Delay In Administration Research Articles

Multidisciplinary standardized protocol decreases time to antibiotic administration for open fractures.

Wound complications after open fracture are common, including superficial and deep infections. Many factors may contribute to outcomes after open fracture, including comorbidities, injury location and characteristics, timing and quality of surgical debridement, and soft tissue coverage. Early prophylactic antibiotic administration is one of the few modifiable factors demonstrated to reduce infection rates. Retrospective comparative study at a single Level 1 Trauma Center evaluated patients age > 18 who presented directly to and were admitted with open long-bone fracture. Primary outcome measure was time from arrival to antibiotic administration pre- and post-implementation of a standardized open fracture protocol. Secondary analysis evaluated percentage of patients receiving antibiotics within one hour for open long-bone fracture, injury characteristics and patient demographics influence on time to antibiotics. Median time to antibiotic administration improved post-protocol (69min vs. 39min, p < 0.001). Patients receiving antibiotics within one hour improved after protocol implementation (42.9% vs. 79.0%, p < 0.001). Antibiotic administration was more often delayed for patients with penetrating injuries compared to blunt injuries (80min vs. 54min, p = 0.003). Patients with penetrating injuries were less likely to receive antibiotics within one hour (46% vs 56%, p < 0.001). The implementation of a standardized protocol reduced the time to antibiotic administration and increased the percentage of patients with open fractures receiving antibiotics within one hour. Penetrating injuries were often not appreciated as open fractures during the initial evaluation, which led to a delay in antibiotic administration. Level III, Therapeutic/Care Management.

EHospitals and Parkinson’s disease care: audit insights from an EPIC-integrated Hospital

Abstract Introduction Parkinson’s disease (PD) is a neurodegenerative condition that affects approximately 145,000 individuals in the UK. PD symptoms are managed primarily through medications such as levodopa and dopamine agonists. Delays or omissions in administering these medications is the primary reason for increased length of stay in up to 73% of emergency admissions.1 This audit investigated the management of PD medications at Cambridge University Hospitals to identify areas for improvement in clinical practice. Aim This audit aimed to evaluate the pharmacological management of PD patients admitted to Cambridge University Hospitals NHS Trust. Specifically, it sought to assess the accuracy of drug histories, the quality of medication administration, and adherence to standards set by Parkinson’s UK ‘Get it on Time’ campaign and NICE.2,3 Methods A cross-sectional audit was conducted, reviewing the records of PD patients admitted over a three-month period. The sample included patients with a confirmed diagnosis of idiopathic PD who were prescribed at least one PD medication. Data were collected retrospectively from the electronic patient records, focusing on ten performance standards. Ethical approval was not required as the study involved a retrospective review of existing clinical records. Results The audit included 63 admissions, predominantly male (65%) with a mean age of 78.5 years. A significant portion of patients (81%) had their drug histories completed by a doctor after clerking, and 90% had orders for their regular treatment generated immediately post-clerking. Pharmacy staff completed drug histories within 24 hours for 81% of patients, though discrepancies between medical and pharmacy histories were noted in 70% of cases. Medication reconciliation within 24 hours was achieved for 83% of patients, yet only 29% received their PD medications on time for every dose. Additionally, 76% did not miss a dose or had a valid reason recorded for missed doses. 83% had PD listed in their electronic problem list after clerking. Alarmingly, just 5% were assessed for Self-Administration of Medicines (SAM), and 76% were assessed by a PD specialist during their stay. Discussion and conclusion The audit revealed substantial gaps in PD medication management, particularly regarding discrepancies between medical and pharmacy drug histories and delays in medication administration. The low rate of SAM assessments and inconsistent PD specialist consultations were also significant concerns. These findings highlight the need for improved documentation practices, such as standardized templates within the EPIC system, and increased pharmacy involvement during early stages of admission. Appropriate staffing levels and better interdisciplinary coordination are essential. The audit identified critical areas for improvement, emphasizing the need for better documentation, timely administration, and enhanced interdisciplinary coordination. Future audits should aim to randomize patient selection over a longer period to minimize bias and provide a more comprehensive assessment of medication management practices. The audit was limited by its retrospective design and the specific three-month timeframe, which may not fully represent broader trends. The exclusion of admissions shorter than 24 hours and the focus on a single hospital trust also limit the generalizability of the findings. Future studies should consider a larger, more randomized sample to validate and expand upon these results.

Experiences of the emergency department environment: a qualitative study with caregivers of people with dementia.

ED crowding and boarding adversely impact older patients' care and outcomes. Little is known about how ED crowding impacts persons living with dementia, a vulnerable population. This study sought to explore ED experiences of caregivers of people with dementia during a period of ED crowding and boarding. We performed semi-structured interviews with caregivers of people with dementia with an ED visit during a period of ED crowding and boarding at two public hospitals experiencing a threefold increasein boardingfrom pre-pandemic levels. Participants were recruited via chart review. We coded data using an inductive approach. Three themes emerged from 29 caregiver interviews: (1) difficulty obtaining assistance, (2) patient harms, and (3) concerns about triage and rooming processes. First, caregivers described having to be proactive to obtain symptom control and assistance with mobility. Second, caregivers observed harms of noise and stimulation provoking agitation and delays in administration of routine medications. Third, caregivers felt it was inappropriate for people with dementia to receive care in waiting room chairs or to receive prolonged hallway care. Caregivers advocated for preferential considerations for rooming and rapid assessment to avoid agitation, facilitatd access to ED staff, and promote patient comfort. Caregivers of people with dementia associated ED environments with difficulty obtaining assistance, patient harms, and triage concerns. Strategies to mitigate the negative impacts of ED crowding on people with dementia should focus on environmental modifications, uptriage of people with dementia, supporting activities of daily living and mobility, andinnovation around patient disposition.

Preferences for speed of access versus certainty of the survival benefit of new cancer drugs: a discrete choice experiment.

The extent to which patients with cancer are willing to accept uncertainty about the clinical benefit of new cancer drugs in exchange for faster access is not known. This study aims to examine preferences for access versus certainty, and to understand factors that influence these preferences. A US nationally representative sample of older adults were recruited via Cint, an online platform for survey research, to take part in an online discrete choice experiment. To be eligible, respondents had to self-report some experience with cancer-ie, they themselves, a close friend or a family member, previously or currently diagnosed with cancer. In the experiment, respondents chose between two cancer drugs, considering five attributes: functional status, life expectancy, certainty of the survival benefit of a new drug, effect of the drug on a surrogate endpoint, and delay in US Food and Drug Administration (FDA) approval time. The first primary outcome was the relative importance of certainty of survival benefit and wait time to respondents. The second primary outcome was willingness to wait for greater certainty of survival benefit, including subgroup analysis by cancer experience, age, education status, race or ethnicity and income. Secondary outcomes were changes in sensitivity to certainty and wait time, depending on the drug's effect on a surrogate endpoint, respondents' functional status, and life expectancy. The study plan was registered with ClinicalTrials.gov, NCT05936632. Between July 7 and July 20, 2023, 998 eligible respondents completed the survey. 870 respondents (461 [53%] male, 406 [47%] female, and three [<1%] other) were included in the final analysis. Respondents showed strong preferences for high certainty of survival benefit (coefficient 2·61, 95% CI 2·23 to 2·99), and strong preferences against a 1-year delay in FDA approval time (coefficient -1·04, 95% CI -1·31 to -0·77). Given very low certainty a drug would provide survival benefit (no evidence linking a surrogate endpoint to overall survival), respondents were willing to wait up to 21·68 months (95% CI 17·61 to 25·74) for high certainty (strong evidence) of survival benefit. A drug's effect on a surrogate endpoint had no significant impact on drug choices (coefficient 0·02, 95% CI -0·21 to 0·25). Older respondents (aged ≥55 years), non-White, lower-income (<$40 000 per year) individuals, and those with the lowest life expectancy, were most sensitive to wait time. Many cancer drugs approved through the FDA's accelerated approval pathway do not offer any survival benefit to patients. In this study, individuals expressed strong preferences for certainty that a cancer drug would offer survival benefit. Some individuals also expressed a higher willingness to wait for greater certainty than would be necessary to assess the survival benefit (over progression-free survival benefit) of most cancer drugs used in the metastatic setting. The London School of Economics and Political Science Phelan United States Centre.

The Black Box of Single-Family Zoning Reform

America faces a staggering housing affordability crisis. The consequences of the crisis include reduced economic productivity, suppressed labor mobility, greater social inequity, and increased homelessness. A scholarly consensus blames excessive land-use regulation for these problems and advocates now call for deregulation. Several jurisdictions have recently elected to allow middle housing—small, multi-family developments—in areas previously zoned for single-family detached housing. The results of these reforms, however, have been disappointing. This Article examines why they have fallen short and how to do better. This Article identifies an analytical disconnect between the deregulatory consensus and actual single-family zoning reforms adopted to date. Given this disconnect and the limited success of single-family zoning reforms thus far, it is unclear why such reforms continue to be adopted. Moreover, these reforms cannot achieve their promised ends. Interviews of middle housing builders in reform jurisdictions reveal legal and structural barriers that prevent market participants from responding to the housing crisis with scale and urgency. This Article proposes several regulatory alternatives that offer a greater probability of success in achieving the consensus’s goals: (1) modestly expanding multi-family zones to allow redevelopment and densification of underutilized non-residential properties; (2) providing affordable-housing density bonuses; (3) streamlining land-use procedures and eliminating administrative delay to reduce uncertainty in permitting processes; and (4) reevaluating financing mechanisms for new housing development. Taken together, these policies are necessary complements to single-family zoning reforms for addressing undersupply of market- and below-market-rate housing.

Delays in Cardiopulmonary Resuscitation, Defibrillation, and Epinephrine Administration in Out-of-Hospital Cardiac Arrest - Composite Time-Dependent Effects of Prehospital Interventions on 30-Day Favorable Neurological Outcomes and Social Implications From a Prospective Nationwide Population-Based Cohort Study.

Our study investigated the prognostic impacts of the interval between collapse and the initiation of cardiopulmonary resuscitation (CPR), and subsequent intervals to defibrillation or epinephrine administration, on 30-day favorable neurological outcomes following out-of-hospital cardiac arrest (OHCA). This nationwide population-based cohort study used the All Japan Utstein Registry, encompassing OHCA patients in Japan between January 2006 and December 2021. The primary outcome was 30-day favorable neurological outcomes, defined as Cerebral Performance Category 1 or 2. Three-dimensional plots and multivariable logistic regression models were used to assess the time-dependent prognostic impacts of prehospital CPR interventions. In all, 184,731 OHCA patients (86,246 with shockable rhythm and 98,485 with non-shockable rhythm) were included in the study. Three-dimensional plots revealed that the interval between collapse and initiation of CPR, and subsequent intervals to defibrillation or epinephrine, were independently associated with 30-day favorable neurological outcomes in the groups with shockable and non-shockable rhythms, respectively (P<0.05 for all). Among patients with witnessed OHCA, there was a dose-response relationship between delays in the collapse-CPR initiation interval, and subsequent intervals to defibrillation or epinephrine administration, and 30-day favorable neurological outcomes. Our findings provide valuable insights into OHCA management.

Development and Validation of a Machine Learning Model for Early Detection of Untreated Infection.

Early diagnostic uncertainty for infection causes delays in antibiotic administration in infected patients and unnecessary antibiotic administration in noninfected patients. To develop a machine learning model for the early detection of untreated infection (eDENTIFI), with the presence of infection determined by clinician chart review. Three thousand three hundred fifty-seven adult patients hospitalized between 2006 and 2018 at two health systems in Illinois, United States. We validated in 1632 patients in a third Illinois health system using area under the receiver operating characteristic curve (AUC). Using a longitudinal discrete-time format, we trained a gradient boosted machine model to predict untreated infection in the next 6 hours using routinely available patient demographics, vital signs, and laboratory results. eDENTIFI had an AUC of 0.80 (95% CI, 0.79-0.81) in the validation cohort and outperformed the systemic inflammatory response syndrome criteria with an AUC of 0.64 (95% CI, 0.64-0.65; p < 0.001). The most important features were body mass index, age, temperature, and heart rate. Using a threshold with a 47.6% sensitivity, eDENTIFI detected infection a median 2.0 hours (interquartile range, 0.9-5.2 hr) before antimicrobial administration, with a negative predictive value of 93.6%. Antibiotic administration guided by eDENTIFI could have decreased unnecessary IV antibiotic administration in noninfected patients by 10.8% absolute or 46.4% relative percentage points compared with clinicians. eDENTIFI could both decrease the time to antimicrobial administration in infected patients and unnecessary antibiotic administration in noninfected patients. Further prospective validation is needed.

UTILITY OF CONTRAST-ENHANCED T2-FLAIR FOR IMAGING OF BRAIN METASTASESUSING A HALF-DOSE HIGH-RELAXIVITY CONTRAST AGENT IN COMPARISON WITH ROUTINE DOSE CONTRAST-ENHANCED BRAIN IMAGING

Aim &amp; Objectives: This study aims to assess the efficacy of delayed contrast-enhanced T2 fluid-attenuated inversion recovery (CE-T2 FLAIR) by using half dose high relaxivity contrast agent to assess the degree of enhancement among the lesions and to detect additional metastatic brain lesions usually smaller lesions(&lt;5mm), which are significantly missed on routine-dose CE-T1 weighted imaging (CE-T1WI). Material &amp; Methods:The main source of data for this study was radiologically diagnosed lung cancer patients who were clinically suspected to have brain metastasis referred from various departments of Silchar Medical College and Hospital. The studywas carried out for a period of 1 year from March 1, 2023, to February 29, 2024, A total of 40 patients with brain metastases were scanned using a SIEMENS TIM AVANTO 1.5T scanner, routine MR pulse sequences pre- and post-contrast administration were acquired. Results: Out of 40 patients, males were more affected (57.5 %) than females (42.5 %). The highest number of cases were found between the 61-70 years age group with the lung (31 cases) being the most common primary malignancy causing brain metastases. A total of 90 lesions were detected among 40 patients which were grouped into A (25 lesions), B (36 lesions), and C (29 lesions) groups. A total of 6 lesions were missed on Routine dose contrast-enhanced brain imaging of which 2 lesions belong to group B (Rim enhancing lesions &gt;5mm) and 4 lesions belong to group C (Lesions &lt;5mm), however, these lesions were picked up on delayed half dose contrast-enhanced FLAIR images. The contrast ratio (CR) on 3 consecutive half dose CE-T2 FLAIR ranged between 59.09%-76.80%, suggesting that delay in imaging post-contrast administration resulted in a significant increase in the contrast ratio (CR) among metastatic lesions. Conclusions: CE-T1-weighted sequences and CE-T2 FLAIR sequences complement each other effectively in evaluating brain metastases. Bigger and homogenously enhancing lesions are best seen on CE-T1-weighted sequences. Smaller lesions and lesions showing rim enhancement are best visualized on delayed (5 min) CE-T2 fluid-attenuated inversion recovery (FLAIR) sequences with half the dose ofcontrast agent (gadobenatedimeglumine) compared to routine dose CE-T1-weighted sequences. This approach serves as a cost-saving measure for both patients and the healthcare system.

Disability Benefit Reform and Benefit Outcomes: A Re-examination of the Introduction of the UK Personal Independence Payment Using Linked Population Data

ObjectivesMany countries face the problem of how to provide support for additional costs faced by disabled people while restricting disability benefit program growth given tight public finances. In 2013, the UK reformed its main additional costs disability benefit with this objective, changing both medical screening and payment rates with the introduction of the Personal Independence Payment (PIP). This study uses newly available linked administrative population data to examine the impact of this major reform on disability benefit receipt. ApproachWe use the newly available 2011CBI dataset, which links Census records to microdata on benefit receipt for the population of England and Wales from 2011-2015. Difference-in-difference and synthetic control methods are used to estimate the reform impact on the probability of flowing onto disability benefits, exploiting the structure of the roll-out of PIP’s introduction across English regions. ResultsIntroducing PIP led to a sharp fall in the probability of disability benefit onflow, with tentative evidence of a partial reversal in the following year. Further analysis is required to quantify the extent to which this reflects well-known administrative delays in processing applications as opposed to a step change in the probability of claims being successful. ConclusionsThis study is the first to present linked administrative population data estimates of the benefit recipiency effects of the introduction of PIP. In doing so it both contributes to the wider international literature on disability benefit reform and provides an early research application of a significant new administrative dataset for England and Wales.

Advent of oral medications for the treatment of hereditary angioedema.

Hereditary angioedema (HAE) is a rare genetic disorder characterized by unpredictable, debilitating episodes of submucosal and/or subcutaneous tissue swelling, which may be life-threatening depending on anatomic location. The two primary management strategies for HAE are ready access to effective on-demand treatment in all patients and the prevention of attacks (short-term prophylaxis [STP] and long-term prophylaxis [LTP]) in appropriate patients. All approved on-demand and most LTP medications require subcutaneous or intravenous administration. Injection-related challenges include trypanophobia (fear of needles), difficulty with self-administration, injection-site reactions (e.g., pain, erythema, bleeding, bruising), and anxiety-all contributing to poor compliance and administration delays. Oral HAE treatments may improve outcomes by reducing treatment barriers. To review oral therapies, approved or in development, for on-demand treatment and/or prevention of HAE attacks. To provide a comprehensive review, data was obtained from publicly available resources through a targeted PubMed literature review and supplemented by information provided on company websites (search cutoff of May 31, 2024). Berotralstat, an oral plasma kallikrein (PKa) inhibitor, is approved for LTP. Sebetralstat, another PKa inhibitor, is the investigational first oral on-demand HAE treatment to complete a phase 3 trial. Deucrictibant, an oral bradykinin B2 receptor antagonist, has completed phase 2 trials for on-demand therapy and LTP. Several other oral PKa inhibitors (ATN249, VE-4666, and VE-4062) are in early development for LTP. Substantial advances have been made in the development of oral treatments for HAE. These treatments have the potential to improve and optimize clinical outcomes, satisfaction, and quality of life among patients with HAE.

Enhancing estate governance through blockchain: An analysis of transparency, efficiency and security in estate management

This study investigates the impact of blockchain technology on estate governance focusing on enhancing transparency, efficiency and security within the sector. A structured questionnaire using a 5-point Likert scale was distributed to 317 estate management professionals to collect quantitative data which was subsequently analyzed using SmartPLS 4. The results underscore transformative potential of blockchain technology revealing strong correlations between its implementation and improved estate governance outcomes. This study demonstrates how blockchain can significantly enhance estate administration by addressing inefficiencies, bolstering security and fostering greater transparency. The proposed framework for integrating blockchain into estate governance offers a comprehensive strategy to manage frozen estates more effectively, reduce administrative delays and minimize disputes. The study's primary contribution lies in its innovative application of blockchain technology to solve prevalent issues in estate management providing a strategic blueprint for future implementations. This study offers actionable insights and practical recommendations for estate management stakeholders emphasizing the critical role of blockchain in ensuring more efficient, transparent and secured governance practices. This study highlights the profound impact blockchain can have on modernizing estate management practices and establishing robust governance frameworks by thoroughly examining the dimensions of transparency, efficiency, and security. This study concludes by advocating for the adoption of blockchain technology to enhance estate governance effectiveness and improve overall management outcomes.

Association between skeletal muscle mass and treatment response in patients with diffuse large B-cell lymphoma

Previous studies have demonstrated that a low skeletal muscle mass (SMM) is an adverse factor for overall survival (OS) in diffuse large B-cell lymphoma (DLBCL). However, its association with the treatment response has not been extensively investigated. This study aimed to determine the association between low skeletal muscle mass (SMM) and treatment response in DLBCL patients. We conducted a retrospective cohort study of 123 patients with DLBCL, in whom SMM was assessed using computed tomography before chemotherapy administration. The demographic characteristics of the patients with low SMM and those with normal SMM were not statistically different. However, there were notable differences in weight and BMI; patients with low SMM had a lower mean weight (59.2 vs 63, p = 0.002) and a higher proportion of patients with normal BMI (61.5% vs. 21.1%, p < 0.001). In addition, patients with low SMM were more likely to receive R-CHOP-like treatment (21.2% vs. 7%, p = 0.022) and experienced more delays in administration (42.9% vs. 33.3%, p = 0.452). Low SMM was not associated with failure to achieve CR (HR 1.9; 95% CI [0.9–4.1] p = 0.84), but it was reported to risk OS in univariate analysis (HR 2.1; 95% CI [1.03–4.2], p = 0.041). An interesting result was the interaction of low SMM with hypertension as a risk factor for not achieving CR (HR 2.7; 95% CI [1.1–6.5] p = 0.034) or OS (HR 7.9; 95% CI [3.4–18.8] p < 0.001). Low SMM was not a risk factor for achieving CR in patients with DLBCL and seemed to play a role in OS.

Early Vasopressor Requirement Among Hypotensive Trauma Patients: Does It Cause More Harm Than Good?

Optimal utilization of vasopressors during early post-injury resuscitation remains unclear. Our study aims to describe the relationship between the timing of vasopressor administration and outcomes among hypotensive trauma patients. This was a retrospective analysis of the 2017-2018 ACS-TQIP database. We included adult (≥18years) trauma patients presenting with hypotension (lowest SBP <90mmHg) who received vasopressors within 6hours of admission. We excluded patients who had a severe head injury (Head-AIS >3) and those with spinal cord injury (Spine-AIS >3). Patients were stratified based on the time to receive vasopressors. Multivariable regression analyses were performed to identify the independent association between timing of vasopressor initiation and outcomes. 1049 patients were identified. Mean age was 55 ± 20years, and 70% of patients were male. The median ISS was 16 [9-24], 80% had a blunt injury, and the mean SBP was 61 ± 24mmHg. The median time to first vasopressor administration was 319 [68-352] minutes. Overall, 24-hour and in-hospital mortality rates were 19% and 33%, respectively. Every one-hour delay in vasopressor administration beyond the first hour was independently associated with decreased odds of 24-hour mortality (aOR: 0.65, P < 0.001), in-hospital mortality (aOR: 0.65, P < 0.001), major complications (aOR: 0.77, P = 0.003), and increased odds of longer ICU LOS (β + 2.53, P = 0.012). There were no associations between the timing of early vasopressor administration and 24-hour PRBC transfusion requirements (P > 0.05). Earlier vasopressor requirement among hypotensive trauma patients was independently associated with increased mortality and major complications. Further research on the utility and optimal timing of vasopressors during the post-injury resuscitative period is warranted. III therapeutic/care management.

Efficacy and outcomes of BCG re-vaccination in COVID-19: a systematic review, meta-analysis, and meta-regression of randomized controlled trials.

The Bacillus Calmette-Guerin (BCG) vaccine has a beneficial "off-target" effect that offers heterologous protection against respiratory tract infections by inducing trained immunity. The need for producing antigen-specific COVID-19 vaccines leads to delays in vaccine administration. Current randomized controlled trials (RCTs) report conflicting data on BCG's efficacy in COVID-19 infection. A comprehensive literature search was conducted using major bibliographic databases to identify RCTs evaluating the outcomes of BCG re-vaccination in COVID-19. For dichotomous outcomes, odds ratios (ORs) with 95% CIs were pooled using the DerSimonian-Laird random-effects model. Statistical significance was set at P less than 0.05. Thirteen RCTs with 13939 participants (7004 in the BCG re-vaccination group and 6935 in the placebo group) were included. BCG re-vaccination did not lead to a statistically significant difference in the incidence of COVID-19 infection [OR: 1.04; 95% CI: 0.91, 1.19; P=0.56], COVID-19-related hospitalizations [OR: 0.81; 95% CI: 0.38, 1.72; P=0.58), ICU admissions [OR: 0.43; 95% CI: 0.13, 1.46; P=0.18], or mortality [OR: 0.67; 95% CI 0.15, 3.04; P=0.60]. For safety outcomes, BCG re-vaccination led to a significant increase in the local injection site complications [OR: 99.79; 95% CI: 31.04, 320.80; P<0.00001], however, the risk of serious adverse events was similar [OR: 1.19; 95% CI: 0.84, 1.67; P=0.33]. BCG re-vaccination does not decrease the incidence of COVID-19 infection, COVID-19-related hospitalizations, ICU admissions, COVID-19-related mortality, and serious adverse events; however, it leads to a rise in local injection site complications. Caution should be exercised when overstating BCG's efficacy in COVID-19 prevention.

Implementation of hospital electronic medical record Patient Friendly Medication Lists and Interim Medication Administration Charts

AbstractPatients discharged from Australian hospitals require a list of current medications at the point of discharge, which is commonly in the form of a Patient Friendly Medication List (PFML). Furthermore, the provision of an Interim Medication Administration Chart (IMAC) reduces the number of medication administration delays and omissions for patients discharged to residential aged‐care facilities. To increase the adoption of PFMLs and IMACs, a new process was developed for creating PFMLs and IMACs directly from the discharge prescription in the Electronic Medical Record (EMR). This retrospective pre‐ and post‐intervention audit aimed to evaluate 1 year of PFML and IMAC generation from three acute metropolitan hospitals, prior to and after transitioning from pharmacy dispensing software to EMR‐generated documents. Despite similar hospital activity, the transition to EMR‐generated PFMLs and IMACs was associated with a 157% increase in PFML provision (7930 vs 20 373), a 220% increase in IMAC provision (1569 vs 5022) and a 99% reduction in the number of items typed into the pharmacy dispensing software that did not require supply (−59 171/year). Discharge dispensary turnaround times were lower in the post‐intervention period (36 min vs 30 min, p &lt; 0.01). In conclusion, the transition to EMR‐generated PFMLs and IMACs was associated with increased provision of these documents, reduced data entry for items not required to be supplied, decreased risk of transcription errors and shortened time taken for the hospital pharmacy to process discharge items. This project was exempt due to the local policy requirements that constitute research by the Eastern Health Office of Research and Ethics (Reference no: QA21‐094). The justification for this ethics exemption was as follows: the project complies with the National Health and Medical Research Council's Ethical considerations in quality assurance and evaluation activities and met local requirements for an audit or quality assurance activity.

Cytoprotective agents in stroke: Still uncertainty in the next frontier

IntroductionDespite substantial improvement of acute ischemic stroke (AIS) care with the advent of extended time windows for intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT), a substantial portion of patients still suffer poor outcomes. Additional adjuvant therapies are needed but pharmacologic interactions among therapies may dictate how they could be used. We conducted a survey to determine physician decision-making regarding the use of cytoprotective agents in patients presenting with AIS. MethodsThe survey was structured, web-based, anonymous, and invite-only among physicians across the world treating patients presenting with AIS. Respondents were asked about the use of a hypothetical cytoprotective agent (that provided an added 10% benefit) in the context of a treatment interaction with IVT or its timing in relation to IVT. ResultsA total of 282 stroke physicians (74.9% males, mean age 46 years) participated in the survey. When the respondent could give both the cytoprotective agent and IVT with no treatment interaction, 177 (78.0%) chose to administer both. In the presence of treatment interaction, 88 (38.3%) would withhold IVT, 83 (36.1%) would withhold the cytoprotective agent and 56 (24.4%) were uncertain. Lastly, 111 (48.9%) were willing to administer the cytoprotective agent if it meant a necessary 10-minute delay in IVT administration. ConclusionsPharmacologic interactions result in major uncertainty about cytoprotective treatment choices.

Exploring factors influencing delayed first antibiotic treatment for suspected early-onset sepsis in preterm newborns: a study before quality improvement initiative

BackgroundEarly-onset sepsis (EOS) is a serious illness that affects preterm newborns, and delayed antibiotic initiation may increase the risk of adverse outcomes.PurposeThe objective of this study was to examine the present time of antibiotic administration in preterm infants with suspected EOS and the factors that contribute to delayed antibiotic initiation.MethodsIn this retrospective study in China, a total of 82 early preterm infants with suspected EOS between December 2021 and March 2023 were included. The study utilized a linear regression analytical approach to identify independent factors that contribute to delayed antibiotic administration.ResultsThe mean gestational age and birth weight of the study population were 29.1 ± 1.4 weeks and 1265.7 ± 176.8 g, respectively. The median time of initial antibiotic administration was 3.8 (3.1-5.0) hours. Linear regression revealed that severe respiratory distress syndrome (RDS) (β = 0.07, P = 0.013), penicillin skin test (PST) timing (β = 0.06, P < 0.001) and medical order timing (β = 0.04, P = 0.017) were significantly associated with the initial timing of antibiotic administration.ConclusionsThere is an evident delay in antibiotic administration in preterm infants with suspected EOS in our unit. Severe RDS, PST postponement and delayed medical orders were found to be associated with the delayed use of antibiotics, which will be helpful for quality improvement efforts in the neonatal intensive care unit (NICU).

Delays to Antibiotics in the Emergency Department and Risk of Mortality in Children With Sepsis

Pediatric consensus guidelines recommend antibiotic administration within 1 hour for septic shock and within 3 hours for sepsis without shock. Limited studies exist identifying a specific time past which delays in antibiotic administration are associated with worse outcomes. To determine a time point for antibiotic administration that is associated with increased risk of mortality among pediatric patients with sepsis. This retrospective cohort study used data from 51 US children's hospitals in the Improving Pediatric Sepsis Outcomes collaborative. Participants included patients aged 29 days to less than 18 years with sepsis recognized within 1 hour of emergency department arrival, from January 1, 2017, through December 31, 2021. Piecewise regression was used to identify the inflection point for sepsis-attributable 3-day mortality, and logistic regression was used to evaluate odds of sepsis-attributable mortality after adjustment for potential confounders. Data analysis was performed from March 2022 to February 2024. The number of minutes from emergency department arrival to antibiotic administration. The primary outcome was sepsis-attributable 3-day mortality. Sepsis-attributable 30-day mortality was a secondary outcome. A total of 19 515 cases (median [IQR] age, 6 [2-12] years) were included. The median (IQR) time to antibiotic administration was 69 (47-116) minutes. The estimated time to antibiotic administration at which 3-day sepsis-attributable mortality increased was 330 minutes. Patients who received an antibiotic in less than 330 minutes (19 164 patients) had sepsis-attributable 3-day mortality of 0.5% (93 patients) and 30-day mortality of 0.9% (163 patients). Patients who received antibiotics at 330 minutes or later (351 patients) had 3-day sepsis-attributable mortality of 1.2% (4 patients), 30-day mortality of 2.0% (7 patients), and increased adjusted odds of mortality at both 3 days (odds ratio, 3.44; 95% CI, 1.20-9.93; P = .02) and 30 days (odds ratio, 3.63; 95% CI, 1.59-8.30; P = .002) compared with those who received antibiotics within 330 minutes. In this cohort of pediatric patients with sepsis, 3-day and 30-day sepsis-attributable mortality increased with delays in antibiotic administration 330 minutes or longer from emergency department arrival. These findings are consistent with the literature demonstrating increased pediatric sepsis mortality associated with antibiotic administration delay. To guide the balance of appropriate resource allocation with time for adequate diagnostic evaluation, further research is needed into whether there are subpopulations, such as those with shock or bacteremia, that may benefit from earlier antibiotics.

Safety and efficacy of peripheral metaraminol infusion in patients with neurological conditions: a single-center retrospective observational study.

Metaraminol is a sympathomimetic amine vasopressor that can be administrated through a peripheral venous access. However, limited evidence restricts its application in critically ill patients. This study aimed to investigate the safety and efficacy of peripheral metaraminol infusion in patients with neurological conditions. Patients who received peripheral metaraminol infusion between May 2019 and April 2022 were recruited. Data on baseline characteristics, clinical parameters, and infusion-related complications were retrospectively collected and analyzed. 273 patients who received metaraminol were enrolled. Of these, 35 (12.8%) patients required central venous catheter insertion due to inability in achieving hemodynamic stability following peripheral metaraminol monotherapy. In 29,574.2 hours of vasopressor infusion, metaraminol infusion resulted achievement of the target blood pressure 73.4% of the time. Meanwhile, adverse events occurred in 5 patients and resolved after local tissue treatment. Metaraminol could provide hemodynamic support and avoid complications associated with a central venous catheter and delay in vasopressor administration. Through careful and close monitoring, peripheral metaraminol infusion is safe and feasible for patients with neurological conditions. Future large-scale, prospective, multicenter studies are needed to evaluate the safety and efficacy of metaraminol infusion through a peripheral intravenous catheter.

Isolated injury, Charlson Comorbidity Index, and transfer from another facility are associated with delay in antibiotic administration: a retrospective study of 963 patients with open fractures.

To identify factors associated with delays in administration and pharmacy and nursing preparation of antibiotics for patients with open fractures. Retrospective review. Level I trauma center. Nine hundred sixty-three adults with open fractures administered antibiotics. Delay in antibiotic administration greater than 66 minutes from arrival and significant pharmacy-related and nursing-related delay. Isolated injury, Charlson Comorbidity Index, and transfer from another facility were associated with delay in antibiotic administration greater than 66 minutes. Injury Severity Score, transfer, and trauma team activation were associated with pharmacy-related or nursing-related delay. Interventions to reduce antibiotic administration time for open fractures should focus on early identification of open fractures and standardization of antibiotic protocols to ensure timely administration even in complex or resource-scarce care situations. Prognostic level III.