Large US Hospital Research Articles

PD-L1 (22C3) expression and prognostic implications in esophageal squamous cell carcinoma

Programmed cell death-ligand 1 (PD-L1) clone 22C3 is the only Food and Drug Administration-approved companion diagnostic test for pembrolizumab for the treatment of esophageal squamous cell carcinoma (ESCC). However, prior studies conducted in Asia and Europe have used various PD-L1 antibody clones other than 22C3. We aimed to study the expression profile of PD-L1, specifically of clone 22C3, in ESCC and its significance with regards to histological features, clinical parameters, and overall survival in a case series from two large US hospital systems. PD-L1 (22C3) immunohistochemistry was performed on 82 specimens obtained from 75 patients. Electronic medical records were reviewed to obtain the clinical and follow-up data. Of these specimens, 39 % (32/82) were negative for PD-L1 (22C3) expression (combined positive score (CPS) of 0). The remaining 50 specimens were positive, with CPSs ranging from 1 to 100. Treated specimens showed decreased PD-L1 (22C3) expression compared to untreated specimens. In the multivariate Cox proportional hazards regression model, PD-L1 (22C3) expression was shown to be a favorable prognostic factor for overall survival (p = 0.03, hazard ratio 0.16) only when the CPSs were ≥ 25, independent of surgery, definitive chemotherapy and/or radiotherapy, immunotherapy, and initial clinical stages. We performed a comprehensive study to investigate the expression profile of PD-L1 clone 22C3 in the US patients with ESCC. Our analysis showed that PD-L1 (22C3) expression decreased in treated specimens, and a CPS of ≥25 was associated with a favorable prognosis.

Impact of neutrophil-to-lymphocyte ratio on clinical outcomes in patients with acute or chronic coronary syndrome undergoing percutaneous coronary intervention

Abstract Background Neutrophil-to-lymphocyte ratio (NLR) has recently emerged as an inflammatory biomarker associated with atherosclerosis and cardiovascular events. However, its role in patients with coronary artery disease (CAD) undergoing percutaneous coronary intervention (PCI) remains unclear. Purpose We aimed to evaluate the clinical impact of baseline NLR in patients undergoing PCI for acute coronary syndrome (ACS) and chronic coronary syndrome (CCS). Methods We retrospectively evaluated all consecutive patients undergoing PCI between 2012-2022 in a large tertiary US hospital. We excluded patients for whom NLR was not available and those who were deemed to have active hematological or infective diseases, including patients presenting with extremely low or high lymphocyte and neutrophil counts or with hs-CRP above 10 mg/L. Quartiles of NLR were derived in the overall population and patients were stratified according to clinical presentation. Within each group, we estimated the risk of 12-month adverse events using the lowest NLR quartile as reference. The primary endpoint was major adverse cardiovascular events (MACE), defined as the composite of all-cause death, myocardial infarction (MI), or stroke. Secondary endpoints were MACE individual components and any periprocedural or post-discharge clinically relevant bleeding. Results A total of 7,201 patients were included in the analysis; of these 3,975 (55.2%) had ACS and 3,226 (44.8%) CCS. Patients in the 4th quartile (NLR > 5.0) were more frequently male, older, and presented more often with chronic kidney disease and complex coronary artery disease. Smoking, diabetes and history of CAD, as well as triglycerides, LDL, non-HDL and total cholesterol levels were lower in the 4th NLR quartile. In patients presenting with CCS, the risk of MACE, all-cause death, MI was similar across NLR quartiles, while the risk of bleeding increased stepwise (Figure 1). In patients presenting with ACS, the 4th NLR quartile had the highest adjusted risk of MACE (HRadj 1.82, 95% CI 1.25-2.67; P=0.002), all cause death (HRadj 2.56, 95% CI 1.41-4.66; P<0.001), and bleeding (HRadj 1.82 95% CI 1.25-2.63, P<0.001) at 1 year, as compared to the lowest quartile (Table 1). Conclusions Among patients undergoing PCI, elevated NLR is strongly associated with risk of MACE and all-cause mortality in patients presenting with ACS but not in those with CCS. Conversely, the risk of bleeding was augmented with higher NLR in both ACS and CCS patients undergoing PCI. In this setting, NLR may inform risk stratification at the time of PCI.

Combined left atrial appendage occlusion and catheter ablation procedure for left atrial arrhythmias: A real-world, propensity-matched analysis.

Real-world studies comparing safety and efficacy of combined percutaneous left atrial appendage occlusion (LAAO) and catheter ablation (CA) to LAAO alone are limited. Patients from a large US hospital system undergoing combined LAAO and left-atrial CA from 8/2020 to 2/2024 were retrospectively analyzed and compared to a control group undergoing LAAO alone. Controls were identified using a 1:2 propensity score match based on LAAO device type (Watchman FLX vs. Amulet), CHA2D2-VASc and Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile international normalized ratio [INR], Elderly, Drugs/alcohol (HAS-BLED) scores and compared for safety, sealing performance and clinical outcomes at 6 months. Patients were younger in the combined (n = 72) than in the control group (n = 144, 70.2 ± 7.3 vs. 76.7 ± 6.9 years, p < 0.001) but otherwise comparable with a mean CHA2D2-VASc score of 4.2 ± 1.1 and 4.4 ± 1.2 (p = 0.26) and HAS-BLED score of 2.2 ± 0.8 and 2.3 ± 0.7 (p = 0.34). Successful LAAO implantation rates were the same (95.8% vs. 95.8%, p = 0.99) with longer procedure times seen in the combined group (156.5 ± 53 vs. 56 ± 26 min, p < 0.001). Both major (1.4% vs. 2.1%, p = 0.72) and minor (27.8% vs. 19.4%, p = 0.17) in-hospital complications were similar between the combined and control group, respectively. At 45 days, presence of peri-device leak (18.3% vs. 30.4%, p = 0.07) and device related thrombosis (4.5% vs. 4.5%, p = 0.96) on transesophageal echocardiogram did not differ. Finally, all-cause mortality (0% vs. 1.4%, p = 0.99), thromboembolic (0% vs. 0%, p = 0.99) and bleeding (6.1% vs. 4.4%, p = 0.73) events during follow-up were comparable. This large, real-world analysis indicates comparable safety and efficiency of combined LAAO and CA when compared with LAAO alone.

Dexamethasone Dose for COVID-19 in a Large U.S. Hospital Network From April 2020 to May 2023.

While potential harm from high doses of systemic dexamethasone for clinical management of COVID-19 is an important concern, little is known about real world dexamethasone dosing in patients hospitalized with COVID-19 in the United States. Descriptive study to assess dexamethasone daily dose in adults with COVID-19 in a large US hospital network, overall and by respiratory support requirements, extracted using semi- structured nursing notes. Of 332 430 hospitalizations with a COVID-19 diagnosis, 201 637 (60.7%) hospitalizations included dexamethasone administration. The mean age of recipients was 63 years, 53.0% were male, and 64.5% White. Median time from admission to dexamethasone administration was 0 day (interquartile range [IQR], 0-1 days) and median duration of use was 5 (IQR, 3-9) days. Almost 80% of hospitalizations received standard daily doses (≤ 6 mg daily), 12.7% moderately high daily doses (> 6- ≤ 10 mg daily), and 8.1% high (> 10- ≤ 20 mg daily) or very high daily dose (> 20 mg daily). Over 20% of COVID-19 hospitalizations requiring no oxygen or simple oxygen received high doses of systemic dexamethasone. Given the findings from the UK RECOVERY trial, and the general uncertainty around safety of higher dexamethasone doses in those requiring more intense respiratory support, standard daily dexamethasone doses of 6 mg or less for hospitalized COVID-19 requiring supplemental oxygen are recommended.

Research findings on addressing social determinants of health in practice: Nurses' perspectives

Background and objective: Assessing and intervening with patients’ SDOH are important to nursing practice. However, there are only a few studies on frontline nurses’ perspectives on integrating the SDOH into clinical practice. The purpose of the study was to assess acute care nurses’ knowledge, confidence, and likelihood for addressing patients’ social determinants of health (SDOH).Methods: A descriptive study was conducted surveying 190 nurses in three hospitals within a large northeastern US hospital system using an adapted 48-item SDOH survey which measured nurses’ confidence in, knowledge of, and likelihood to address the SDOH with patients.Results: Respondents reported a high level of knowledge and confidence in addressing the determinants of stress and social support as factors compared with lower percentages of respondents who identified less knowledge and confidence in addressing patients’ education level, race. income, unemployment, and job security factors.Conclusions: The findings support that didactic educational interventions are needed as well as experiential learning around addressing patients’ SDOH.

Near-Infrared Technology for Improved PIVC Placement: A Clinical Technology Implementation Model

ABSTRACT Aims: To share lessons learned from an evidence-based practice (EBP) initiative that implemented near-infrared (NIR) technology in a large US hospital system. A Clinical Technology Implementation Model (CTIM©) that can be adapted for use in other health institutions is presented. Background: EBP implementation, including the adoption of new cutting-edge technologies, is crucial to improving patient care. Yet there are significant delays in changes to clinical practice, often due to organisational challenges that stifle the implementation process. The evidence−practice gap is increasingly evident in peripheral intravenous access (PIV). Implementation science offers new insights into the challenges of updating clinical practice, which can support EBP implementation. Evaluation: Recent literature on implementation science, change theory, PIV access, NIR technology, and patient outcomes were reviewed. A model that can help nurse managers implement technology that aligns with EBP is presented, drawing on experience from the adoption of NIR vein visualisation to enhance PIV access in a large US hospital system. Key issue: A pervasive hesitancy in healthcare to embrace technology, coupled with the challenges of implementing a change to practice, has led to limited application of EBP PIV access guidelines and a stagnant standard of care. Conclusion: This article provides nurse managers with the tools necessary to successfully implement EBP, drawing on the experience from implementing NIR in a large US hospital. Nurse managers are uniquely positioned to lead the way in embracing technology to improve care and reduce the evidence−practice gap.

Near-infrared technology for improved PIVC placement: a clinical technology implementation model.

To share lessons learned from an evidence-based practice (EBP) initiative that implemented near-infrared (NIR) technology in a large US hospital system. A Clinical Technology Implementation Model (CTIM©) that can be adapted for use in other health institutions is presented. EBP implementation, including the adoption of new cutting-edge technologies, is crucial to improving patient care. Yet there are significant delays in changes to clinical practice, often due to organisational challenges that stifle the implementation process. The evidence-practice gap is increasingly evident in peripheral intravenous access (PIV). Implementation science offers new insights into the challenges of updating clinical practice, which can support EBP implementation. Recent literature on implementation science, change theory, PIV access, NIR technology, and patient outcomes were reviewed. A model that can help nurse managers implement technology that aligns with EBP is presented, drawing on experience from the adoption of NIR vein visualisation to enhance PIV access in a large US hospital system. A pervasive hesitancy in healthcare to embrace technology, coupled with the challenges of implementing a change to practice, has led to limited application of EBP PIV access guidelines and a stagnant standard of care. This article provides nurse managers with the tools necessary to successfully implement EBP, drawing on the experience from implementing NIR in a large US hospital. Nurse managers are uniquely positioned to lead the way in embracing technology to improve care and reduce the evidence-practice gap.

Abstract 12974: Sex Differences in Invasive Coronary Angiography at a Large Urban US Hospital

Introduction: Invasive coronary angiography (ICA) is a common procedure to evaluate for ischemic heart disease. Significant sex differences in referral for invasive coronary angiography as well as intervention have been reported. The aim of the current study was to evaluate the impact of male and female sex on patterns of ICA at a large urban hospital. Methods: We retrospectively reviewed hospital procedures performed at UF Health Jacksonville between 2014 and 2018. The electronic health record was queried. Total number of cases and number of cases who did not undergo percutaneous coronary intervention (PCI) or coronary artery bypass graft at the same encounter were retrieved. Chi-square was used to compare groups and odds ratio with 95% confidence interval calculated, and a p-value &lt;0.05 was considered statistically significant. Results: A total of 5556 patients underwent ICA with a men (n=3307) to women (n=2249) ratio of 1.47. Similarly, the ratios of fractional flow reserve (FFR) and intravascular ultrasound (IVUS) were lower in women as compared to men. The mean age for male patients was 61±12 years and &lt;3% were &lt;40 years old. The mean age for female patients was 62±13 years and &lt;3% were &lt;40 years old. Female gender was significantly associated with lower likelihood of having intervention with a male versus female odds ratio (OR) of 1.5 [95% CI 1.4-1.7, p &lt;0.001]. However, those females who underwent PCI had the same ratio of receiving balloon angioplasty, stents or atherectomy as compared to males. Conclusion: In a large urban US clinical center with a diverse and underserved population, being a woman significantly decreases the likelihood of referral for ICA as well as PCI. Our study aligns with prior investigations and underscores the need for further studies to clarify the underlying causes of these differences.

Enhancement and external validation of algorithms using diagnosis codes to identify invasive Escherichia coli disease

Objective To assess the predictive accuracy of code-based algorithms for identifying invasive Escherichia coli (E. coli) disease (IED) among inpatient encounters in US hospitals. Methods The PINC AI Healthcare Database (10/01/2015–03/31/2020) was used to assess the performance of six published code-based algorithms to identify IED cases among inpatient encounters. Case-confirmed IEDs were identified based on microbiological confirmation of E. coli in a normally sterile body site (Group 1) or in urine with signs of sepsis (Group 2). Code-based algorithm performance was assessed overall, and separately for Group 1 and Group 2 based on sensitivity, specificity, positive and negative predictive value (PPV and NPV) and F1 score. The improvement in performance of refinements to the best-performing algorithm was also assessed. Results Among 2,595,983 encounters, 97,453 (3.8%) were case-confirmed IED (Group 1: 60.9%; Group 2: 39.1%). Across algorithms, specificity and NPV were excellent (>97%) for all but one algorithm, but there was a trade-off between sensitivity and PPV. The algorithm with the most balanced performance characteristics included diagnosis codes for: (1) infectious disease due to E. coli OR (2) sepsis/bacteremia/organ dysfunction combined with unspecified E. coli infection and no other concomitant non-E. coli invasive disease (sensitivity: 56.9%; PPV: 56.4%). Across subgroups, the algorithms achieved lower algorithm performance for Group 2 (sensitivity: 9.9%–61.1%; PPV: 3.8%–16.0%). Conclusions This study assessed code-based algorithms to identify IED during inpatient encounters in a large US hospital database. Such algorithms could be useful to identify IED in healthcare databases that lack information on microbiology data.

Candida auris‒Associated Hospitalizations, United States, 2017-2022.

Using a large US hospital database, we describe 192 Candida auris‒associated hospitalizations during 2017-2022, including 38 (20%) C. auris bloodstream infections. Hospitalizations involved extensive concurrent conditions and healthcare use; estimated crude mortality rate was 34%. These findings underscore the continued need for public health surveillance and C. auris containment efforts.

Validation of a Deep Learning–Based Model to Predict Lung Cancer Risk Using Chest Radiographs and Electronic Medical Record Data

Lung cancer screening with chest computed tomography (CT) prevents lung cancer death; however, fewer than 5% of eligible Americans are screened. CXR-LC, an open-source deep learning tool that estimates lung cancer risk from existing chest radiograph images and commonly available electronic medical record (EMR) data, may enable automated identification of high-risk patients as a step toward improving lung cancer screening participation. To validate CXR-LC using EMR data to identify individuals at high-risk for lung cancer to complement 2022 US Centers for Medicare & Medicaid Services (CMS) lung cancer screening eligibility guidelines. This prognostic study compared CXR-LC estimates with CMS screening guidelines using patient data from a large US hospital system. Included participants were persons who currently or formerly smoked cigarettes with an outpatient posterior-anterior chest radiograph between January 1, 2013, and December 31, 2014, with no history of lung cancer or screening CT. Data analysis was performed between May 2021 and June 2022. CXR-LC lung cancer screening eligibility (previously defined as having a 3.297% or greater 12-year risk) based on inputs (chest radiograph image, age, sex, and whether currently smoking) extracted from the EMR. 6-year incident lung cancer. A total of 14 737 persons were included in the study population (mean [SD] age, 62.6 [6.8] years; 7154 [48.5%] male; 204 [1.4%] Asian, 1051 [7.3%] Black, 432 [2.9%] Hispanic, 12 330 [85.2%] White) with a 2.4% rate of incident lung cancer over 6 years (361 patients with cancer). CMS eligibility could be determined in 6277 patients (42.6%) using smoking pack-year and quit-date from the EMR. Patients eligible by both CXR-LC and 2022 CMS criteria had a high rate of lung cancer (83 of 974 patients [8.5%]), higher than those eligible by 2022 CMS criteria alone (5 of 177 patients [2.8%]; P < .001). Patients eligible by CXR-LC but not 2022 CMS criteria also had a high 6-year incidence of lung cancer (121 of 3703 [3.3%]). In the 8460 cases (57.4%) where CMS eligibility was unknown, CXR-LC eligible patients had a 5-fold higher rate of lung cancer than ineligible (127 of 5177 [2.5%] vs 18 of 2283 [0.5%]; P < .001). Similar results were found in subgroups, including female patients and Black persons. Using routine chest radiographs and other data automatically extracted from the EMR, CXR-LC identified high-risk individuals who may benefit from lung cancer screening CT.

Gender and ethnicity bias in medicine: a text analysis of 1.8 million critical care records.

Gender and ethnicity biases are pervasive across many societal domains including politics, employment, and medicine. Such biases will facilitate inequalities until they are revealed and mitigated at scale. To this end, over 1.8 million caregiver notes (502 million words) from a large US hospital were evaluated with natural language processing techniques in search of gender and ethnicity bias indicators. Consistent with nonlinguistic evidence of bias in medicine, physicians focused more on the emotions of women compared to men and focused more on the scientific and bodily diagnoses of men compared to women. Content patterns were relatively consistent across genders. Physicians also attended to fewer emotions for Black/African and Asian patients compared to White patients, and physicians demonstrated the greatest need to work through diagnoses for Black/African women compared to other patients. Content disparities were clearer across ethnicities, as physicians focused less on the pain of Black/African and Asian patients compared to White patients in their critical care notes. This research provides evidence of gender and ethnicity biases in medicine as communicated by physicians in the field and requires the critical examination of institutions that perpetuate bias in social systems.

Perceptions of tap water associated with low-income Michigan mothers' and young children's beverage intake.

To quantify perceptions of tap water among low-income mothers with young children residing in Michigan and examine associations between perceptions of tap water, mothers' and young children's beverage intake, and mothers' infant feeding practices. Cross-sectional study. Online survey. Medicaid-insured individuals who had given birth at a large Midwestern US hospital between fall 2016 and fall 2020 were invited by email to complete a survey in winter 2020 (N 3881); 15·6 % (N 606) completed eligibility screening, 550 (90·8 %) were eligible to participate, and 500 (90·9 %) provided valid survey data regarding perceptions of tap water, self and child beverage intake, and infant feeding practices. Two-thirds (66·2 %) of mothers reported that their home tap water was safe to drink without a filter, while 21·6 % were unsure about the safety of their home tap water. Mothers' perceptions of their home tap water were associated with their own tap and bottled water intake and their young children's tap water and bottled water intake. Mothers with more negative perceptions of tap water in general, independent of their perceptions about their home tap water, consumed more bottled water and sugar-sweetened beverages, and their young children drank bottled water and fruit drinks more frequently. Few associations were observed between mothers' perceptions of tap water and infant feeding practices. Uncertainty about tap water safety and negative perceptions of tap water are common among low-income Michigan mothers. These beliefs may contribute to less healthful and more costly beverage intake among mothers and their young children.

Environmental footprint of regular and intensive inpatient care in a large US hospital

PurposeEnvironmental sustainability is a growing concern to healthcare providers, given the health impacts of climate change and air pollution, and the sizable footprint of healthcare delivery itself. Though many studies have focused on environmental footprints of operating rooms, few have quantified emissions from inpatient stays. This study quantifies solid waste and greenhouse gas emissions (GHGs) per bed-day in a regular inpatient (low intensity) and intensive care unit (high intensity).MethodsThis study uses hybrid environmental life cycle assessment (LCA) to quantify average emissions associated with resource use in an acute inpatient unit with 49 beds and 14,427 hospitalization days and an intensive care unit (ICU) with 12 beds and 2536 hospitalization days. The units are located in a single tertiary, private hospital in Brooklyn, NY, USA.Results and discussionAn acute care unit generates 5.5 kg of solid waste and 45 kg CO2-e per hospitalization day. The ICU generates 7.1 kg of solid waste and 138 kg CO2-e per bed day. Most emissions originate from purchase of consumable goods, building energy consumption, purchase of capital equipment, food services, and staff travel.ConclusionsThe ICU generates more solid waste and GHGs per bed day than the acute care unit. With resource use and emission data, sustainability strategies can be effectively targeted and tested. Medical device and supply manufacturers should also aim to minimize direct solid waste generation.

Feasibility and Effect of Reiki on the Physiology and Self-perceived Stress of Nurses in a Large US Hospital.

Nurses experience stress in the workplace. We evaluated the feasibility and effect of Reiki to relieve stress of staff nurses during a work shift. All Reiki treatments were completed without interruption and lasted 30 minutes. Stress scores, respiratory rate, and heart rate were significantly decreased immediately following the Reiki treatment.

828-P: Inpatient Provider Experience with Diabetes Technology Use on General Medicine Wards: Continuous Subcutaneous Insulin Infusion (CSII) and Continuous Glucose Monitors (CGM)

In the advent of increased use of technology in diabetes care, the management of CSII and CGM devices in the inpatient setting has not been well described. We conducted a non-incentivized survey among inpatient licensed independent practitioners (LIP) at 4 large US hospital systems to assess their knowledge, comfort, and behaviors related to the use of CSII and CGM in the inpatient setting. Of 128 respondents, 83% were day and night hospitalists, 10% advanced practice providers, and 7% primary care physicians. Most LIPs worked in academic centers (68%), 18% at community teaching hospitals, with 93% having diabetes consult service, and 55% having dedicated teams to assist with use of CSII and CGM. Most respondents (96%) rated inpatient hyperglycemia treatment as important, and 93% of LIPs agreed that CSII should be continued in the inpatient setting in the absence of contraindication. However, only half (49%) reported reviewing CSII settings on admission, and of those, only 50% were confident with interpreting those parameters to guide therapy. Almost two-thirds (64% ) of providers reported knowledge of a CSII policy at their institution. The most common barriers to continuing CSII included lack of LIP knowledge and perceived lack of nursing knowledge regarding CSII. LIPs were less familiar with the use of CGM, with 72% being unaware or not at all familiar with their institution’s policy. Of 64 respondents who cared for a patient with CGM in the preceding 6 months, 56% reported not reviewing CGM data to guide therapy. Most inpatient providers value glycemic control and use of DM technology; however, many reported limited in-depth knowledge of CSII and CGM devices for optimal use to guide clinical care in the inpatient setting. Educational programs and collaboration between LIPs and endocrinologists are needed to safely optimize the use of CSII and CGM in the hospital setting. Disclosure N. Z. Madhun: None. R. J. Galindo: Consultant; Self; Abbott Diabetes, Boehringer Ingelheim International GmbH, Eli Lilly and Company, Novo Nordisk, Sanofi US, Valeritas, Inc., Research Support; Self; Dexcom, Inc., Novo Nordisk. J. Donato: None. P. Hwang: None. H. F. Shabbir: None. M. Fowler: Other Relationship; Self; AstraZeneca. E. Molitch-hou: None. G. E. Umpierrez: Research Support; Self; AstraZeneca, Dexcom, Inc., Novo Nordisk. M. Lansang: Consultant; Self; Sanofi, Research Support; Self; Dexcom, Inc.

Real-world safety of catheter ablation for atrial fibrillation with contact force or cryoballoon ablation

PurposeReal-world data can help medical administrators, physicians, and payers make evidence-based decisions regarding treatment choices. The objective of this study was to compare real-world safety outcomes with the latest catheter technologies used for the treatment of atrial fibrillation (AF).MethodsThe Vizient Health Systems database, a large US hospital database, was used to compare acute complications in AF ablation with the contact force sensing THERMOCOOL SMARTTOUCH® Catheter or the THERMOCOOL SMARTTOUCH® SF Catheter (ST) versus the second-generation Arctic Front Advance™ Cryoablation Catheter (CB2) between September 2015 and June 2017. The primary outcome was a composite safety endpoint of acute ablation-related complications defined via ICD-10 diagnosis and procedure codes, including tamponade and other pericardial events, respiratory complications, stroke, cerebral or pre-cerebral occlusion/stenosis without infarction, vascular access complications, hemorrhage, phrenic nerve injury, myocardial infarction, and pulmonary embolism.ResultsIn total, 1473 ablations met all inclusion criteria (407 ST, 1066 CB2). Ablations for paroxysmal AF (PAF) had a lower complication rate than ablations for persistent AF (PsAF) (6.1% vs. 7.3%), as did ablations with ST compared with CB2 within each AF type (PAF 6.0% vs. 6.1%, PsAF 6.3% vs. 7.8%). Neither ablation catheter nor AF type was statistically significant after controlling for site volume, patient age, and comorbid conditions (ST vs. CB2: OR 0.86, p = 0.5544; PsAF vs. PAF: OR 1.08, p = 0.7376).ConclusionAcute ablation-related complication rates were low and were not significantly associated with catheter technology. Increased risk of complication was attributable to low-volume sites and baseline patient characteristics.

Nurse-Reported Bullying and Documented Adverse Patient Events: An Exploratory Study in a US Hospital.

Negative nurse work environments have been associated with nurse bullying and poor nurse health. However, few studies have examined the influence of nurse bullying on actual patient outcomes. The purpose of the study was to examine the association between nurse-reported bullying and documented nursing-sensitive patient outcomes. Nurses (n = 432) in a large US hospital responded to a survey on workplace bullying. Unit-level data for 5 adverse patient events and nurse staffing were acquired from the National Database of Nursing Quality Indicators. Generalized linear models were used to examine the association between bullying and adverse patient events. A Bayesian regression analysis was used to confirm the findings. After controlling for nurse staffing and qualification, nurse-reported bullying was significantly associated with the incidence of central-line-associated bloodstream infections (P < .001). Interventions to address bullying, a malleable aspect of the nurse practice environment, may help to reduce adverse patient events.

Antimicrobial Resistance or Delayed Appropriate Therapy-Does One Influence Outcomes More Than the Other Among Patients With Serious Infections Due to Carbapenem-Resistant Versus Carbapenem-Susceptible Enterobacteriaceae?

BackgroundThe relative contribution of antimicrobial resistance versus delayed appropriate treatment to the clinical and economic burden of Enterobacteriaceae infections is not well understood.MethodsUsing a large US hospital database, we identified all admissions between July 2011 and September 2014 with evidence of serious Enterobacteriaceae infection. The “index date” was the earliest date on which a culture positive for Enterobacteriaceae was drawn. Infections were classified as carbapenem-resistant (CRE) or carbapenem-susceptible (CSE). Receipt of antimicrobials with activity against all index pathogens on the index date or ≤2 days thereafter was deemed as “timely”; all other instances were “delayed.” Associations between CRE status and delayed appropriate therapy on outcomes were estimated using inverse probability weighting and multivariate regression models (ie, logistic model for discharge destination and composite mortality [in-hospital death or discharge to hospice] or generalized linear model for duration of antibiotic therapy, hospital length of stay [LOS], and costs).ResultsA total of 50 069 patients met selection criteria; 514 patients (1.0%) had CRE. Overall, 67.5% of CSE patients (vs 44.6%, CRE) received timely appropriate therapy (P < .01). Irrespective of CRE status, patients who received delayed appropriate therapy had longer durations of antibiotic therapy and LOS, higher costs, lower likelihood of discharge to home, and greater likelihood of the composite mortality outcome (P for trend < .01).ConclusionsDelayed appropriate therapy is a more important driver of outcomes than CRE, although the 2 factors are somewhat synergistic. Better methods of early CRE identification may improve outcomes in this patient population.

The impact on life cycle carbon footprint of converting from disposable to reusable sharps containers in a large US hospital geographically distant from manufacturing and processing facilities.

BackgroundSustainable purchasing can reduce greenhouse gas (GHG) emissions at healthcare facilities (HCF). A previous study found that converting from disposable to reusable sharps containers (DSC, RSC) reduced sharps waste stream GHG by 84% but found transport distances impacted significantly on GHG outcomes and recommended further studies where transport distances are large. This case-study examines the impact on GHG of nation-wide transport distances when a large US health system converted from DSC to RSC.MethodsThe study’s scope was to examine life cycle GHG emissions during 12 months of facility-wide use of DSC and RSC at Loma Linda University Health (LLUH). The facility is an 1100-bed US, 5-hospital system where: the source of polymer was distant from the RSC manufacturing plant; both manufacturing plants were over 3,000 km from the HCF; and the RSC processing plant was considerably further from the HCF than was the DSC disposal plant. Using a “cradle to grave” life cycle GHG tool we calculated the annual GHG emissions of CO2, CH4 and N2O expressed in metric tonnes of carbon dioxide equivalents (MTCO2eq) for each container system. Primary energy input data was used wherever possible and region-specific energy-impact conversions were used to calculate GHG of each unit process over a 12-month period. The scope included Manufacture, Transport, Washing, and Treatment & disposal. GHG emissions from all unit process within these four life cycle stages were summed to estimate each container-system’s carbon footprint. Emission totals were workload-normalized and analysed using CHI2test with P ≤ 0.05 and rate ratios at 95% CL.ResultsConverting to RSC, LLUH reduced its annual GHG by 162.4 MTCO2eq (−65.3%; p < 0.001; RR 2.27–3.71), and annually eliminated 50.2 tonnes of plastic DSC and 8.1 tonnes of cardboard from the sharps waste stream. Of the plastic eliminated, 31.8 tonnes were diverted from landfill and 18.4 from incineration.DiscussionUnlike GHG reduction strategies dependent on changes in staff behavior (waste segregation, recycling, turning off lights, car-pooling, etc), purchasing strategies can enable immediate, sustainable and institution-wide GHG reductions to be achieved. This study confirmed that large transport distances between polymer manufacturer, container manufacturer, user and processing facilities, can significantly impact the carbon footprint of sharps containment systems. However, even with large transport distances, we found that a large university health system significantly reduced the carbon footprint of their sharps waste stream by converting from DSC to RSC.