Illinois Hospital Research Articles

A novel auditing procedure for an oral chemotherapy process improvement project.

164 Background: A process to standardize ordering, documentation, and administration of inpatient oral chemotherapy was implemented at the University of Illinois Hospital and Health Sciences System. The process requires oncology clinician review and endorsement of inpatient oral chemotherapy drug orders via an oral chemotherapy note within the electronic health record. Pharmacists are instructed to reject oral chemotherapy drug orders that lack this required documentation. A novel auditing procedure was established in order to track adherence to these new requirements and provide real time and adaptable feedback to front-line staff critical to the project’s success. Methods: To support continuous quality improvement (QI) with this project, an auditing tool was developed in REDCap, a secure, web-based data management application. The auditing tool was originally developed as a traditional web-based data collection instrument with the primary purpose of tracking performance. By utilizing more advanced features offered by the REDCap platform, the auditing tool generated automated follow-up surveys to pharmacists involved in non-adherent outlier cases. The survey solicited information on the root cause of non-adherence, and based on the end-user response, provided adaptable continuing education tailored to this root cause. Results: Between June and September 2015, a total of 67 orders for oral chemotherapy were audited. Compliance with process improvement requirements was noted in 58%, 100%, 78%, and 93% of cases in June, July, August, and September, respectively. Outlier surveys were sent to 12 pharmacists in the non-adherent cases; of 11 responses, the most common response reflected an unfamiliarity with the process. Following targeted education, through September 2015, no single pharmacist has been involved in more than one non-adherent case. Conclusions: The novel auditing tool supported the continuous quality improvement process by engaging front-line staff, generating automated and real time surveys for outlier responses, and providing targeted and personalized education aimed at resolving the root cause in non-adherent cases. As such, it can be applied towards any REDCap QI projects.

Does Bariatric Surgery Improve Renal Function?

Introduction: Obesity is a health problem that is reaching epidemic proportions. The risk of developing chronic kidney disease (CKD) is higher in obese patients. Decreasing weight could translate into an improvement in renal function. In addition, renal function can be improved by the resolution of hypertension and diabetes. The main objective of this study is to analyze renal function in obese patients undergoing sleeve gastrectomy (SG). Material and Methods: This study is a nonrandomized, controlled retrospective review of 223 patients who underwent a minimally invasive SG at the University of Illinois Hospital and Health System between January 2008 and December 2013. In patients with CKD, renal function parameters were measured preoperatively and at 6 months postoperatively. Renal function was evaluated by GFR that was estimated using the creatinine clearance (CrCl) according to the Cockcroft–Gault (CG) equation. Statistical analysis was performed using Student's t test for continuous paired data. Resu...

Abstracts from ATTD 2016 9th International Conference on Advanced Technologies & Treatments for Diabetes Milan, Italy-February 3-6, 2016.

Abstracts from ATTD 2016 9th International Conference on Advanced Technologies & Treatments for Diabetes Milan, Italy-February 3-6, 2016.

Abstract TMP82: Community Education-Impact of Knowing Your Sign

Stroke remains one of the leading causes of death and disability in the United States. Even with increased community education on stroke, the most common reason for delay in seeking medical attention is lack of recognition of the signs, symptoms and time sensitivity of stroke treatment. It is compelling to see the amount of patients that do not present for emergency treatment within three hours of symptom onset. This lack of awareness and delay in arrival was found to contribute to decreased candidacy for stroke treatment and leads to increased chances of disability. The critical need for community partnerships specifically aimed at educating on recognition of stroke signs, symptoms and treatment options was identified. The goal of this project was to demonstrate the correlation between community education and decreasing symptom onset to door time. Method: This retrospective study performed at a Central Illinois hospital reviewed data including symptom onset to door times from January 2014 to March 2015 as one method of determining the effectiveness of community education. Intervention time frames were held between April 2014 to December 2014 with a 3 month pre and post intervention phase. Inclusion criteria: any stroke code that presented through triage or via EMS. Exclusion criteria: in house stroke codes and symptom onset that was unknown. Results: In the first quarter of 2014, the average time it took patients to present to the Emergency Department from symptom onset was 233 minutes. Post-implementation data revealed the average symptom onset to door time was 63 minutes which accounts for a nearly 73% decrease in arrival time. Conclusion: Over 20 Community Education sessions on stroke signs, symptoms and the importance of seeking prompt medical attention were held over a nine month period. This community education on stroke was effective because there was a decrease in stroke symptom onset to the Emergency Department which created more eligible patients to receive emergency stroke treatment. This study validated that by providing intense community education aimed at the recognition of stroke signs, symptoms and treatment options, more patients were eligible to receive emergent stroke treatment because the arrival time was drastically shortened.

Using design methods to provide the care that people want and need.

Kim Erwin is an Assistant Professor at IIT Institute of Design and trained in user-centered design methods, which put people at the center of any problem space so as to develop solutions that better fit their everyday lives, activities and context. Her expertise is in making complex information easier to understand and use. Her research targets communication tools and methods for collaborative knowledge construction built through shared experiences. Her book, Communicating the New: Methods to shape and accelerate innovation focuses on helping teams explore, build and diffuse critical knowledge inside organizations. Jerry Krishnan is a Professor of Medicine and Public Health, and Associate Vice President for Population Health Sciences at the University of Illinois Hospital & Health Sciences System. He pioneered the use of Analytic Hierarchy Process to elicit the expressed needs of stakeholders for research. He previously served as Chair of the US FDA Pulmonary and Allergy Drugs Advisory Committee and is a Principal Investigator in NIH and Patient Centered Outcomes Research Institute (PCORI)-funded research consortia. He chairs the US National Heart, Lung, and Blood Institute (NHLBI) Clinical Trials review committee and the PCORI Improving Healthcare Systems merit review panel.

Epidemiology of Carbapenem-Resistant Enterobacteriaceae Infection and Colonization at the University of Illinois Hospital in Chicago, Illinois

Epidemiology of Carbapenem-Resistant Enterobacteriaceae Infection and Colonization at the University of Illinois Hospital in Chicago, Illinois

AIDS-Related Vs. Non-AIDS-Related Diffuse Large B-Cell Lymphoma. Analysis of the County Hospital AIDS Malignancy Project (CHAMP)

Introduction: Stroger Hospital of Cook County (CCH) and the Ruth M. Rothstein CORE Center (CC) are the largest health providers for HIV+ patients (pts) in Chicago and among the largest in the United States. Together, CCH and CC treat over 5,500 HIV+ individuals per year and 60 newly diagnosed HIV-associated cancers yearly. In addition, CCH is the largest safety net hospital in Illinois; in the calendar year 2010, it had over 32,000 outpatient hematology/oncology clinic visits. The County Hospital AIDS malignancy project (CHAMP) is a prospective database of all HIV-associated hematological malignancies from 1995 to present. Here we analyzed the demographic, histological, germinal center status, outcome data, and HIV characteristics of pts with AIDS-related diffuse large B-cell lymphoma (AR-DLBCL). As a control, we compared these data to DLBCL pts not infected with HIV, intra-institutionally instead of national historical controls to better understand the AR-DLBCL population of the inner-city, a mostly minority, and one of the largest growing HIV populations.Methods: We screened the CCH cancer registry from 2001 to 2014, and 240 non-HIV pts were identified to have DLBCL. We searched the CHAMP database for cases of DLBCL from the same period. From 196 lymphomas, 51 were identified. Only pts who had a confirmed pathology report as DLBCL were included in this study. We subsequently identified the HIV characteristics, overall survival (OS), and patient demographics for all pts. In addition to OS data in both cohorts, we compared outcomes based on chemotherapy, stage, germinal center (defined by the HANS algorithm), and IPI status.Statistics: Non-parametric Fisher's exact test was used to examine the difference in proportion of pts in both the HIV and non-HIV arm. Survival data were analyzed using Kaplan-Meier analysis and Cox Proportional Hazards model.Results: The M:F ratio was 7.5:1 in AR-DLBCL and 1.9:1 in the non-HIV cohort (P<0.001). The median CD4+ count for the HIV population was 107 cells/mm3. Patients with germinal center DLBCL had a median CD4+ count of 196 cells/mm3 vs. non-germinal of 87 cells/mm3. The racial composition of the 2 cohorts showed a significantly higher percentage of African-Americans (AA) in the HIV cohort, 51% vs. 35% in the non-HIV, (p<0.04) and no difference in Caucasian or Hispanic populations. The AR-DLBCL population was younger. Only 4% of the HIV pts were 60 years and older compared to 32% in the non-HIV cohort. The HIV positive pts tended to present with more advanced disease. Seventy two % vs. 53% in the non-HIV cohort presented with stage III/IV disease (p <0.01). Only 18% vs. 38% in the non-HIV cohort presented with stage I/II disease (p <0.006). Of pts tested, there were no differences in GC (68 (n=15) vs. 66% (n=77) or NGC (32 (n=7) vs. 34% (n=39)) between HIV and non-HIV cohorts. The OS of the AR-DLBCL at 5 years was 54% vs. 77% in the non-HIV cohort (p<0.003). However, since 2009, pts with AR-DLBCL have been treated with daEPOCHR (Sparano et al, Blood 2010) at CCH, and since then no difference in OS compared to the non-HIV cohort has been identified. At 5 year follow up, the OS of AR-DLBCL was 81% treated with daEPOCHR (n=11) vs. 77% (n=108) in the non-HIV population (p 0.081). Comparing survival between each cohort by stage there was a trend to poorer outcomes in the AR-DLBCL for stage III/IV disease, 58% vs. 75% 5-year survival (p 0.064). Similarly, there was little difference in comparing each cohort by IPI score due to the small number of pts in each IPI category in the HIV cohort.Conclusions: In assessing the cases of AR-DLBCL, it appears to be a disease of AA (51% vs. 35%) men (88% vs. 53%) compared to the non-HIV population at the same institution. But when compared to the general population of Chicago, where AA constitute only 33% of the population, the disparity is more pronounced. Patients are also younger, 4% vs. 32% over 60 years of age. In addition, the AR-DLBCL pts present with more advanced disease (72% vs. 53%). As a whole, the AR-DLBCL cohort had a poorer OS survival than the non-HIV population, at 5 years, 54% vs. 77%. Importantly, pts with AR-DLBCL had the same OS as the non-HIV cohort, 81% vs. 77%, with a 5 year follow up when treated with daEPOCHR despite HIV pts presenting with a higher stage. Thus, education and screening in the AA community is needed, as this is an AA male disease in the inner city. It is also clear that treatment with daEPOCHR should be the therapy of choice when treating AR-DLBCL. DisclosuresNo relevant conflicts of interest to declare.

Chronic Opioid Use Pattern in Adult Patients with Sickle Cell Disease

Background: Pain, the hallmark complication of sickle cell disease (SCD), is largely managed with opioid analgesics in the United States (1, 2). There is a common perception that SCD patients tend to use high dose of opioids chronically (3, 4), but comprehensive data regarding the long-term use of opioids in this patient population is lacking.Methods: A cohort of 359 adults (age ≥ 18 years old) with the diagnosis of SCD followed at University of Illinois Hospital in FY 2010-2013 was enrolled in a prospective natural history study. An outpatient clinic visit with comprehensive laboratory closest to the enrollment date was selected as the focal point of this report. A total of 140 patients had consistent outpatient follow-up defined as ³4 visits between 6 months prior to and 6 months after this clinic visit (the study period). Pain medication prescribing records, number of hospital admissions, and other clinical variables during the study period were collected and evaluated with descriptive statistics and Spearman correlation.Results: Among the 140 patients analyzed, 74% took short-acting opioid medications and 31% took long-acting opioid medications (Table 1). The median daily opioid dose was 4.8 mg oral morphine equivalents (OME) with an interquartile range (IQR) of 0 to 14.7 mg. Sixty-six percent of patients used less than 10 mg OME daily whereas 11% used more than 50 mg OME daily (Figure 1). Among the short-acting opioids, acetaminophen-hydrocodone was the most commonly used medication (34% of patients) followed by immediate-release morphine (23%) and acetaminophen-codeine (20%) (Table 2). Extended-release morphine was used by 24% of the patients. Twelve patients (8.6%) were prescribed with nonsteroidal anti-inflammatory drugs (NSAIDs), and 16% used medications treating neuropathic pain. The Spearman correlation test with Bonferroni correction showed that the dose of opioid usage was significantly associated with the number of hospital admissions due to vaso-occlusive crisis (VOC) (p<0.0001) (Table 3). Hydroxyurea use, hemoglobin genotype, history of avascular necrosis (AVN) and 25-OHD levels did not correlate with opioid dose.Summary: The doses and types of opioid medications used by adult SCD patients vary widely. The majority of patients use a relatively low dose (<10 mg OME daily). The dose of chronic opioid use has a strong correlation with the frequency of hospital admissions due to VOC, demonstrating the necessity of finding an alternative pain management approach in treating sickle cell pain.1. L. R. Solomon, J Natl Med Assoc102, 1025 (Nov, 2010).2. P. Tanabe, Z. Martinovich, B. Buckley, A. Schmelzer, J. A. Paice, J Emerg Nurs41, 227 (May, 2015).3. W. T. Zempsky, JAMA302, 2479 (Dec 9, 2009).4. B. S. Shapiro, L. J. Benjamin, R. Payne, G. Heidrich, J Pain Symptom Manage14, 168 (Sep, 1997).The relative frequency = the number of patients taking certain dose of opioids/total number of patients. [Display omitted] [Display omitted] [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Another Frontier in Microbiome Research: Preterm Birth

After Elise and Todd Jackson’s son, Elijah, was born 14 weeks prematurely in 2002, he spent 7 months in the neonatal intensive care unit at Rockford Memorial Hospital in north central Illinois. Although Elijah is now an active and healthy 12-year-old, because of medical problems stemming from his prematurity, as an infant he was given a feeding tube, underwent surgery to close the duct between his pulmonary artery and aorta, and needed a tracheotomy to help him breathe. “I literallymoved toRockford tobewith him,” said Elise Jackson, whose home is 45 miles away in Elgin, Illinois. “I didn’t want to leave his bedside.” The exact cause of Elijah Jackson’s preterm birth was never determined, as is often the case with premature infants. Some well-known links with prematurity include urinary tract and vaginal infections, preeclampsia, diabetes, and conception using assisted reproductive technologies. But in a recent study, researchers at the March of Dimes Prematurity Research Center at Stanford University explored a lesser-known frontier: the relationship between preterm birth and the microbial composition of the vagina and other sites in the body. Finding new ways to prevent premature birth could help improve a somewhat embarrassing statistic: at 12%, the United States has a higher rate of preterm births than Canada, Mexico, Europe, and most Latin American countries (http://bit.ly /1x6idvM). One of 9 babies were born prematurely in the United States in 2012, according to the Centers for Disease Control and Prevention (CDC), and preterm birth, defined as birth occurring before 37 weeks of pregnancy, is the leading cause of death and long-termneurologicaldisabilities for infants (http://1.usa.gov/1yeRSuE).

A5164 - Preoperative Outcomes and Weight Loss in Super-Super Obese Male Patients

Introduction: Body Mass Index (BMI) is an independent predictor of overall mortality and risk of vascular disease. In the U.S., obesity (BMI 440) rates are 32.6% among males and 36.2% among females. Bariatric surgery is associated with weight loss and the reduction of certain medical comorbidities in obese adult patients However, there is limited literature regarding male sex as a predictor of periand post-operative outcomes in super-super obese patients who underwent bariatric surgery. The aim of this study was to examine whether male sex predicts pre-surgical comorbidities, perioperative outcomes and % excess weight loss in super-super obese patients who underwent bariatric surgery. Material and Methods: This study was a nonrandomized, controlled, retrospective review of 750 patients who underwent sleeve gastrectomy (SG) or Roux-en-Y Gastric Bypass (RYGB) surgery at the University of Illinois Hospital and Health Sciences System from January 2008 to June 2014. From this group, 89 SSO patients were selected for inclusion in this study. Patients were divided into two groups (male/female) based on sex. Patient demographics, pre-surgical comorbidities, perioperative outcomes, post-operative complications (leak and conversions to open surgery), operating time, length of hospitalization, and percent excess weight loss (% EWL) at 6, 12 and 24 months were examined. Results: Out of 89 super-super obese patients, 19.1% (n1⁄417) patients were male and 81.9% (n1⁄462) were female. In males, 52.9% (n1⁄49) were African-American, 41.2% (n1⁄47) were Caucasian, and 5.8% (n1⁄41) were Hispanic (po.05). All male patients underwent SG. There were no significant sex differences in presurgical comorbidities, length of hospitalization, or post-operative complications (1 vs. 0) between males and females, respectively. Perioperative parameters showed operative time was longer in males versus females (po.05). Percent excess weight loss at 6 months was 24.2% vs. 32.7%, (n.s.), 34.3% vs. 47.9% at 12 months (po.05) and 35.3% vs. 52.7% at 24 months (n.s.) followup for males and females respectively. Conclusions: Male sex predicted longer operative time and lower % excess weight loss at 6 months. A larger sample size with longer follow up is warranted in order to further understand reasons for the sex differences in these variables in order to improve weight loss outcomes in both males and females.

Utilization of Spontaneous Awakening Trials in Mechanically Ventilated Patients

SESSION TITLE: Mechanical Ventilation and Respiratory Failure Posters SESSION TYPE: Original Investigation Poster PRESENTED ON: Wednesday, October 28, 2015 at 01:30 PM - 02:30 PM PURPOSE: The purpose of this study is to establish current duration of time from intubation to first spontaneous awakening trial (SAT) and variables that may be associated with decreased likelihood of implementation of this intervention. These results will inform a clinical trial designed to increase adherence to daily spontaneous awakening and spontaneous breathing trials in patients with acute respiratory failure. METHODS: Patients from Northwestern Memorial Hospital (NMH), a tertiary academic medical center in Chicago, Illinois, and Northwestern Lake Forest Hospital, a community hospital affiliated with NMH located in an affluent suburb of Chicago, were included. Patients were excluded if they were less than 18 years of age at intubation, on the ventilator less than 12 hours, had a tracheostomy at time of hospital admission, suffered cardiac arrest immediately prior to or during their admission, were transitioned to comfort-focused care, or were managed on continuous intravenous sedation for alcohol withdrawal or delirium tremens. Based on power calculations, we collected data from the first 377 patients who were intubated in the intensive care units and met our inclusion criteria from June 23, 2013, to October 11, 2013. RESULTS: In our sample, mean age at intubation was 60.6 years, 153 (40.6%) were women, and 214 (56.8%) self-identified as white or Caucasian, 100 (26.5%) as black or African-American. Out of the 377 patients included in the analysis, 39 (10.3%) were never started on sedative infusions and of those who were started on infusions of sedatives (narcotics, benzodiazepines, and/or propofol), median time to first SAT (defined as at least 4 hours off all sedative infusions) was 40.6 hours. Of the patients started on sedative infusions, 270 (79.9%) did not receive an SAT within the first 24 hours of intubation. CONCLUSIONS: Median time to first SAT was substantially longer than recommended by most professional organizations and only a small number of patients had an SAT within the first 24 hours of intubation. CLINICAL IMPLICATIONS: Daily SATs are associated with reduced duration of mechanical ventilation and intensive care unit stay, and this data gives us evidence that adherence to this best practice is low and helps inform the design of a novel intervention to improve these rates. DISCLOSURE: The following authors have nothing to disclose: Margaret Ragland, Shayna Weiner, Curtis Weiss No Product/Research Disclosure Information

Are Hospital Surgical Quality Teams Well Versed in Carrying out Quality and Process Improvement Initiatives: A Baseline Assessment of Quality Improvement Knowledge at 55 Illinois Hospitals

Berger, Elizabeth R. MD; O’Leary, Kevin J. MD; Johnson, Julie K. MSPH, PhD; Reinhart, Stephen P. MBA; Farrell, Paula R. RN; Yang, Anthony D. MD, FACS; Barsness, Katherine A. MD, FACS; Halverson, Amy L. MD, FACS; Thomas, Juliana M. MPH; Bilimoria, Karl Y. MD, FACS Author Information

Accumetrics-based clopidogrel dosing in endovascular neurosurgery

Introduction:The role of the VerifyNow test to guide clopidogrel therapy in neurosurgical patients is still unclear. This study compared outcomes in patients undergoing neurointerventional procedures on either standard clopidogrel or tailored clopidogrel regimens.Methods:Adult patients undergoing neurointerventional procedures from 1 May 2002 to 31 December 2012 at the University of Illinois Hospital and Health Sciences System were included if they were receiving dual antiplatelet therapy (DAPT) for their procedure. Patients were categorised based on the use of VerifyNow to guide therapy. The primary endpoint was the incidence of thromboembolic complications within 6 months post procedure. Secondary endpoints included the incidence of haemorrhagic complications and death. P2Y12 reaction units (PRU) were recorded when available and categorised based on relation to procedures and/or events.Results:A total of 228 patients were screened with 130 meeting inclusion criteria. Ninety patients were grouped into the standard therapy arm and 30 patients into the tailored therapy arm. There were no differences in the incidence of ischaemic complications (1.1 vs 2.5%, P = 0.522), haemorrhagic complications (17.8 vs 15.0%, P = 0.455) or death (3.0 vs 0%, P = 0.552). Seventeen of 32 patients (53.1%) with PRUs were clopidogrel resistant defined as a PRU >180.Discussion:Use of the VerifyNow test to guide clopidogrel therapy in patients undergoing neurointerventional procedures did not result in a decrease in the incidence of thromboembolic complications compared to standard therapy. There was no difference in the incidence of haemorrhagic complications or death. Further studies are needed to evaluate the impact of tailored therapy using VerifyNow.

Sleep Patterns During Hospitalization Following Hematopoietic Stem Cell Transplantation.

To characterize patient-reported and objective sleep assessments and provide a preliminary examination of the relationships among sleep, quality of life, and demographic or treatment factors. A secondary data analysis using a descriptive-correlational design. University of Illinois Hospital and Health Sciences System. 40 patients undergoing a hematopoietic stem cell transplantation (HCT) hospitalized for the conditioning regimen, stem cell infusion, and immediate recovery period. Each patient wore a wrist actigraph continuously from the fourth day following HCT to the eighth day to objectively assess sleep patterns (total sleep time, sleep onset latency, sleep efficiency, wake after sleep onset, and number of awakenings). At the end of the five-day period, patients completed measures of sleep disturbance and quality of life. Objective sleep (total sleep time, sleep onset latency, sleep efficiency, wake after sleep onset, and number of awakenings), subjective sleep (sleep disturbance), and quality of life. The mean total nighttime sleep (objectively obtained) was 232 minutes (SD = 71 minutes), with 14 patients (35%) sleeping less than three consecutive hours during one or more study days. Age was negatively correlated with patient-reported sleep disturbance. Patient-reported sleep disturbance was significantly associated with length of hospital stay. No correlations were found between patient-reported and objective sleep assessments. This study objectively documents inadequate and irregular sleep in hospitalized patients undergoing HCT. Sole reliance on patient-reported sleep assessments may not represent the full extent of the problem. Attempts to streamline care during the night by not waking patients for routine care unless indicated by the patient's condition (as advocated by the American Academy of Nursing) and providing supportive care for symptoms (such as diarrhea) during the night may reduce the number of awakenings and possibly improve overall sleep quality.

Pediatric emergency department visits and hospitalizations due to food-induced anaphylaxis in Illinois

BackgroundRates of food-induced anaphylaxis among children remain uncertain. In addition, little is known about the demographics of children who have experienced food-induced anaphylaxis resulting in emergency department (ED) visits and/or subsequent hospitalizations. ObjectivesTo evaluate trends in ED visits and hospital admissions due to food-induced anaphylaxis among Illinois children and to identify socioeconomic variation in trend distribution. MethodsIllinois hospital discharge data compiled by the Illinois Hospital Association were used to identify ED visits or hospitalizations for food-induced anaphylaxis in Illinois hospitals from 2008-2012. Data for children aged 0 to 19 years who were Illinois residents and received a diagnosis of food-induced anaphylaxis based on International Classification of Diseases, Ninth Revision, Clinical Modification codes (995.60 through 995.69) were included for analysis. ResultsThere was a significant increase in the rate of ED visits and hospital admissions due to food-induced anaphylaxis among children in Illinois during the 5-year period, with an annual percent increase of 29.1% from 6.3 ED visits and hospital admissions per 100,000 children in 2008 to 17.2 in 2012 (P < .001). Increases in visit frequency were observed for all study variables, including age, sex, race/ethnicity, insurance type, metropolitan status, hospital type, and allergenic food. Visits were most frequent each year for Asian children and children with private insurance. However, the annual percent increase in visits was most pronounced among Hispanic children (44.3%, P < .001) and children with public insurance (30.2%, P < .001). ConclusionED visits and hospital admissions for food-induced anaphylaxis have increased during a 5-year period among children in Illinois, regardless of race/ethnicity and socioeconomic status.

A Vascular Access Team's Journey to Central Venous Catheter and Arterial Line Placement

BackgroundThe frequency with which vascular access specialists (VASs) are placing peripherally inserted central catheters (PICCS) has allowed for the improvement and expansion of the skill set by using advanced insertion techniques such as the modified Seldinger technique and ultrasound for real-time imaging. The use of real-time imaging has decreased complications such as arterial puncture and has improved success rates. Due to this positive influence on patient outcomes, many VASs are moving to the placement of central venous catheters (CVC). MethodWe describe the service improvement process of expanding a vascular access team (VAT) practice to include the placement of CVCs and arterial lines in a large community hospital in Illinois. We also outline the history of vascular access and the journey of a VAT. ResultsBy following a methodic approach toward implementation of practice expansion, our VAT has gone from solely placing PICCS to the placement of CVCs in the internal jugular, axillary/subclavian, and femoral veins and to the placement of arterial lines. ConclusionsVASs have the capacity to positively influence patient safety and outcomes even further by placing CVCs, rather than simply staying with the current scope of practice by placing intravenous lines, midlines, and PICCs. Patient outcomes will improve as VASs move to the placement of CVCs, and the costs associated with potential complications will improve also. Moving to the placement of CVCs is vital to the specialty of vascular access and will continue the breadth and depth of service provided by VASs.

Effect of Operative Time on Risk of Venous Thromboembolism After Benign Hysterectomy or Myomectomy [3

INTRODUCTION: Increased operative time has been shown to increase the risk of postoperative venous thromboembolism (VTE) in women undergoing hysterectomy for malignancy. The purpose of this study is to determine whether increased operative time increases the risk of VTE after hysterectomy or myomectomy performed for benign indications. METHODS: Electronic medical records were reviewed for women who underwent hysterectomy or myomectomy for benign indications at the University of Illinois hospital between January 1, 2009, and December 31, 2013. The case group was comprised of women diagnosed with VTE within 42 days of surgery. Women who underwent the same procedures during the same time period but did not develop VTE made up the control group. Student t-tests and odds ratios with 95% confidence intervals were calculated to determine the risk of VTE based on operative time. RESULTS: There were 16 women in the case group and 64 in the control group. All women had received intraoperative mechanical thromboprophylaxis. The mean age of those in the case and control groups was 41.4 years and 40.5 years, respectively; this difference was not statistically significant (P=.652). The mean body mass index was 31.8 for those in the case group and 30.1 for those in the control group, a non–statistically significant difference (P=.361). The mean operative time for those in the case group was 239 minutes and 200 minutes for those in the control group; this difference was not statistically significant (P=.072). Patients with operative times of 240 minutes or more had an increased risk of VTE (OR=4.33, 95% CI=1.353–13.87). CONCLUSION/IMPLICATIONS: Operative time longer than 4 hours increases the risk of developing postoperative VTE. Additional measures for thromboprophylaxis should be considered in this population.

Hospital outcomes and economic costs from poisoning cases in Illinois

Context. Since 2009, poisonings have been the leading cause of fatal injuries in the United States (US) and remain a continuing public health issue. Because of the varying definitions for what constitutes a poisoning case, there are inconsistencies in the annual number of cases reported among national health surveys. Objectives. The main objective of this study was to describe poisonings treated in Illinois hospitals by type of exposure, as well as to detail demographic characteristics, acute outcomes, and general cost estimates for those exposed to poisoning. We also compared a broad definition for poisoning used in our analysis with the definitions used by four national health surveys in order to assess the adequacy of various definitions in capturing poisonings for surveillance. Material and methods. We conducted a comprehensive analysis of outpatients and inpatients treated in Illinois hospitals in 2010 using the Illinois hospital database. Age-adjusted incidence rates were calculated. Results. In Illinois, 425,491 patients were treated in hospitals for poisoning in 2010, of whom 222,339 were inpatients. The age-adjusted incidence rate was 3,189 per 100,000 persons, with an average length of stay among inpatients of 5.5 days. The cumulative hospital charges were $7.9 billion. Discussion and conclusion. The definitions used in national surveys miss 60–90% of poisoning cases. Poisoning is the leading cause of fatal injuries in the U.S., but as this study shows broadening the definition for poisoning may provide a more accurate representation of the direct and indirect effects of poisoning in the US.

Abstracts from theCenter to Advance Palliative Care National Seminar Pathways to Quality Palliative CareNovember 13–15, 2014Orlando, Florida

Abstracts from theCenter to Advance Palliative Care National Seminar Pathways to Quality Palliative Care<i>November 13–15, 2014</i><i>Orlando, Florida</i>

A presedation fluid bolus does not decrease the incidence of propofol-induced hypotension in pediatric patients.

Propofol is commonly used in pediatric sedation, which may cause hypotension during induction. Our goal was to determine the effect of a preinduction 20-mL/kg isotonic fluid bolus on propofol-induced hypotension, assess clinical signs of hypoperfusion during hypotension, and evaluate for age-related propofol dosing differences. This prospective, randomized, controlled, nonblinded study was conducted at Children's Hospital of Illinois. Patients were children 6 to 60 months of age who needed sedation for MRI or auditory brainstem-evoked response testing. The treatment group received a preinduction 20-mL/kg isotonic saline bolus before procedure initiation. Patients were continuously monitored via cardiorespiratory monitor with pulse oximetry and end-tidal carbon dioxide measurements. Cardiovascular indices and clinical signs of hypoperfusion were compared between groups, and propofol dosing differences were compared between age groups. One hundred twenty-six patients were randomly assigned to treatment (n=52) or control (n=74) conditions. Twelve patients in the treatment group and 14 patients in the control group experienced postinduction hypotension, as defined by the Pediatric Advanced Life Support guidelines. One patient in each group was given volume resuscitation when blood pressure did not improve after a reduction in the propofol infusion rate. No hypotensive patients had physical signs of hypoperfusion, and patients≤1 year of age needed significantly more propofol. A 20-mL/kg preinduction isotonic saline bolus does not prevent propofol-induced hypotension. No clinical signs of hypoperfusion were noted with induced hypotension, and infants≤12 months old need significantly more propofol per kilogram for procedures.