Community Hospital System Research Articles

Isotope selection and PSA failure in prostate seed implant: Experience with CS-131 in a community hospital system.

375 Background: A recent large single institutional study reported excellent long-term biochemical control and survival for Cs-131 prostate implant. This isotope has short half-life (9.7 days) with clinical advantages including shorter duration of symptoms. We previously showed Cs-131 dosimetry to be quantitatively similar to I-125 with improved homogeneity (mean percent V150 36% for I-125 versus 27% for Cs-131 (p < 0.0001). Our objective was to evaluate PSA failure rates and dosimetric outcomes in a multi-institutional community based setting. Methods: Within an IRB approved retrospective study, we compared outcomes for three groups of permanent prostate implant patients treated at Ascension Macomb Oakland, Ascension Saint John, and Ascension Providence Rochester Hospitals over a 10 year time interval. The comparison groups included isotopes Cs-131 (n = 66; t1/2 9.7 days), I-125 (n = 60; t1/2 60 days), and Pd-103 (n = 60; t1/2 17 days). Kaplan Meier estimates of PSA failure used the nadir plus 2 (Phoenix) definition. Results: Standard permanent implant doses employed were 145 Gy for I-125 monotherapy or 109 Gy for combination therapy. The dose for Cs-131 was 115 Gy for monotherapy and 85 Gy for combination therapy. For Pd-103, the doses employed were 125 Gy and 90 Gy for mono- and combination therapy, respectively. Median age at diagnosis was Cs-131; 69 (range 49-80), I-125; 71 (49-78), and Pd-103; 70 (60-82). Mean pretreatment PSA values were Cs-131 5.73 ng/ml, I-125 6.62 ng/ml, and for Pd-103 8.87 ng/ml. Median PSA follow up was 30 months and the median PSA value at 60 months was 0.11 ng/ml. There was excellent PSA control for all three groups of cases (p = NS), however with fewer failures using Cs-131. Conclusions: Permanent interstitial brachytherapy continues to be an attractive option for treatment early stage prostate cancer. Only a few large single institutional studies have examined PSA failure rates or dosimetric aspects of shorter half-life Cs-131 seed implants. This series confirms wide applicability of Cs-131 permanent prostate seed implant in the community hospital setting.

238: Maternal Early Warning Trigger tool improves clinical care in large community hospital system

We compare maternal morbidity and clinical care metrics before and after implementation of a maternal early warning trigger (MEWT) tool. This is a quasi-experimental study of maternal morbidity and care metrics within three linked hospitals comparing 52 weeks before and 54 weeks after electronic MEWT implementation (encompassing 20,000 pregnancy encounters). We compare severe maternal morbidity overall as well as within the subcategories of hemorrhage, hypertension, cardiopulmonary and sepsis in addition to relevant process metrics. We describe the MEWT trigger rate in addition to MEWT sensitivity and specificity for morbidity overall and by morbidity type. The morbidity rate ratio increased from 1.6 per 100 deliveries in the pre MEWT period to 2.06 per 100 deliveries in the post MEWT period (IRR 1.28, p=0.018), however in cases of septic morbidity, time to appropriate antibiotics decreased (pre MEWT: 1.87 hours vs post MEWT: 0.75 hours, p=0.036) and in cases of hypertensive morbidity, care escalation within 60 minutes improved (pre MEWT: 62% vs post MEWT: 83%, p=0.04). In cases of cardiopulmonary morbidity, time from vital sign alteration to diagnostic study or treatment trended down (3.82 hours vs 1.5 hours, p= 0.465). The MEWT trigger rate was 2.3%, ranging from 0.8% in the less acute centers to 2.9% in our tertiary center. MEWT sensitivity for morbidity overall was 50% (if ideally implemented); sensitivity for hemorrhage morbidity was lowest (30%), however ranged between 69% for septic morbidity, 74% for cardiopulmonary morbidity and 82% for cases of hypertensive morbidity. Overall maternal morbidity did not decrease after implementation of MEWT, however several clinical metrics improved. MEWT sensitivity for hemorrhage was low, and because hemorrhage dominates administrative morbidity, clinical metrics around sepsis, hypertension, and cardiopulmonary morbidity are important to track as markers of MEWT efficacy. The electronic implementation of MEWT has unique challenges which affect its performance. Future work will include strategies to improve implementation.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

2157. Evaluation of the Utility of the MRSA Nasal PCR Assay in a Community Healthcare System

BackgroundThe MRSA nasal PCR assay is a rapid, noninvasive test that has demonstrated a strong negative predictive value (NPV), as high as 99%, for ruling out MRSA pneumonia. These findings are based primarily on literature from large academic centers, which have evaluated both the positive predictive value (PPV) and NPV of MRSA nasal PCR assays. Investigators sought to assess the NPV of the MRSA nasal PCR assay to rule out MRSA pneumonia within a community healthcare system. To the best of our knowledge, this is the largest study from a community hospital and the only study from a community healthcare system for the utilization of a nasal PCR assay to rule out MRSA pneumonia.MethodsThis is a multicenter, retrospective study of adult patients with both an MRSA nasal PCR assay and positive respiratory culture (sputum, bronchoalveolar lavage, or endotracheal aspirate). Data were collected from September 2014 through August 2015 at three community hospitals (bed size ranging from 328 to 706) across two states within a healthcare system. The study was approved by the Baptist Memorial Hospital Institutional Review Board. PPV and NPV 95% confidence intervals (95% CI) were calculated as previously described in the literature.ResultsA total of 808 patients were included in the analysis across the three hospitals. The total incidence of MRSA in positive sputum samples was 14.9% across the three facilities. Our study demonstrated an overall NPV of 95.1% (93.2, 96.6%) and a PPV of 65.9% (95% CI 57.2, 73.9%). The high NPV was retained despite unit type, resulting in 94.9% (95% CI 92.7, 96.6%), 96.3% (95% CI 90.8, 99.0%), and 94.7% (95% CI 74.0, 99.9%) for the intensive care units (ICU), medical-surgical units, and the emergency department, respectively (Table 1).ConclusionWe concluded that the high NPV of a negative MRSA nasal PCR assay to rule out MRSA pneumonia persisted within a community hospital system. With the results of our study, we plan to utilize institution-specific data along with previously published literature to encourage earlier discontinuation of anti-MRSA antibiotics in patients being treated for pneumonia with negative MRSA nasal PCR assays. Our study demonstrates the validity of the assay in the large community hospital setting with similar findings to studies at large academic institutions. Disclosures All authors: No reported disclosures.

2870 Flexible Endoscopic Diverticultomy: Development of a Community-Based Referral Program and Ways to Improve Efficiency and Outcomes

INTRODUCTION: Until recently Flexible endoscopic diverticulotomy (FED) has not gained momentum among GI endoscopists in USA due to a variety of reasons including new skill set, referral patterns, procedural risks and complexity. Thus far it has been limited to select university hospitals, restricting its availability. We present a case series of FED performed in our community hospital system. METHODS: Retrospective review was performed from the start of the FED program over 3 months in 2018. We established a new multi-disciplinary Advanced GERD & Esophageal Services (PAGES) program through which patients were reviewed and selected. All were performed by a single interventional ESD (endoscopic submucosal dissection) trained endoscopist. RESULTS: Mean age 69yrs; mean Eckardt score (EDS) 5. Prominent symptoms were dysphagia and weight loss. Diagnosis was established by imaging or EGD. ESD knives were used. Clips were placed on the diverticular base. The thickness and length of the cricopharyngeal bar varied from 0.7- 3 cm (mean: 1.8) and 3- 5 cm (mean: 3.6) respectively. Total operative time depended on the length of the septum, thickness, the type of knife used and varied from 25-168 min (mean:62). The transition from other ESD knives to scissor type knives reduced our operative time by 50% (168 down to 40min) (Table 1). Patients were discharged home 6 hrs post-procedure. A routine predischarge esophagogram was obtained to document complete excision of cricopharyngeal bar. One case of intraoperative bleeding was controlled using a coagrasper. No blood transfusions or second endoscopic procedures were required to control bleeding. One patient was readmitted within 24 hrs of discharge for control of N/V. The success of the procedure was measured using 4 week post-operative EDS. Three of five patients achieved complete symptom resolution at week 1. Two patients had occasional dysphagia (EDS:1) and regurgitation (EDS:1) respectively. All were symptom free at the end of week 4 (EDS: 0 -1) (Table 2). CONCLUSION: Transoral FED gives the gastroenterologists the opportunity to be the forerunners in managing ZD. The vast majority of these patients present to GI physicians with a complaint of dysphagia. The development of the multi-disciplinary program to identify and triage patients, scissor type ESD knife, and a fellowship trained advanced endoscopist are the recipe to success for a tertiary community program.

Data Collection System for Tracking Hospital Librarians’ Productivity

Librarians gather data on multiple aspects of their work. Much of the data collection revolves around the library’s resources, but what may be passed over during this data collection is information on how librarians are expending their time and effort. A group of librarians from a community hospital system designed a Microsoft Access database to collect such data and has been recording librarians’ efforts for more than three years. The librarians use the data in annual reports and can track trends to evaluate service priorities and maximize effective use of the librarians’ time.

Effect of prescriber peer comparison reports on fluoroquinolone use across a 16‐facility community hospital system

IntroductionAntimicrobial stewardship programs (ASPs) continuously strive to optimize antibiotic use, while minimizing antibiotic‐associated adverse events. Among potential targets for antibiotic use reduction, fluoroquinolones (FQs) are an attractive drug class for ASPs due to their wide spectrum of activity, known adverse event profile, and availability of less toxic therapeutic options. The use of peer comparison on antibiotic use by ASPs has been described but is limited primarily to the outpatient setting.ObjectivesTo assess the impact of peer comparison using prescriber‐specific reports on FQ use and hospital‐acquired Clostridioides difficile rates across a 16‐facility community hospital system.MethodsIn January 2017, we began providing quarterly facility‐specific peer comparison reports to high‐volume antibiotic prescribers in three different medical specialties across our health‐system: Internal Medicine/Hospitalists/Family Medicine, Intensivists/Pulmonologists, and infectious diseases (ID). We completed a quasi‐experimental study designed to assess aggregated hospital data, evaluating FQ days of therapy/1000 patient days (DOT/1000 PD) in the intervention period (January‐December 2017), and compared with the baseline period (January‐December 2016). Additional outcomes that were evaluated include total antibiotic consumption (DOT/1000 PD), total percentage of antibiotics attributable to FQs, and cases of hospital‐acquired C. difficile/10000 PD (HA‐CD).ResultsCompared with the baseline period, FQ use decreased by 29% (baseline—83.9 DOT/1000 PD; intervention—58.5 DOT/1000 PD; P < 0.001). The overall percentage of antibiotics that were attributable to FQs also decreased in the intervention period (baseline—15.4%; intervention—11.3%; P < 0.001). During the intervention period, there were no significant increases in other key antibiotic classes, including antipseudomonal beta‐lactams and third‐generation cephalosporins. The rate of HA‐CD decreased by 20% in the intervention period compared with baseline.ConclusionIn a large community hospital system, the use of peer comparison reports based on prescriber specialty reduced FQ use, and may potentially reduce adverse events associated with FQ use.

Retired Surgeons as Mentors for Surgical Training Graduates Entering Practice: An Underutilized Resource.

Our study evaluated the willingness of retired surgeons to mentor newly trained surgeons. Although mentoring is very important during the transition in practice, many novice surgeons are faced with inadequacy or lack of mentoring. A survey regarding mentorship of new surgeons was sent in April 2018 to retired general, colorectal, vascular, and cardiothoracic surgeons that are members of the American College of Surgeons. The analysis of the data was performed in September 2018 and October 2018. A total of 2295 of 5282 surveys were completed (43.4% response rate). Mean age was 79.0 ± 0.8 years, mean retirement age was 63.9 ± 0.1 years, and mean interval since retirement was 15.2 ± 0.9 years. Most retired surgeons were in private practice (66.4%), with other practice environments, including academic teaching hospital (12%), academic/private combination (11.3%), employment by community hospital or health system (6.4%), veteran affairs institution (2.7%), military hospital (1%), and Indian Health Service (0.09%). Approximately a third (31.1%) of respondents were not mentored when they first entered practice. The vast majority (98.3%) of participants considered mentoring beneficial during transition in practice. More than half (51.2%) of retired surgeons are interested in mentoring recently trained surgeons, with most of them (81.8%) willing to mentor even for free. Our findings suggest that a significant number of retired surgeons are enthusiastic about mentoring young surgeons during their transition in practice. Specific programs are necessary to meet the needs of newly hired surgeons and better utilize the expertise of retired surgeons.

1233. An Automated E-mail Notification Systemic to Infectious Disease Specialists and Effect on the Management of Staphylococcal aureus Bacteremia in a Community Hospital setting

Background Staphylococcus aureus is the leading cause of community and healthcare-associated bacteremia and carries a high burden with a substantial mortality, ranging from 20 to 40 %. Evidence suggests infectious disease (ID) consultation improves mortality and adherence to the Infectious Diseases Society of America (IDSA) guidelines. Due to complications from a lack of ID consultation, a notification system consisting of automated e-mails to ID providers was implemented. The objective of this study was to review the impact of the automatic notification to ID consultants with positive blood culture results in a community hospital system.MethodsCases of staphylococcus aureus bacteremia were identified from the microbiology database by at least one positive blood culture. The automated e-mail notification system was implemented in December 2014. ID providers were encouraged to verbally contact primary providers for positive results. Cases of bacteremia prior to implementation of the automated notification system were compared with those post-intervention. Patients under age 18 were excluded. Data gathered included mortality, re-admission rates, and compliance with IDSA guidelines.ResultsThere were no significant differences in inpatient mortality (9 vs. 18%, P = 0.180). 30-day mortality between the two groups (18 vs. 20%, P = 0.815). The 30-day readmission rate among surviving patients was reduced by 50% (40% vs. 19%, P = 0.014). Compliance with antibiotic duration in complicated bacteremia increased post-intervention (57% vs. 85%, P = 0.04).ConclusionAn automatic notification to ID specialists reporting patients with Staphylococcus aureus bacteremia led to improved compliance with IDSA guidelines regarding antibiotic duration and reduced re-admission rates. There was no effect on overall mortality.Table 1: Patient DemographicsPre Intervention (N = 57)Post Intervention (N = 60) P-valueAverage patient age (years)64.462.20.448Male63%63%1Immunosuppressed16%13%0.80Complicated bacteremia70%69%1Table 2: Patient OutcomesPreintervention(N = 57)Postintervention(N = 60) P-valueInpatient mortality9%18%0.18030-day mortality (%)18%20%0.815Readmitted within 30 days40%19%0.014Bedside ID consult75%78%0.888Appropriate antibiotic duration-complicated bacteremia (>28 days)57%85%0.04 All authors: No reported disclosures.

How automatic notification of infectious disease specialists impacted the management of Staphylococcus aureus bacteremia in a community hospital setting

ABSTRACTObjective: The objective of this study was to review the impact of an automatic email notification to infectious disease consultants.Design: Cases were identified from a community hospital system microbiology database by at least one positive blood culture. Records were reviewed both before (2013 and 2014) and after (2015 and 2016) the implementation of the automated email system (intervention). Prior to this policy, consultation with the infectious disease (ID) specialist was at the discretion of the primary team.Results: There were no significant differences in 30-day mortality between the two groups (18 vs 20%, p = 0.10). However, a trend of shorter hospital stays (12.2 vs 9.5 days, p = 0.03) and reduced 30 day readmissions (40% vs 19%, p = 0.03) was observed and antibiotics prescribed for complicated cases was more appropriate (57% vs 85%, p = 0.004).Conclusions: In this study population, the implementation of an automatic email generator to ID specialists was associated with a shorter hospital length of stay, less 30-day readmissions and more appropriate length of antibiotics prescribed in complicated cases of SAB. The authors recommend future studies replicating the methodology employed here with larger sample sizes before consideration of employing a similar automatic email ID consult generation at other health systems.

Phased implementation of an antimicrobial stewardship program for a large community hospital system

Antimicrobial stewardship is recommended as a crucial mechanism to reduce the emergence of antimicrobial resistance. The purpose of this article was to describe implementation of antimicrobial management programs (AMPs) across a large health system of community hospitals. The initiative was structured in 4 phases. Although each phase was implemented sequentially, facilities could progress at their own pace. Phase goals needed to be met before moving to the next phase. The 4 phases included preparatory, foundational, clinical care optimization, and refinement. A survey was administered prior to the initiative in 2010, and modified surveys were administered in 2015 and 2017. Stewardship activities improved in most areas of the AMP initiative in 2015, with substantial improvement by 2017. Important changes included an increase in established programs, from 82% in 2010 to 88% and 96% in 2015 and 2017, respectively. Physician Champions increased from 73% in 2010 to 94% in 2017. Advances were made in the use of evidence-based treatment recommendations, antibiogram development, prospective audit and feedback for antimicrobials, tracking of antibiotic usage metrics, and a cost reduction of 40% from baseline. A well-designed, phased approach to implementing AMP can help community hospitals and hospital systems recognize substantial clinical and financial benefits.

Using Twitter to identify healthcare consumer sentiment

Twitter is a social networking service, founded in 2006, and now with over 400 million monthly active users. This study was designed to assess the utility of Twitter as a tool for the assessment and comparison of healthcare systems. Java and R programs were used to capture, analyze, and compare Tweets posted about one academic university hospital system and two community hospital systems in a large metro area in the Southeastern United States throughout 2016. Natural language processing with sentimental analysis was used in conjunction with an object clustering algorithm to categorize and quantify positive versus negative posts regarding care received at these facilities. An analysis of the positive and negative tweets for the academic facility was completed. Among the 12,579 Tweets captured for 2016, 89.4% were associated with the academic medical center, 9.7% with community hospital #1, and 0.9% with community hospital #2. Relative to annual patient visits, the use of Twitter was 0.31% for the academic hospital, 0.34% for community hospital #1, and 0.03% for community hospital #2. A majority of Tweets were positive for all three hospital systems. Hospital system #2 received the highest percentage of positive and the lowest percentage of negative tweets ( Table 1 ). The subject of positive comments concerning the academic facility were hospital staff, hospital facilities, and hospital services, while the negative comments focused on appointments, wait time, and emergency room visits. This study demonstrates the utility of Twitter to determine the overall sentiment of a segment of users of competing healthcare systems. In our initial analysis, we were able to compare the largest competitors of our academic system and to assess the topics of the positive and negative comments made by our healthcare system users. Further study and development of computing techniques are needed to fully maximize the potential this tool offers.

Rapid identification of gram‐negative bacteremia and impact on antipseudomonal antibiotic consumption with antimicrobial stewardship at a community hospital system

BackgroundRapid identification of gram‐negative bacteremia can improve time to effective antibiotic therapy and antibiotic de‐escalation; however, there are little data that quantify the change in antibiotic utilization. This study evaluates the impact of the Verigene gram‐negative blood culture test (BC‐GN) in combination with an antimicrobial stewardship team (AST) intervention on antipseudomonal (AP) antibiotic utilization in a community hospital system among infections where AP antibiotics are not necessary.MethodsThis multicenter, pre‐post, quasi‐experimental pilot study was conducted at Scripps Health in San Diego, California. Internal antibiogram data was reviewed, and among the 4 targets of Escherichia coli, Klebsiella pneumoniae, Klebsiella oxytoca, and Proteus species (that lacked resistance genes) detected by the BC‐GN test, antimicrobial sensitivities did not warrant therapy with AP antibiotics. The BC‐GN test was performed at each site where clinical pharmacists notified physicians of results and assisted with antibiotic modifications. The primary end point was AP vs non‐AP antibiotic consumption within the first 5 days of admission. This was measured by days of therapy per patient day (DOT/PD). Secondary end points included hospital and intensive care unit (ICU) length of stay (LOS) and mortality.ResultsA total of 1051 patients were included; 512 in the pre‐intervention group, and 539 in the intervention group. Compared with the pre‐intervention group, AP antibiotic consumption significantly decreased (0.4 vs 0.2 DOT/PD, P < .0001) and non‐AP antibiotic consumption significantly increased (0.6 vs 0.8 DOT/PD, P < .0001) in the intervention group. Overall median LOS was 5 days vs 5 days (P = .85) and median ICU LOS was 3 days vs 2 days (P = .12), in the pre‐intervention and intervention groups, respectively. Mortality was similar between groups (7.0% vs 5.2% in the pre‐intervention and intervention groups, P = .21).ConclusionRapid identification of gram‐negative bacteremia with AST intervention decreased AP antibiotic consumption among infections caused by pathogens where AP coverage is not needed.

Abstract WMP91: Post-Stroke Healthcare Utilization: Patterns in Stroke Follow-up Care in a Community Hospital System - A Preliminary Analysis From the Greater Cincinnati/Northern Kentucky Stroke Study

Introduction: Immediate post-stroke discharge destination is easily determined. Long-term disposition and healthcare utilization is more difficult to study due to the variability in outcomes, including multiple transitions for many patients. We sought to longitudinally determine place of residence and physician follow-up in a defined population. Methods: Our population-based stroke epidemiology study retrospectively ascertains hospitalized ischemic and hemorrhagic strokes via ICD-9/10 codes within 5 counties in the greater Cincinnati metropolitan region. For this study, post-stroke dispositions and physician encounters for ischemic strokes that presented to one healthcare system of 4 community hospitals from 1/1/15 to 12/31/15 were analyzed by mining patient electronic medical records (EMRs). Disposition was analyzed at discharge, 3, and 6 months post-stroke, and outpatient and emergency department (ED) visits, and hospital admissions, were tabulated at 3, 6, and 12 months. The first post-discharge physician encounter was also assessed, and time to encounter was considered. Previous analysis has shown that this network is relatively self-contained with few transfers to other health systems, making it ideal for this study. Results: See figure for details. Only 17% of the cohort saw a neurologist within 1 year, whereas 73% saw a primary care provider (PCP) and 37% saw a cardiologist. PCPs accounted for 56% of the first post-stroke encounters. Over 24% of the cohort visited the ED or were re-hospitalized before having their first outpatient visit. Conclusions: In a community setting, PCPs are responsible for the majority of post-stroke care, and fewer than one in five patients sees a neurologist post-stroke. Future work will include additional analysis to determine whether the results from this health system are consistent with others in our region.

Scholar 7: The Development of Regional Community Hospitals' Scholastic Environment.

The importance of increasing scholarly activity has been highlighted among residency programs currently accredited by the American Osteopathic Association (AOA) to ensure a smooth transition to the single accreditation system. The Scholar 7 program, a series of seven 2-hour sessions, was created to aid faculty and residents in the pursuit of scholarly work and to facilitate change in an entire community hospital system's environment by creating a self-replicating scholarly culture in a timely and cost-efficient manner. Skills were taught by means of preparation and submission of a research protocol to the institutional review board (IRB) along with grant proposals. The authors tracked scholarly work, IRB submissions, and grants awarded to participants during the 2015-2016 academic year. The results were compared in a post-hoc fashion with previous classes since 2007-2008 within the same hospitals system. The Scholar 7 program successfully aided faculty in achieving their required pursuit of scholarly work in 8 months. This program has the potential to help AOA-focused residency programs meet the scholarly requirements of the Accreditation Council for Graduate Medical Education.

The Prevalence of Interstitial Pneumonia With Autoimmune Features (IPAF) With Positive Serology in an Academic Community Hospital System

The Prevalence of Interstitial Pneumonia With Autoimmune Features (IPAF) With Positive Serology in an Academic Community Hospital System

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OBJECTIVES/SPECIFIC AIMS: Improving public health requires effective community-engaged approaches. The Better Together Lebanon County initiative plans to create opportunities for improved health and quality of life by aligning strategies of local organizations, previously working independently. METHODS/STUDY POPULATION: Better Together began with a 1-day summit, convening stakeholders with the goal of coordinating efforts and maximizing resources in the Lebanon community. Key stakeholders were identified using the socioecological model to assist with planning, goal setting, and developing outcomes for this initiative. Representation included community members, hospital systems, restaurants, school administrators, nonprofit organizations (including YMCA, American Heart Association), grocery stores and policy makers such as the mayor, health departments, and state representatives. RESULTS/ANTICIPATED RESULTS: The Better Together summit brought together almost 200 individuals representing 82 local organizations to share ideas and evoke collaboration around decreasing health disparities. Attendees learned about programs within and outside of their communities and volunteered for task forces to propel the community forward. Currently, we have members committed to further this work through Action Teams within the sectors of Physical Activity, Healthy Food Access and Family and Community Engagement. DISCUSSION/SIGNIFICANCE OF IMPACT: Convening individuals from many layers of the community helps to ensure discussions are representative of the overall community voice. It is vital to facilitate effective collaboration that includes networking, identifying assets and areas of improvement, brainstorming solutions and integrating research and best practices to improve the health of a community.

Using Research Findings to Design an Evidence-Based Practice Curriculum.

Evidence from a system-wide research study highlighted strengths and weaknesses in evidence-based practice (EBP) implementation, beliefs, and organizational readiness. To address this evidence, a curriculum was developed within the context of the shared governance and EBP models for nursing practice. The curriculum, Evidence-Based Practice: Clinical Applications in Professional Nursing Practice, consists of five modules that provide the knowledge, skills, and abilities relative to each step of EBP. The learning approach incorporates classroom- and unit-based education, facilitated by EBP curriculum mentors. Each module is rolled out quarterly for a 15-month curriculum cycle. Outcome data include pre- and post-learning assessments, in addition to EBP projects. This seamless approach to nursing education, based on research findings and established shared governance and EBP models, can be undertaken by community hospital systems. J Contin Nurs Educ. 2017;48(4):184-189.

Vascular Complications After Total Knee Arthroplasty—A Single Institutional Experience

BackgroundVascular complications during total knee arthroplasty (TKA) are uncommon but potentially devastating. We evaluated cases of vascular complication during TKA in our high-volume, community hospital system. MethodsPatients were identified by cross-referencing billing codes for TKA with diagnosis codes for vascular complication during the same hospital stay between January 1, 2010 and December 31, 2014. Clinical and radiographic data, time to diagnosis, intervention, and outcomes were collected. ResultsWe identified 13 vascular complications in 9951 TKAs (0.13%). Average age was 66.2 years (95% CI: 5.55; range: 54.1-87.9), 12 (92.3%) were female, average body mass index was 32.3 (5.17; 20-50), and average Charlson Comorbidity Index was 4.08 (1.03; 2-7). Black females (relative risk = 18.33, 95% CI: 6.20-54.22) were at particularly high risk. Preoperatively, 6 knees exhibited varus coronal malalignment and 2 valgus malalignment (only 1 >15°). None had flexion contracture >10°. Four knees exhibited vascular calcifications on preoperative radiographs. Twelve were diagnosed and treated the same day as index TKA and 1 on postoperative day 2. All underwent interventions: 9 stents, 2 endarterectomies, 1 thrombectomy, and 1 bypass. One patient sustained a peroneal nerve injury; 3 had persistent stiffness postoperatively that improved after manipulation. There were no revision surgeries, further vascular intervention, compartment syndrome, periprosthetic joint infection, amputation, or mortality. ConclusionIncidence of vascular complications at our community-based hospital system is in line with previous reports. Black race and female gender were significant risk factors. Although outcomes were remarkable for a high rate of stiffness and one peroneal neuropathy, the devastating complications of amputation, compartment syndrome, periprosthetic joint infection, or early mortality were not observed.

Impact of Single-Breath Mindfulness Technique on Physician Burnout and Stress

Introduction: Stress and burnout among health care providers can have serious repercussions. Mindfulness techniques, particularly when delivered by abbreviated training programs, have been studied for their success in managing symptoms and perceptions of stress and burnout among health care workers serving at the bedside, in clinic, as specialists, and in administration. Materials and Methods: Our suburban community hospital system introduced an eight week, video-module based, single-breath mindfulness technique training program to a group of 23 physicians with a range of experience (0-38 years; 48% primary care). Repeated measures ANOVA were used to evaluate changes across the study period (baseline, end of study, and 8 weeks post-intervention). Multiple linear regression was used to assess the relationship between burnout/stress measures at baseline and provider sex, age, years in practice, and field of practice (primary care or specialty). Results: 19 (83%) providers completed the program and 12 (52%) completed assessments at each time point. Significant improvements were observed across the study period in emotional exhaustion (p=0.01), personal accomplishment (p=0.007), and stress (p<0.001). The extent to which providers depersonalize their patients was not significantly impacted (p=0.14). No significant associations were observed between provider characteristics and burnout/stress metrics at baseline. However, at the α=0.10 level, primary care providers reported a significantly lower sense of personal accomplishment (-6.0 points, 95% CI: -12.2, 0.2 points; p=0.08) at baseline. Conclusions: Symptoms of stress and burnout are equally likely to be observed in providers across discipline, age, sex, and experience. A flexible, easy to use, single-breath based mindfulness program can yield significant improvements for these professionals.

Reagentless Bacterial Identification Using a Combination of Multiwavelength Transmission and Angular Scattering Spectroscopy

Optics based technologies are being advanced by many diagnostic companies around the globe. This resurgence is being driven by several factors including novel materials, enhanced computer power, nonlinear optics, and advances in algorithmic and statistical analysis. This study expands on a previous paper that evaluated the capability of a reagent-free optical profiling platform technology that used multiwavelength transmission spectroscopy to identify bacterial pathogens from pure culture. This study combines multiwavelength angular scattering with transmission based analysis into a single algorithm that will identify bacterial pathogens. Six predominant organisms,S. aureus, E. coli,K. pneumoniaeandP. aeruginosa,E. faecalis,and coagulase negativeStaphylococcus, were analyzed from a total of 753 clinical isolates received from three large community hospital systems. The bacterial identification method used for comparison in this study was the Vitek-2 (bioMerieux) which utilizes a biochemically based identification system. All of the clinical isolates received were blinded as to their identification until completion of the optical analysis. Sensitivities ranged from 87.7 to 94.6% with specificities ranging from 97.2 to 99.9% indicating that optical profiling is a powerful and exciting new technology that could be developed for the rapid identification of pathogens without the use of chemical reagents.