Christiana Care Health Services Research Articles

Increased Intravenous N-Acetylcysteine Dosing Following Massive Acetaminophen Ingestion: A Case Report

Kristen M. Audley, Postgraduate Year-2, Critical Care Pharmacy Resident, Christiana Care Health Services I Pharmacy Services Administration, Newark, DE. Jamie M. Rosini, Clinical Pharmacy Specialist, Emergency Medicine, Postgraduate Year-2 Critical Care Residency Program Director, Christiana Care Health Services I Pharmacy Services Administration, Newark, DE

Reducing Use of Restraints in Intensive Care Units: A Quality Improvement Project.

Use of physical restrainst is scrutinized in intensive care units today. Usage rates for the 5 intensive care units in the Christiana Care Health Services, Newark, Delaware, were higher than the National Database of Nursing Quality Indicators mean rate of 9.61% to 15.43% for many months during fiscal years 2013 and 2014. To reduce and sustain the restraint rates to less than the national database mean rates for all 5 intensive care units. A quality improvement process was used that included forming a multiunit restraint collaborative; reviewing restraint data, including self-extubation rates; surveying staff nurses to examine alignment with evidence-based practice; and selecting a new restraint-alternative product. All 5 intensive care units were able to successfully decrease restraint rates to less than the national database mean for the majority of the months since the start of the restraint collaborative in September 2012. Use of a restraint collaborative with subsequent adoption of restraint alternatives led to a decrease in restraint rates for the 5 intensive care units to less than the national database mean, enabled sustained success, and helped align nurses' beliefs with evidence-based practice.

Centering Prenatal Care

INTRODUCTION: The Centering Pregnancy prenatal care model is a group care model which incorporates standard prenatal assessment and education into a series of sessions in which patients are encouraged to participate in their own healthcare and learn from their peers. The aim of this study was to compare outcomes for traditional care patients at one high volume health center with the institution's Centering Pregnancy patients, focusing on preterm birth. METHODS: This study is a retrospective cohort analysis of 5,003 traditional care and 444 Centering Pregnancy deliveries at Christiana Care Health Services from 2009 until 2014. Eligible patients initiated care in the first trimester with the resident hospital service. Parity, race, and prior preterm birth were controlled for. RESULTS: Mean gestational age at delivery was significantly higher in the Centering Pregnancy cohort (38.67 vs 38.15, P=.0004). After correction for parity, race, and prior preterm delivery, Centering Pregnancy was protective for preterm delivery before 34 weeks (OR: .43, P=.006). There also was a nonsignificant trend towards lower rates of preterm delivery before 37 weeks in the Centering Pregnancy cohort (OR: .73, P=.062). NICU admission was higher in the traditional care group (18.31% vs 12.61%). Birthweight and five minute APGAR of 9 were similar between groups. CONCLUSION: This large retrospective study shows decreased preterm birth rates with Centering Pregnancy in an at risk population. The clinician should be open to providing prenatal care outside of the traditional framework, especially for disadvantaged patients at high risk of poor pregnancy outcome.

Boosting Response: The Impact of Immune Checkpoint Inhibitors on Radiation Treatment Schedules

1Department of Radiation Oncology, Christiana Care Health Services Inc., Newark DE 19713, USA 2Center for Translational Cancer Research, Helen F Graham Cancer Center and Research Institute, Christiana Care Health Services Inc., Newark DE 19713, USA 3Department of Radiation Oncology, Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA 19107, USA 4Department of Radiation Physics, MD Anderson Cancer Center, Houston, TX 77030, USA 5Departments of Biological Sciences and Medical Laboratory Sciences, University of Delaware, Newark DE 19713, USA *Corresponding author Jennifer Sims-Mourtada, PhD Senior Clinical Scientist Center for Translational Cancer Research Helen F Graham Cancer Center and Research Institute Christiana Care Health Services Inc. Newark DE 19713, USA; Departments of Biological Sciences and Medical Laboratory Sciences University of Delaware Newark DE 19713, USA Tel. 302-623-4648 Fax: 1-302623 -4314 E-mail: jsimsmourtada@christianacare.org

Abstract B66: Delaware/Christiana Care Oncology patient advocates for clinical trials

Abstract B66: Delaware/Christiana Care Oncology patient advocates for clinical trials

Molecular Epidemiology in Neonatal Pasteurellosis

To the Editors: P asteurella multocida is a nonmotile, facultative anaerobic, bipolar staining, gram-negative coccobacillus. Humans can become asymptomatic carriers from animal contact and a source of transmission. Few studies have characterized P. multocida strains and confirmed animal and/or human exposure as the direct source of neonatal infection. A 25-day-old infant was admitted with P. multocida (Vitek, bioMérieux, Durham, NC) sepsis and meningitis with positive blood and cerebrospinal fluid cultures. He received a 21-day course of ampicillin (minimal inhibitory concentration < 0.12 μg/mL; Vitek, bioMérieux, Durham, NC) with complete resolution of symptoms during the first week of therapy. On follow-up appointment at 8 months of age, neurologic and developmental assessments were appropriate for his age. Surveillance investigation of close human and animal contacts was performed during the infant’s hospitalization. Throat cultures from the parents and vaginal cultures from the mother were negative for P. multocida. Mouth swabs obtained from both family dogs grew Pasteurella haemolytica. Mouth cultures from an outside cat grew P. multocida. Pulse-field gel electrophoresis (PFGE) and ribotyping analysis were performed at the Infectious Disease Research Laboratory, Christiana Health Care System. DNAs of the isolates recovered from the patient’s CSF and the oral specimens from household pets were digested with SmaI and examined by PFGE. Ribotyping analysis (RiboPrinter System, DuPont Qualicon, Wilmington, DE) of P. multocida strains isolated from the patient and the household cat demonstrated that the strain recovered from the cat was unrelated to the strain isolated from the patients’ cerebrospinal fluid. P. multocida neonatal sepsis and meningitis, although rare, are potentially preventable infections that remain associated with a significant morbidity and mortality in this age group. Most neonatal pasteurellosis cases reported in the English language literature are associated with animal exposure. Nonetheless, only 4 publications used genetic analysis to confirm that the recovered strains from animal contacts were in fact the same P. multocida strains responsible for the neonatal infections.1–4 One study used restriction fragment length polymorphism banding patterns derived from southern blotting and hybridization.3 The other studies used ribotying and/or PFGE to compare 16sRNA gene sequences from reference database with the isolates.1,2,4 Studies that used genetic techniques demonstrated identical strains in the household contacts and the affected infants. In our experience, detailed epidemiologic tracing of his parents and animal contacts failed to recover P. multocida, but in the household cat. DNA analysis by ribotyping and PFGE confirmed that the neonatal infection was caused by a different P. multocida strain, the 1 recovered from the animal. Holst et al5 characterized the clinical manifestations and epidemiology of P. multocida subspecies. In their series of 146 cases, P. multocida subspecies multocida was recovered from the 5 patients presenting with septicemia with or without known animal exposure. Of the 2 isolates recovered from CSF in patients with meningitis, 1 belonged to subspecies multocida and the other to subspecies septica. Animal studies suggest that P. multocida subspecies septica strains might have a greater affinity to cause central nervous system infections.6 Whether certain strains are more likely than others to cause sepsis and meningitis in newborns is unknown. Genetic analysis could assist to characterize the epidemiology and to better understand mechanisms of spread for this infection in neonates. This report emphasizes that DNA fingerprinting of recovered P. multocida isolates must be a requisite to confirm the link between exposure and infection. Andrew S. Wood, MD Department of Pediatrics Bryn Mawr Hospital Bryn Mawr, PA Elyse E. Foraker, BS MT (ASCP) Christiana Care Health Services Wilmington, DE Cecilia Di Pentima, MD, MPH Infectious Diseases Division Department of Pediatrics Vanderbilt University Nashville, TN

A Comparison of Obstetric Maneuvers for the Acute Management of Shoulder Dystocia

Department of Obstetrics and Gynecology, Christiana Care Health Services, Newark, Delaware Financial Disclosure: The author did not report any potential conflicts of interest.

672: The impact of parity on spontaneous preterm birth in women with a twin gestation

TWIN GESTATION DANIELLE CASTAGNOLA, MATTHEW HOFFMAN, KHANH-HA NGUYEN, ANTHONY SCISCIONE, Christiana Care Health Services, Newark, Delaware, Christiana Care Health System, Obstetrics and Gynecology, Newark, Delaware, Christiana Care Health Services, Maternal-Fetal Medicine, Newark, Delaware OBJECTIVE: Twin pregnancies are at high risk for prematurity. The ability to Stratify these women by risk factors would be very useful in guiding clinical practice and resources. We sought to determine whether there was an association between parity and preterm birth in women with twin pregnancies. STUDY DESIGN: Using a contemporaneously maintained obstetrical database, we identified all women with twin gestations who delivered at our tertiary care center from 1/98 to 6/07. Our primary outcome was spontaneous preterm delivery 34 weeks. Patients with indicated preterm births were excluded. Univariable analysis was performed with a p-value of 0.05 viewed as statistically significant. RESULTS: A total of 2636 twin births to 1318 women were identified during the study period. The mean gestational age at birth was 34.4 weeks for the entire cohort. Nulliparity was associated with an increased risk of delivering 34 weeks, having a fetus 1500 grams and 2500 grams (Table 1). Compared to multiparous patients (categorized by parity 1,2, or 3), nulliparous patients were more likely to have their infants admitted to the NICU (41% v. 37%, 31%, and 40%, p 0.05), and more likely to develop PIH (14% v. 7%, 11%, and 10%, p 0.001). Increasing parity ( 1) did not confer further benefit in any outcome. CONCLUSION: Nulliparous women with a twin gestation are more likely to deliver prematurely compared to multiparous patients.

EVOLUTION AND OUTCOMES OF A RAPID RESPONSE TEAM

PURPOSE: In 2000, Christiana Care Health Services (CCHS) developed the Stabilization, Telemetry, Administration, Teaching (STAT) Nurse program to provide a critical care nurse as a resource to the nursing units. This program was implemented to support the growth of flexible telemetry capability to every hospital bed. In 2005, that program was expanded to the Rapid Response Team (RRT) by the addition of a respiratory therapist and a senior medical resident. The goal of the program was twofold: first, to provide skilled medical assessment and treatment rapidly; and secondly, to train medical staff to recognize the subtle, early warning signs of patient deterioration. We compared outcome data from the STAT nurse program to the RRT program.

A randomized trial of active versus expectant management of the third stage of labor

STAGE OF LABOR MATTHEW HOFFMAN, FATIMA NAQVI, ANTHONY SCISCIONE, Christiana Hospital, Newark, Delaware, Christiana Care Health Services, Obstetrics and Gynecology, Newark, Delaware, Drexel University College of Medicine, Obstetrics and Gynecology, Philadelphia, Pennsylvania OBJECTIVE: We sought to compare active management of the third stage of labor to the more traditional expectant management. STUDY DESIGN: We conducted a randomized controlled trial of women who had an uncomplicated term vaginal delivery. Women were randomized to either expectant or active management of the third stage of labor before delivery. Active management consisted of a standardized oxytocin infusion immediately following delivery of the fetus coupled with cord traction and fundal massage. The expectant group had cord traction and fundal massage upon signs of placental separation coupled with a standardized oxytocin infusion following placental delivery. Our primary outcome variable was the mean change in hematocrit pre and post delivery. Univariate analysis was performed using Student’s t test with unequal variance, Wilcoxon rank sum, c and Fisher exact test when appropriate. A P value of ! .05 was statistically significant. RESULTS: One hundred and fifty women were randomized between August 2002 and November 2003 (72 active management and 78 expectant management). Active management of the third stage of labor was associated with a shorter duration of the third stage of labor (7.3 minutes vs. 9.8 minutes; P value ! .0001). Although there was no difference in incidence of postpartum hemorrhage (EBL >500 mL) in the expectant versus the actively managed groups (17.39% vs. 11.11%; P = .302), the mean change in hct was significantly less in women who were in the actively managed group (2.5 vs. 3.35 P = .0475). There was no significant difference in the need for placental extraction or retained placentas between the groups. CONCLUSION: Active management of the third stage of labor was associated with faster delivery of the placenta and a smaller decrease in the mean pre and post-delivery hematocrit. S82 SMFM Abstracts

Cesarean delivery does not offer a benefit to extremely low birthweight (ELBW) neonates in the breech presentation

(ELBW) NEONATES IN THE BREECH PRESENTATION SHARI GELBER, DAVID PAUL, AMY MACKLEY, ANTHONY SCISCIONE, Drexel University College of Medicine, Department of Obstetrics and Gynecology, Philadelphia, Pennsylvania, Christiana Care Health Services, Dept of Neonatology, Newark, Delaware OBJECTIVE: The ideal mode of delivery for ELBW infants in the breech presentation is controversial. Recent reports have found a significant neonatal benefit to breech ELBW infants delivered by cesarean. We sought to compare the neonatal outcomes in ELBW (!1000 g) neonates in the breech presentation delivered vaginally versus by cesarean. STUDY DESIGN: Case-cohort study of all infants !1000 g in the breech presentation delivered at a single tertiary care institution between 1993 and 2003. Infants with congenital anomalies were excluded. The primary outcome variable was neonatal death. Demographic information, and potential confounding variables were recorded. Univariate analysis comparing mode of delivery with outcome variables was performed by ANOVA and c, and multivariate analysis was performed by logistic regression. A P ! .05 was considered significant. RESULTS: A total of 68,000 deliveries were performed during the study period, of which 216 (0.3%) were ELBW in the breech presentation. Of those, 160 (74%) delivered by cesarean and 56 (26%) delivered vaginally. There was no significant difference in maternal age, chorioamnionitis, preterm rupture of the membranes, antibiotic use, ethnicity or oligohydramnios. On univariate analysis, infants delivered vaginally had a lower gestational age (24.5 vs 26.1 weeks; P ! .01), were smaller (695 g vs 779 g; P ! .01), more likely to have preterm labor (90% vs 71%; P = .01), less likely to have preeclampsia (0% vs 17%; P = .001), more likely to die (46% vs. 31%; P = .046), and more likely to have intraventricular hemmorhage (IVH) (30% vs. 50%; P = .01). There was no difference in periventricular leukomalacia. On multivariate analysis controlling for gestational age, steroid use, preeclampsia, preterm labor and oligohydramnios, there was no significant difference in neonatal death (O.R. 0.76; 95% CI 0.34-1.7), all IVH (O.R. 0.64; 95% CI 0.32-1.3), or grade III-IV IVH (O.R. 1.04; 95% CI 0.46-2.3). CONCLUSION: Cesarean delivery of ELBW neonates in the breech presentation does not appear to improve neonatal outcomes.

Neonatal outcomes in very low birth weight (VLBW) infants exposed to antenatal indocin versus sulindac

ANTENATAL INDOCIN VERSUS SULINDAC SHARI GELBER, DAVID PAUL, AMY MACKLEY, ANTHONY SCISCIONE, Drexel University College of Medicine, Department of Obstetrics and Gynecology, Philadelphia, Pennsylvania, Christiana Care Health Services, Dept of Neonatology, Newark, Delaware OBJECTIVE: Sulindac, a similar but chemically distinct non-steroidal antiinflammatory drug (NSAID) has been reported to have a better safety profile compared to indocin. We sought to compare the neonatal outcomes in VLBW neonates exposed to antepartum indocin versus antepartum sulindac. STUDY DESIGN: We reviewed our neonatal database for infants !1500 g delivered between 1993 and 2003 with antenatal exposure to either indocin or sulindac for tocolysis. Infants with congenital anomalies were excluded. Outcome variables included bronchopulmonary dysplasia (BPD), necrotizing enterocolitis (NEC), intraventricular hemorrhage (IVH), patent ductus arteriosus (PDA), and death. Univariate analyses were performed by ANOVA and chi squared. A P ! .05 was considered significant. RESULTS: A total of 68,000 deliveries were performed during the study period. 965 VLBW infants treated for preterm labor were admitted to the intensive care nursery, 147 (15%) of whom were exposed to indocin and 51 (5%) of whom received sulindac. There were no significant differences between the indocin and sulindac cohort in gestational age, birth weight, maternal age, chorioamnionitis, mode of delivery, or antepartum antibiotic use. More infants in the indocin cohort received steroids (88% vs. 75%; P= .02), MgSO4 (81% vs 63% P = .02), and were multiple gestations (47% vs 24% P = .003). There was no difference in rate of IVH (29% vs. 31%; P = .7), grade III-IV IVH (16% vs. 16% P = .91), NEC (10% vs. 12%; P= .77) death (17% vs. 27%; P = .13), or PDA (31% vs 27%; P = .61). However, the group exposed to antenatal indocin was more likely to have BPD (66% vs 35%; P = .0001). Even after controlling for potential confounders using logistic regression, there was an increased risk of BPD in the indocin cohort (OR 3.7; 95% CI = 1.8-7.6). There were no significant differences in IVH (OR 0.75; 95% CI = 0.34-1.6), grade III-IV IVH (OR 1; 95% CI = 0.49-2.0) or death (OR 0.40; 95% CI = 0.14-1.1). CONCLUSION: Neonates exposed to antenatal indocin versus sulindac appear S120 SMFM Abstracts

A multidisciplinary team approach to cancer care in a community based teaching hospital

6102 Background: In June 2002 the Helen F. Graham Cancer Center (HFGCC) at Christiana Care Health Services (CCHS) opened its doors to establish the multi-disciplinary team approach for cancer care. This program was deemed necessary in view of the fact that the State of Delaware has the fourth highest cancer incidence and mortality rates in the United States. Methods: Disease site Multi-disciplinary Centers (MDC's) were established in Genitourinary, Head and Neck, Hepatobiliary -Pancreatic, Lymphoma, Neuro-Oncology, Thoracic/Esophageal, Colorectal, and Breast. A surgeon, medical and radiation oncologist was assigned to each of the MDC's. Physicians needed to meet certain performance expectations in order to participate in the MDC's. Support services consisting of psychology, nutrition, genetic counseling, social service, oncology nurse care manager, and a clinical trials research nurse were assigned to each of the MDC's. CCHS is an NCI funded Clinical Community Oncology Program. Results: In the first 7 months, June through December 2002, there were 921 patient visits in the MDC's at the HFGCC. In the second 7 months, January through July 2003, patient visits increased to 1,563. From 6/1/02 through 11/18/03 there were 309 patients placed on NCI Cooperative Group trials at CCHS . Of the 390 patients, there were 42 patients ( 13%) that were placed on NCI clinical trials as per their visit to the MDC's. This was 7% of the 580 patients seen in the MDC's from 6/1/03 through 11/18/03. The percentage of analytic cases ( first treatment or diagnosis at CCHS) accrued to clinical trials in 2001 and 2002 were 10.0% and 13.2% respectively. Patients saved on average 3 weeks of physician appointment time by visiting the HFGCC where they were seen by the surgeon, medical and radiation oncologist in one visit. Conclusions: The disease site multi-disciplinary team approach to cancer care decreased the time to patient care planning and treatment and has continued to be an additional mechanism for patient accrual to NCI clinical trials. No significant financial relationships to disclose.

A multidisciplinary team approach to cancer care in a community based teaching hospital

6102 Background: In June 2002 the Helen F. Graham Cancer Center (HFGCC) at Christiana Care Health Services (CCHS) opened its doors to establish the multi-disciplinary team approach for cancer care....

Establishing the multidisciplinary care of patients with cancer in the state of Delaware.

Delaware has the fifth highest cancer death rate in the U.S. As part of a comprehensive program to decrease the cancer mortality and incidence in the state, an infrastructure to establish the multidisciplinary care of patients with cancer was established. In May 2002, Christiana Care Health Services opened the Helen F. Graham Cancer Center to meet the specific need for coordinated and centralized comprehensive cancer care. This effort took the cooperation of many individuals in a community-based teaching hospital, the largest of six acute care hospitals in the state. These efforts have led to a 13% accrual rate to the Community Clinical Oncology Program funded by the National Cancer Institute. The effort also led to the establishment of multidisciplinary disease site centers with representation from the three major physician disciplines of surgery, medical oncology, and radiation oncology. In addition, translational research projects, a tissue procurement center, and genetic counseling and testing with the establishment of a high-risk family cancer registry and collaborative efforts with hospitals across the state were established. The current article reviewed the continued success of this program in the state of Delaware in the effort to reduce the cancer incidence and mortality.

Role of clinical pharmacists in outpatient HIV clinics.

Journal Article Role of clinical pharmacists in outpatient HIV clinics Get access Kelly Cantwell-McNelis, Pharm.D., Kelly Cantwell-McNelis, Pharm.D. Clinical Pharmacy Specialist HIV Community Program, Christiana Care Health Services, Wilmington, DE Address correspondence to Dr. Cantwell-McNelis at the HIV Community Program, Christiana Care Health Services, Wilmington Hospital Annex, P.O. Box 1668, Wilmington, DE 19899-1668 (kmcnelis@christianacare.org). Search for other works by this author on: Oxford Academic Google Scholar Christopher W. James, Pharm.D. Christopher W. James, Pharm.D. Clinical Pharmacy Specialist HIV Community Program, Christiana Care Health Services, Wilmington, DE Search for other works by this author on: Oxford Academic Google Scholar American Journal of Health-System Pharmacy, Volume 59, Issue 5, 1 March 2002, Pages 447–452, https://doi.org/10.1093/ajhp/59.5.447 Published: 01 March 2002

Family reactions during infants' hospitalization in the neonatal intensive care unit.

The purpose of this investigation is to assess family stress, coping, perceptions of their infant, and alterations in mood that may result from the hospitalization of their critically ill newborn infant. Eligible patients were those infants hospitalized in the Special Care Nursery (SCN) at Christiana Care Health Services, who were born up to 31 weeks' gestational age. Twenty-seven families (mothers and/or fathers) completed four questionnaires at 2-week intervals during the course of their premature infants' hospitalization. Data were primarily evaluated by using analysis of variance (ANOVA)/multivariate analysis of variance (MANOVA). A score for neonatal acute physiology (SNAP) was obtained in each infant to assess the effect of the severity of neonatal illness on the questionnaire variables. Families with high stress scores on the Parental Stressor Scale had different coping strategies than those with less stress scores. A high level of maternal depressive symptomatology was associated with altered methods of coping, general stress, and perception of infant health. There was no relationship between the SNAP score on the overall level of stress families. Families who completed more than two questionnaires differed from those who only completed two or less questionnaires, although the sample size was too small to assess longitudinal changes in this study population. Level of stress and depressive symptoms are two major influences of how families cope with the current hospitalization of a premature infant. The degree of neonatal illness is not a major contributor to the parents' coping ability. Healthcare providers need to understand these dynamics when supporting families during the hospitalization of their premature infant.

Thirty Years in September, A Nurse’s Memoir

From Thomason Hospital, El Paso, Tex; Louisiana State University Health Sciences Center, School of Nursing, New Orleans, La; Sharon Regional Health System, Sharon, Pa; Christiana Care Health Services, Newark, Del; University of Colorado Hospital, Denver, Colo.

Healing Back Pain Naturally: The Mind–Body Program Proven to Work

From Thomason Hospital, El Paso, Tex; Louisiana State University Health Sciences Center, School of Nursing, New Orleans, La; Sharon Regional Health System, Sharon, Pa; Christiana Care Health Services, Newark, Del; University of Colorado Hospital, Denver, Colo.

Core Handbooks in Pediatrics, Pediatric Primary Care: Well-Child Care

From Thomason Hospital, El Paso, Tex; Louisiana State University Health Sciences Center, School of Nursing, New Orleans, La; Sharon Regional Health System, Sharon, Pa; Christiana Care Health Services, Newark, Del; University of Colorado Hospital, Denver, Colo.