Connecticut Hospitals Research Articles

A Guideline-Based Policy to Decrease Intensive Care Unit Admission Rates for Accidental Hypothermia.

Despite guidelines advising passive rewarming for mild accidental hypothermia (AH), patients are frequently admitted to intensive care unit (ICU) for active rewarming using a forced-air warming device. We implemented a new policy at our institution aimed at safely reducing ICU admissions for AH. We analyzed our practice pre- and post-policy intervention and compared our experiences with acute care hospitals in Connecticut. A retrospective chart review was performed on 203 participants with AH identified by primary and secondary discharge codes. Our new policy recommended passive rewarming on the medical floors for mild hypothermia (>32°C) and ICU admission for moderate hypothermia (<32°C). Practices of other Connecticut hospitals were obtained by surveying ICU nurse managers and medical directors. Over a 3-year period, prior to rewarming policy change, 64% (n = 92) of patients with AH were admitted to ICU, with a mean ICU length of stay (LOS [SD]) of 2.75 (2.2) days. After the policy change, over a 3-year period, 15% (n = 9) were admitted to ICU (P < .001), with an ICU LOS of 2.11 (0.9) days (P = 0.005). In both groups with AH, altered mental status, infection, and acute alcohol intoxication were the most common diagnoses at presentation. Alcohol intoxication was more prevalent in the post-policy intervention group, pre 17% versus post 46% (P < .001). No complications such as dermal burns or cardiac arrhythmias were noted with forced-air warming device use during either time period. Among the 29 hospitals surveyed, 20 used active rewarming in ICU or intermediate care units and 9 cared for patients on telemetry units. Most hospitals used active external rewarming for core body temperature of <35°C; however, 37% of hospitals performed active rewarming at temperatures >35°Cor lacked a policy. Reserving forced-air warming devices for the treatment of moderate-to-severe hypothermia (<32°C) significantly reduced ICU admissions for AH.

Survivorship Care Preferences: A Pilot Study of Young Adults With Cancer

Adolescents and young adults (AYAs) face increased risk for physical, social, and cognitive late complications of cancer therapy. Strategies are needed to better engage AYAs in survivorship research. This study aimed to determine the feasibility of enrolling AYAs within six months of diagnosis to a survivorship study and assess their health concerns and survivorship care preferences. Patients aged 15–34 years who were diagnosed with leukemia, lymphoma, or sarcoma at three Connecticut hospitals from 2008–2011 were identified and recruited by mail. Participants and their physicians received a survivorship care plan. Participants completed surveys at 6 months and 18 months after diagnosis. Recruiting AYAs to survivorship research remains challenging, even when approaching them soon after diagnosis. Novel strategies are needed for nurses and other healthcare team members to engage AYAs in survivorship care and research.

Using Hospitalization and Mortality Data to Identify Areas at Risk for Adolescent Suicide

PurposeThe purpose of this study is to use statewide data on inpatient hospitalizations for suicide attempts and suicide mortality to identify communities and school districts at risk for adolescent suicide. MethodsFive years of data (2010–2014) from the Office of the Connecticut Medical Examiner and the Connecticut Hospital Inpatient Discharge Database were analyzed. A mixed-effects Poisson regression model was used to assess whether suicide attempt/mortality rates in the state's 119 school districts were significantly better or worse than expected after adjusting for 10 community-level characteristics. ResultsTen districts were at significantly higher risk for suicidal behavior, with suicide mortality/hospitalization rates ranging from 154% to 241% of their expected rates, after accounting for their community characteristics. Four districts were identified as having significantly lower risk for suicide attempts than expected after accounting for community-level advantages and disadvantages. ConclusionsData capturing hospitalization for suicide attempts and suicide deaths can inform prevention activities by identifying high-risk areas to which resources should be allocated, as well as low-risk areas that may provide insight into the best practices in suicide prevention.

Evaluation of a Screening Program to Detect Critical Congenital Heart Defects in Newborns

To report the results of and to identify problems with implementing a screening program to detect critical congenital heart defects (CCHDs) in newborns by using differential pulse oximetry (POx). Charts of all live-born infants from 4 Yale-New Haven health system hospitals in Connecticut between January 1 and December 31, 2014, were reviewed. Of 10 589 newborns, 171 (1.6%) underwent an echocardiogram before screening, 10 320 (97.5%) were screened by POx, and 98 (0.9%) were not screened. Thirteen newborns (0.1%) were diagnosed with a CCHD. No infants with CCHDs were identified through POx screening (POxS) alone. Eleven (85%) were already suspected of having a CCHD lesion on the basis of prenatal ultrasound, 1 (8%) was diagnosed because of clinical concern before undergoing screening, and 1 (8%) had a false-negative screening result, but a CCHD was identified after an echocardiogram was performed because a murmur was heard. Four infants with a positive POx screen showed noncritical cardiac lesions by echocardiogram. The majority of infants were screened within the recommended 24 to 72 hours of age interval and had POx screens that were interpreted and documented correctly. Of 10 316 infants with negative POx screens, 52.1% were still in the Yale-New Haven Hospital health system at 1 year of age and no CCHD lesions were listed in their charts. Although a CCHD screening program was effectively implemented, perhaps because most children with a CCHD (85%) were detected antenatally by ultrasound, in our hospital system POxS did not lead to a substantial increase in the early identification of CCHDs.

Breast Cancer Management with Melanie E Royce: BOLERO-4 Phase II Trial of First-Line Everolimus Plus Letrozole in ER + , HER2 - Advanced Breast Cancer

Melanie E Royce* speaks to Roshaine Wijayatunga, Managing Commissioning Editor: Melanie E Royce is a Professor in the Department of Internal Medicine, Division of Hematology/Oncology at the University of New Mexico Comprehensive Cancer Center (UNM CCC) in Albuquerque, NM, USA. She received her PhD and MD degrees at the University of Cincinnati, Ohio; then completed her Internal Medicine Residency at Yale University-New Haven Hospital in Connecticut and Medical Oncology Fellowship at The University of Texas MD Anderson Cancer Center in Houston, Texas where she subsequently joined the faculty until she moved to Albuquerque, to be one among the first batch of oncology faculty recruits to help establish an National Cancer Insititute (NCI)-designated CCC in the state of NM. At UNM CCC, she serves as the Director of the Multidisciplinary Breast Cancer Clinic and Programs and Co-Leader of the Women’s Cancer Program. She is engaged in the care of breast cancer patients and is the Principal Investigator for several breast cancer clinical trials at the UNM CCC. On a national level, she serves on the Breast Cancer Committee of the Southwest Oncology Group and the NCI Breast Oncology Local Disease Task Force. Beyond breast cancer, she has a wider involvement in clinical research being the Director of the Clinical Protocol and Data Management of the UNM CCC and the contract Principal Investigator for the NM Minority/Underserved NCI Community Oncology Research Program, a grant that enhances patient and provider access to NCI-led clinical trials. The NM NCI Community Oncology Research Program in partnership with the NM Cancer Care Alliance, a state-wide clinical trials consortium, facilitates access to an expansive array of clinical trials to virtually all cancer patients statewide.

Implementing High Reliability for Patient Safety

When data in the National Healthcare Safety Network database showed higher rates of infections in Connecticut than in other states, the Connecticut Hospital Association (CHA) launched the first-of-its-kind statewide initiative in 2010 to improve patient safety by eliminating all-cause preventable patient harm using high-reliability science. In 2015, after 2 years of planning and 3 years of training, hospitals and other health care organizations across the state adopted high reliability as part of their safety culture and as a result have decreased the incidence of preventable harm. This article reviews the current state of patient safety, explains high reliability, and discusses key factors CHA used to assess readiness and prepare health care organizations for implementation.

Hearing Loss in the Last Two Years of Life: A Population-Based Study (S772)

admissions while improving quality of life, yet only 37% of advanced cancer patients report having had them, and most happen near the very end of life. Research Objectives. To describe oncologists’ perspectives on facilitators of and barriers to GoC conversations with patients with advanced cancer. Methods. Semi-structured interviews with oncologists at academic, community, and municipal hospitals (n1⁄44) in New York and Connecticut. Topics include approach to GoC conversations, facilitators, barriers, and organizational influences. We analyze data using interpretive description. Results. Participants to date (n1⁄412 of 25) are 83% male, they have a mean age of 45 (range 32-66) and 18 years (range 6-40) in practice, and 50% received training in GoC. Facilitators of GoC conversations include patient characteristics of higher health literacy and poor functional status and having a supportive practice environment (e.g., palliative care resources). Barriers include patient characteristics of being young and newly diagnosed, patient-family conflict, and physicians’ emotions. Although most participants felt GoC conversations should be ongoing, some reported two distinct conversations: an early ‘‘introductory’’ conversation about cancer basics and treatment goals and a ‘‘near the end’’ conversation about risks and benefits of further treatment and DNR. These conversations had different triggers. Perceived best timing of GoC conversations varied by subspecialty. Conclusion. While data collection is ongoing, we have identified facilitators of and barriers to GoC conversations, some of which may be remediable by enabling oncologists to conduct GoC conversations despite difficult circumstances and emotional reactions, activating patients/family via increasing health literacy or peer support, advancing palliative-informed practice environments, and creating subspecialty-specific guides for timing of GoC conversations. Analyses are underway to help clarify the two distinct content conversations and connections between them. Implications for Research, Policy or Practice. By addressing findings in Oncotalk, a program to train oncologists in palliative care skills, we hope to improve content and timing of GoC conversations.

Trends in Tuberculosis Cases at a Connecticut Hospital, 2005–2014

Trends in Tuberculosis Cases at a Connecticut Hospital, 2005–2014

Early Medicaid Expansion In Connecticut Stemmed The Growth In Hospital Uncompensated Care.

As states continue to debate whether or not to expand Medicaid under the Affordable Care Act (ACA), a key consideration is the impact of expansion on the financial position of hospitals, including their burden of uncompensated care. Conclusive evidence from coverage expansions that occurred in 2014 is several years away. In the meantime, we analyzed the experience of hospitals in Connecticut, which expanded Medicaid coverage to a large number of childless adults in April 2010 under the ACA. Using hospital-level panel data from Medicare cost reports, we performed difference-in-differences analyses to compare the change in Medicaid volume and uncompensated care in the period 2007-13 in Connecticut to changes in other Northeastern states. We found that early Medicaid expansion in Connecticut was associated with an increase in Medicaid discharges of 7-9 percentage points, relative to a baseline rate of 11 percent, and an increase of 7-8 percentage points in Medicaid revenue as a share of total revenue, relative to a baseline share of 10 percent. Also, in contrast to the national and regional trends of increasing uncompensated care during this period, hospitals in Connecticut experienced no increase in uncompensated care. We conclude that uncompensated care in Connecticut was roughly one-third lower than what it would have been without early Medicaid expansion. The results suggest that ACA Medicaid expansions could reduce hospitals' uncompensated care burden.

Nurses’ Perception of the Facilitators and Barriers to the Implementation of Safe Sleep Recommendations in the Hospital Inpatient Setting

Poster Presentation Objective To identify facilitators and barriers to modeling and teaching safe sleep recommendations in the hospital inpatient setting to guide development of nursing education. Design Qualitative study. Setting Three hospitals in Connecticut and Virginia. Sample The total sample size was 41 nurses and staff members. Methods We conducted five focus groups with 41 nurses and other staff. Focus groups were facilitated by a trained moderator using a script modified in an iterative process. Discussions were digitally recorded and transcribed. Using standard qualitative techniques, data were organized with qualitative software and analyzed with constant comparative methods to identify key themes and subthemes. Results Three main themes emerged as key facilitators and barriers: Previously held beliefs of families and providers could facilitate and act as barriers to modeling and teaching safe sleep recommendations. Nurses described many families not wanting to follow recommendations based on their cultural beliefs or previous practices. Inconsistent provider messages were seen as a barrier. Nurses and other health care providers were reported to sometimes give mothers messages contrary to recommendations of the American Academy of Pediatrics. Nurses felt that messages to families would only be effective if consistent. External forces can drive the success of messaging to providers and families. Nurses cited regulations from outside accreditation bodies and protocols as drivers for delivering accurate information. Many nurses noted that media messages and infant products sold in stores (such as bumpers) were often contrary to recommendations. Conclusion/Implications for Nursing Practice We identified key themes that are important to consider when developing a program to educate nursing staff to teach and model safe sleep messages that included overcoming families’ cultural beliefs about infant care practices, the importance of uniform messages, and the influence of external regulations and contradictory media images.

Investigation of the Impact of the Massachusetts Health Care Reform on Hospital Costs and Quality of Care

In 2006, the Massachusetts legislature passed a landmark health care reform bill (the Reform) that has served as a model for the national health care reform. By aiming to provide “access to affordable, quality, accountable health care,” the goals of this reform were to reduce the number of uninsured Massachusetts residents while containing the growth of health care costs and improving the quality of health care services. The current paper examines the impact of the Reform on the quality of care in addition to hospital costs simultaneously from a perspective of efficiency analysis. We develop an integer-valued non-radial Russell data envelopment analysis (DEA) model, which is unit variant and calculate the hospitals’ efficiency directly. However, the proposed integer-valued model is non-linear. The current paper thus transforms this model into a parametric integer linear programming. We develop a method to derive its optimal solutions. We then use the new DEA model to calculate and compare the efficiency scores of hospitals in Massachusetts and Connecticut pre- and post-Reform. The analysis shows that the Reform has achieved its cost containment and quality improvement goals at the same time. These analyses provide potentially useful information to hospital regulators and government regulators, especially in light of the national interest on health care legislation.

Assessing surge capacity expansion plan awareness and attitudes: A survey of Connecticut hospitals

This study aimed to ascertain levels of awareness and attitudes of healthcare professionals within four hospital personnel categories, regarding their facility’s surge capacity expansion plan. The exploratory descriptive study used a 14-question electronic survey to collect data from hospital personnel in four labour categories. A total of 292 hospital staff from 32 Connecticut hospitals completed the survey, including executive staff, mid-level management staff, incident command hospital staff and emergency planning contacts. The strongest levels of agreement were found to be: the need for an emergency planning contact, understanding surge expansion roles and responsibilities, and provision of enhanced training and heightened participation in drills and exercises. Statistical significance was found when comparing hospital personnel categories in seven of the 14 survey questions that related to time at hospital, understanding personal role in surge event, understanding staff role in surge event, participating in events to increase surge awareness, understanding alternative care facility roles and responsibilities, understanding incident command system (ICS) roles and responsibilities and the need for ICS training. Findings demonstrate that some personnel perceive that their institutions are sub-optimally prepared to expand surge capacity. Education and training are important factors that contribute to improving these perceptions and help guide institutional preparedness and response efforts.

Individual and organizational predictors of pediatric psychiatric inpatient admission in connecticut hospitals: a 6month secondary analysis.

The objective of this study is to test the hypotheses that bipolar disorders or depressive disorders, minority status, and the presence of pediatric inpatient psychiatric unit will be individual predictors of pediatric psychiatric inpatient admission, and to provide a model that will evaluate which individual and organizational characteristics predict pediatric psychiatric inpatient. For this purpose, a secondary analysis of the medical records of 1,520 pediatric patient visits between January 1, 2008 and June 30, 2008, was conducted using univariate and multivariate logistic regression. Independent predictors of pediatric psychiatric inpatient admission were presence of bipolar and depressive disorders, greater average daily census, and increasing operating margin. Minority status was a significant predictor of not being admitted, as was presence of an anxiety disorder, greater total margin and older age. The results indicate that both individual and organizational factors impact disposition outcomes in particular subsets of pediatric patients who present to emergency departments for psychiatric reasons.

Successful reduction in catheter-associated urinary tract infections: Focus on nurse-directed catheter removal

Despite using sterile technique for catheter insertion, closed drainage systems, and structured daily care plans, catheter-associated urinary tract infections (CAUTIs) regularly occur in acute care hospitals. We believe that meaningful reduction in CAUTI rates can only be achieved by reducing urinary catheter use. We used an interventional study of a hospital-wide, multidisciplinary program to reduce urinary catheter use and CAUTIs on all patient care units in a 300-bed, community teaching hospital in Connecticut. Our primary focus was the implementation of a nurse-directed urinary catheter removal protocol. This protocol was linked to the physician's catheter insertion order. Three additional elements included physician documentation of catheter insertion criteria, a device-specific charting module added to physician electronic progress notes, and biweekly unit-specific feedback on catheter use rates and CAUTI rates in a multidisciplinary forum. We achieved a 50% hospital-wide reduction in catheter use and a 70% reduction in CAUTIs over a 36-month period, although there was wide variation from unit to unit in catheter reduction efforts, ranging from 4% (maternity) to 74% (telemetry). Urinary catheter use, and ultimately CAUTI rates, can be effectively reduced by the diligent application of relatively few evidence-based interventions. Aggressive implementation of the nurse-directed catheter removal protocol was associated with lower catheter use rates and reduced infection rates.

Compounding pharmacy industry has outgrown its regulatory system, ASHP and FDA say

In the half year since a compounding pharmacy in Massachusetts announced a recall of all its products “due to the potential risk of contamination,” two other pharmacies declared recalls “due to lack of sterility assurance.” And at least two additional compounding pharmacies have recalled their maybe-not-so-sterile products after FDA personnel inspected the facilities. The human toll is real. Five patients have been diagnosed with a serious eye infection after receiving bevacizumab that Clinical Specialties Compounding Pharmacy had repackaged into single-use syringes from the manufacturer’s vials, the Georgia pharmacy stated on March 20. More than 50 patients have died and about 680 others in 20 states have been diagnosed with a fungal infection after receiving an injection of methylprednisolone acetate produced by the New England Compounding Center, according to the latest federal report. A Connecticut hospital was more fortunate. Among the i.v. solutions received from Med Prep Consulting Inc. were five 50-mL bags of magnesium sulfate in 5% dextrose injection that turned out to contain mold, the New Jersey compounding pharmacy reported on March 16.

The End of the Beginning

The End of the Beginning

P02.35. Methodology in integrative medicine research: challenges and solutions from a randomized clinical control trial using adapted yoga

Purpose This randomized controlled clinical study evaluated the efficacy of adapted yoga (vs. usual care) to reduce psychosocial risks, which have been clinically shown to impact morbidity and mortality in implantable cardioverter defibrillator (ICD) recipients. The ICD collects and records real-time cardiac data, which were used in the study. Methods Forty-six patients participated from a hospital in Connecticut. All participants were administered validated measures on psychosocial risk factors at weeks one and eight of the eight-week intervention. Patients in the intervention group participated in a weekly adapted yoga class for eighty minutes for eight weeks with assigned home practices. Clinical measures, including patients’ current and past medical health status and device usage, were collected three months prior to the study, during the study, and at a six-month follow-up. Results Data revealed that the yoga group’s overall shock anxiety decreased while the control group’s increased, t(4.43, 36), p<0.0001 (total). The yoga group had less shock anxiety, t(2.86,36) p=0.007 (mean consequence), greater overall self-compassion, t(-2.84,37), p=0.007 (total), and greater mindfulness (equanimity) regarding emotions, t(-2.10,37) p=0.04 (mindfulness), than the control group. Exploratory analyses utilizing a linear model (R2=.98) of the observed anti-tachycardia pacing (ATP) events revealed that the expected number of ATP events in the intervention group was significantly lower than the control group. Additionally, the expected number of ATP events increased more rapidly as a function of the initial ATP events for the control group than for the intervention group. Conclusion Our study demonstrated psychological benefits from a program of adapted yoga compared to usual care for ICD recipients. Marked improvements were reported in total shock anxiety, self-compassion, sense of equanimity, and decreased likelihood of ATPs. The data supports the continuation of research in mind-body interventions to better understand the role of complementary medicine to address ICD-specific psychosocial stress and its potential contributory role in cardiac outcomes.

Treating Agitation in ER Requires Delicate Balancing Act

Treating Agitation in ER Requires Delicate Balancing Act

Evaluation of the Connecticut hospital emergency department syndromic surveillance system for monitoring of community gastrointestinal illness

Evaluation of the Connecticut hospital emergency department syndromic surveillance system for monitoring of community gastrointestinal illness

Who Is Paying the Price? Loss of Health Insurance Coverage Early in Psychosis

Who Is Paying the Price? Loss of Health Insurance Coverage Early in Psychosis