Inpatient Floor Research Articles

COVID-19 in solid organ transplant recipients: Initial report from the US epicenter.

Solid organ transplant recipients may be at a high risk for SARS‐CoV‐2 infection and poor associated outcomes. We herein report our initial experience with solid organ transplant recipients with SARS‐CoV‐2 infection at two centers during the first 3 weeks of the outbreak in New York City. Baseline characteristics, clinical presentation, antiviral and immunosuppressive management were compared between patients with mild/moderate and severe disease (defined as ICU admission, intubation or death). Ninety patients were analyzed with a median age of 57 years. Forty‐six were kidney recipients, 17 lung, 13 liver, 9 heart, and 5 dual‐organ transplants. The most common presenting symptoms were fever (70%), cough (59%), and dyspnea (43%). Twenty‐two (24%) had mild, 41 (46%) moderate, and 27 (30%) severe disease. Among the 68 hospitalized patients, 12% required non‐rebreather and 35% required intubation. 91% received hydroxychloroquine, 66% azithromycin, 3% remdesivir, 21% tocilizumab, and 24% bolus steroids. Sixteen patients died (18% overall, 24% of hospitalized, 52% of ICU) and 37 (54%) were discharged. In this initial cohort, transplant recipients with COVID‐19 appear to have more severe outcomes, although testing limitations likely led to undercounting of mild/asymptomatic cases. As this outbreak unfolds, COVID‐19 has the potential to severely impact solid organ transplant recipients.

An Orthopaedic Department's Response to the COVID-19 Health-Care Crisis: Indirect and Direct Actions with Thoughts for the Future.

An Orthopaedic Department's Response to the COVID-19 Health-Care Crisis: Indirect and Direct Actions with Thoughts for the Future.

COVID-19 Response in the Global Epicenter: Converting a New York City Level 1 Orthopedic Trauma Service into a Hybrid Orthopedic and Medicine COVID-19 Management Team.

The SARS-COV-2 (COVID-19) pandemic has placed unprecedented challenges on the health care system in the United States with New York City at its epicenter. By the end of the 8 week (4/23/2020) since the virus's emergence in New York City, there have been 142,432 confirmed COVID-19 cases and 10,977 deaths attributed to complications from COVID-19-related illnesses. Secondary to policies enacted by the New York State government to limit spread of the virus, Orthopedic Surgery departments at hospitals around the area have witnessed an abrupt change in clinical demands. At a local level one trauma hospital in Queens, New York, Orthopedic Surgery elective cases have been cancelled, trauma consult volume has experienced a sharp decline, and both residents and attendings have been repurposed to meet the new clinical demands of this medical crisis. Our own orthopedic surgery service has adopted care for patients normally admitted to an internal medicine service in a novel Ortho-Medical COVID-19 management team. We prepared this primer to make our experience with caring for COVID-19 patents available as a reference for other surgical subspecialty services preparing to adjust the clinical focus of their hospital teams during this or future pandemics. LEVEL OF EVIDENCE:: Level V.

MP66-01 HEMATURIA COMMUNICATION

INTRODUCTION AND OBJECTIVE: Gross hematuria can be a challenge to describe for non-urologic health care providers. Tools to aid in accuracy of communication are lacking and not commonly incorporated in healthcare systems. Our aim is to determine the current status of hematuria communication and assess the ability to improve consistency in communication by using a color picture guide and specific assessment prompting. METHODS: We prospectively performed a single-institution, hospital wide-assessment including all inpatient floor nurses. A 15-item questionnaire was distributed electronically during a 3 week completion period. To evaluate hematuria communication, participants were shown an image of indwelling catheter tubing with gross blood in the urine. In 2 sequential pages, participants were asked to describe the same hematuria image using 1) currently established electronic medical record selection choices, then 2) using a newly devised color reference guide with specific prompting to evaluate clarity and presence of blood clots. Comparisons were made between assessments to evaluate the number of unique responses and rate of documenting clarity and clots. RESULTS: A total of 311 nurses participated in the survey (response rate of 21%) from varied health care settings including the intensive care unit (32%), medical floor (22%), surgical floor (18%), Urology floor (5%), or other (23%). Although the majority of nurses previously managed a patient with active hematuria (87%), 35% believed the urine in the catheter bag was most informative when describing patients with hematuria. The number of unique responses significantly decreased when using a color reference guide compared to current hospital practice (n=9 vs n=37, respectively). All nurses commented on clots (100% vs 1%) and clarity (100% vs 87%) after specific prompting compared to lower rates for current practices. Majority of nurses described the color reference guide as useful (n=287, 97%) and would utilize the tool in current practice if readily available (n=291, 98%). CONCLUSIONS: A newly devised hematuria color guide and prompting assessment significantly reduced variations in hematuria descriptions from health care providers. Nearly all surveyed nursing personnel would prefer to utilize such methodology when describing patients with hematuria. Prospective implementation to assess impact is warranted to further evaluate the potential benefit with hematuria communication. Source of Funding: N/A

Evaluating the effect of hospital setting on outcomes for neonatal abstinence syndrome.

This study aims to evaluate the impact of hospital setting on outcomes for infants with neonatal abstinence syndrome. We conducted a retrospective study in two hospitals and three different hospital units. The inpatient group (n = 60) was managed on general inpatient floors, the NICU group (n = 50) was managed primarily in an NICU, and the combination group (n = 49) was managed in both NICU and inpatient units. The primary outcome was length of stay. Secondary outcomes included breastfeeding rates, morphine usage rates, and hospital costs. The length of stay in the inpatient group (8.5 days) was significantly lower than the combination group (18 days) and NICU group (23 days) (p < 0.01). The inpatient group had significantly lower rates of morphine treatment and hospital costs with no difference in breastfeeding rates. Infants with neonatal abstinence syndrome had a significantly shorter length of stay and less use of morphine when managed on inpatient units versus NICU.

COVID-19 and Renal Failure: Challenges in the Delivery of Renal Replacement Therapy.

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), first officially reported in December 2019 in Wuhan City, Hubei province, China, and has since lead to a pandemic. Most cases result in minor symptoms such as cough, fever, sore throat, myalgia, fatigue, nausea, diarrhea, loss of smell, and abdominal pain. As of April 8, 2020, more than 1,485,000 cases of COVID-19 have been reported in more than 200 countries and territories, resulting in over 90,000 deaths. Outcomes are worse in elderly patients, particularly males, and those with comorbidities, but can affect any age group. The incidence of acute kidney injury in patients with COVID-19 infection is about 3-15%; and in patients with severe infection requiring care in the intensive care unit, the rates of acute kidney injury increased significantly from 15% to 50%. Acute kidney injury is an independent risk factor for mortality in COVID-19 patients. The nephrologists, as well as intensivists, are facing immense daily challenges while providing care for these patients in the inpatient setting as well as end-stage renal disease patients on chronic dialysis in both inpatient and outpatient settings. In the current review article, we discussed the epidemiology and etiology of acute kidney injury, management of acute kidney injury including renal replacement therapy options (both hemodialysis and peritoneal dialysis) for inpatient floor, as well as intensive care unit settings. We also discussed the challenges faced by the outpatient dialysis units with COVID-19 infection. We discussed measures required to limit the spread of infection, as well as summarized the guidance as per the Centers for Disease Control and Prevention (CDC), American Society of Nephrology (ASN), American Society of Diagnostic and Interventional Nephrology (ASDIN) and the Vascular Access Society of the Americas (VASA).

Performance of an Automated Screening Algorithm for Early Detection of Pediatric Severe Sepsis.

To create and evaluate a continuous automated alert system embedded in the electronic health record for the detection of severe sepsis among pediatric inpatient and emergency department patients. Retrospective cohort study. The main outcome was the algorithm's appropriate detection of severe sepsis. Episodes of severe sepsis were identified by chart review of encounters with clinical interventions consistent with sepsis treatment, use of a diagnosis code for sepsis, or deaths. The algorithm was initially tested based upon criteria of the International Pediatric Sepsis Consensus Conference; we present iterative changes which were made to increase the positive predictive value and generate an improved algorithm for clinical use. A quaternary care, freestanding children's hospital with 404 inpatient beds, 70 ICU beds, and approximately 60,000 emergency department visits per year PATIENTS:: All patients less than 18 years presenting to the emergency department or admitted to an inpatient floor or ICU (excluding neonatal intensive care) between August 1, 2016, and December 28, 2016. Creation of a pediatric sepsis screening algorithm. There were 288 (1.0%) episodes of severe sepsis among 29,010 encounters. The final version of the algorithm alerted in 9.0% (CI, 8.7-9.3%) of the encounters with sensitivity 72% (CI, 67-77%) for an episode of severe sepsis; specificity 91.8% (CI, 91.5-92.1%); positive predictive value 8.1% (CI, 7.0-9.2%); negative predictive value 99.7% (CI, 99.6-99.8%). Positive predictive value was highest in the ICUs (10.4%) and emergency department (9.6%). A continuous, automated electronic health record-based sepsis screening algorithm identified severe sepsis among children in the inpatient and emergency department settings and can be deployed to support early detection, although performance varied significantly by hospital location.

Bronchoscopic delivery of aminocaproic acid as a treatment for pulmonary bleeding: A case series

ObjectiveBronchoscopy is an essential therapeutic modality in the treatment of pulmonary bleeding. Although numerous endoscopic treatments exist, topical ε-aminocaproic acid has not been described in the literature. This study documents the use of this novel treatment for pulmonary bleeding and compares it to available evidence for tranexamic acid, a similar anti-fibrinolytic agent. DesignCase-series study. SettingICU and general inpatient floors of a tertiary medical center. PatientsForty-six patients receiving endobronchial ε-aminocaproic acid for the treatment or prevention of pulmonary bleeding. Measurements and main resultsOf the 46 patients included in the study, 41.6% and 13% presented with non-massive and massive hemoptysis, respectively. In patients with active pulmonary bleeding, endobronchial application of ε-aminocaproic acid and accompanying therapies resulted in cessation of bleeding in 94.7% of cases. A total of six patients received ε-aminocaproic acid monotherapy; in three patients with active bleeding, 100% achieved hemostasis after treatment. Of the 36 patients successfully treated for active pulmonary bleeding, 27.8% had recurrent bleeding within 30 days. Thirty-day adverse events were as follows: death (10 patients), deep vein thrombosis (2 patients), renal failure (2 patients), and stroke (2 patients). ConclusionsEndobronchial administration of ε-aminocaproic acid during bronchoscopy may be a safe and efficacious option in the treatment and prevention of pulmonary bleeding. Further studies are necessary to better define ε-aminocaproic acid's safety profile, optimal routes of administration, and comparative effectiveness to tranexamic acid.

Impact of Intravenous Opioid Shortage on Managing Pain Crisis in Sickle Cell Disease

Background: Vaso-occlusive crisis (VOC) is the hallmark complication of sickle cell disease (SCD) (1), and usually requires intravenous (IV) opioid treatment in emergency room (ER) or acute care center (ACC), a designated observation unit to manage uncomplicated VOC (2). Starting October 2017, there was a critical nationwide drug shortage in parental hydromorphone, a commonly used medication to treat VOC. In April 2018 the University of Illinois Health System (UI Health) adopted a standardized pain management protocol that limited opioids in the ER or ACC to two doses of IV or IM morphine and/or oral opioid. This study evaluates the impact of this standardized pain management protocol on managing VOC in SCD. Methods: A total of 373 SCD adults treated at UI Health from May 2017 to Oct 2018 had at least one ER or ACC visit or hospitalization for VOC. Data on VOC-related patient visits to the ACC, ER, and admissions to the inpatient floors were collected from the electronic medical record and evaluated based on three time periods (prior to shortage: May 2017-Oct 2017; transition: Oct 2017-Apr 2018; and post protocol: Apr 2018-Oct 2018). Descriptive statistics, the Cochrane trend test and Jonckheere-Terpstra trend test were used for data analysis. The study was approved by the Institutional Review Board prior to the initiation of chart review. Results: Between May 2017 and Oct 2018, the 373 SCD adult patients had a total of 1,915 ACC, 2,635 ER and 1,832 inpatient visits. After implementation in April 2018, the compliance rate with the standardized pain protocol was 99.7% in the ACC and 85.1% in the ER. In the ACC, the number of visits decreased after standardized pain protocol implementation, whereas the number of visits increased in the ER (Figure 1). The admission rate to the inpatient service from the ACC increased significantly while the admission rate from the ER remained relatively stable (Table 1). The numbers of opioid doses and the total opioid dose to treat VOC decreased in the ACC, but not in ER. Utilization of oral opioids increased in both settings (Table 1). The number of inpatient hospitalizations increased with implementation of the standardized protocol (542 vs. 626 vs. 664), and the 30-day readmission rate increased (49% vs. 51% vs. 57%, p = 0.003), but the length of hospital stay was reduced (p &lt; 0.001). Summary: Implementation of a standardized pain treatment protocol due to the parenteral hydromorphone shortage decreased the utilization of the ACC compared to the ER and the inpatient service, and resulted in reduced opioid dose but increased admission rates from the ACC. The 30-day readmission rate to inpatient service increased but the length of stay was reduced. A standardized pain protocol that limits opioids to two doses in the acute setting may not be an optimal approach. Reference: F. B. Piel, M. H. Steinberg, D. C. Rees, Sickle Cell Disease. N Engl J Med376, 1561-1573 (2017).J. Han et al., Program expansion of a day hospital dedicated to manage sickle cell pain. Am J Hematol93, E20-E21 (2018). Disclosures Saraf: Novartis: Consultancy, Membership on an entity's Board of Directors or advisory committees; Pfizer: Research Funding. Gordeuk:CSL Behring: Consultancy, Honoraria, Research Funding; Global Blood Therapeutics: Consultancy, Honoraria, Research Funding; Novartis: Consultancy, Honoraria, Research Funding; Modus Therapeutics: Consultancy, Honoraria; Imara: Research Funding; Ironwood: Research Funding; Inctye: Research Funding; Pfizer: Research Funding; Emmaus: Consultancy, Honoraria.

Is it fair to compare? A patient and family experience of two healthcare systems and neurosurgical teams within a two-week period

As the mother of a 28-year-old son with cerebral palsy and hydrocephalus, and as a healthcare consultant focused on patient experience and professional development, I have a unique perspective and skill set. Recently he experienced symptoms that included an excruciating headache, neck pain and lethargy. Fearing his ventriculoperitoneal shunt had malfunctioned, he went to the emergency room and was later admitted on the neuro inpatient floor for a three-day hospitalization. His original shunt had been placed in 1991, and he never had an issue with until August 2018. While in the hospital, he was informed that he was no longer shunt-dependent and that his headaches were a result of a pulled muscle in his neck, which would eventually resolve itself. He was discharged from the hospital with over-the-counter pain medicine for his neck pain and sent home. Thirteen days later, he was admitted to a different healthcare system, where the condition was quickly identified as hydrocephalus due to a shunt malfunction; neurosurgery was emergently performed, resulting in a six-day stay. These two hospitalizations, in such a short amount of time, provided completely different patient and family experiences, not to mention completely different clinical outcomes. When the patient satisfaction survey arrived in his mailbox following both hospitalizations, his survey answers were drastically different. This article will share examples of how healthcare professionals can positively impact the patient and family experience, even when the medical outcomes are not optimal, and how those interactions can positively impact patient satisfaction scores.

1616. Confronting Measles: The View from a New York City Health System at the Center of the Outbreak

BackgroundA measles outbreak was identified in NYC in October, 2018. Over 430 cases have been confirmed to date, mostly in under-vaccinated children. Due to referral patterns, our health system provided care to a large number of these patients in the ambulatory, Emergency Department and inpatient settings, placing significant pressure on Infection Prevention and Control efforts. Our response utilized the engineering, administrative, protective equipment and educational hierarchy of controls to prevent transmission to patients, visitors and staff.MethodsPatients residing from outbreak zip codes were flagged in our electronic medical record. Screening for symptoms, measles exposure, vaccine opportunities and education were provided when patients presented for care. Enhanced controls for premature infants and immunocompromised patients were enacted. Automated emails to providers caring for patients from the outbreak area served as reminders to consider measles in differential diagnosis. As most cases of measles occurred in children, special effort was taken to prevent transmissions in pediatrics. Patient rooms on multiple inpatient floors were converted to negative pressure with respect to corridor, as admitted patients developed symptomatic (contagious) illness while hospitalized. We limited all nonimmune visitors <5 years from entering inpatient units. Patients were contacted prior to ambulatory visits, procedures, and surgery to ensure patients from outbreak zip codes were triaged appropriately. Automated alerts to Infection Control when measles testing was ordered allowed timely implementation of prevention measures and surveillance. Finally, educational materials for patients and visitors were translated into 7 languages and shared with other NYC hospitals.ResultsTo date, 95 patients with suspect measles presented to our system, with 20 patients (16 pediatric and 4 adult) laboratory-confirmed cases requiring hospital admission due to measles pneumonia, hepatitis, and encephalitis. There was no evidence of transmission within the hospital and ambulatory setting to patients or staff.ConclusionA coordinated response involving engineering and administrative controls, PPE training and education is necessary when confronting a large urban measles outbreak.Disclosures All authors: No reported disclosures.

SUPRAGLOTTIC AIRWAY PLACEMENT REDUCES TIME TO ADVANCED AIRWAY DURING IN-HOSPITAL CARDIAC ARREST

SESSION TITLE: Wednesday Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM PURPOSE: Airway assessment is integral to advanced cardiac life support (ACLS). Cardiac arrests in the intensive care unit (ICU) may facilitate rapid advanced airway placement owing to more staff and proximity of intensivists. Inpatient floors are more challenging however, as staff experienced in rapid advanced airway placement are not immediately available. Our institution, a 914 bed quaternary care referral center, previously relied on certified registered nurse anesthetists (CRNAs) to perform endotracheal intubation during non-ICU in-hospital cardiac arrests (ICHAs). In an effort to shorten the time to establish an airway in non-ICU ICHAs, our respiratory therapy department hypothesized that allowing rapid-response respiratory therapists (RRTs) to insert a supraglottic airway during ICHAs should decrease the time between ICHA announcement and placement of an advanced airway. Previous studies have not shown a difference between supra- and subglottic airways and markers of ventilation/perfusion or outcomes in out-of-hospital cardiac arrests. METHODS: In October of 2018, supraglottic airway training and education on inclusion/exclusion criteria was performed. Inclusion criteria: unconscious non-ICU patients experiencing IHCA. Exclusion criteria: consciousness, trismus, pharyngo-perilaryngeal trauma or mass. Subsequently, a project was approved by the institution’s code blue committee that allowed RRTs to insert supraglottic airways (i-gel® Intersurgical) in patients suffering an IHCA on inpatient floors. Data was collected on 12 IHCAs over 5 months, including arrest time, time to supraglottic airway placement, and time to subglottic intubation (if performed). For comparison, data on length of time from IHCA to intubation was collected on 12 randomly selected non-ICU ICHAs prior to 2018. RESULTS: Prior to supraglottic airway use, the average time from ICHA announcement to intubation was 15.33 minutes (range 4-38 minutes). After initiation of the supraglottic airway project, average time from ICHA to supraglottic airway was 4.7 minutes (range 1-7 minutes). For those intubated after supraglottic airway placement, the average time from IHCA to subglottic intubation was 17.6 minutes (range 10-30 minutes). During this project, no dislodgements of the supraglottic airway or aspiration events occurred. In all cases, the ACLS protocol based on American Heart Association guidelines was followed with no complications noted. CONCLUSIONS: Empowerment of RRTs to insert a supraglottic airway significantly reduces time between IHCA and advanced airway placement. More research is needed to determine correlation between time to advanced airway and immediate survival, survival to hospital discharge, and neurologic sequelae. CLINICAL IMPLICATIONS: This study demonstrates that an advanced airway can be established during IHCA without having to wait for personnel experienced in endotracheal intubation. DISCLOSURES: No relevant relationships by Idrees Mogri, source=Web Response No relevant relationships by Adan (Adam) Mora, source=Web Response No relevant relationships by Robert Ritchey, source=Web Response No relevant relationships by Rahul Sawhney, source=Web Response No relevant relationships by Mark Whitford, source=Web Response

87 The Effects of Observation Unit Location and Physician Staffing on Patient Outcomes

Observation units have become increasingly common in recent years. Observation units (OUs) can be staffed by emergency physicians or by Internal Medicine Department (IM) physicians. The location of these units can vary from close proximity to the emergency department or to remote locations, such as on an inpatient floor. There is a paucity of data regarding ideal staffing models and location of OUs. We sought to evaluate the effect, if any, that OU location and staffing specialty might have on patient outcomes.

CROSS-SECTIONAL SURVEY ASSESSING A CULTURE OF SAFETY AT A LARGE PUBLIC HOSPITAL

SESSION TITLE: Wednesday Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM PURPOSE: High-risk industries with a narrow tolerance for errors such as healthcare pay considerable attention to studying safety. Such research has expanded from focus on morbidity and mortality to recognition of ways in which organizational structure, team dynamic, and working conditions impact a climate of patient safety within an institution. The Safety Assessment Questionnaire (SAQ) solicits employee perceptions of teamwork, safety, job satisfaction, stress recognition, management, and working conditions. Validation studies suggest this tool is reliable and responsive to interventions. This study was designed to identify baseline gaps in safety culture among various provider disciplines within our institution. METHODS: The study was conducted in a large public teaching hospital. We used the abbreviated Short Safety Assessment Questionnaire (sSAQ), which explores the same domains as the SAQ via 36 questions graded on a 5-point Likert scale. The survey was distributed over a month-long period to all housestaff rotating on the inpatient medicine floor and in the medical and cardiac intensive care units (MICU and CCU respectively), as well as to medicine floor attendings, MICU and CCU nurses, and inpatient respiratory therapists. Response to the survey was voluntary and anonymous. RESULTS: Responses were obtained from 86% of the rotating housestaff, 91% of floor attendings, 41% of MICU nurses, 24% of CCU nurses, and 33% of respiratory therapists. Housestaff overall responded positively to job satisfaction, stress recognition, and working conditions, while ICU-based housestaff were additionally positive regarding teamwork and patient safety climate. Attendings answered favorably to job satisfaction and stress recognition. CCU nurses scored highest in the domains of safety climate and job satisfaction, while MICU nurses were most satisfied with stress recognition. Nursing units also differed in negative perceptions; CCU nurses expressed that communication breakdown commonly interfered with delivery of patient care, and MICU nurses felt burdened by insufficient staffing for patient volume. Respiratory therapists scored low in stress recognition, perception of management, and working condition domains. They looked favorably on collaboration with nurses but were neutral toward collaboration with physicians. CONCLUSIONS: Responses to the sSAQ revealed discrepancies between provider disciplines regarding perception of safety culture across six different domains. CLINICAL IMPLICATIONS: Improvement in scores across domains in the SAQ has shown association with shorter ICU stays, decreased rates of ventilator-associated pneumonias and blood-stream infections, and lower mortality. Our survey demonstrates a clear opportunity within our institution for targeted quality improvement initiatives which can be tailored to different provider disciplines in order to improve safety culture and optimize patient outcomes. DISCLOSURES: My spouse/partner as a Advisory Committee Member relationship with CORECEPT Please note: $1001 - $5000 Added 03/15/2019 by Vikramjit Mukherjee, source=Web Response, value=Consulting fee No relevant relationships by Maria Sunseri, source=Web Response No relevant relationships by Amit Uppal, source=Web Response No relevant relationships by Brandon Walsh, source=Web Response

Prevalence of organ-space surgical site infections after appendectomy for ruptured appendix in children

Introduction: Appendicitis can be classified as non-perforated and perforated; based on such classification, the reported organ-space surgical site infection (OS-SSI) rate is 0.8% and 18%, respectively.Objective: To establish the prevalence of OS-SSI in patients with perforated appendicitis treated in a pediatric hospital in 2012.Materials and methods: Retrospective, observational and descriptive study conducted at Fundación Hospital Pediátrico La Misericordia, with a random sample of 200 patients, of which 160 met the inclusion criteria.Results: 20 patients (12.5%) presented with OS-SSI and all of them received antibiotic treatment; 70% did not require abscess drainage. Patients ≥8 years of age had 5 times more abscesses than younger ones (17.6% vs. 3.4%). OS-SSI was found in 33% of patients with free fecalith and in 50% of the patients who required postoperative management at the ICU vs. 9.5% of the patients who received management in the intermediate care unit and the inpatient hospital floors. The total rate of surgical site infection was 24.3% (11.8% superficial, 0% deep and 12.5% organ-space).Conclusions: The prevalence of OS-SSI found here is lower than what has been reported in the literature. Being 8 years or older and having free fecalith are risk factors to develop this type of infection. The higher frequency of OS-SSI in patients treated at the ICU during the post-operative period observed here suggests that this condition may be associated with septic shock.

Reduction in Length of Stay and Morphine Use for NAS With the "Eat, Sleep, Console" Method.

To reduce average length of stay (ALOS) in infants with neonatal abstinence syndrome (NAS) transferred to the inpatient floor from the mother-infant unit. Secondarily, we aimed to reduce morphine exposure in these infants. Using quality improvement methodology, we redesigned our approach to NAS on the inpatient floor. Key interventions included transitioning from a modified Finnegan Neonatal Abstinence Scoring System to the "Eat, Sleep, Console" method for withdrawal assessment, reeducation on nonpharmacologic interventions, and adding as-needed morphine as initial pharmacotherapy. Data for infants ≥35 weeks' gestation with confirmed in utero opioid exposure and worsening symptoms of NAS requiring transfer to the inpatient floor were obtained, including ALOS, number of morphine doses, and total morphine amount administered. Infants with conditions requiring nothing by mouth for >12 hours or morphine initiation in the ICU were excluded. ALOS for infants (baseline n = 40; intervention n = 36) with NAS transferred to the inpatient floor decreased from 10.3 to 4.9 days. Average morphine administered decreased from 38 to 0.3 doses per infant. No infant in the intervention period required scheduled morphine. The percent of all infants transferred to the floor for NAS requiring any morphine decreased from 92% at baseline to 19% postimplementation. There were no observed adverse events or NAS-related readmissions in the intervention period. Transitioning to the Eat, Sleep, Console assessment with re-enforcement of nonpharmacologic care and use of as-needed morphine as initial pharmacotherapy resulted in a notably decreased ALOS and near elimination of postnatal opioid treatment of infants with NAS managed on our inpatient floor.

Improving Access To Interpreter Services For Patients And Families With Limited English Proficiency

BACKGROUND: Health disparities among patients with limited English -proficiency (LEP) are well documented in the literature. Barriers to communication for LEP patients affect quality of care, length of stay and readmission rates. Our aim is to increase the frequency of interpretations on the pediatric inpatient floors from 1.7 interpretations per patient per day (baseline) to 2.5 interpretations per day by 12/31/2018. METHODS: A 2016 needs assessment was conducted to identify opportunities to improve care for patients and families with LEP. One of …

Novel Cross-Care Continuum Medication Alerts Decrease Duplicate Medication Errors For Pediatric Care Transitions

Purpose: Although computerized Provider Order Entry (CPOE) and Clinical Decision Support (CDS) are essential elements of EHR order management thatr improve medication safety in many settings, CPOE has also been implicated in introducing or facilitating certain types of medication errors. Our institution, a free-standing children’s medical center, identified persistent post-EHR implementation and upgrade problems with duplicate medication errors in patients transferred from Emergency Department or Operating Room to inpatient floor. Analysis of the …

A Hospital-Level Intervention to Improve Outcomes of Opioid Exposed Newborns

PurposeThe purpose of this quality improvement project was to determine if non-pharmacologic strategies such as a rooming-in approach to care for newborns at risk of developing neonatal abstinence syndrome (NAS) would reduce total length of stay (LOS) and reduce the need for pharmacologic treatment. Design and methodsThis was a quality improvement project utilizing a retrospective chart review. Records of newborns with in-utero methadone or buprenorphine exposure were reviewed who were born between January 2016–July 2017 and July 2017–August 2018 at Wellspan Health York Hospital. Starting in July 2017, newborns exposed to opioids who transitioned normally remained with their mothers for monitoring in the newborn nursery. Monitoring for withdrawal was continued on the pediatric floor after the mother's discharge from the post-partum floor. ResultsThe primary outcome of total LOS was reduced from 14 days to 10.1 days (p = 0.014). The total length of pharmacologic treatment decreased from 15.68 days to 9.71 days (p = 0.023). ConclusionsA rooming-in approach to care including management on a pediatric floor can reduce total length of stay and the duration of pharmacologic treatment in newborns with NAS. Newborns with NAS can be safely managed in an inpatient pediatric floor. Practice implicationsImplementing a rooming-in approach to care of newborns at risk of developing NAS can improve outcomes through a decreased length of hospital stay and decreased duration of pharmacologic treatment. This approach improves access to critical care services by safely monitoring newborns with NAS on an inpatient pediatric floor.

Diversion Principle Reduces Skin Flora Contamination Rates in a Community Hospital.

Blood culture contamination is a common problem faced by medical centers and leads to significant cost. A possible method to reduce contamination is to discard the initial aliquot of blood, which contains skin and bacteria. To determine whether the rate of contaminant blood cultures could be reduced by changing the order of draw to divert the first 7 mL to a gold- or green-top tube. A preintervention and postintervention study was conducted. During the 18-month intervention phase (September 2015-February 2017), all nurses in the emergency department and inpatient floor phlebotomists collected blood cultures by drawing the first 7 mL of blood into a gold- or green-top tube followed by drawing blood for blood culture bottles. The 18 months immediately preceding the study period (February 2014-July 2015) were used for comparison. There was an overall statistically significant decrease in contamination rate from 2.46% in the prediversion protocol group to 1.70% in the postdiversion protocol group (P < .001). Emergency department drawn cultures and inpatient cultures showed significant decrease in contamination rates between the preprotocol and postprotocol groups, 2.92% versus 1.95% (P < .001) for emergency department, and 1.82% versus 1.31% (P = .03) for inpatient. We noted less month-to-month variation during the study period compared with the preintervention period. By using this simple diversion method, we were able to improve blood culture contamination rates for our emergency department and inpatients while incurring no added cost to the procedure.