Hospitals In Iowa Research Articles

Invited Symposium 1: Traumatic Brain Injury: Highlighting the Contributions of Dr. Harvey S. Levin Ph.D., ABPP-CN, FACSM 1946 - 2022

Invited Symposium 1: Traumatic Brain Injury: Highlighting the Contributions of Dr. Harvey S. Levin Ph.D., ABPP-CN, FACSM 1946 - 2022

Going into town or staying home: Rural patient experience and preference with home-based versus clinic-based telehealth.

Telehealth is a model of care with potential to improve access, and in turn outcomes, for people living in rural areas. Since 2013, our endocrine clinic-based telehealth program has provided care at rural community hospitals in Nebraska and Iowa. At the start of the COVID-19 pandemic, when regulations around telehealth were adjusted, patients previously seen via clinic-based telehealth had the option to continue clinic-based visits or have a home-based telehealth visit. There is no literature comparing patient experiences between home-based and clinic-based telehealth. The purpose of this study was to understand rural patient preferences regarding endocrinology home-based versus clinic-based telehealth visits. This was a survey study of adult, rural patients who experienced both a clinic-based and home-based telehealth visit with their established endocrinology provider. Respondents were asked about demographics, their reason for visit, preference for home versus clinic-based telehealth, and how they would have received care if telehealth were not an option. Forty-two patients (40.8%) responded to the survey, with 27 patients (64.3%) preferring home-based telehealth. There were no significant differences between the groups. However, 47.5% of patients would not have sought specialty care if telehealth were not an option. This survey of endocrine patients experienced in both clinic-based and home-based telehealth indicates that, while most respondents preferred home-based telehealth, there are distinct advantages to each model and patients appreciate having options. We believe it is important to maintain both lines of service to provide patient-centered care and improve access to specialty care.

In-depth assessment of critical access hospital stewardship program adherence to the CDC Core Elements in Iowa and Nebraska.

In 21 antimicrobial stewardship programs in critical-access hospitals in Nebraska and Iowa that self-reported nonadherence to a CDC Core Element or Elements, in-depth program assessment and feedback revealed that accountability and education most needed improvement. Recommendations included providing physician and pharmacist training, tracking interventions, and providing education. Program barriers included lack of time and/or personnel and antimicrobial stewardship and/or infectious diseases expertise.

Patients in Iowa Counties Lacking Hospitals With Labor and Delivery Services Disproportionately Receive Care at Level III Maternal Care Hospitals When Undergoing Cesarean Delivery: A Retrospective Longitudinal Study.

Introduction Many obstetrical patientsfrom rural areas in the United States lack hospitals that provide labor and delivery care. Our objective was to examine the effects of such patientson caseloads of cesarean deliveries at Iowa hospitals withlevel III maternal care, as defined by the Iowa Department of Public Health(e.g., with obstetric anesthesiologists). Methods Thisretrospective longitudinal studyincludedeverydischarge with cesarean delivery in the state of Iowa from October 2015 through June 2021. There were N=60,534 such deliveries from 76 hospitals, of which three were level III, and the rest were level I or II.Poisson regression models with robust variance estimation and controlling for geography, maternal risk factors, and insurance, were used to evaluate the binary outcome of whether patients received care at the university level III hospital in Eastern Iowa, or not. Similar models were also developed for care at the two private level III hospitals in Central Iowa, or not.Differences in the mean probabilities of receiving care at the level III hospitals were then estimated using logistic regression, with results reported in units of changes in cases per week at the hospitals. Results Statewide, the university level III hospital performed 7.4% of the cesarean deliveries, and the two private level III hospitals performed 23.4%.Patients from counties in which nocesarean deliveries were performedduring the quarter of the year when they underwent a cesarean delivery disproportionately received care at level III hospitals versus levels I and II hospitals. Lower 99% confidence limits for incremental risk ratios were 1.46 and 4.20, respectively. Cesarean deliveries among patients residing in counties where no hospital had a labor and delivery ward were distributed unequally between thecounties of the hospitals with level III maternal care. Therewere approximately 1.09 (standard error 0.10) extra cesarean deliveries per week at the university hospital versus 5.81 (standard error 0.11) at the private hospitals. The 1.09 vs 5.81 difference was caused, in part, by the effects of insurance and other hospitals with similar services. Conclusions Patients residing in counties without labor and delivery care disproportionately go to level III hospitals. These results can help anesthesiologists, obstetricians, and analystsat hospitals with large tertiary (level III) programs interpret their annual increases in total obstetric anesthesia activity.

Low Prevalence of Designated Lactation Spaces at Hospitals and Ambulatory Surgery Centers in Iowa: An Educational Tool for Graduates' Job Selection.

Many anesthesiologists and nurse anesthetists want to continue breastfeeding their babies when returning to work from maternity leave. The cornerstone of breast milk supply maintenance is breast milk pumping sessions at regular intervals. These breast milk pumping sessions require time and private space for lactation. We surveyed Iowa hospitals and ambulatory surgery centers and created an educational spreadsheet to guide inquiry and postgraduate job selection of our anesthesiology residents and nurse anesthetist students (eg, when considering future family planning). The survey and spreadsheet showed a low prevalence of dedicated lactation space for anesthesia practitioners near the surgical suites.

Rural Telehealth Visits in the Management of Type 1 Diabetes.

Despite advances in and increased adoption of technology, glycemic outcomes for individuals with type 1 diabetes (T1D) have not improved. Access to care is limited for many, in part due to a shortage of endocrinologists and their concentration in urban areas. Managing T1D via telehealth has potential to improve glycemic outcomes, as the barriers of travel-related time and cost are mitigated. Our endocrine telehealth program started in 2013 and currently provides care to nine rural community hospitals in Nebraska and Iowa. A retrospective cohort study was performed to evaluate glycemic outcomes in people with T1D who received care at these telehealth clinics from 2013-2019. Data were collected on age, race, gender, prior diabetes provider, use of diabetes technology, and A1c values over time. One hundred thirty-nine individuals were followed for an average duration of 32 months (range 4-69 months). Sixty-six percent of people were previously under the care of an endocrinologist. The most common therapeutic action, in addition to insulin adjustment, was addition of a CGM (52%). Each year in telemedicine care was associated with a decline of 0.13% in A1c (95% CI: -0.20, -0.06). There was no association between A1c and age or gender. When stratifying by previous diabetes provider, all groups had a statistically significant decline in A1c, even those with a previous endocrine provider. There was no statistically significant decline in A1c based on addition of technology. We have shown that traditional telehealth visits are an effective way to provide care for people with T1D long-term and may provide distinct advantages to home telehealth visits.

Hospitals’ Web Site Lists of Their Interventional Pain Procedures Inadequately Reflect the Diversity of Their Actual Pain Medicine Practices

Background Multidisciplinary chronic pain management includes many types of interventional pain procedures. However, navigating the landscape of providers offering such services is challenging. Objective We investigated whether stakeholders (e.g., patients, referring physicians, hospital administrators, nurses working for insurance companies, and state officials) could accurately judge the diversity of interventional services actually provided based on information gathered from hospital Web sites. Study design This was an observational cohort study. Setting All 119 nonfederal hospitals in Iowa were included in the study. Methods We recorded the publicly available data presented on all hospital Web pages related to interventional pain procedures. We counted the listed types of procedures and numbers of pain medicine physicians portrayed. We compared those results with actual performed interventional pain procedures calculated using contemporaneous data from the Iowa Hospital Association. The diversity of types of procedures performed was quantified using the inverse of the Herfindahl index. Results No pain medicine physician was identified on the Web site for 87.4% of hospitals. Such hospitals accounted for 61.4% of the interventional pain procedures performed statewide. The partial Kendall correlation between the count of types of procedures listed on Web sites and the number of pain medicine physicians, controlling for the performed procedures during the year, was too small to be informative: 0.22 (95% Confidence Interval [CI], 0.07 to 0.38; P = .005). The one-sided upper confidence limit that included 0.50 (i.e., moderate) was the 99.98% limit. The partial correlation between the count of types of procedures listed on Web sites and the actual diversity of types of procedures performed, controlling for the performed procedures during the year, was not statistically significant: 0.12 (95% CI, -0.03 to 0.28; P = .12). The partial Kendall correlation between the number of pain medicine physicians listed on the Web sites and the diversity of types of procedures performed was not significant: 0.03 (95% CI, -0.13 to 0.19; P = .73). Limitations This study was limited to the state of Iowa, where we found that 38.6% of interventional pain procedures were performed at hospitals with at least one pain medicine physician. The 38.6% is substantively less than the corresponding estimate of 54.2% for the state of Florida. The estimate of 38.6% exceeds the estimate of 30.4% for critical access hospitals in the United States nationwide. Although the heterogeneity is as expected, it shows that findings are likely to be heterogeneous across regions. Conclusions Stakeholders could not have accurate awareness of the spectrum of services provided by multidisciplinary pain medicine clinics and physicians based on currently reported data, even if they sought it out from publicly available information. Transparency will need to come from pain medicine physicians, at facilities providing the full diversity of services, releasing quantitative data about the services that they provide (e.g., counts by procedure).

Exploring the Potential Limitations of Using Medicare Data to Study the Spread of Infections from Hospital Transfers

Background: Patient sharing between hospitals has long been known to be a contributor to the regional transmission of hospital-acquired infections. This inter–healthcare-facility connectedness suggests that regional, as opposed to local, control and surveillance strategies should be favored. However, the absence of easily and universally accessible patient transfer data hampers researchers and public health agencies who wish to build accurate network models of interfacility transmissions. Medicare data offer only a biased subsample of the full patient transfer network, but because it is widely available, this data source has historically been used for inference and simulation studies. Objective: The purpose of this study was to determine whether Medicare data could successfully be recalibrated to more closely resemble 100% inpatient capture data. Methods: We used data from the Healthcare Cost and Utilization Project (HCUP) to construct 100% capture and Medicare-only patient sharing networks among hospitals in Iowa, Wisconsin, and Nebraska. We used matrix decomposition techniques on the Medicare-only networks along with hospital characteristics from the American Hospital Association (AHA) data for feature construction in a truncated Poisson regression model, and we used Monte Carlo integration to obtain predicted values. These predicted values served as calibrated Medicare-only networks. We split the patient transfer data into training and testing sets and computed the mean squared prediction error (MSPE) for the testing data. We also built an individual based model (IBM) using HCUP and AHA data to perform epidemic simulations that depended on a matrix of patient transfer rates between hospitals. We then compared epicurves from these IBMs resulting from 100% capture networks, Medicare-only networks, and our calibrated networks. Results: Our calibrated networks reduced the MSPE with respect to Medicare-only networks by 84%, 47%, and 88% for Iowa, Wisconsin, and Nebraska, respectively. Although the epicurves from Medicare-only networks differed considerably from that from 100% capture networks, our calibrated networks retained high fidelity to the curves obtained from 100% capture networks. Conclusions: Medicare-only networks greatly underestimate the number of patients transferred between hospitals. Our approach allows us to use Medicare data to estimate networks when 100% inpatient capture is unavailable.Funding: NoneDisclosures: None

Using the NHSN Tap Report and Standardized Utilization Ratio to Decrease Urinary Catheter Utilization

<h3>Background</h3> Our facility had the highest urinary catheter standardized utilization ratio (SUR) in our hospital system, which consists of nine acute care hospitals in Nebraska and Iowa. Using the NHSN Tap report and SUR, we were able to focus on the specific unit with the highest SUR's, which was the 29-bed orthopedic medical surgical unit. <h3>Methods</h3> We completed a chart review of IUC's in place on this unit, and were able to determine that a majority of the usage was related to orthopedic surgical patients. After completing a literature review for best practices for utilizing and removing IUC in this patient population, we updated the orthopedic order sets to use alternative urinary collection methods, such as a external female catheter or urinal, prior to inserting a IUC. Orthopedic surgeons allowed removal of the urinary catheter in certain cases in the operating room or post-anesthesia care unit before the patient was transferred to the inpatient units, or did not insert a IUC during the procedure. <h3>Results</h3> During our initial chart audit in October and November 2018, our orthopedic surgeons completed 117 procedures in that time from and 67% of these cases included patients that were admitted to the orthopedic unit was a foley catheter. In September and October 2019, our orthopedic surgeons completed 90 procedures in that time from and 30% of these cases were patients that were admitted to the orthopedic unit was a foley catheter. This was a 37% improvement in IUC utilization in this patient population. <h3>Conclusions</h3> Overall, our interventions had drastically improve our indwelling urinary catheter SUR on our orthopedic medical surgical unit and have helped us to decrease the risk for catheter-associated urinary tract infections for our patients at our facility.

A Partnership Approach to Paternity Establishment: Child Welfare Research and Training Project Ecological Model and Preliminary Data

This article provides an ecological model of child support facilitation through broad efforts to maintain high rates of paternity establishment via agency–university collaboration. The study utilized administrative data (2,208 electronic records from the Bureau of Health Statistics) on voluntary paternity affidavits (VPA) rejected by the Iowa Department of Public Health. These records represented all rejected VPAs from 70 hospitals in Iowa for 6 months in 2017. Results indicated that the majority of VPAs were not accepted for minor errors (78%) such as missing information rather than incorrect information. Results also indicated variation among hospitals and hospital regions in the reasons for rejection. Outreach to hospitals targeting affidavit completion is a potential step for increasing paternity establishment.

1026. Ertapenem Use During Antibiotic Stewardship Interventions in Community Hospitals

BackgroundAntimicrobial stewardship programs (ASP) promote the judicious use of antimicrobials to reduce antimicrobial resistance and improve patient outcomes. In our institution, we identified the overutilization of ertapenem and implemented several interventions to decrease its usage. The objective of this study was to assess the impact of these interventions on ertapenem use, rates of surgical site infection (SSI), carbapenem-resistant Enterobacteriaceae (CRE), and hospital-onset Clostridioides difficile infection.MethodsThis was a retrospective study conducted in 3 community hospitals in Iowa and Illinois using surveillance of anonymized antibiotic and infection control data from 2015 to 2018. Target ASP interventions included a daily retrospective review of ertapenem use, alternative alerts to providers through electronic health records (EHR), carbapenem restriction to infectious disease (ID) providers, and educational meetings with high-use provider groups. The primary outcome was the usage trend of ertapenem, and secondary outcomes were rates of SSI, CRE, and hospital-onset C. difficile infection. Interrupted time series analysis was performed to assess changes in the rates over the study period.ResultsAn overall significant reduction in ertapenem use was observed in all 3-community hospitals from 2015 to 2018. Ertapenem days of therapy adjusted for case-mix index per 1000 patient-days was 11.2 in 2015 and 2.05 in 2018. Two breakpoints were identified; the addition of an ID trained pharmacist to the ASP (10/2016) and educational meetings with colorectal surgeons (5/2017). No significant difference was seen for hospital-onset C. difficile infection, SSI, or CRE. Purchase costs decreased for ertapenem by 81% in 2018 compared with 2015(P < 0.001).ConclusionAdding an ID trained pharmacist to an ASP decreased usage of ertapenem. The majority of ertapenem use was for surgical prophylaxis, and our data suggested that educational meetings with a high-usage group were effective. Surgical site infection rates did not increase when narrower spectrum surgical prophylaxis was used. Overall hospital-acquired C. difficile rate was unchanged, possibly due to alternative antibiotic use. Our study suggests ASP interventions can be cost saving. Disclosures All authors: No reported disclosures.

Observational Study of the Distribution and Diversity of Interventional Pain Procedures Among Hospitals in the State of Iowa

Background: Critical access hospitals represent 61% of hospitals in the rural United States, and 68% of hospitals in Iowa. The role of small hospitals, such as critical access hospitals, in providing interventional chronic pain procedures is unknown. Objectives: We evaluated whether: a) the diversity of interventional pain procedures offered by hospitals is related to their size and is attributable principally to lumbosacral epidural injections; b) critical access hospitals contribute substantively to the count and diversity of pain procedures; and c) whether most interventional pain procedures performed at hospitals’ facilities are performed by relatively few proceduralists or by the cumulative activity of many clinicians. Study Design: This research involved an observational cohort design with a sample size of n = 283,940 interventional pain procedures. Setting: Data were collected from hospital-owned facilities in the state of Iowa from July 2012 through September 2017. Methods: The diversity of types of interventional pain procedures performed statewide was quantified in terms of the relative proportions of procedures at each hospital using the Herfindahl index. Bilinear weighted least squares regression quantified the relationship between the inverse of the Herfindahl and the percentage of procedures that were lumbar or caudal epidural. Kendall tau concordances quantified the relationship between counts of interventional pain procedures and hospital size. Using a blinded version of the National Provider Identifier of the clinician with primary responsibility for performing the principal procedure of the ambulatory visit, we calculated the percentage shares of interventional pain procedures performed by the 1% and 5% of proceduralists who performed the most procedures. Results: The diversity of types of procedures substantively differentiated among hospitals. Heterogeneity among hospitals in the proportion of procedures that were lumbar or caudal epidural injections substantively contributed to the heterogeneity among hospitals (P &lt; .001). Hospitals performing more procedures tended to have greater diversity of types of procedures (P &lt; .001). However, the strength of the concordance was small (Kendall τb = 0.332), showing substantial heterogeneity among hospitals. The 82 critical access hospitals statewide cumulatively accounted for 23.9% of interventional pain procedures. The critical access hospitals’ procedures were mostly (67.7%) lumbar or caudal epidural injections (P &lt; .001), greater than the 48.9% of the other 41 hospitals (P &lt; .001). Procedures were concentrated among proceduralists. The 1.0% of the proceduralists performing the most procedures performed 64.8% of procedures. The 5.0% of proceduralists performing the most procedures performed 87.7% of procedures. Limitations: The data are procedures were performed in hospital-owned facilities of Iowa. Conclusions: Although busier pain programs, based on procedures per week, generally performed more types of procedures, the variability was so large that the number of procedures a pain program performs per week cannot validly be used to infer the diversity of the hospital’s pain medicine practice. Hospitals with pain medicine programs that lack diversity in the types of procedures performed may provide limited options for patients and be susceptible to changes in payment for individual procedures. Relatively few proceduralists performed the vast majority of the procedures. Key words: Critical access hospitals, Herfindahl, interventional pain procedures, managerial epidemiology, pain medicine, state outpatient procedure database, lumbar epidural

Types of internal facilitation activities in hospitals implementing evidence-based interventions.

Implementation models, frameworks, and theories recognize the importance of activities that facilitate implementation success. However, little is known about internal facilitation activities that hospital personnel engage in during implementation efforts. The aim of the study was to examine internal facilitation activities at 10 critical access hospitals in rural Iowa during their implementation of TeamSTEPPS, a patient safety intervention, and to identify characteristics that distinguish different types of facilitation activities. We followed 10 critical access hospitals for 2 years after the onset of implementation, conducting quarterly interviews with key informants. On the basis of the transcripts from the first two quarters, a coding template was developed using inductive analyses. The template was then applied deductively to code all interview transcripts. Using comparative analysis, we examined the characteristics that distinguish between the facilitation types. We identified four types of facilitation activities-Leadership, Buy-in, Customization, and Accountability. Individuals and teams engaged in different types of facilitation activities, both in a planned and an ad hoc manner. These activities targeted at both people and practices and exhibited varying temporal patterns (start and peak time). There are four types of facilitation activities that hospitals engage in while implementing evidence-based practices, offering a parsimonious way to characterize facilitation activities. New theoretical and empirical research opportunities are discussed. Understanding the types of facilitation activities and their distinguishing characteristics can assist managers in planning and executing implementations of evidence-based interventions.

Heterogeneity among hospitals statewide in percentage shares of the annual growth of surgical caseloads of inpatient and outpatient major therapeutic procedures

Study objectiveSuppose that it were a generalizable finding, in both densely populated and rural states, that there is marked heterogeneity among hospitals in the percentage change in surgical caseload and/or in the total change in caseload. Then, individual hospitals should not simply rely on federal and state forecasts to infer their expected growth. Likewise, individual hospitals and their anesthesiology groups would best not rely on national or US regional surgical trends as causal reasons for local trends in caseload. We examined the potential utility of using state data on surgical caseload to predict local growth by using 6 years of data for surgical cases performed at hospitals in the States of Florida and Iowa. DesignObservational cohort study. Setting303 hospitals in Iowa and Florida. MeasurementsCases with major therapeutic procedures in 2010 or 2011 were compared pairwise by hospital with such cases in 2015 and 2016. Changes in counts of cases were decreases or increases, while study of growth set decreases equal to zero. Main resultsHospitals in Iowa had slightly lesser percentage changes than did hospitals in Florida (Mann-Whitney P = 0.016). Hospitals in Iowa had greater variability among hospitals in the change in counts of cases with a major therapeutic procedure than did hospitals in Florida (P < 0.0001). The 10% of hospitals with the largest growths in counts of cases accounted for approximately half of the total growth in Iowa (70%) and Florida (54%). The large share of total growth attributable to the upper 10th percentile of hospitals was not caused solely by the hospitals having large percentage growths, based on there being weak correlation between growth and percentage growth, among the hospitals that grew (Iowa: Kendall's tau = 0.286 [SE 0.120]; Florida tau = 0.253 [SE 0.064]). ConclusionsEven if the data from states or federal agencies reported growth in surgical cases, there is too much concentration of growth at a few hospitals for statewide growth rates to be useful for forecasting by individual hospitals and anesthesiology groups.

Abstract TP231: Predicting Emergency Medical Services Use in a Rural State

Introduction: Hospital arrival by emergency medical services (EMS) is important for decreasing time from stroke onset to arrival and increasing the rate of rtPA use. In rural states, like Iowa, EMS is an often volunteer and dispersed resource which may influence the use of private vehicles. Objective: The objective of this study was to identify predictors of EMS use compared to private vehicle transport in Iowa stroke patients. Methods: A retrospective analysis was conducted using 2016 data collected by the Iowa Stroke Registry. The Iowa Stroke Registry is a statewide, concurrent database used to improve the Iowa Stroke System and quality of stroke care between EMS and hospitals in Iowa (1 comprehensive center, 15 primary centers, and 9 acute stroke hospitals). Inclusion was limited to arrival by EMS or private vehicles in the year 2016; all other arrivals were excluded. Predictors of EMS use were evaluated from admission, arrival, demographic, medical history, and hospital data. Chi square analyses and multivariate logistic regression were performed to determine associations and predictors of EMS use. Significance was at the 0.05 probability level. Results: The inclusion criteria was met by 2650 patients with 1335 (50.4%) arriving by EMS. A total of 1739 patient records were included in the analysis and 829 (47.7%) arrivals were from EMS compared to private vehicles. Results from the multivariate analysis indicated that EMS use was significantly associated with patients aged 65 or older, Native Americans, neurological symptoms of altered consciousness, aphasia, and weakness, history of atrial fibrillation, antidepressant medication use, hormone replacement therapy, and arrival in the northeast, south central, and southeast regions of the state. Private vehicle use was associated with resolved stroke symptoms at initial exam and the ability to ambulate independently prior to stroke. Patients arriving by EMS were more likely to arrive in the first 2 hours of symptom onset and receive rtPA compared to private vehicle arrivals. Conclusion: The proportion of arrivals by EMS and private vehicles were similar in 2016. Neurological symptoms of stroke, age, ambulatory status and region of the state were the most influential factors in determining EMS use.

Abstract TP305: Geographical Dispersion of Patients Referred to a Comprehensive Stroke Center in a Rural Setting

Introduction: Most patients with stroke in Iowa are initially seen in small community hospitals and are subsequently transferred to another institution with a higher level of care. The Iowa Stroke Registry (ISR) was developed to assess the system of stroke care in the state. Community hospitals in the state are supported by the comprehensive stroke center (CSC) through consultation for acute stroke treatment. The objective for this project was to analyze the geographical dispersion of transfers to the CSC to begin an evaluation of the system of stroke care in the state. Method: We analyzed the prospectively collected data in the Iowa Stroke Registry (ISR). The ISR has collected data from 32 hospitals: comprehensive (1), primary (15), and stroke capable hospitals in Iowa beginning in 2010. To date over 23, 000 patients have been enrolled. Information from this analysis included the CSC data only collected in a national database and imported ino the ISR from 2015-April, 2017 that included zip code data. During that time period 2576 patients were direct admissions or transfers to the CSC. Distances were based on the number of miles between the patients’ and CSC zip code. Results: Approximately 80% of all stroke patients at the CSC were transferred from a community hospital. Patients originated in 78 of the 99 counties in Iowa. The median distance was 63 miles. Of the transfers from local hospitals, 86% were within 90 miles with the largest group 60-89 miles from the CSC. Of all patients transferred for ischemic stroke approximately 30% received treatment with intravenous alteplase at the outside hospital. Conclusion: In conclusion, these data suggest a high degree of geographical dispersion for stroke patients transferred to a CSC in a rural state. This analysis of the system of stroke care in Iowa indicates the CSC provided support to multiple community hospitals for acute stroke treatment. Further analysis of the system of stroke care is needed to better understand patient transfers including mode of transfer and reason for transfer.

Newborn drug testing practices in Iowa birthing hospitals.

Federal law mandates states to have policies and procedures to identify newborns exposed to maternal substance use during pregnancy. National guidelines for newborn drug testing are lacking; therefore, procedures are variable and determined by state law and local practices. In Iowa, maternal substance use during pregnancy is considered child abuse and must be reported.The objective of this study was to identify newborn drug testing policies and procedures among birthing hospitals in Iowa. This was a cross sectional survey of all birthing hospitals in Iowa identified via the Statewide Perinatal Care Program. An electronic survey was sent to the representative at each affiliated hospital. Sixty-nine of 76 hospitals completed the survey for a 90.8% response rate. Newborn drug testing is ordered in 97.1% of responding hospitals with most testing 25% or less of newborns annually. The majority utilized a risk assessment tool (89.6%), although many (62.7%) also allowed for provider discretion. No hospital performed universal testing of all newborns. 86.6% of hospitals reported all positive newborn drug test results including illicit and/or prescription drugs to child protective services. 35.0% of hospitals notified mothers of the report and 45.5% offered substance abuse services and/or treatment to the mothers. Most Iowa birthing hospitals perform newborn drug testing and report all positive test results to child protective services. The majority use risk assessment tools. Maternal notification practices and referral for substance use disorder treatment are suboptimal and represent an area for future improvement.

Lack of generalizability of observational studies' findings for turnover time reduction and growth in surgery based on the State of Iowa, where from one year to the next, most growth was attributable to surgeons performing only a few cases per week

Study objectiveThree observational studies at large teaching hospitals found that reducing turnover times resulted in the surgeons performing more cases. We sought to determine if these findings are generalizable to other hospitals, because, if so, reducing turnover times may be an important mechanism for hospitals to use for growing caseloads. DesignObservational cohort study. Setting116 hospitals in Iowa with inpatient or outpatient surgery from July 1, 2013 through June 30, 2015. SubjectsSurgeons in Iowa, each with a unique identifier among hospitals. MeasurementsThe independent variable was the number of inpatient and outpatient cases that each surgeon performed each week during the first fiscal year beginning July 1, 2013. The dependent variables were surgeons' number of inpatient and outpatient surgical cases, and intraoperative work relative value units (RVU's) for outpatient cases, during the second fiscal year. Main resultsThe average hospital in Iowa had less than half of its growth from year 1 to year 2 in numbers of cases among surgeons who performed >2 cases per week in the baseline year (23.0%±2.5% [SE], P<0.0001 comparing mean to 50%). Less than half the growth in RVU's was among those surgeons (18.1%±2.2%, P<0.0001). The average hospital in Iowa had less than half of its growth in numbers of cases among surgeons who performed 2 or fewer cases per week at the hospital during the baseline year and >2 cases per week at other hospitals in the state during that year (24.4%±2.6%, P<0.0001). Less than half the growth in RVU's was among those surgeons (21.3%±2.5%, P<0.0001). ConclusionsMost (≥50%) annual growth in surgery, both based on the number of total inpatient and outpatient surgical cases, and on the total outpatient RVU's, was attributable to surgeons who performed 2 or fewer cases per week at each hospital statewide during the preceding year. Therefore, the strategic priority should be to assure that the many low-caseload surgeons have access to convenient OR time (e.g., by allocating sufficient OR time, and assigning surgeon blocks, in a mathematically sound, evidence-based way). Although reducing turnover times and anesthesia-controlled times to promote growth will be beneficial for a few surgeons, the effect on total caseload will be small.

At most hospitals in the state of Iowa, most surgeons' daily lists of elective cases include only 1 or 2 cases: Individual surgeons' percentage operating room utilization is a consistently unreliable metric

Study objectivePercentage utilization of operating room (OR) time is not an appropriate endpoint for planning additional OR time for surgeons with high caseloads, and cannot be measured accurately for surgeons with low caseloads. Nonetheless, many OR directors claim that their hospitals make decisions based on individual surgeons' OR utilizations. This incongruity could be explained by the OR managers considering the earlier mathematical studies, performed using data from a few large teaching hospitals, as irrelevant to their hospitals. The important mathematical parameter for the prior observations is the percentage of surgeon lists of elective cases that include 1 or 2 cases; “list” meaning a combination of surgeon, hospital, and date. We measure the incidence among many hospitals. DesignObservational cohort study. Setting117 hospitals in Iowa from July 2013 through September 2015. SubjectsSurgeons with same identifier among hospitals. MeasurementsSurgeon lists of cases including at least one outpatient surgical case, so that Relative Value Units (RVU's) could be measured. Main resultsAveraging among hospitals in Iowa, more than half of the surgeons' lists included 1 or 2 cases (77%; P<0.00001 vs. 50%). Approximately half had 1 case (54%; P=0.0012 vs. 50%). These percentages exceeded 50% even though nearly all the surgeons operated at just 1 hospital on days with at least 1 case (97.74%; P<0.00001 vs. 50%). The cases were not of long durations; among the 82,928 lists with 1 case, the median was 6 intraoperative RVUs (e.g., adult inguinal herniorrhaphy). ConclusionsAccurate confidence intervals for raw or adjusted utilizations are so wide for individual surgeons that decisions based on utilization are equivalent to decisions based on random error. The implication of the current study is generalizability of that finding from the largest teaching hospital in the state to the other hospitals in the state.

The Iowa Disinfection Cleaning Project: Opportunities, Successes, and Challenges of a Structured Intervention Program in 56 Hospitals.

OBJECTIVE A diverse group of hospitals in Iowa implemented a program to objectively evaluate and improve the thoroughness of disinfection cleaning of near-patient surfaces. Administrative benefits of, challenges of, and impediments to the program were also evaluated. METHODS We conducted a prospective, quasi-experimental pre-/postintervention trial to improve the thoroughness of terminal room disinfection cleaning. Infection preventionists utilized an objective cleaning performance monitoring system (DAZO) to evaluate the thoroughness of disinfection cleaning (TDC) expressed as a proportion of objects confirmed to have been cleaned (numerator) to objects to be cleaned per hospital policy (denominator)×100. Data analysis, educational interventions, and objective performance feedback were modeled on previously published studies using the same monitoring tool. Programmatic analysis utilized unstructured and structured information from participants irrespective of whether they participated in the process improvement aspects to the program. RESULTS Initially, the overall TDC was 61% in 56 hospitals. Hospitals completing 1 or 2 feedback cycles improved their TDC percentages significantly (P90% for at least 38 months. A survey of infection preventionists found that lack of time and staff turnover were the most common reasons for terminating the study early. CONCLUSION The study confirmed that hospitals using this program can improve their TDC percentages significantly. Hospitals must invest resources to improve cleaning and to sustain their gains. Infect Control Hosp Epidemiol 2017;38:960-965.