Care Hospital In Boston Research Articles

Antibiotic Exposure and Room Contamination Among Patients Colonized With Vancomycin-Resistant Enterococci

To determine whether total and antianaerobic antibiotic exposure increases the risk of room contamination among vancomycin-resistant enterococci (VRE)-colonized patients. A 14-month study in 2 intensive care units at an academic tertiary care hospital in Boston, Massachusetts. All patients who acquired VRE or were VRE-colonized on admission and who had environmental cultures performed. We performed weekly environmental cultures (2 sites per room) and considered a room to be contaminated if there was a VRE-positive environmental culture during the patient's stay. We determined risk factors for room contamination by use of the Cox proportional hazards model. Of 142 VRE-colonized patients, 35 (25%) had an associated VRE-positive environmental culture. Patients who contaminated their rooms were more likely to have diarrhea than those who did not contaminate their rooms (23 [66%] of 35 vs 41 [38%] of 107; P = .005) and more likely to have received antibiotics while VRE colonized (33 [94%] of 35 vs 86 [80%] of 107; P = .02). There was no significant difference in room contamination rates between patients exposed to antianaerobic regimens and patients exposed to nonantianaerobic regimens or between patients with and patients without diarrhea, but patients without any antibiotic exposure were unlikely to contaminate their rooms. Diarrhea and antibiotic use were strongly confounded; although two-thirds of room contamination occurred in rooms of patients with diarrhea, nearly all of these patients received antibiotics. In multivariable analysis, higher mean colonization pressure in the ICU increased the risk of room contamination (adjusted hazard ratio per 10% increase, 1.44 [95% confidence interval, 1.04-2.04]), whereas no antibiotic use during VRE colonization was protective (adjusted hazard ratio, 0.21 [95% confidence interval, 0.05-0.89]). Room contamination with VRE was associated with increased mean colonization pressure in the ICU and diarrhea in the VRE-colonized patient, whereas no use of any antibiotics during VRE colonization was protective.

Managing anticoagulant related coagulopathy

There are several parenteral anticoagulants in use currently in the US. These include unfractionated heparin (UFH) commonly referred to as heparin, low-molecular weight heparins (LMWHs), synthetic pentasaccharide (fondaparinux), vitamin K antagonists (VKA) and direct thrombin inhibitors. The properties including mode of elimination, half-life, antidote and dose adjustment in renal failure of these drugs are listed in Table 1. VKA are the only orally approved anticoagulants with warfarin being the most commonly used in the United States with approximately three million users. This number of chronic warfarin users continues to increase annually as the baby boomers age and as patients over the age of 65 increase. It is estimated that approximately 26,000 major bleeding events occur annually in the United States. According to a recent study the incidence of anticoagulant associated intracerebral hemorrhage, the most feared and morbid bleeding complication, has quintupled in the US population in the 1990s [1]. The majority of this change can be explained by increasing warfarin use. A recent prospective study of 101 consecutive inpatients admitted to a tertiary care hospital in Boston [2] that looked at a cohort of patients with anticoagulation-associated hemorrhage suggested that excessive anticoagulation contributed independently to increased morbidity and mortality in hospitalized patients. The overall mortality at 60 days was 26% (13/50) in the excessive group compared with 10% (5/51) in the nonexcessive group (P = .03). Excessive warfarin therapy was associated with an increased 60-day mortality (P = .049), in contrast to excessive anticoagulation with UFH or LMWH alone (P = .27) or UFH or LMWH as a ‘‘bridge’’ to warfarin therapy (P = .10). Multivariate regression identified excessive anticoagulation as an independent predictor of 60-day mortality (adjusted hazard ratio [HR], 4.17; 95% confidence interval [CI], 1.39–12.49; P = .01), along with intracranial hemorrhage (adjusted HR, 6.16; 95% CI, 1.75– 21.67; P = .005) and active cancer (adjusted HR, 3.79; 95% CI, 1.13–12.70; P = .03).

Preventing the influx of vancomycin-resistant enterococci into health care institutions, by use of a simple validated prediction rule.

The goal of this study was to develop a validated prediction rule for identification of patients harboring vancomycin-resistant enterococci (VRE) at hospital admission. A model for the prediction of patients harboring VRE at admission was created and validated by assigning weighted point values to independent risk factors associated with harboring VRE at admission, in 2 different cohorts of patients from 2 tertiary care hospitals in Boston, Massachusetts. Patients with VRE isolated from clinical culture samples collected within 48 h of hospital admission were compared with patients not harboring VRE. To assess the diagnostic accuracy of the prediction rule, the main outcome measures were patient demographic characteristics, comorbid illnesses, hospitalizations, and antibiotic exposure. A total of 412 patients were enrolled. A risk index score was derived by using the following 6 independent risk factors associated with VRE recovery within 48 h of hospital admission: previous isolation of methicillin-resistant Staphylococcus aureus (MRSA), whether the patient was receiving long-term hemodialysis, transfer from a long-term care facility, antibiotic exposure, prior hospitalization, and age >60 years. On the basis of a point score >or=10, the sensitivity, specificity, and positive and negative predictive values of this prediction rule were 44%, 98%, 81%, and 90%, respectively. This validated clinical prediction rule provides a novel strategy for the identification of patients at high risk of harboring VRE at hospital admission. Implementation of this rule may reduce the influx of VRE into health care institutions and the overall prevalence of VRE, by targeting VRE-screening measures and contact isolation precautions for these high-risk patients.

How physicians perceive hospitalist services after implementation: anticipation vs reality.

To determine whether internists' attitudes toward the hospitalist model change after implementation of a new inpatient service. Cross-sectional surveys performed in 1998 and 2000. Tertiary care hospital in Boston, Mass. A total of 236 internal medicine board-certified physicians affiliated with Beth Israel Deaconess Medical Center. Responses to survey items regarding attitude toward inpatient care and the hospitalist model. We used multivariable models to determine factors associated with physician responses. Of physicians surveyed in 2000, 236 (69%) responded; 145 (61%) had also responded in 1998. The mean (SD) age of respondents was 46.4 (10.8) years; 157 (66.5%) were male; and 146 (61.9%) were primary care providers. In 2000, more physicians agreed that "caring for inpatients is an inefficient use of my time" (P<.001), and that "use of a hospitalist service improves quality of care" (P =.002). In 2000, more physicians disagreed that "use of a hospitalist service diminishes physician career satisfaction" (P<.001), and that "use of the hospitalist service adversely affects the physician-patient relationship" (P<.001). No differences were detected in responses to questions regarding patient satisfaction or overall career satisfaction. In multivariable models, older physicians were more likely to favor the hospitalist model; those with busier inpatient practices were more negative (P<.05 for each). Physician specialty or being a primary care provider was not associated with attitudes toward the hospitalist model. Following experience with a hospitalist system, physician attitude, including concerns regarding career satisfaction and relationships with patients, toward a voluntary hospitalist model improved. Future research should investigate whether the hospitalist model affects patient satisfaction and quality of care.

Lightening the burden for preceptors: consider adding a "Faculty Model" week to orientation.

The physical and emotional stress on preceptors creates a conundrum as hospitals expand and/or experience higher rates of nursing staff turnover. When chosen well, preceptors are an excellent way to integrate and teach new nurses. However, being a preceptor can often be an added burden in a busy hospital climate. Creating innovative systems, within new nurse orientation, that respect the preceptor role and provide some relief have much merit in today's bustling hospital environment. The creation of such a system in a large tertiary care hospital in Boston, MA, entitled the Faculty Model Pilot Program, seems to be both supporting the overworked preceptors and providing a comprehensive standardized practice week for newly hired medical/surgical nurses. The pilot program appeared to increase not only their knowledge of the hospital itself but also the standards of patient care throughout the hospital. This added week seemed to provide a good understanding of general nursing practice prior to the acquisition of the unit-based, specific knowledge; thus, lightening the burden for unit preceptors.

Prevalence of Deep Venous Thrombosis Among Patients in Medical Intensive Care

OBJECTIVE--To determine the frequency of deep venous thrombosis (DVT) in medical intensive care unit (MICU) patients. DESIGN--Prospective ultrasound case series. SETTING--An MICU in a large tertiary care hospital in Boston, Mass. SUBJECTS--Patients older than 18 years of age admitted to the MICU with an anticipated stay of more than 48 hours. MAIN OUTCOME MEASURE--Deep venous thrombosis as detected by ultrasonography with color Doppler imaging performed twice weekly in the MICU and once within 1 week of discharge from the MICU. RESULTS--Deep venous thrombosis was detected in 33% (95% confidence interval, 24% to 43%) of 100 eligible patients during the 8-month study period. Forty-eight percent (16/33) were proximal lower extremity DVT, and 15% (5/33) were upper extremity DVT associated with central venous catheters, with one patient having both upper and proximal lower extremity DVT. Ultrasound examination results led to inferior vena cava filter placement in three patients, initiation of full-dose anticoagulation in four patients, initiation or continuation of low-dose subcutaneous heparin in 10 patients, follow-up ultrasound studies in three patients, central line removal in one patient, and no intervention in 10 patients due to active bleeding, prior filter, or heparin-induced thrombocytopenia. Two patients remained anticoagulated for other reasons. In this series, there was no difference in age, gender, body mass index, diagnosis of cancer, recent surgery, duration of hospitalization prior to DVT detection, and DVT prophylaxis between patients with DVT and those without. CONCLUSIONS--An unexpectedly high rate of DVT was detected by ultrasound in these MICU patients despite prophylaxis in 61%. Traditionally recognized DVT risk factors failed to identify patients who developed DVT. Routine ultrasound surveillance or more intensive prophylaxis regimens may be warranted in this patient population if these DVT rates are confirmed in other settings.