Huntsville Hospital Research Articles

The Use of Drugs that Should be Avoided or Used with Caution in Patients Hospitalized for Acute Decompensated Heart Failure.

Heart failure (HF) is a pervasive global health concern, with acute decompensated heart failure (ADHF) contributing significantly to morbidity and mortality. Medications used in patients with HF may exacerbate HF or prolong the QT interval, posing additional risks. The objective is to assess the prevalence and utilization patterns of medications known to cause or exacerbate HF and prolong the QT interval among patients with ADHF. Understanding these patterns is crucial for optimizing patient care and minimizing potential risks. A retrospective chart review was conducted at Huntsville Hospital, Huntsville, USA, covering 602 patients with ADHF over a 40-month period. Inclusion criteria involved age ≥ 18 years, a history of HF, and ADHF admission. The 2016 American Heart Association Scientific Statement was used to identify drugs that may cause or exacerbate HF and those that could prolong the QT interval RESULTS: Among the 602 patients, 57.3% received medications causing or exacerbating HF, notably albuterol (34.9%) and diabetes medications (20.4%), primarily metformin, followed by urologic agents (14.3%), mostly tamsulosin, and nonsteroidal anti-inflammatory drugs (NSAIDs) (6.1%). Moreover, 82.9% were on medications prolonging the QT interval, with loop diuretics, amiodarone, ondansetron, and famotidine most prevalent. Furthermore, 42.1% of the patients received more than two concomitant medications that prolong the QT interval, which can further exacerbate the risk of torsades de pointes. This study underscores the high prevalence of HF-causing or HF-exacerbating medications and QT-prolonging drugs in patients with ADHF. Healthcare professionals must be cognizant of these patterns, advocating for safer prescribing practices to optimize patient outcomes and reduce the burden of HF-related hospitalizations.

Impact of the COVID-19 pandemic on gender disparities in acute coronary syndrome patterns.

BackgroundGlobal evidence has emerged showing fewer Acute Coronary Syndrome (ACS) cases than expected during the COVID-19 pandemic. Our study aims to evaluate the incidence of ACS before and after the onset of the COVID-19 pandemic and analyze differences in gender distribution, and type of presentation.MethodsThis is a retrospective study of 997 patients who presented to Huntsville Hospital's catheterization lab for elective and emergency catheterization for ACS and non-ACS during a four-week period from February 26, 2020, to March 10, 2020, and from March 25, 2020, to April 8, 2020, and compared with the equivalent weeks in 2019.ResultsWe report a 45.5% decrease in ACS cases presenting during the COVID-19 pandemic between March 25, 2020, to April 8, 2020 compared to equivalent weeks in 2019, with a significant drop in percentage of female patients presenting by 30.6%. Upsurge in STEMI cases and a drop in NSTEMI cases was observed during the COVID pandemic compared to 2019.ConclusionsPatients presenting after the onset of the pandemic had elevated cardiac markers, representing higher severity and potentially presenting later in the disease course. The number of total ACS cases and percentage of females presenting to the catheterization lab before the COVID surge (February/March 2019 and 2020) almost remained stable. This comparison data provides validity that the drop in ACS case volume and females in March/April 2020 is more likely due to the pandemic and not due to improvements in overall cardiovascular health metrics. Reasons for this disparity are likely multifaceted and deserve further investigation.

The Efficacy of Registered Dietitian Interventions in Type 2 Diabetes Management in a Family Practice Clinic in North Alabama

Background: Diabetes self-management education and support (DSMES) and medical nutrition therapy (MNT) have been proven to improve patient outcomes. However, many patients rely on their physician solely for diabetes education despite referrals for diabetes education outside of the physician’s office. Objective: Our aim was to optimize type 2 diabetes management in a family practice clinic by providing patients with individualized DSMES and MNT by a Registered Dietitian inside of the family practice clinic. Methods: A random sample of 40 charts was chosen from the electronic medical records of patients with type 2 diabetes completing DSMES and individualized MNT with a Registered Dietitian. Data was extracted from a retrospective chart review on hemoglobin A1C levels before and after appointments with the Registered Dietitian in the family practice clinic from September 2015-November 2015. Analyses were used to assess frequency of patients decreasing their hemoglobin A1C levels, which reveals good glycemic control. Results: A paired sample t test was performed (n=40). The results revealed that post DSMES and MNT Hemoglobin A1C values (M = 6.84%, SD ± 1.0) were significantly lower than the pre DSMES and MNT Hemoglobin A1C values (M = 7.17%, SD ± 1.3), t (40) = 2.89, p < 006. Conclusions: Many healthcare professionals can give dietary advice to patients, but Registered Dietitians are trained to provide individualized nutrition therapy to patients. Combining the knowledge of the physician and registered dietitian can help patients to reach optimal diabetes control in order to prevent or minimize complications. Research has demonstrated a 1% decrease in Hemoglobin A1C levels result in a 21% reduction in diabetes associated mortality, a 14% reduction in myocardial infarction, and a 37% reduction in microvascular complications. Disclosure B.H. Chester: Employee; Self; Huntsville Hospital Diabetes Control Center, Wayne G. Stanley, MD, PC, Boston Heart Diagnostics. W.G. Stanley: Other Relationship; Self; Wayne G. Stanley, MD, PC. G. Thangiah: None.

Utilization of Kaizen Methodology to Promote Safe Care Paradigms in Neonatal ICUs

Keywords: Kaizen, Staffing Models, Care Paradigms Institutions: 1. Huntsville Hospital, Huntsville, AL, United States 2. Joe DiMaggio Children’s Hospital, Hollywood, FL, United States 3. Banner Thunderbird Medical Center, Phoenix, AZ, United States 4. Baptist South Medical Center, Montgomery, AL, United States Background: Allied Health Personnel are being utilized to enhance the care teams in Neonatal Intensive Care Units. Staffing models for Neonatologist and Allied Health Care Providers varies depending on the type, size, location, and acuity of the NICU. State …

Seasonal variation of respiratory pathogen colonization in asymptomatic health care professionals: A single-center, cross-sectional, 2-season observational study

BackgroundThe purpose of this study was to determine the seasonal variance of potentially pathogenic bacterial and viral organisms in nasopharyngeal specimens obtained from asymptomatic health care professionals (HCPs) during the 2014 winter and summer months.MethodsNasopharyngeal specimens from 100 HCPs were collected from Huntsville Hospital (Huntsville, AL) during the winter and from 100 HCPs during the summer. All subjects were tested for 22 viruses and 19 bacteria using Target Enriched Multiplex Polymerase Chain Reaction. Both seasonal cohorts were composed of students, nurses, physicians, and residents.ResultsOf the 100 HCPs tested during the winter, 34 subjects were colonized with at least 1 bacterium, and 11 tested positive for at least 1 virus. Methicillin-resistant Staphylococcus aureus (MRSA), Moraxella catarrhalis, and coronavirus were the most frequently detected potentially infectious agents. Of the 100 HCPs tested during the summer, 37 tested positive for at least 1 bacterium, and 4 tested positive for a viral agent. The most prevalent bacteria were MRSA and Klebsiella pneumonia.ConclusionNasopharyngeal carriage among asymptomatic HCPs was common, but the frequency and presence of potential pathogens varied with each season. Understanding the colonization and infection potential of upper respiratory organisms is important, particularly for viruses. Although asymptomatic HCPs certainly harbor a number of different potentially infectious agents, future studies are needed to determine whether colonized pathogens are transmitted or initiate infection in at-risk patient populations.

Point-of-Care Platelet Reactivity Determination with VerifyNow-P2Y12 following Administration of Clopidogrel or Prasugrel: Data from a Real-World, Clinical Care Inpatient Setting

Objectives: To describe VerifyNow-P2Y12 (VN-P2Y12, Accumetrics, San Diego, CA) results from patients treated with either clopidogrel or prasugrel who were seeking care in a hospital setting. Background: VN-P2Y12 is a point-of-care device that measures platelet reactivity to adenosine diphosphate. Past assessments of thienopyridine therapy utilizing VN-P2Y12 have largely come from clinical trial settings. There are limited data from real-world settings. Methods: Electronic medical record data from Huntsville Hospital (Huntsville, AL) for those who underwent VN-P2Y12 testing for clopidogrel or prasugrel between January 1, 2009 and October 31, 2010 were analyzed. The VN-P2Y12 data included P2Y12 reaction units (PRUs) and device-reported percentage of inhibition. Descriptive analyses were conducted with t tests, and a logistic regression model was estimated to assess the association between patient characteristics and the likelihood of platelet nonresponse. Results: In total, 2882 tests (2476 with clopidogrel and 406 with prasugrel) were analyzed. For clopidogrel and prasugrel, respectively, mean PRU standard deviation (SD) was 206 (90) and 107 (93; P < 0.0001) and mean % inhibition (SD) was 31% (26%) and 63% (31%; P < 0.0001). Treatment with clopidogrel alone (odds ratio [OR] = 5.25; P < 0.0001), being non-Caucasian (OR = 1.48; P = 0.0440), obese (OR = 1.49; P = 0.0010), anemic (OR = 3.29; P < 0.0001), diabetic (OR = 1.75; P < 0.0001), and having a history of myocardial infarction (OR = 1.57; P < 0.0001) were significant predictors of having PRU ≥ 235. Conclusion: This real-world data analysis shows results that are consistent with clinical trial results, namely that compared with clopidogrel, prasugrel is associated with significantly lower PRU and greater percentage of inhibition, regardless of age, race, gender, diabetes, obesity, or proton pump inhibitor use.

Continuous Quality Improvement Initiative for Pressure Ulcer Prevention

Hospital-acquired pressure ulcers can extend a patient's length of stay, decrease health-related quality of life, and increase the risk of mortality and cost of patient care. Although risk assessment and pressure ulcer prevention efforts had been in place for many years, our facility continued to be more than national averages and we identified a need for extensive education and consistency throughout the organization in order to reduce hospital-acquired pressure ulcer occurrences. The continuous quality improvement initiative implemented by Huntsville Hospital created a clinical culture of pressure ulcer prevention, resulting in improved patient outcomes and cost savings.

Baby Steps: One Hospital's Quest to Improve Its Breastfeeding Practices

Newborn Care Poster Presentation Purpose for the Program Though numerous research studies show the positive effect of the United Nations International Children's Emergency Fund (UNICEF)/World Health Organization (WHO) Baby Friendly Hospital Initiative on breastfeeding rates, only 143 hospitals in the United States have undertaken the necessary steps to become Baby Friendly. In the current economic climate, some hospitals may be concerned about potential costs, including refusing free formula, and others may face cultural or institutional barriers to full implementation. In 2011, Huntsville Hospital for Women & Children began an initiative to improve its breastfeeding practices. Alabama has the fourth lowest breastfeeding rate in the nation, with less than 60% of infants ever having been breastfed. At Huntsville Hospital, about three‐fourths of women intend to breastfeed (similar to the national rate). To support these mothers, hospital leaders decided to advance breastfeeding practices to be in line with the Baby Friendly Hospital Initiative and evidence‐based practice. Proposed Change Using the Baby‐Friendly steps as guidelines, a committee of interested staff and leaders from the postpartum unit planned and implemented a series of interventions focused on breastfeeding. Implementation, Outcomes, and Evaluation Staff members were first surveyed about breastfeeding knowledge and education ability. Survey data were used to create a mandatory full‐day course for all unit nurses that focused on areas where staff needed further education. Additional steps undertaken by the unit included replacing the patient discharge bags that display the formula company with bags that contain the hospital logo, increasing lactation consultant hours on the unit, creation of a unit‐specific breastfeeding booklet for staff, changing the infants’ intake/output sheet to include breastfeeding education for parents, and to not distribute pacifiers unless specifically requested by parents. Preliminary data indicated that the breastfeeding course objectives were met and patient satisfaction scores related to breastfeeding assistance were high. Despite the hospital's initial successes, it still faces many challenges in its quest to implement all 10 steps of the Ten Steps to Successful Breastfeeding as outlined by the Baby Friendly Hospitals Initiative. In a state with traditionally low breastfeeding rates, barriers include getting families to room‐in with infants, encouraging physicians’ infant assessments and other interventions to be performed in patient rooms, increasing funding for lactation consultants at night and on weekends, looking at ways for mothers who had a cesarean delivery to breastfeed their infants within 1 hour of delivery, and implementing breastfeeding support groups. Implications for Nursing Practice Increased staff knowledge, high patient satisfaction scores, and movement toward compliance with the Baby Friendly Hospital's Ten Steps to Successful Breastfeeding are all positive signs of improved breastfeeding practices at Huntsville Hospital. Other hospitals that want to work toward Baby Friendly practices can learn from Huntsville's successes and continued challenges in improving its breastfeeding policies and practices.

Protecting Our Littlest Patients: A Newborn Falls Prevention Strategy

Childbearing Poster Presentation Objective To reduce and prevent newborn falls at Huntsville Hospital for Women and Children. Design Evidence‐based quality improvement project. Sample Mother/baby patients and staff. Methods There were seven newborn falls during a 7‐month time period on the hospital's postpartum unit. After the first falls, the unit formed a committee to create a policy on newborn fall prevention and to develop education and tools for family members and staff to decrease the incidence of infant falls/drops. Committee members used information from review of the seven falls events, from a comprehensive literature review on newborn falls, and from information collected by the unit's Nurse Manager from other hospitals with similar numbers of deliveries. Implementation Strategies As a result of the committee's work, the following interventions targeting family members have currently been implemented: information on newborn falls added to safety instruction sheet read to, given to, and signed by parents at admission: new crib cards with information on falls prevention; room posters and mirror clings with falls information created; and falls information to be added as a crawl on unit's Newborn Channel. Parents are also educated on newborn falls during childbirth classes. Strategies targeting staff members include staff education on falls through a mandatory class, e‐mails, staff meetings, and unit flyers; a new Fall Risk Assessment Tool added to charting system; and a Newborn Post‐Fall Debriefing Form created for use after fall events. The Newborn Falls Policy is now in use and includes protocol for parental education, infant transport, placement of infant for sleeping, review of maternal medications, assessment of environment and mother's level of consciousness, and actions for preventing falls during infant feedings. In addition, Falls Committee staff members are meeting with pediatricians who see patients at Huntsville Hospital to plan a unified protocol for physician response to newborn falls. Results No newborn falls have occurred in the time period since the implementation of this comprehensive falls prevention strategy. Conclusion/Implications for Nursing Practice The issue of newborn falls (drops) in the hospital is one that has only been recognized as a problem in recent years. With little in the literature to provide evidence‐based guidelines for a uniform healthcare policy response, hospitals are developing their own strategies to reduce and prevent newborn falls. Other hospitals seeking to reduce and prevent newborn falls may learn from the experience of Huntsville Hospital in its newborn falls initiative.

Effect of Intermittent Nesiritide Administration on Kidney Function

We read with interest the recent article by Ng et al that described no difference in the incidence of acute renal injury in patients with acute decompensated heart failure (HF) receiving either nitroglycerin or nesiritide. On the other hand, their results suggested preservation of renal function by nesiritide. This prompted us to report our findings on the effect of periodic outpatient administration of nesiritide on renal function in patients with refractory HF unresponsive to optimal oral therapy. We reviewed the charts of 46 patients with chronic HF refractory to optimal oral therapy who received intermittent nesiritide infusions at the HF clinic at Huntsville Hospital, Alabama, United States. Intravenous nesiritide was given as a bolus of 2 mcg/kg followed by 0.01 mcg/kg per min over 4 to 6 hours at each visit to the clinic (ranged from twice a week to once every 3 weeks depending on the severity of symptoms). Patients were followed over a period of 6 months for worsening of renal function defined as an increase in serum creatinine of more than 0.5 mg/dL. We excluded patients with baseline serum creatinine of >2.5 mg/dL or those on dialysis. Patients received between 8 and 40 infusions of nesiritide during the 6-month period, none of them received an inotropic agent because of clinical evidence of decompensated HF and none died during the study period. At the beginning of the study, mean serum creatinine was 1.28 + 0.48 mg/dL, with no significant change after 6 months, 1.29 + 0.50 mg/dL (P > .05). None of the patients had an increase in serum creatinine of more than 0.5 mg/dL at the end of the study. Our findings suggest that repetitive administration of nesiritide does not worsen kidney function as assessed by serum creatinine and are in agreement with the findings of Ng et al. When assessing the kidney function based on the definition of Ng et al, an acute rise in creatinine of 0.3 mg/dL or 25% from the baseline, we noted that only 2 of 45 patients met this definition (P > .05). This study was limited by its open-label design, the relatively small number of patients studied, and the absence of a comparable group. The concern about nesiritide’s negative effect on renal function stemmed from a meta-analysis that suggested an increased risk of worsening renal function associated with the use of nesiritide. Although the meta-analysis is certainly hypothesis generating, part of the data used in this analysis were pooled from early dosing trials where the doses of nesiritide used were higher than the US Food and Drug Administration (FDA)approved dose. In addition, none of them were powered to look at the effect of nesiritide on renal function. On the other hand, the recent landmark Acute Study of Clinical Effectiveness of Nesiritide in Decompensated Heart Failure (ASCEND-HF) trial, a randomized trial with >7000 patients, has concluded that nesiritide does not compromise renal function when used in acute decompensated HF. In addition, other recent studies suggest that there was no evidence of worsening renal function with nesiritide. Our study differs from those trials as our patients did not have decompensated HF, yet they had severe symptoms despite optimal oral therapy. In addition, our patients received multiple nesiritide infusions, ranging from 8 to 40, over a 6-month period. Despite receiving repetitive dosing of intravenous nesiritide, patients with chronic HF refractory to optimal oral therapy maintained a stable renal function over a 6-month period. Nesiritide seems to be safe and does not compromise renal function. Yet, the drug should not be used for intermittent outpatient infusions and should be limited to inpatients use, as approved by FDA.

Stroke scans and radiation risk

Stroke scans and radiation risk

University of Alabama School of Medicine

University of Alabama School of Medicine

Transformation of a Pharmacy Department: Impact on Pharmacist Interventions, Error Prevention, and Cost

Current medical literature supports the unit-based (UB) pharmacy concept as a best practice. In an effort to determine its feasibility, Huntsville Hospital (Huntsville, Alabama) conducted a pilot study to compare the central-based (CB) model with the UB model and then implemented the new model. Data were collected for two high-volume nursing units for 10 days for each model. Pharmacists practicing in the UB setting documented more interventions than the CB pharmacist by a factor of three to one, resulting in an 85% increase in cost avoidance. Converting the pharmacy services to a UB model entailed creating 16 new pharmacist positions. Extrapolation of the savings for the UB model ($520 per day) and the CB model ($280) for 1 year suggested that adoption of the UB model would generate an additional $87,600 in cost avoidance for these two nursing units. Each new pharmacist was trained for at least 3 months before being scheduled to work independently as a UB pharmacist. Clinical interventions by pharmacists greatly increased after implementation of the UB model. The baseline monthly average of interventions for the 6 months before implementation was 239, and the monthly cost avoidance was $21,300. In October 2001, the first full month of implementation, there were 1,315 interventions and a monthly cost avoidance of $130,192. Converting to the UB model has required a considerable increase in the number of pharmacist positions, yet there has been a dramatic increase in clinical pharmacy interventions, with a corresponding decrease in drug expenditures.

A Four-Year Experience with Patient Individualized Heparin and Protamine Dosing Using the Hemochron® RxDx™ System

Cardiac surgical case histories, collected over 4 years at Huntsville Hospital in Alabama, were reviewed for 2,293 patients. Patients were separated into two dosing groups for both heparin and protamine, hospital empirically dosed and Hemochron RxDx dosed. Review of the heparin dosing information found that incomplete data were collected for 47 patients, leaving 2,246 patients eligible to be evaluated for heparin dose comparison. Both RxDx recommended and empirically calculated doses were recorded, as well as the actual dose given. Of the 2,246 patients, 1671 were administered heparin according to the RxDx calculated dose, and the remaining 575 patients were dosed according to the hospital’s empirical protocol. The average RxDx calculated heparin dose was 17% greater then the empirically calculated heparin dose (350 U/kg) (p &lt; .001). Anticoagulation to target ACT (480 sec) was achieved in 92% of the patients dosed according to the RxDx recommended dose; whereas, in the empirically dosed patient group only 80% of the patients reached the target ACT after initial heparin bolus dose. Incomplete protamine dosing data was recorded for 336 patients, leaving a total of 1,957 patients available for protamine dose evaluation. All patients had an RxDx protamine calculation, empirical protamine calculation, and actual amount of protamine dosed recorded. Of the 1,953 patients, 1,764 were dosed according to the RxDx recommended dose, with the remaining 189 patients dosed empirically (1 mg protamine/100 U of heparin). In both the RxDx and the empirical groups, 96% of the patients returned to baseline following initial protamine infusion. The overall RxDx dose (293 mg) was 16% lower than the average empirical dose (348 mg). The RxDx system has been shown to be an effective method for determining patient-specific dosing for both heparin and protamine. This long-term clinical experience demonstrates the consistency and reliability of patient maintenance using this individualized dosing system, which has been shown, in other independent evaluations, to lead to improved patient outcomes.

Medical Care in the Nursing Home

To Editor.— We were interested in review entitled Medical Care in Nursing Home by Dr Ouslander.1He did a superb job in describing problems and recommending solutions for care of patients in our nursing homes. But we would like to take exception to his statement that the majority of primary care physicians do not participate in care of nursing home residents.2 Our recent survey of all graduates of family practice residency at University of Alabama in Huntsville/ Huntsville Hospital since 1976 showed that 75% made monthly visits to nursing homes, with an average of 16 patients seen per month. We believe that all students and residents who are interested in primary care should be exposed to nursing home patients during their educational process and that this approach should be added to Dr Ouslander's lists of strategies to improve medical