Large US Hospital Research Articles

Human factors-based risk analysis to improve the safety of doffing enhanced personal protective equipment.

To systematically assess enhanced personal protective equipment (PPE) doffing safety risks. We employed a 3-part approach to this study: (1) hierarchical task analysis (HTA) of the PPE doffing process; (2) human factors-informed failure modes and effects analysis (FMEA); and (3) focus group sessions with a convenience sample of infection prevention (IP) subject matter experts. A large academic US hospital with a regional Special Pathogens Treatment Center and enhanced PPE doffing protocol experience.ParticipantsEight IP experts. The HTA was conducted jointly by 2 human-factors experts based on the Centers for Disease Control and Prevention PPE guidelines. The findings were used as a guide in 7 focus group sessions with IP experts to assess PPE doffing safety risks. For each HTA task step, IP experts identified failure mode(s), assigned priority risk scores, identified contributing factors and potential consequences, and identified potential risk mitigation strategies. Data were recorded in a tabular format during the sessions. Of 103 identified failure modes, the highest priority scores were associated with team members moving between clean and contaminated areas, glove removal, apron removal, and self-inspection while preparing to doff. Contributing factors related to the individual (eg, technical/ teamwork competency), task (eg, undetected PPE contamination), tools/technology (eg, PPE design characteristics), environment (eg, inadequate space), and organizational aspects (eg, training) were identified. Participants identified 86 types of risk mitigation strategies targeting the failure modes. Despite detailed guidelines, our study revealed 103 enhanced PPE doffing failure modes. Analysis of the failure modes suggests potential mitigation strategies to decrease self-contamination risk during enhanced PPE doffing.

Identifying Complications and Optimizing Consultations following Transradial Arterial Access for Cardiac Procedures

The radial approach to cardiac procedures has become increasingly common. Although previous studies have suggested a favorable risk profile, serious complications can occur. The purpose of this study is to examine the incidence, subsequent treatment, and outcome of all suspected significant neurovascular complications following transradial cardiac procedures at a large US hospital. We reviewed all patients who underwent a left heart catheterization, coronary angiogram, or percutaneous coronary intervention via the transradial approach at a single large academic medical center in the United States between 2010 and 2016. Consultations to the vascular and hand surgery services were examined to assess demographic variables, risk factors, presenting symptoms, subsequent treatment, and outcome of all serious complications. A total of 9,681 radial access cardiac procedures were performed during the study period. Twenty-four cases (0.25%) were suspected to have major complications and subsequently received consults. A total of 18 complications were diagnosed, including 8 vascular injuries or perforations, 4 hematomas, 4 radial artery occlusions, 1 case of compartment syndrome, and 1 severe radial artery spasm. Of the complications noted, 3 (16.7%) required operative interventions, but all recovered neurovascular function. Radial artery access for cardiac procedures has become increasingly common and has been associated with a low rate of major peripheral neurovascular complications. The majority (83.3%) of complications were successfully treated with a nonoperative management algorithm.

Carbapenem-Nonsusceptible Gram-Negative Pathogens in ICU and Non-ICU Settings in US Hospitals in 2017: A Multicenter Study.

BackgroundInfections caused by Gram-negative pathogens resistant to carbapenems have limited treatment options and are associated with increased morbidity and mortality. We evaluated the rates, infection sources, and pathogen types associated with carbapenem-nonsusceptible (Carb-NS) Gram-negative isolates in intensive care unit (ICU) and non-ICU settings in a large US hospital database.MethodsWe conducted a retrospective cross-sectional analysis of carbapenem susceptibility of all nonduplicate isolates of Gram-negative pathogens collected from January 1, 2017, to December 31, 2017, at 358 US hospitals in the BD Insights Research Database. Carb-NS isolates included all pathogens reported at the institutional level as intermediate or resistant.ResultsOf 312 075 nonduplicate Gram-negative isolates, 10 698 (3.4%) were Carb-NS. Respiratory samples were the most frequent source of Carb-NS isolates (35.2%); skin/wound accounted for 23.6%. Pseudomonas aeruginosa was the most common Carb-NS pathogen (58.5% of isolates), and about 30% were Enterobacteriaceae. The highest rates of Carb-NS were found in Acinetobacter spp. (35.6%) and P. aeruginosa (14.6%). The rate of Carb-NS was significantly higher in ICU (5.4%) vs non-ICU settings (2.7%; P < .0001 in univariate analysis). This difference remained significant in multivariable analysis after adjusting for infection and hospital characteristics (odds ratio, 1.35; 95% confidence interval, 1.17–1.56; P < .0001).ConclusionsInfections caused by Carb-NS isolates pose a significant clinical problem across different sources of infection, species of pathogen, and hospital settings. Widespread infection prevention and antimicrobial stewardship initiatives, in combination with new treatment options, may be required to reduce the burden of carbapenem resistance in health care settings.

The (Un)Compromise Effect

The compromise effect—i.e., the preference for the middle option—is an established bias in behavioral economics, but has not been experimentally validated in the field. In the current study I test the compromise effect in a natural context, and whether this bias can be used to stimulate active choice—the (un)compromise effect. In a mail fund raiser for a large US hospital, I evaluate their baseline ask string [$10, $50, $100, $ ] to an extended version [$10, $50, $100, $250, $500, $ ]. In line with the compromise effect, the extended ask string increases the average amount given and the share of donors giving $100, which is now the middle option. Importantly, however, and in line with a model of contextual inference, revealing the middle option is not necessary for the effect to arise. The (un)compromise ask string [$10, $500, $ ] generates the same average amount given and same share giving $100, as the extended ask string—the only difference being that 90 percent of donors, instead of 30 percent, use the open-ask alternative. Hence, by only providing informative end points of a distribution, organizations can benefit from the compromise effect and at the same time promote individuality by stimulating active choice. I discuss theoretical and practical implications of the results.

Vitamin D: the more we know, the less we know.

Over the last 20 years there have been numerous studies, including NHANES III (the National Health and Nutrition Examination Survey III), the Women's Health Study, and the Nurses' Health Study, showing an association between decreased 25-hydroxyvitamin D [25(OH)D]6 concentrations in blood and the risks of cardiovascular disease, stroke, cancer, fractures, and mortality (see the Supplemental Reading List that accompanies the online version of this Q&A at http://www.clinchem.org/content/vol61/issue3). Approximately 10 years ago, these studies led to recommendations from multiple professional societies that the definition of 25(OH)D deficiency be changed from <20 ng/mL (50 nmol/L) to <30 ng/mL (75 nmol/L). In the US, we and other institutions saw the volume of 25(OH)D testing increase 5–6-fold between 2004 and 2007. Furthermore, the use of <30 ng/mL (75 nmol/L) to define 25(OH)D deficiency results in almost half of the tested population in a large Midwestern US hospital, such as ours, as being vitamin D deficient. In late 2010, the Institute of Medicine (IOM) issued a report that vitamin D supplementation was unlikely to be beneficial for any condition other than bone health and that blood concentrations of 20 ng/mL (50 nmol/L) or greater were sufficient for maintaining bone health. Since then, several metaanalyses have failed to show that low 25(OH)D concentrations are associated with risk for any of the above-mentioned nonskeletal chronic conditions, with the possible exception of fractures. Complicating the association of 25(OH)D blood concentrations with risk has been the poor agreement among 25(OH)D immunoassays (e.g., differences in recognition of 25(OH)D2 and 25(OH)D3, the 2 forms of commercial supplements of the vitamin), for which there are ongoing efforts to standardize 25(OH)D assays. Further complicating what we know and don't know is the recent discovery of genetic polymorphisms in vitamin D binding proteins (VDBPs) that segregate well between blacks and …

Impact on carbon footprint: a life cycle assessment of disposable versus reusable sharps containers in a large US hospital

Hospitals are striving to reduce their greenhouse gas (GHG) emissions. Targeting supply chain points and replacing disposable with reusable items are among recommendations to achieve this. Annually, US hospitals use 35 million disposable (DSC) or reusable sharps containers (RSC) generating GHG in their manufacture, use, and disposal. Using a life cycle assessment we assessed the global warming potential (GWP) of both systems at a large US hospital which replaced DSC with RSC. GHG emissions (CO(2), CH(4), N(2)O) were calculated in metric tons of CO(2) equivalents (MTCO(2)eq). Primary energy input data was used wherever possible and region-specific conversions used to calculate the GWP of each activity. Unit process GHGs were collated into manufacture, transport, washing, and treatment and disposal. The DSC were not recycled nor had recycled content. Chemotherapy DSC were used in both systems. Emission totals were workload-normalized per 100 occupied beds-yr and rate ratio analyzed using Fisher's test with P ≤0.05 and 95% confidence level. With RSC, the hospital reduced its annual GWP by 127 MTCO(2)eq (-83.5%) and diverted 30.9 tons of plastic and 5.0 tons of cardboard from landfill. Using RSC reduced the number of containers manufactured from 34,396 DSC annually to 1844 RSC in year one only. The study indicates sharps containment GWP in US hospitals totals 100,000 MTCO(2)eq and if RSC were used nationally the figure could fall by 64,000 MTCO(2)eq which, whilst only a fraction of total hospital GWP, is a positive, sustainable step.

Antipsychotic drugs and risk of pulmonary embolism

Antipsychotic drugs (APs) expose users to several adverse effects. Some reports describe an increased risk of venous thromboembolism for particular drugs in this family. To examine the association between the risks of pulmonary embolism (PE) and AP use and assess any dose-effect relationships. This is a retrospective analysis of data in 'Premier's Perspective' a large US hospital database for 2006. Adults in the AP group had at least one prescription of AP. Logistic regression analysis was performed to detect association between PE and AP use. The dose-effect relationship was assessed according to quantities and administration routes. Analyses were adjusted for potential confounders: age, sex, the components of the Charlson co-morbidity index, diagnoses of infection, sepsis, inflammatory bowel disease, psychotic disorders and hospital inpatient or outpatient status. Among 28,723,771 adults included in 2006, 450,951 (1.6%) were prescribed AP. Haloperidol was most commonly prescribed (157,667 patients or 35.0%), but atypical APs represented over 78% of prescriptions. The risk of PE was higher in AP users than in the total population (OR = 1.17 [95%CI 1.13-1.21]; p < 0.001) and depended on the type of AP used: clozapine was associated with the highest risk. Risk seemed correlated to higher doses. Non-hospital prescription data were unavailable, potentially underestimating the number of patients exposed. The relative timing of AP prescription and PE was not available. Results did not include deep vein thrombosis. This study suggests an increased risk of PE with AP treatment, varying with type of AP and dependent on dose.

Unruptured Intracranial Aneurysms: Why Clinicians Should Not Resort to Epidemiologic Studies to Justify Interventions

The treatment of unruptured aneurysms (UAs) continues to make the news. In a series of well-written articles, we are told that there is something to learn from looking at death and discharge to long-term facilities from a large US hospital data base, cross-matching International Classification of

Analyzing the Flow of Knowledge with Sociometric Badges

This paper presents a collection of “best practices” for the use of “Sociometric Badges” that support automatic collection of face-to-face interaction between workers within an organization. The practices presented aim to improve data quality over legacy methods allowing insights into the processes and structures of an enterprise's de-facto communication networks. Our approach uses dynamic Social Network Analysis (dSNA) to make it easier for executives to analyze and manage communications networks. The practical applicability of the approach was evaluated by case studies conducted in three different organizations: (1) the marketing department of a medium sized bank in Germany, (2) the post-anesthesia care unit at a large US hospital, (3) teams of software developers in a Nordic European country. For the analysis, we tracked, amongst others, all personal interactions between the knowledge workers in a department or team using sociometric badges worn by each employee for the duration of the case studies. We analyzed this sociometric data as well as emails and instant messages exchanged between the employees and compared it with performance data of individuals and teams. The paper highlights 16 key lessons learnt during these studies. The first nine lessons focus on overcoming the employee's privacy concerns to set up the necessary technology infrastructure, and the final seven provide general findings for efficient management of knowledge workers based upon the results of the case studies.