Danbury Hospital Research Articles

Preparing medical students for field experiences in low-resource settings: Development and evaluation of a pre-travel trigger video and large group discussion module

outcomes according to the UN Millennium Development Goals cannot be achieved without appropriate surgical services1. The Lancet Commission on Global Surgery recognizes surgical training as a cost effective intervention equivalent to vaccination and antiretroviral public health initiatives2. Yet the number of adequately trained physicians to perform basic surgical procedures, especially in women’s health, is severely lacking3. Combining the delivery of surplus medical equipment and ongoing surgical teaching will improve women’s health globally. Surgical Training and Research (STAR) International and Danbury Hospital/Western Connecticut Health Network (WCHN) have a collaborative relationship with the Ugandan national referral center, Mulago Hospital, to improve supervision and training for OB/ GYN physicians. Structure/Method/Design: Danbury Hospital/WCHN established an innovative global health (GH) program, which includes weekly lectures, journal clubs, and monthly GH seminars. Residents are funded for a six-week elective rotation abroad. Faculty from partner institutions are invited to participate in a 4-week observership at WCHN. The OB/GYN department dedicates resources to enhance collaboration with Mulago Hospital. In one year, STAR International was created and raised twenty thousand dollars to donate four complete sets of surgical instruments necessary to perform gynecologic surgery. Additional equipment and medications including suction, cautery, antibiotics, and anesthetic agents were also donated, and a surgical teaching camp was organized. In June 2014, two gynecologic surgeons, two OB/GYN residents, an anesthesiologist, and a nurse traveled to Mulago Hospital to increase exposure, supervision, and surgical skills of Ugandan OB/GYN residents. Outcomes & Evaluation: Over the one week surgical camp, 23 procedures were performed: 6 total abdominal hysterectomies, 8 ovarian cystectomies or salpingoopherectomies, 5 ectopic pregnancies, and debridement of 4 pelvic abscesses. Ugandan residents also received advanced training on LEEPs with a new cautery machine and supplies. All cases involved one attending gynecologist, one Ugandan resident and one Danbury Hospital resident. Seven Ugandan residents participated. The attending anesthesiologist also taught 4 Ugandan anesthesiology residents. Going Forward: The first surgical training camp at Mulago Hospital was a successful introduction of a long-term partnership that focuses on building capacity of Ugandan physicians. Both Mulago faculty and residents received the camp well, as both parties identified teaching and supervision to be lacking at Uganda’s national referral hospital. With the collaboration of academic partners, STAR International plans to hold camps several times a year and provide continuity of surgical training. The mission of STAR International is to increase the number of women treated effectively for their diseases, and to enhance the surgical skill of Ugandan physicians, allowing them to provide necessary gynecologic surgical therapies to Ugandan women. Funding: Funds for the Surgical Training camp were recruited from crowd-sourced funding and from WCHN. Abstract #: 01ETC064

Newtown Shuns Spotlight as It Tries to Heal

Back to table of contents Previous article Community NewsFull AccessNewtown Shuns Spotlight as It Tries to HealAaron LevinAaron LevinSearch for more papers by this authorPublished Online:18 Dec 2013https://doi.org/10.1176/appi.pn.2013.12b29AbstractThe people of Newtown, Conn., choose a low-key remembrance for the children and educators lost in last year’s mass shooting at an elementary school.Yet another melancholy anniversary passed December 14 as Newtown, Conn., chose to remember in its own way the massacre of 20 schoolchildren and seven adults last year in Sandy Hook Elementary School.The town’s first selectman (mayor), Pat Llodra, announced in October that there would be no official activity to mark the tragedy. Remembrance would be “quiet, personal, and respectful,” she said.To do otherwise would only open old wounds, said Charles Herrick, M.D., chair of the Department of Psychiatry and Behavioral Health at Danbury Hospital (Psychiatric News, July 10).“The experience last December was traumatizing for the whole town,” he told Psychiatric News. “The press, the gifts, the donations overwhelmed the town. They fear something like that will happen again, and that would not be appropriate.”That the anniversary falls in the midst of the holiday season is no help either, he said.Some area residents have sought to turn their grief into action under the aegis of Sandy Hook Promise. The organization advocates prevention of gun violence by promoting “mental wellness, connection to the community, and gun safety.”“They want to educate people, to give them a better understanding of mental health issues, and when and where and how to seek help,” said Herrick.Over the intervening year, mental health care for families, survivors, and other residents has largely been provided by private clinicians in the area, said Herrick. A Yale University team offered training in cognitive-behavioral therapy and trauma-informed care to those clinicians. Danbury Hospital has provided other support and education. The state chapter of the American Academy of Child and Adolescent Psychiatry granted funds for a mental health “navigator” in a local pediatrician’s office, a role that will be taken over by the local Office of Victim’s Services next summer.In October and November, Sandy Hook Elementary School was demolished. The building, constructed in 1956, would have required an expensive renovation to bring it up to code, but some townspeople were not sorry to see it erased from the map, said Herrick.On November 25, the state’s attorney released a 48-page summary of the Connecticut State Police investigation into the incident. The report noted that the gunman, Adam Lanza, was given a diagnosis of Asperger’s syndrome in 2005 and was treated by “mental health professionals.”It went into detail on how Lanza spent his last months, and then on December 14, killed his mother, went to the school, and shot the children and educators.The report did not suggest a motive. ■ ISSUES NewArchived

Clinical Features of Takotsubo Cardiomyopathy - A Single-Center Experience

Takotsubo cardiomyopathy (TTC), also known as transient apical ballooning syndrome or stress-induced cardiomyopathy, is a distinctive reversible condition often affecting postmenopausal women after a stressful event. It is characterized by sudden temporary systolic dysfunction of the apical and/or mid-segments of the left ventricle. The underlying mechanisms have not yet been elucidated, but several hypotheses include catecholamine cardiotoxicity, microvascular dysfunction and coronary artery spasm. We conducted a retrospective descriptive study on patients with the discharge diagnosis of TTC from 2003 to 2012 at Danbury Hospital, Danbury, Conn., USA. A total of 78 patients met the Modified Mayo Criteria for the Diagnosis of TTC and were included in the study. Clinical characteristics at baseline, past surgical and medical history including psychiatric records were reviewed and recorded. The mean age was 70.5 ± 14 years, 87% (n = 68) were women, of which 11.7% (n = 8) were aged ≤55 years. Depression was present in 20.5% (n = 16) of the patients and anxiety in 30.8% (n = 24). Twenty-one patients (27.3%) reported a preceding emotional stressful event and 31 (40.3%) had a preceding physical stressor. Fifty patients (64.1%) presented with chest pain, 28 (35.9%) had ST-segment elevation upon admission and 5 (6.3%) died during their hospital stay. TTC is becoming an increasingly recognized condition and clinicians should include it in the differential diagnosis of patients presenting with a suspected acute coronary syndrome. It is frequent in postmenopausal women with preceding physical or emotional stress and overall prognosis is good among patients who survive the initial acute phase of heart failure.

Prevalence and Consequences of Vitamin D Insufficiency in Women With Takotsubo Cardiomyopathy

The purpose of this study was to identify the prevalence and clinical consequences of vitamin D insufficiency in patients with takotsubo cardiomyopathy. Takotsubo cardiomyopathy is a syndrome of acute, transient left ventricular dysfunction seen predominantly in postmenopausal women after acute emotional or physical stress. Postmenopausal women have a high prevalence of bone and musculoskeletal consequences related to hypovitaminosis D. Although rickets is known to cause a reversible dilated cardiomyopathy in children, the importance of vitamin D for adult cardiovascular health is less understood. We prospectively identified patients diagnosed with takotsubo cardiomyopathy at Danbury Hospital from April 2009 through January 2011, collected demographic, clinical, laboratory, and angiographic data, and performed serum 25 hydroxyvitamin D levels during the index hospitalization. Vitamin D insufficiency was defined as serum 25-hydroxy-vitamin D less than 30 ng/mL. We compared parameters of myocardial damage and heart failure between patients with and without vitamin D insufficiency. A χ² test and a Student's t test were used for categorical and continuous variables, respectively. Statistical significance was set at P < .05 (2 tailed). Twenty-seven women were diagnosed with takotsubo cardiomyopathy during the study period. The mean age was 67.4 years (SD 10.4). The serum 25-hydroxyvitamin D levels were performed on 25 patients, and 17 of these had hypovitaminosis D (68%). A comparison of laboratory and imaging parameters between the 2 groups revealed that patients with hypovitaminosis D had a slightly higher mean left ventricular end-diastolic pressure and lower mean left ventricular ejection fraction (P < .05), suggestive of slightly worse heart failure. Women diagnosed with takotsubo cardiomyopathy have a high prevalence of vitamin D insufficiency. In our prospective study of 25 women with takotsubo cardiomyopathy, this was associated with worse hemodynamic parameters.

Newtown Organizes MH Services For the Long Term

Back to table of contents Previous article Next article Community NewsFull AccessNewtown Organizes MH Services For the Long TermAaron LevinAaron LevinSearch for more papers by this authorPublished Online:1 Feb 2013https://doi.org/10.1176/appi.pn.2013.2a12AbstractMental health providers in Newtown, Conn., collaborate to plan long-term care for townspeople after December’s deadly school shooting.The big St. Bernard lay on the floor in the hallway, waiting to have its belly rubbed.Irvin Jennings, M.D., supervises Mikey the Therapy Dog at the Reed Intermediate School in Newtown, Conn., after the shooting at Sandy Hook Elementary School in DecemberIrvin Jennings, M.D.True, St. Bernards aren’t part of the standard psychiatry residency, but this one and 14 other canines of varying breeds joined the resources gathered in the family assistance center set up in Newtown, Conn., after the shooting rampage last December that left 20 children and seven adults dead.A therapy-dog organization brought the St. Bernard and friends, Save the Children set up an arts-and-crafts room, and three mental health organizations provided more-conventional care at the Reed Intermediate School in Newtown.Wellmore, a mental health services organization with expertise in mobile crisis services; Danbury Hospital; and Family and Children’s Aid (FCA) collaborated on operating a site to which people affected by the tragedy could go for therapy or just a sympathetic ear, said FCA’s executive and medical director, Irvin Jennings, M.D.“What evolved was a wonderful model,” Jennings told Psychiatric News. “It was part grief counseling and part kids’ play area.”Each organization had staff members there every day for the following week, with FCA doing administrative work (like vetting the credentials of volunteer counselors) as well as providing clinical services. The dogs “just showed up,” said Jennings. Kids could pet the dogs or do art projects while their parents talked with counselors. The center logged at least 1,350 encounters in its first 10 days of operation.Even the dogs played well together, he said.Eventually, a collection of town and state agencies, along with representatives from the school district and local government, coalesced with the three groups running the crisis center into a coordinating council, said Charles Herrick, M.D., chief of psychiatry at Danbury Hospital. The council is now assessing community needs and organizing the transition to longer-term services“We hope to establish some kind of ongoing drop-in center to provide information and have clinicians available to do screening and refer as needed,” said Herrick in an interview. “Our plan is to build capacity with trained clinicians.”The council will start by creating a list of three sets of clinicians: those who are already seeing affected children and families, those with specific training in trauma-focused care, and those who will need training in such care.Psychologist Stephen Marans, Ph.D., of the Yale Child Study Center, and Steven Southwick, M.D., a posttraumatic stress disorder specialist at the West Haven Veterans Affairs Medical Center, will lead the training.Danbury Hospital has only a small child and adolescent psychiatry department, so it will concentrate on adult services while linking younger people to primary care physicians, he said. The hospital will train the latter to use screening tools and look for somatic complaints in children that may have been triggered by the event.In the longer term, coordination for local resources will be managed by Newtown Youth and Family Services, said Jennings. Local resources should be adequate to serve those who need services.“This is a pretty therapy-rich area, between private practices and nonprofit agencies,” he said. “People in Newtown want to stay in Newtown, so we’re trying to be sensitive to that view.”The coordinating council must build for the long term, said Herrick. At one early meeting, a state official reported that health officials from Colorado’s Columbine High School and Aurora, Colo., scenes of previous mass shootings, had called to offer support. They also noted that people in those towns reexperienced their own tragedies when they heard about Newtown.“So we have to make a longstanding commitment in our community to have services available,” said Herrick.Perhaps that will also mean having that St. Bernard on call. ■The Newtown Youth and Family Services’ Web site is http://www.newtownyouthandfamilyservices.org. ISSUES NewArchived

The Use of Transthoracic Echocardiography and Adherence to Appropriate Use Criteria at a Regional Hospital

The sharp increase in health care costs over the past decade has prompted health care providers to reevaluate how diagnostic imaging is utilized. In response to the need for more rational use of imaging services, the American College of Cardiology Foundation and the American Society of Echocardiography have developed appropriate use criteria (AUC) for transthoracic echocardiography to guide itsutilization. Although community and regional hospitals, such as Danbury Hospital, account for 85% ofregistered hospitals in the United States, very little is known about adherence to the AUC at these institutions. The electronic medical records of 1,205 patients who underwent inpatient transthoracic echocardiography from January 1 to June 30, 2008, were retrospectively examined to determine the reasons for ordering the studies. The 2007 and 2011 AUC were used to classify indications as appropriate, inappropriate, or uncertain. Using the 2007 AUC, 86% of echocardiographic examinations were classified as appropriate. One percent had indications that were inappropriate, and there were no uncertain indications. Thirteen percent of studies were ordered for reasons not defined by the 2007 AUC. The most common appropriate indications were symptoms due to suspected cardiac etiology, initial evaluation after acute myocardial infarction, and acute chest pain with suspected myocardial ischemia. When evaluated using the 2011 AUC, appropriate and inappropriate indications increased to 97% and 2%, respectively. Ninety-three percent of undefined studies, using the 2007 AUC, could be classified using the 2011 guidelines. Consistent with studies conducted at university hospitals, Danbury Hospital, a regional hospital, showed good adherence to the AUC. This suggests that the AUC are valuable across a large continuum of inpatient settings and can serve as an excellent guide for utilization and appropriateness.

Educating for the Future

The current lack of perioperative clinical rotations in nursing schools makes it imperative that perioperative nurses create ways to entice the next generation of nurses to work in the OR. At Danbury Hospital, Danbury, Connecticut, the OR manager and clinical educators looked at the challenges that nursing students face in the perioperative clinical setting and created an orientation to help to ease their fears about observing in the OR, familiarize them with the perioperative nursing role, and perhaps encourage more nursing students to consider perioperative nursing as a career. We used the “AORN guidance statement: The value of clinical learning activities in the perioperative setting in undergraduate nursing curricula” as a framework for a perioperative orientation class that addresses the challenges and meets the students' academic goals. We also used the nursing curriculum objectives from Western Connecticut State University, Danbury, to plan the students' clinical experience in surgery. Our approach has attracted more student interest in perioperative nursing than in previous years, resulting in more students requesting a perioperative clinical rotation or senior practicum.

Use of a Sacral Silicone Border Foam Dressing as One Component of a Pressure Ulcer Prevention Program in an Intensive Care Unit Setting

In 2008, patients in the intensive care unit (ICU) at Danbury Hospital, Danbury, Connecticut, experienced 79 pressure ulcers. As a result, pressure ulcer-prevention interventions were standardized in critical care and medical-surgical units and education was provided to all direct patient care staff about principles of skin care and prevention. Following these efforts, 53 ICU patients developed pressure ulcers in the sacral area in fiscal year 2009, representing a 12.5% incidence for the ICU as compared to a 3.4% overall pressure ulcer incidence for the total hospital. In order to achieve additional reduction in pressure ulcer incidence, we replicated an initiative that called for application of a silicone foam dressing every 3 days to determine its effect on sacral pressure ulcer incidence in the ICU. We found that the use of the dressing further diminished the incidence of sacral pressure ulcers in our patients.

Abstract 8734: The Utility of Troponin I in Two Cohorts of Cardiac Patients: Implications for Clinical Practice

Background: Minor elevations in troponin I are common among patients with chronic coronary artery disease (CAD) and those with new supraventricular tachyarrhythmia (SVT). These troponin I elevations are often attributed to an acute coronary syndrome (ACS). However, minor elevations in troponin I may be present for other reasons, such as demand ischemia. Our aim was to observe the prevalence of troponin I elevations in patients with: 1) new onset atrial fibrillation (A-fib), flutter (A-flutter) or SVT and 2) known CAD following exercise, and to assess the hypothesis that troponin I elevations in these settings would not be indicative of ACS. Methods: This study included two components. First, a retrospective review of 740 charts of patients with new onset A-fib, A-flutter or ectopic SVT presenting to the Danbury Hospital Emergency Department between July 2009 and July 2010. Excluded were 45 patients with symptoms and EKG changes indicating ACS on admission. Second, a separate sample of 75 patients with known CAD presenting to the Danbury Hospital Cardiology Clinic for follow-up imaging stress tests were recruited. Eligible patients underwent a stress test and perfusion imaging and had one troponin I sample drawn prior to the stress test and a second at the completion of all imaging four hours later. Results: Among patients with new A-fib, A-flutter and SVT, 31.9% had minor elevations in troponin I levels (values ranged from 0.05-1.0 ng/mL). In those with elevation, 64% had no documented CAD. In addition, for those with elevation, 78.4% had new onset A-fib, 11.3% had new onset A-flutter and 10.4% had new onset SVT. In the separate cohort of patients with CAD who underwent stress testing, 38.7% had troponin elevation following exercise. A total of 50.7% of these patients had no evidence of ischemia by EKG and perfusion and 54.7% had a Duke Treadmill score greater than or equal to 5. Conclusion: For patients with chronic CAD subject to physical stress or those with new onset A-fib, flutter or SVT, small elevations in troponin I are fairly common, and often do not indicate ACS. In a cost containment environment, expensive therapy and testing of these patients may be unnecessary.

73 A Case of Acute Kidney Injury with Unexplained Osmotic Nephrosis

A CASE OF ACUTE KIDNEY INJURY WITH UNEXPLAINED OSMOTIC NEPHROSIS Roma Cruz, Ranil Gajanayaka, Panupong Lisawat , Glen Markowitz, Raymond Raut, Winston Shih. Danbury Hospital, Danbury, CT, USA Osmotic nephrosis is a pathologic term used to describe the pattern of vacuolization and swelling of the proximal renal tubular cells. This has been associated with infusion of sucrose, maltose, mannitol, dextran and iodinated contrast media. We report a case of osmotic nephrosis in a patient with no exposure to these agents. A 62 year old white female presented with 36 hour history of anuria. Her medical history is significant for hypertension and diabetes mellitus. Medications on admission included Valsartan, Hydrochlorothiazide, Metformin, Insulin,Simvastatin and Saxagliptin which was started 3 months before. On admission, physical exam was unremarkable. Initial laboratory exam revealed BUN 40 mg/dl, creatinine of 5.6 mg/dl, from a baseline of 1.3 mg/dl, 2 months prior. Both kidneys are of normal size and without hydronephrosis. Urinalysis revealed 3+ protein, 3+blood, 9-30 WBC. Complement levels, ANA, ANCA, hepatitis serologies and HIV were negative. Patient remained anuric, her serum creatinine peaked at 9.94 mg/ dL and she required 2 sessions of hemodialysis. A kidney biopsy was consistent with osmotic nephrosis. Patient spontaneously started diuresing on the 4 hospital day and was discharged a week later with a serum creatinine at its baseline 1 mg/dL. Cases of acute kidney injury and acute tubular necrosis have been reported with Sitagliptin (Januvia-another DPP4 inhibitor) and Exenatide(Byetta GLP-1 analog) and have been associated with rapid improvement once these medications were discontinued. Renal biopsies were performed in a minority of cases. This is, to our knowledge, the first case of AKI that occurred in the presence of Saxagliptin with no exposures that could explain the osmotic nephrosis.

Perceptions of Empowerment Among ED Nurses

Nurses' perceptions of empowerment have been linked to a number of variables in the hospital workplace, including job satisfaction, autonomy, and work effectiveness. Yet there have been no previous studies of perceptions of empowerment specifically among emergency department (ED) nurses. Registered nurses (RNs) employed in the EDs of 6 hospitals in a major health care system in the eastern United States were surveyed regarding their perceptions of empowerment. Of the 240 RNs eligible to participate, there were 167 usable surveys. There was a moderate level of empowerment among the RNs who participated, consistent with the level of empowerment reported in several other studies of staff nurses and nurses in other positions. The moderate level of empowerment in this sample may be attributed to the many opportunities for RN involvement in the hospitals within this health care system. Nurse leaders can initiate programs focused on enhancing RN perceptions of empowerment. In addition, there is a need for further research among RNs with different specialty preparation.

A Leadership Initiative to Improve Communication and Enhance Safety

The EMPOWER project was a collaborative effort to promote a culture of patient safety at Danbury Hospital through an interdisciplinary leadership-driven communication program. The "EMPOWER" component includes Educating and Mentoring Paraprofessionals On Ways to Enhance Reporting of changes in patient status. Specifically, the EMPOWER program was designed to prepare paraprofessional staff (PPS) to communicate changes in patient status using SBAR (situation, background, assessment, recommendations) structured communication. The specific project goals included (a) translation of SBAR structured communication methods for use with PPS, (b) reduction of cultural and educational barriers to interdisciplinary communication, and (c) examination of the effect of the EMPOWER intervention on the PPS communication practices and perceptions of the patient safety culture. Results of the project indicate a change in the use of SBAR throughout the institution, with particular improvement in communication from PPS to professional staff.

University of Vermont College of Medicine

University of Vermont College of Medicine

HPB Surgery Can Be Safely Performed in a Community Teaching Hospital

IntroductionThere is ongoing debate about feasibility of performing hepatobiliopancreatic (HPB) cases in low-volume, community hospitals. We decided to analyze outcomes of HPB surgical cases done in our community hospital and compare it with published data from academic centers and/or national data. Materials and MethodsWe reviewed all HPB cases (liver, pancreas, and bile duct cases) performed in an 8-year-period (2001–2009) by HPB-fellowship-trained general surgeon (P.F.S.) at the Danbury Hospital, CT, USA. All electronic files of the patients, who underwent HPB surgery, were reviewed, and all pertinent clinical information was retrieved. Complications and mortality were recorded for length of hospital stay and 30 days after discharge. All complications were graded according to Clavien classification. Pancreatic specific complications—pancreatic fistula/leak and delayed gastric emptying—were graded using International Study Group on Pancreatic Fistula and International Study Group of Pancreatic Surgery definitions. ResultsThere were 140 HPB cases. These included 33 pancreatoduodenectomies, 29 distal pancreatectomies, 52 hepatic cases, and 26 cases of other cases involving pancreas and biliary tract. Overall complication rate was 36.4%. Using Clavien classifications, there were 26 grade 1 complications, 21 grade 2 complications, and four grade 3 complications. Two patients underwent reoperation for postoperative complications. Overall mortality was 0.7% (one patient). Pancreas-specific complications included 6% pancreatic leak rate after pancreatoduodenectomy and 24.1% leak rate for distal pancreatectomy. ConclusionHPB surgery could be safely performed in community setting, with morbidity and mortality comparable to high-volume centers.

Severity scoring in community-acquired pneumonia caused by Streptococcus pneumoniae: a 5-year experience

Multiple severity scoring systems have been devised and evaluated in community-acquired pneumonia (CAP), but a simplified set of prognostic indicators has not yet been developed. Streptococcus pneumoniae is the most frequent aetiological agent of CAP. Our aim was to characterise the outcome in the light of different severity scoring systems and to compare the predictive values of different sets of clinical parameters, using available clinical data for pneumococcal CAP patients. This is a case series retrospective analysis that included consecutive adult pneumococcal CAP patients admitted to Danbury Hospital between 1 January 1996 and 31 December 2000. The aetiology was confirmed by positive sputum and/or blood cultures. The severity assessment included the Pneumonia Outcome Research Trial (PORT) and British Thoracic Society (BTS) scoring systems and other additional parameters. Primary end-points were in-hospital CAP-attributable deaths and length of hospitalisation. N = 151 patients with S. pneumoniae CAP were identified. The mean (± standard deviation) age at the time of diagnosis was 68 (±15) years. Thirty-three patients (22%) were admitted to the medical intensive care unit. The mean (median) hospitalisation duration was 7.5 (±5) days. Door-to-antibiotic mean (median) administration time was 3.7 (2) hours. Most frequent antibiotics used initially were cephalosporins plus/minus macrolides or fluoroquinolones. The mean (± standard deviation) PORT score was 105 (±37). The observed CAP-related mortality was 9/151 (5.9%, 95% confidence interval: 3–9%). The mortality rate in ICU was 18% (6/33). Sixty-nine patients (45%) had S. pneumoniae bacteraemia an admission. The bacteraemic and non-bacteraemic patients had similar PORT scores (107 vs. 104, P = 0.66), length of hospitalisation (8 vs. 7 days, P = 0.41) and mortality rates (9% vs. 4%, P = 0.30). In conclusion, patients admitted with pneumococcal CAP, although severe and with multiple co-morbidities had low in-hospital mortality rates and lengths of hospitalisation. Neither prior antimicrobial use (or failure) nor antimicrobial resistance contributed to an adverse outcome. S. pneumoniae bacteraemia failed to correlate with need for ICU, length of stay, higher morbidity index or fatal outcome. Low rates of empirical antibiotic use for non-bacterial infections in the local community, implementation of an emergency department protocol for CAP therapy, early recognition of higher risk patients and placement in ICU, use of broad spectrum antibiotics, infectious disease approval or critical pathway restriction for admission orders, could all have combined to effect a good outcome for these patients.

Milagros.

Cortney Davis is a nurse practitioner at Danbury Hospital in Danbury, CT, and author of I Knew a Woman: Four Women Patients and Their Female Caregiver. Reflections is coordinated by Veneta Masson:[email protected].

False-Positive Phencyclidine Immunoassay Results Caused by Venlafaxine and O-Desmethylvenlafaxine

We recently observed three occurrences of false-positive results for phencyclidine (PCP) on urine samples tested with the Syva® RapidTest d.a.u.® 9 Test Panel (Syva Company, subsidiary of Dade Behring Inc.). The RapidTest d.a.u. 9 device is a single-use, one-step, solid-phase immunochromatographic assay for the qualitative, discrete detection of several drugs/drug metabolites in human urine (1). The urine samples were collected from three different patients who were seen in our Emergency Department within 3–4 weeks after we had implemented the RapidTest device in our laboratory (Danbury Hospital). Because PCP is not a commonly used drug in our locale and the rare positive results have usually been confirmed as false positives, three positive PCP results in such a short time period immediately aroused suspicion. Patient A was a 52-year-old male with schizoaffective disorder who was admitted to the psychiatry service. Patient B was a 93-year-old female from a nursing home who was admitted with a hip fracture. Patient C was a 50-year-old female admitted for opiate and benzodiazepine overdose. None of these patients had a history of PCP use or presented with symptoms consistent with use of this drug. Patient A’s urine gave negative results for all other drugs tested with the RapidTest. Patient B’s urine also tested positive for benzodiazepines and barbiturates; these results could be attributed to medications documented in this patient’s medical record: lorazepam, clonazepam, and phenytoin …

The Best NICU in America 2002 Danbury Hospital Danbury, Connecticut

I HAVE READ SEVERAL OF YOUR LETTERS DECLARING THAT they are “The Best NICU in America” and I had to write because I truly believe that I work in “The Best NICU in America.” I have been involved in neonatal nursing in some aspect or another since I graduated from Ohio State University in 1977. I worked at Children’s Hospital of Philadelphia’s NICU as a new graduate, and at Ohio State University’s NICU. Both were wonderful experiences and helped me to get started on the right track when it came to my neonatal nursing career. In 1983 I moved to Connecticut and started to work at Danbury Hospital in their NICU. I am currently an NNP but have held management and staff positions there. I feel privileged to have been in several positions in this NICU because it has given me the chance to experience nursing from all aspects.

OUTPATIENT INTRAVENOUS ANTIBIOTIC THERAPY IN MEDICARE PATIENTS: COST-SAVINGS ANALYSIS

The Medicare policy of refusing reimbursement for outpatient intravenous antibiotic therapy contributes to prolonged inpatient length of stay and increased hospital costs for Medicare patients. A program for the outpatient management of Medicare patients who required intravenous antibiotic therapy was created under the management of the Infectious Diseases Department of the Danbury Hospital and was paid for by the hospital. Forty-eight inpatients with infections that required prolonged intravenous antibiotic therapy were selected for enrollment. Cost savings resulting from early discharge in both high- and low-occupancy settings were calculated by a unique and accurate system of cost accounting in which both fixed and variable costs were considered. All 48 patients were either cured or improved. Of the 11 different infections treated, the most common were osteomyelitis (24 patients) and endocarditis (seven patients). Calculated cost savings resulting from early hospital discharge of Medicare patients were $335,394 during high occupancy and $48,368 during low occupancy. The net cost savings to the hospital were $293,332, or $6111 per patient.

Connecticut Supreme Court Denies Claim of Emergency Room Negligence

In Barrett v. Danbury Hospital (232 Conn. 242; 654 A.2d 748 (1995)), the Supreme Court of Connecticut held that the fear of contracting or transmitting HIV or any other blood-borne pathogens is not a compensable injury and does not give rise to a negligence or a medical malpractice claim. The court's decision affirmed the holding of a Connecticut trial court.In June 1990, Allen Barrett was admitted to Danbury Hospital complaining of abdominal pain. He had a history of gall bladder trouble. Barrett was placed on a stretcher in the emergency room. The attending physician diagnosed Barrett's pain as a gallstone condition. During the course of his examination, the doctor noticed that Barrett was sitting in blood. The physician subsequently performed a rectal examination of Barrett to locate the source of the blood. The physician determined that the patient was not bleeding, but that the blood was in fact coming from two slits in the vinyl pad that covered the stretcher on which Barrett sat.