Large Academic Tertiary Care Hospital Research Articles

Social determinants of health and sepsis: a case-control study.

We aimed to identify whether social determinants of health (SDoH) are associated with the development of sepsis and assess the differences between individuals living within systematically disadvantaged neighbourhoods compared with those living outside these neighbourhoods. We conducted a single-centre case-control study including 300 randomly selected adult patients (100 patients with sepsis and 200 patients without sepsis) admitted to the emergency department of a large academic tertiary care hospital in Hamilton, ON, Canada. We collected data on demographics and a limited set ofSDoH variables, including neighbourhood household income, smoking history, social support, and history of alcohol disorder. We analyzed study data using multivariate logistic regression models. The study included 100 patients with sepsis with a median [interquartile range (IQR)] age of 75 [58-84] yr and 200 patients without sepsis with a median [IQR] age of 72 [60-83] yr. Factors significantly associated with sepsis included arrival by ambulance, absence of a family physician, higher Hamilton Early Warning Score, and a recorded history of dyslipidemia. Important SDoH variables, such asindividual or household income and race, were not available in the medical chart. In patients with SDoH available in their medical records, no SDoH was significantly associated with sepsis. Nevertheless, compared with their proportion of the Hamilton population, the rate of sepsis cases and sepsis deaths was approximately two times higher among patients living in systematically disadvantaged neighbourhoods. This study revealed the lack of available SDoH data in electronic health records. Despite no association between the SDoH variables available and sepsis, we found a higher rate of sepsis cases and sepsis deaths among individuals living in systematically disadvantaged neighbourhoods. Including SDoH in electronic health records is crucial to study their effect on the risk of sepsis and to provide equitable care.

Leveraging Lean Six Sigma principles in an Indian tertiary care hospital: a case study

PurposeWorkflow optimisation is crucial for establishing a viable acute stroke (AS) intervention programme in a large tertiary care centre. This study aims to utilise Lean Six Sigma (LSS) principles to enhance the hospital's workflow.Design/methodology/approachThe Action Research methodology was used to implement the project and develop the case study. The study took place in a large tertiary care academic hospital in India. The Define-Measure-Analyse-Improve-Control approach optimised the workflow within 6 months. Lean tools such as value stream mapping (VSM), waste audits and Gemba were utilised to identify issues involving various stakeholders in the workflow. Sigma-level calculations were used to compare baseline, improvement and sustainment status. Additionally, statistical techniques were effectively employed to draw meaningful inferences.FindingsLSS tools and techniques can be effectively utilised in large tertiary care hospitals to optimise workflow through a structured approach. Sigma ratings of the processes showed substantial improvement, resulting in a five-fold increase in clinical outcomes. Specifically, there was a 43% improvement in outcome for patients who underwent acute stroke revascularisation. However, certain sigma ratings deteriorated during the control and extended control (sustainment) phases. This indicates that ensuring the sustainability of quality control interventions in healthcare is challenging and requires continuous auditing.Research limitations/implicationsThe article presents a single case study deployed in a hospital in India. Thus, the generalisation of outcomes has a significant limitation. Also, the study encounters the challenge of not having a parallel control group, which is a common limitation in quality improvement studies in healthcare. Many studies in healthcare quality improvement, including this one, are limited by minimal data on long-term follow-up and the sustainability of achieved results.Originality/valueThis study pioneers the integration of LSS methodologies in a large Indian tertiary care hospital, specifically targeting AS intervention. It represents the first LSS case study applied in the stroke department of any hospital in India. Whilst most case studies discuss only the positive aspects, this article fills a critical gap by unearthing the challenges of applying LSS in a complex healthcare setting, offering insights into sustainable quality improvement and operational efficiency. This case study contributes to the theoretical understanding of LSS in healthcare. It showcases its real-world impact on patient outcomes and process optimisation.

Identifying the need for infection-related consultations in intensive care patients using machine learning models

Infection-related consultations on intensive care units (ICU) have a positive impact on quality of care and clinical outcome. However, timing of these consultations is essential and to date they are typically event-triggered and reactive. Here, we investigate a proactive approach to identify patients in need for infection-related consultations by machine learning models using routine electronic health records. Data was retrieved from a mixed ICU at a large academic tertiary care hospital including 9684 admissions. Infection-related consultations were predicted using logistic regression, random forest, gradient boosting machines, and long short-term memory neural networks (LSTM). Overall, 7.8% of admitted patients received an infection-related consultation. Time-sensitive modelling approaches performed better than static approaches. Using LSTM resulted in the prediction of infection-related consultations in the next clinical shift (up to eight hours in advance) with an area under the receiver operating curve (AUROC) of 0.921 and an area under the precision recall curve (AUPRC) of 0.541. The successful prediction of infection-related consultations for ICU patients was done without the use of classical triggers, such as (interim) microbiology reports. Predicting this key event can potentially streamline ICU and consultant workflows and improve care as well as outcome for critically ill patients with (suspected) infections.

Clinical characteristics of Mpox at a single center in Saudi Arabia: a retrospective study

Objectives: Mpox (formerly known as monkeypox) is a viral infection that has been linked to a global outbreak as recent as in the year 2022. Mpox outbreaks have been increasingly reported in non-endemic regions since 2017 with over 23,000 cases reported in 80 countries as of August 1, 2022. Objective of study was describe the clinical characteristics, treatment and outcomes of Mpox disease as experienced in a tertiary care center in Riyadh, Saudi Arabia from May 2022 till the study date. Methodology: This retrospective chart review study was conducted in a large academic tertiary care hospital in Riyadh, Saudi Arabia. Data were obtained from administrative and electronic medical records and analyzed. Results: Of 33 patients suspected to have Mpox since May 2022, 16 tested positive. In total, 18.8% of patients with Mpox (3/16) had a personal history of recent travel, and 62.5% (10/16) reported some form of recent sexual contact. All the patients presented with rash, and most of them (93.8%) had anogenital rash. The mean number of skin lesions was 6.69, and no one reported coexisting sexually transmitted diseases. In addition, 31.25% (5/16) received antivirals, and no mortality was recorded. Conclusions: Mpox infection demonstrated a variety of signs and symptoms, with all patients presenting with dermatological manifestations. The spread of this disease in our region exhibited some dissimilarities in the clinical presentation and coexisting infections. This highlights the importance of maintaining a high index of suspicion and a low threshold for testing in order to halt further spread.

Portomesenteric Venous Thrombosis after Colorectal Surgery: A Retrospective Study

CONTEXT: Postoperative Portomesenteric venous thrombosis (PMVT), is a rare but significant condition that occurs in colorectal surgery patients. PMVT involves thrombus formation in veins such as the portal, superior mesenteric, inferior mesenteric, or splenic vein, often following colon and rectum surgical resection. Recognized risk factors include cancer and inflammatory bowel disease. AIMS: The research aimed to evaluate the prevalence, associated risk factors, and treatment methods for PMVT in a large academic tertiary care hospital. SETTINGS AND DESIGN: Retrospective review METHODS: A retrospective review of 750 colorectal surgeries was conducted, examining patient medical histories, operative details, perioperative medications, and postoperative complications. STATISTICAL ANALYSIS USED: Categorical variables were presented as frequencies and percentages, whereas continuous variables were presented as a mean +/- Standard deviation. Comparative analysis used odds ratios to understand the association between categorical risk factors and PMVT, and independent samples t-tests for continuous variables RESULTS: PMVT was identified in 0.8% of the 621 patients meeting the inclusion criteria, all of whom had underlying cancer. These patients were successfully treated with anticoagulants, without the need for surgery or resulting in any mortality at 45 days postoperatively. No significant variables associated with PMVT were identified in this cohort. CONCLUSIONS: PMVT after colorectal surgery, while rare, is predominantly seen in patients with cancer. The outcomes in these cases were favorable with medical therapy alone. Larger, long-term studies are recommended to further investigate risk factors and effective management strategies for PMVT.

Prevalence and factors associated with COVID-19 among healthcare workers at a university hospital in Thailand.

Globally, healthcare workers (HCWs) have a high risk of SARS-CoV-2 infection, but less is known about healthcare workers in Thailand. We estimated the prevalence and risk factors for COVID-19 among HCWs in Bangkok, Thailand. A retrospective cohort study was conducted at a large tertiary care academic hospital in Thailand from May 2020 to May 2021. HCWs that presented with fever and/or acute respiratory tract symptoms who tested with RT-PCR were identified, and their clinical data were collected. There were 1432 HCWs with fever and/or acute respiratory tract symptoms during May 2020 and May 2021. A total of 167 patients were front-line HCWs and 1265 were non-front-line HCWs. Sixty HCWs (4.2%) developed COVID-19; 2 were front-line and 58 were non-front-line HCWs. The prevalence of COVID-19 in front-line HCWs was 1.7% (2/167), and 4.6% (58/1265) in non-front-line HCWs (P = .04). In addition, non-front-line HCWs, non-medical staffs, history of contact with a confirmed COVID-19 case at home/family, unvaccinated status, fair compliance to personal protective equipment (PPE) standard, and initial presentation with pneumonia were significantly more common in HCWs with COVID-19 than those without COVID-19 (P < .05). Front-line HCWs, history of contact with a confirmed COVID-19 case at the clinical care areas in the hospital, vaccinated status, good compliance to PPE standards, and initial presentation with upper respiratory infection were significantly more common in HCWs without COVID-19 than those with COVID-19 (P < .05). Multivariate analysis revealed history of exposure with confirmed COVID-19 case at home or in family, unvaccinated status, non-frontline-HCWs, non-medical staffs, and fair compliance to PPE standard to be independent factors associated with COVID-19 in HCWs. COVID-19 was more common in non-front-line HCWs at this tertiary hospital. Thai guidelines on infection prevention and control for COVID-19 seem to be effective in preventing SARS-CoV-2 transmission. Therefore, the adherence to these recommendations should be encouraged.

An exploration of expectations and perceptions of practicing physicians on the implementation of computerized clinical decision support systems using a Qsort approach

BackgroundThere is increasing interest in incorporating clinical decision support (CDS) into electronic healthcare records (EHR). Successful implementation of CDS systems depends on acceptance of them by healthcare workers. We used a mix of quantitative and qualitative methods starting from Qsort methodology to explore expectations and perceptions of practicing physicians on the use of CDS incorporated in EHR.MethodsThe study was performed in a large tertiary care academic hospital. We used a mixed approach with a Q-sort based classification of pre-defined reactions to clinical case vignettes combined with a thinking-aloud approach, taking into account COREQ recommendations The open source software of Ken-Q Analysis version 1.0.6. was used for the quantitative analysis, using principal components and a Varimax rotation. For the qualitative analysis, a thematic analysis based on the four main themes was performed based on the audiotapes and field notes.ResultsThirty physicians were interviewed (7 in training, 8 junior staff and 15 senior staff; 16 females). Nearly all respondents were strongly averse towards interruptive messages, especially when these also were obstructive. Obstructive interruption was considered to be acceptable only when it increases safety, is adjustable to user expertise level and/or allows deviations when the end-user explains why a deviation is desirable in the case at issue. Transparency was deemed an essential feature, which seems to boil down to providing sufficient clarification on the factors underlying the recommendations of the CDS, so that these can be compared against the physicians’ existing knowledge, beliefs and convictions.ConclusionAvoidance of disruptive workflows and transparency of the underlying decision processes are important points to consider when developing CDS systems incorporated in EHR.

Abstract No. 256 Implementation and early performance of a joint internal medicine–interventional radiology bedside procedure service

To evaluate the early performance of a novel bedside procedure service jointly managed by the Department of Medicine and Division of Interventional Radiology, dubbed the Joint IM-IR Central Procedure Service (CPS), at a single-center, large academic tertiary care hospital

Cardiotoxicity in Patients With Lung Cancer Receiving Thoracic Radiotherapy and Immune-Checkpoint Therapy

Immune checkpoint inhibitors (ICIs) have been widely adapted as part of the treatment of locally advance and metastatic lung cancer. ICIs can lead to severe immunogenic related cardiotoxicities, however, the overall cardiotoxic profile of these agents when combined with thoracic radiation therapy is not well defined. Here, we assessed the risk of cardiotoxicity in ICI-treated lung cancer patients with or without cardiac radiation from thoracic radiotherapy.Retrospective data was collected on Stage III-IV small-cell lung cancer (SCLC) and non-small-cell lung cancer (NSCLC) patients who received ICIs between 2015 and 2018 at a large academic tertiary care hospital. All cardiotoxicities associated with ICI were assessed by a cardiologist and in correlation with history of thoracic radiotherapy (RT), the timing of RT in relation to ICI, and the mean RT heart dose. Multivariate analysis was performed on multiple logistic regression including the Framingham risk score and steroid use during the ICI therapy.Of 194 ICI-treated patients evaluated, 66 (34.02%) and 128 (65.98%) had Stage III and IV SCLC or NSCLC, respectively, the median age was 64 years (range, 36-88), and 42.47% were female. Within the total cohort, 55.2% (n = 107/194) patients had received thoracic RT at a median dose of 60.4 Gy (range, 15-75). Cardiotoxicities such as non-ST elevated myocardial infarction and new onset supraventricular tachycardias were observed in 13 (12.2%) of those who had thoracic RT versus 9 (10.3%) who did not (P = 0.87). There were 38 patients who received RT concurrently with ICI and did not develop any cardiotoxicity whereas cardiotoxicity was observed in 14.1% (n = 22/156) of those who did not receive concurrent RT (univariate, P = 0.030; multivariate, P = 0.055). There were no significant differences in the mean heart RT dose, Framingham risk score, and steroid treatment between patients that received concurrent RT with ICI versus non-concurrent RT/ICI.ICI-related cardiotoxicities were not significantly associated with patients who received concurrent thoracic radiotherapy. Univariate analysis suggests a potential cardioprotective effect of thoracic RT with ICI's, which may be due to modulation of the immune response through reduction of lymphocytes involved in autoimmune processes. A larger cohort study will be conducted to further evaluate this potential cardioprotective effect.

600. Decreased Hospital Readmission After Programmatic Strengthening of an Outpatient Parenteral Antimicrobial Therapy (OPAT) Program

BackgroundAlthough it is recommended that an OPAT program should be managed by a formal OPAT team that supports the treating physician, many OPAT programs face challenges in obtaining necessary program staff (i.e nurses or pharmacists) due to limited data examining the impact of a dedicated OPAT team on patient outcomes. Our objective was to compare OPAT-related readmission rates among patients receiving OPAT before and after the implementation of a strengthened OPAT program.MethodsThis retrospective quasi-experiment compared adult patients discharged on intravenous (IV) antibiotics from the University of Illinois Hospital before and after implementation of programmatic changes to strengthen the OPAT program. Data from our previous study were used as the pre-intervention group (1/1/2012 to 8/1/2013), where only individual infectious disease (ID) physicians coordinated OPAT. Post-intervention (10/1/2017 to 1/1/2019), a dedicated OPAT nurse provided full time support to the treating ID physicians through care coordination, utilization of protocols for lab monitoring and management, and enhanced documentation. Factors associated with readmission for OPAT-related problems at a significance level of p< 0.1 in univariate analysis were eligible for testing in a forward stepwise multinomial logistic regression to identify independent predictors of readmission.ResultsDemographics, antimicrobial indications, and OPAT administration location of the 428 patients pre- and post-intervention are listed in Table 1. After implementation of the strengthened OPAT program, the readmission rate due to OPAT-related complications decreased from 17.8% (13/73) to 6.5% (23/355) (p=0.001). OPAT-related readmission reasons included: infection recurrence/progression (56%), adverse drug reaction (28%), or line-associated issues (17%). Independent predictors of hospital readmission due to OPAT-related problems are listed in Table 2.Table 1. OPAT Patient Demographics and Factors Pre- and Post-intervention Table 2. Factors independently associated with hospital readmission in OPAT patients ConclusionAn OPAT program with dedicated staff at a large academic tertiary care hospital was independently associated with decreased risk for readmission, which provides critical evidence to substantiate additional resources being dedicated to OPAT by health systems in the future.Disclosures All Authors: No reported disclosures

Outcomes in Hispanics With COVID-19 Are Similar to Those of Caucasian Patients in Suburban New York.

BackgroundDespite reported higher rates and worse outcomes due to COVID‐19 in certain racial and ethnic groups, much remains unknown. We explored the association between Hispanic ethnicity and outcomes in COVID‐19 patients in Long Island, New York.MethodsWe conducted a retrospective cohort study of 2,039 Hispanic and non‐Hispanic Caucasian patients testing positive for SARS‐CoV‐2 between March 7 and May 23, 2020, at a large suburban academic tertiary care hospital near New York City. We explored the association of ethnicity with need for intensive care unit (ICU), invasive mechanical ventilation (IMV), and mortality.ResultsOf all patients, 1,079 (53%) were non‐Hispanic Caucasians and 960 (47%) were Hispanic. Hispanic patients presented in higher numbers than expected for our catchment area. Compared with Caucasians, Hispanics were younger (45 years vs. 59 years), had fewer comorbidities (66% with no comorbidities vs. 40%), were less likely to have commercial insurance (35% vs. 59%), or were less likely to come from a nursing home (2% vs. 10%). In univariate comparisons, Hispanics were less likely to be admitted (37% vs. 59%) or to die (3% vs. 10%). Age, shortness of breath, congestive heart failure (CHF), coronary artery disease (CAD), hypoxemia, and presentation from nursing homes were associated with admission. Male sex and hypoxemia were associated with ICU admission. Male sex, chronic obstructive pulmonary disease, and hypoxemia were associated with IMV. Male sex, CHF, CAD, and hypoxemia were associated with mortality. After other factors were adjusted for, Hispanics were less likely to be admitted (odds ratio = 0.62, 95% confidence interval = 0.52 to 0.92) but Hispanic ethnicity was not associated with ICU admission, IMV, or mortality.ConclusionsHispanics presented at higher rates than average for our population but outcomes among Hispanic patients with COVID‐19 were similar to those of Caucasian patients.

A comparison of three approaches for laparoscopic single-site (LESS) myomectomy: conventional, robotic, and hand assisted.

The objective of this study is to determine the feasibility and explore criteria for patient selection for three methods of LESS myomectomy: conventional (C-LESS), robotic-assisted (RA-LESS), and hand-assisted (HA-LESS). This was a retrospective case review of 72 patients with uterine myomas, conducted in a large academic tertiary care hospital between March 1, 2015, and November 7, 2018. LESS myomectomy via conventional, robotic, and hand-assisted routes. 43 patients underwent C-LESS, 15 underwent RA-LESS, and 14 underwent HA-LESS, with no conversions to open abdominal myomectomy. The operative outcomes were compared across the three approaches. The HA-LESS group had the largest mean number (HA: 6.9; C: 3.7; RA: 2.9, P=0.001), diameter (HA: 11.3 cm; C: 9.3 cm; RA: 7.1 cm, P=0.035), and weight (HA: 850.1 g; C: 320.7 g; RA: 181.1 g, P=0.003) of myomas removed per patient. The use of this method was also found to have a direct correlation with estimated preoperative uterine size (HA: 20.1 weeks; C: 16.2 weeks; RA: 12.0 weeks, P=0.001. Operative time and postoperative stay were found to be not statistically different across groups. We conclude that all three types of LESS myomectomy are feasible with comparable surgical outcomes. Most importantly, our findings indicate that hand assistance can be combined with C-LESS myomectomy for large or multi-fibroid uterus without compromising operating time or patient recovery. Notably, we found that uterine size could be a useful tool for the determination of the surgical approach.

MON-118 Reducing Unnecessary Repeat HbA1c Testing in a Tertiary Academic Hospital

BackgroundGlycated hemoglobin (HbA1c) is a surrogate marker of glycemia over the preceding three months, where the last 30 days contributes to 50% of the value (1). Therefore guidelines often recommend repeating HbA1c only after 3 months in most situations (2), but repeat testing of HbA1c is often conducted earlier when not warranted (3). We aimed to conduct a Quality Improvement (QI) initiative to reduce unnecessary repeat testing of HbA1c at a large tertiary care academic hospital in Toronto, Ontario by 50% by May 2020.Methods:The Model for Improvement Quality Improvement (QI) framework was used in the design of the QI project to reduce repeat HbA1c. Problem characterization was conducted to understand root causes and iterative Plan-Do-Study-Act cycles were used to develop a change intervention. Unnecessary HbA1c tests were the primary outcome and defined as repeat HbA1c testing within 60 days; the top three specialities that ordered unnecessary HbA1c tests were targeted for education prior to implementation of the change intervention.Results:Baseline data on all HbA1c tests in 2018 revealed repeat testing in approximately 10% of 15,290 HbA1c tests, with estimated potential savings of more than $11,000 based on the provincial reimbursement rate. The top 3 ordering specialities targeted for education included Nephrology (n=410 repeat HbA1c tests), Cardiology (n=246 repeat HbA1c tests), and Endocrinology (n=136 repeat HbA1C tests). Root cause analysis revealed that providers often ordered repeat HbA1c tests due to being unaware of prior results and a knowledge gap of testing recommendations. A laboratory forced function will be implemented on December 1, 2019 to cancel any repeat HbA1c tests within 60 days and calls to the lab to add HbA1c testing will be tracked.Conclusions:Repeat HbA1c testing is frequent in hospital settings and can be an important target for QI efforts. A forced function to cancel processing of repeat HbA1c may be an appropriate QI intervention to reduce repeat testing to promote high-value care. Ongoing data analysis will be conducted to assess the impact of this intervention.References(1) Goldstein DE, Little RR, Lorenz RA, Malone JI, Nathan D, Peterson CM, Sacks DB. Tests of Glycemia in Diabetes. Diabetes Care 2004;27(7): 1761-1773.(2) Berard LD, Siemens R, Woo V. Diabetes Canada 2018 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada: Monitoring Glycemic Control. Can J Diabetes 2018;42(Suppl 1):S47-S53.(3) Chami N, Simons JE, Sweetman A, Don-Wauchope AC. Rates of inappropriate laboratory test utilization in Ontario. Clinical Biochemistry 2017;50: 822-827.

CE Article: Nursing-Placed Midline Catheters and Ultrasound-Guided Peripheral IVs Promote More Appropriate Catheter SelectionCE

Highlights Abstract Purpose: Deep vein thrombosis (DVT) and central line-associated bloodstream infection (CLABSI) are serious complications of peripherally inserted central catheters (PICCs). Because of these risks, midline catheters (MCs) and ultrasound-guided peripheral intravenous catheters (USGPIVs) were added to the capabilities of the host institution’s nursing-based venous access team (VAT), which operates under the direction of Interventional Radiology (IR). This report evaluates this effort to reduce PICCs and MCs through appropriate patient-centered device choice. Materials: A retrospective analysis of PICCs, MCs, and USGPIVs placed in inpatients in a large tertiary care academic hospital was conducted, using the VAT’s record supplemented with data from the IR quality assurance database. Analysis of hospital records of upper extremity DVT and CLABSI was also performed. Results: The VAT documented 33,113 PICC, 12,135 MC, and 14,300 USGPIV placements from September 2001 to March 2018. From the peak of PICC placements in 2006 to the peak of MCs in 2010, PICCs decreased 23% (P &amp;lt; 0.01), while MCs increased 93% (P &amp;lt; 0.001). Following full implementation of USGPIV in January 2016, MCs decreased 34% from 2015 to 2016 (P &amp;lt; 0.01) with no concurrent decrease in PICCs (P = 0.72). CLABSI rates per 1000 central venous catheter days decreased from 1.5 to 0.44 (P &amp;lt; 0.01), coinciding with an unrelated CLABSI reduction initiative. No interpretable trends in DVT counts were discovered. Conclusions: Appropriate use of MCs and USGPIVs by an IR-supported VAT significantly decreased PICCs and MCs, respectively.

Clustered Microcysts at Breast US: Outcomes and Updates for Appropriate Management Recommendations.

Background Clustered microcysts are common, especially in perimenopausal women, and are seen in up to 6% of US examinations. However, there are limited published data on appropriate assessment and management recommendations for clustered microcysts on breast US images. Purpose To determine outcomes of lesions identified as clustered microcysts on breast US images to help guide appropriate management recommendations. Materials and Methods Lesions classified as clustered microcysts at breast US were retrospectively identified in women at two hospitals (a large tertiary care academic hospital and a National Comprehensive Cancer Network-designated comprehensive cancer center) within one metropolitan health system from 2005 through 2015. If US-guided tissue sampling was performed, results were obtained from the pathology or cytology reports. If sampling was not performed, only lesions with at least 24 months of imaging follow-up or any imaging follow-up with interval resolution or decrease in size were included in the study. Data were evaluated using standard statistics, Fisher exact tests, and Wilcoxon rank sum tests. Results A total of 189 women (median age, 52 years [interquartile range, 46-59 years]) with 196 lesions classified as clustered microcysts on US images were included in this study. During the surveillance period of at least 24 months and at tissue diagnosis, malignancy was not found in any of the 196 lesions (0%) (95% confidence interval: 0.0%, 1.9%). A total of 158 of 196 (80%) lesions were followed with imaging, and 38 of 196 (20%) lesions underwent percutaneous sampling. During the follow-up period, 28 of 158 (18%) lesions spontaneously resolved, 13 of 158 (8%) decreased in size, and one of 158 lesions (0.6%) increased at 18-month follow-up but then became stable. One hundred sixteen of 158 lesions (73%) demonstrated no change at follow-up imaging, 38 of 196 (19%) lesions underwent percutaneous sampling, and 38 of 38 (100%) revealed benign results. Conclusion No malignancies were identified in this series. These results further support the existing literature that lesions characterized as clustered microcysts demonstrate a very low risk of malignancy and can be classified as benign. Biopsy may be safely avoided. © RSNA, 2020 See also the editorial by Berg in this issue.

Association of Surgical Jacket and Bouffant Use With Surgical Site Infection Risk

Surgical site infections (SSIs) are associated with increased morbidity and mortality. Various measures have been enacted decrease the occurrence of SSIs involving the regulation of the attire worn by the operating room staff, at times without sufficient peer-reviewed literature to support their implementation. To evaluate whether the combination of mandated surgical jackets and bouffants in the operating room is associated with the risk of surgical site infection. A retrospective cohort study of 34 042 inpatient surgical encounters at a large academic tertiary care hospital was performed. Three periods between January 2017 and October 2018 were compared, corresponding with implementation of surgical jackets and the subsequent mandate of surgical jackets plus bouffant head covers. All inpatient surgical cases were included from University of Alabama at Birmingham University Hospital, a single-center, large academic tertiary care hospital. The study comprised a consecutive sample of all inpatient surgical cases over a 22-month period. No surgical jackets or bouffants mandated (8 months), surgical jackets mandated (6 months), both surgical jackets and bouffants mandated (8 months). The primary study outcome was SSIs, which were collected from institutional infection control monthly summary reports, according to the National Healthcare Safety Network definitions for superficial incisional, deep incisional, and organ/space SSIs. Secondary outcomes included wound dehiscence, postoperative sepsis, death, and cost of interventions. A total of 34 042 inpatient surgical encounters cases were included in the analysis over the 22-month study period. Of the total patients, 16 380 were women (48%) and 17 638 were men (52%). There was no significant difference in the risk of SSI (1.01% vs 0.99% vs 0.83%; P = .28), mortality (1.83% vs 2.05% vs 1.92%; P = .54), postoperative sepsis (6.60% vs 6.24% vs 6.54%; P = .54), or wound dehiscence (1.07% vs 0.84% vs 1.06%; P = .20) between the 3 groups. Receipts from the first 6 months of the 2018/2019 fiscal year provided an estimated expenditure of more than $300 000 annually on surgical jackets. Bouffants were found to be less expensive than surgical skull caps. The results of this study suggest that surgical jackets and bouffants are neither beneficial nor cost-effective in preventing SSIs. Institutions should evaluate their own data to determine whether recommendations by outside governing organizations are beneficial and cost-effective.

Delayed inpatient diagnosis and isolation of active pulmonary tuberculosis patients, a large tertiary care academic hospital experience in Riyadh, Saudi Arabia. What are we missing?

Objectives:To identify pulmonary tuberculosis (PTB) delayed inpatient diagnosis duration and contributing factors in an academic center in Saudi Arabia (SA).Methods:Retrospective review of all culture-confirmed PTB cases between May 2015 and April 2019. The outcomes were the timing between admission and suspicion of PTB or isolation to either early group (within 24 hours of admission) and late group (24 hours after admission).Results:Forty-nine cases were included with a median age of 49 years; a third of them were above 65 years of age. Most patients were of Saudi nationality and male. Approximately 38% of the cases were in the delayed group, half of them were smear-positive, with an average delay of 5.5 days. This was significant with age above 65 years (odds ratio [OR]=8.93, 95% confidence interval [CI]=2.22-35.95) presence of non-respiratory symptoms (OR=5.6, 95% CI=1.56-19.98), malignancy (OR=13.38, 95% CI=1.46-122.71), chronic medical problems (OR=4.90, 95% CI=1.31-18.32), missed chest x-ray findings (OR= 48, 95% CI=8.63-266.88) or procalcitonin level above 0.5 ng/mL (OR=12, 95% CI=1.58-91.08).Conclusion:Physicians in SA need to have a low threshold for PTB consideration in elderly patients or those with a history of malignancy. A careful review of the initial chest x-ray might help to overcome missing cases of PTB.

Stress Testing the Resuscitation Room: Latent Threats to Patient Safety Identified During Interprofessional In Situ Simulation in a Canadian Academic Emergency Department.

Emergency department (ED) resuscitation is a complex, high-stakes procedure where positive outcomes depend on effective interactions between the health care team, the patient, and the environment. Resuscitation teams work in dynamic environments and strive to ensure the timely delivery of necessary treatments, equipment, and skill sets when required. However, systemic failures in this environment cannot always be adequately anticipated, which exposes patients to opportunities for harm. As part of a new interprofessional education and quality improvement initiative, this prospective, observational study sought to characterize latent safety threats (LSTs) identified during the delivery of in situ, simulated resuscitations in our ED. In situ simulation (ISS) sessions were delivered on a monthly basis in the EDs at each campus of a large tertiary care academic hospital system, during which a variety of scenarios were run with teams of ED health care professionals. LSTs were identified by simulation facilitators and participants during the case and debriefing and then grouped thematically for analysis. During the study period, 22 ISS sessions were delivered, involving 58 cases and reaching 383 ED health care professionals. 196 latent safety threats were identified through these sessions (mean= 3.4 LSTs per case) of which 110 were determined to be "actionable" at a system level. LSTs identified included system/environmental design flaws, equipment problems, failures in department processes, and knowledge/skill gaps. Corrective mechanisms were initiated in 85% of actionable cases. Effective quality improvement and continuing education programs are essential to translate these findings into more resilient patient care.ISS, beyond its role as a training tool for developing intrinsic and crisis resource management skills, can be effectively used to identify system issues in the ED that could expose critically ill patients to harm.

Implementation of a Multimodal Pain Management Order Set Reduces Perioperative Opioid Use after Liver Transplantation.

Nonopioid strategies to optimize pain management in patients after liver transplantation remain underexplored. The purpose of this study was to evaluate whether the use of a multimodal pain management (MPM) order set would reduce postoperative opioid use in adult patients after liver transplantation. Retrospective pre- and post-order set implementation study. Large academic tertiary care hospital. Thirty-one adults who underwent liver transplantation were included; of these, 18 received provider-managed pain regimens (pre-MPM group: August 20, 2016-January 17, 2018), and 13 received the MPM order set (post-MPM group: January 18-July 31, 2018) after implementation of the order set on January 18, 2018. The MPM order set included standardized receipt of acetaminophen 650mg every 6hours, gabapentin 300mg every 8hours (adjusted for renal function), and opioids for breakthrough pain. Patients managed with the MPM order set received, on average, 30.6 fewer opioid morphine milligram equivalents per day after final extubation than patients who did not receive MPM (median 16, interquartile range [IQR] 4.5-45.6 vs median 46.6, IQR 30.1-75.2; Mann-Whitney U test, p=0.031). Although patients in the post-MPM group had significantly worse renal function at baseline, no other statistically significant differences in baseline characteristics, pain scores, or prescribed outpatient opioids were noted between groups. Patients in the pre-MPM group had a shorter intensive care unit and overall length of stay; however, patients in the post-MPM group may have had more complex postoperative courses contributing to these differences. Implementation of the MPM order set significantly reduced postoperative opioid use in liver transplant recipients. Our results provide a compelling rationale to further investigate the use of a non-opioid-centered strategy to optimize pain management in patients recovering from liver transplantation, a population vulnerable to the risks of opioid use such as opioid use disorder, increased susceptibility to adverse effects, and poor allograft and survival outcomes.

Implementation of an ICU Recovery Clinic at a Tertiary Care Academic Center.

Objectives:Post-ICU clinics may facilitate the care of survivors of critical illness, but there is a paucity of data describing post-ICU clinic implementation. We sought to describe implementation of our ICU recovery clinic, including an assessment of barriers and facilitators to clinic attendance.Design:Adults admitted to the medical ICU of a large tertiary care academic hospital with shock and/or respiratory failure requiring mechanical ventilation were screened for participation in a newly formed ICU recovery clinic. Participant selection and attendance rates were tracked. Reasons for nonattendance were assessed by phone call in a subset of patients.Setting:A newly formed ICU recovery clinic of a large tertiary care academic hospital.Patients:All patients admitted to the medical ICU were screened.Interventions:ICU recovery clinic appointments were scheduled for all eligible patients. A subset of nonattenders were called to assess reasons for nonattendance.Measurements and Main Results:Over 2 years, we admitted 5,510 patients to our medical ICU. Three hundred sixty-two were screened into the recovery clinic. One-hundred sixty-six were not scheduled for clinic; major reasons included discharge to hospice/death in the hospital (n = 55) and discharge to a facility (n = 50). One-hundred ninety-six patients were scheduled for a visit and of those, 101 (52%) arrived to clinic. Reasons for nonattendance in a surveyed subset of nonattenders included patient’s lack of awareness of the appointment (50%, n = 9/18), financial concerns (17%, n = 3/18), and transportation difficulty (17%, n = 3/18).Conclusions:ICU recovery clinics may address the needs of survivors of critical illness. Barriers to clinic attendance include high mortality rates, high rates of clinic appointment cancelations and nonattendance, and discharge to locations such as skilled nursing facilities or long-term acute care hospitals. Improved communication to patients about the role of the clinic may facilitate attendance and minimize canceled appointments.