillin and cefotaxime as currently defined. Consistent with substantial replacement of infecting serotypes since the introduction of 7-valent pneumococcal conjugate vaccine (PCV7), none of the predominant infecting serotypes was included in PCV7, although all except for 6A were contained in PPV23. The overall mortality at 30 days was 16% and was similar in vaccinated and nonvaccinated subjects. IPD causes a wide spectrum of disease. Mortality is substantial. PPV23 is clearly not fully protective.

Door‐to‐balloon times are reduced in ST‐elevation myocardial infarction by emergency physician activation of the cardiac catheterisation laboratory and immediate patient transfer

To assess whether a collaborative interdepartmental pathway involving emergency department (ED) physicians activating the cardiac catheterisation laboratory (CCL) with immediate patient transfer to the CCL reduces door-to-balloon (DTB) times for patients with suspected ST-elevation myocardial infarction (STEMI). A quasi-experimental before-and-after observational study using a prospective database, supplemented by chart review, of consecutive patients transferred from the ED to the CCL for suspected STEMI, from January 2007 to October 2009, at Sir Charles Gairdner Hospital, an adult tertiary-care hospital, Western Australia. Median DTB time and proportion of patients with DTB time of < 90 minutes. Secondary outcomes, based on analysis of predefined subgroups, included door-to-activation time, activation-to-balloon time and false-positive activations of the CCL. Two hundred and thirty-four patients underwent emergency coronary angiography for suspected STEMI, with 188 (80%) undergoing percutaneous coronary intervention (118 before and 70 after implementation of the new pathway). Following implementation of the new pathway, median DTB time reduced from 97 to 77 minutes (P < 0.001), median door-to-activation time from 28 to 15 minutes (P = 0.002) and median activation-to-balloon time from 66 to 53 minutes (P < 0.001). The proportion of patients with recommended DTB time of < 90 minutes increased from 41% to 77% (P < 0.001) with no change in false positive CCL activation rates (12% v 11%; P = 0.38). ED physician activation of CCL with immediate patient transfer is associated with highly significant improvements in DTB time without increased false positive rates.

What do healthcare workers think? A survey of facial protection equipment user preferences

Data on healthcare workers'(HCWs) self-reported knowledge regarding selection of facial protection equipment, usage preferences and compliance are limited. We used a questionnaire on the use of facial protection equipment at a 700-bed adult tertiary care hospital employing approximately 7000 HCWs. Clinical areas targeted were those with frequent users of N95 respirators: intensive care unit, emergency room, respiratory services, and internal medicine. Respiratory therapists were also invited. In all, 137 questionnaires (68.5%) were returned. Most (72.8%) reported that training on the use of facial protection equipment was 'sufficient' to 'excellent'. The PFR95 and 3M 1860 Cone were used most frequently (56%) followed by the 3M 1870 Pocket (42%). While 95% reported having been fit-tested, only 60% were tested annually. PRF95 use exceeded the number of HCWs fit-tested for the item. Overall comfort and compliance scores were 13.6/20 and 21.5/25, respectively, for respirators and 7.7/10 and 18.5/25 for protective eyewear. No relationship between comfort and years of use of either respirators or protective eyewear was found. The results highlight potential failures in effectiveness in the use of personal protective equipment that could compromise HCW safety, and support observations that compliance in the workplace is usually less than in the research setting.