Local Community Hospital Research Articles

Reducing Unnecessary Transfusions of RBCs in Inpatients Admitted Across Niagara Health Community Hospitals.

Blood products are scarce resources. Audits on the use of red blood cells (RBCs) in tertiary centers have repeatedly highlighted inappropriate use. Earlier retrospective audit at our local community hospitals has demonstrated that only 85% and 54% of all requests met Choosing Wisely Canada guidelines for pre-transfusion hemoglobin (Hb) of 80 g/L or less and single unit, respectively.We sought to improve RBC utilization by 15% over a period of 12 months (meeting Choosing Wisely Canada criteria of pre-transfusion Hb ≤80g/L by >80% and single-unit transfusion by >65%). Following repeated PDSA (Plan-Do-Study-Act) cycles, we implemented educational strategies, prospective transfusion medicine (TM) technologist-led screening of orders, and an RBC order set. The 3-month median percentages of appropriate RBC use for pre-transfusion Hb and single unit (September-November 2021) across all 3 hospitals were 90% and 71%, respectively. Overall, the rate of appropriate RBCs based on pre-transfusion Hb remained above target (>80%), with minimal improvement across all hospitals (median percentage at pre- and post-technologist screening periods of 87% and 90%, respectively). The median percentage of appropriate RBCs based on single-unit transfusion orders has improved across all Niagara Health hospitals with sustained targets (3-month median percentage at pre- and post-technologist screening and most recent time periods of 54%, 56%, and 71%, respectively). We have taken a collaborative, multifaceted approach to optimizing utilization of RBCs across the Niagara Health hospitals. The rates of appropriate RBC use were comparable with the provincial and national accreditation benchmark standards. In particular, the TM technologist-led screening was effective in producing sustained improvement with respect to single-unit transfusion. One of the balancing outcomes was increasing workload on technologists. Local and provincial efforts are needed to facilitate recruitment and retention of laboratory technologists, especially in community hospitals.

Abstract WP78: Large Vessel Occlusion Triage and Routing Utilized for Long-Distance Stroke Transports by Emergency Medical Services (LVO TRUST EMS)

Introduction: Endovascular treatment (EVT) is the most effective therapy in acute ischemic stroke (AIS) with large vessel occlusion (LVO) but its practice is limited to comprehensive stroke centers (CSC). Previous studies have suggested that trained Emergency Medical Services (EMS) professionals can successfully detect LVO cases using a validated screening tool. For these cases, direct transfer to CSC bypassing community hospitals could lead to better outcomes. Methods: This is a retrospective cohort study from 01/01/2018-12/31/2022 of patients with suspected stroke transported by EMS providers from 14 community agencies (primarily fire paramedics) in Southeastern Massachusetts (EMS Region V). When stroke was suspected, EMS providers applied the Field Assessment Stroke Triage for Emergency Destination (FAST-ED) score to assess severity. Bypass of local community hospitals for direct transport to CSC was generally considered for patients with FAST-ED ≥4 and approval of the Region V EMS Medical Director, with the goal of early intervention for severe strokes. In addition to standard education on the use of the FAST-ED score, the EMS agencies received annual aggregate performance feedback and individual case feedback (when requested) from the CSC. Data were collected from the Electronic Health Record (EHR) on demographics, comorbidities, final diagnoses, FAST-ED scores, NIHSS and acute treatments. Descriptive statistics were performed to describe the accuracy of diagnosis and rates of treatment. Results: Among 166 triaged patients to go directly to CSC, 57.6% (95/166) were diagnosed with AIS, and 61.1% (58/95) of them were found to have LVO. There was a higher proportion of AIS or intracranial hemorrhage (ICH) in cases with higher FAST-ED scores. Only 23.4% (39/166) of the cases were diagnosed with stroke mimics, primarily related to lower FAST-ED scores. In total, 36.9% of patients with AIS received EVT: thrombectomy with standard window tPA (21.1%) or late presenter tPA (LKW ≥ 4.5 h, 1.1%), and without tPA (14.7%). Conclusions: A diverse group of community-based EMS services in Southeastern Massachusetts using a prehospital tool can identify patients with severe stroke, i.e. AIS due to LVO or ICH, with acceptable diagnostic accuracy.

The Delivery Model of Perceived Medical Service Quality Based on Donabedian's Framework.

The implementation of the National Health Insurance has transformed the medical care landscape in Taiwan, rendering perceived medical service quality (PMSQ) and patient satisfaction significant focal points in medical care management. Past studies mostly focused on the technical aspects of medical care services, while overlooking the patients' perception of services and the delivery process of PMSQ in the medical care experience. This study integrated the theoretical framework of the Donabedian SPO model and the SERVQUAL questionnaire. The survey was conducted among the outpatients of three types of medical institutions in northern Taiwan: academic medical centers, metropolitan hospitals, and local community hospitals. A total of 400 questionnaires were collected, and 315 valid questionnaires remained after eliminating the incomplete ones. This study established a PMSQ delivery model to explore patients' perceptions of medical service quality. It was found that the variable, Assurance, could deliver the PMSQ and enhance the Medical outcome (MO), while improving the variable, Tangible, in medical institutions could not significantly enhance the MO. These findings emphasize the importance of healthcare institutions prioritizing the professional background, demeanor of their healthcare staff, treatment methods, and processes over tangible elements.

Abstract 12544: Point-of-Care Ultrasound Estimation of Right Atrial Pressure Predicts Early Readmission in Patients With Acute Decompensated Heart Failure

Introduction: We previously developed and validated a highly accurate non-invasive, point-of-care ultrasound (POCUS) technique that uses right internal jugular vein (RIJV) compliance to predict elevated right atrial pressure (RAP). We sought to determine whether this POCUS technique would predict 30-day readmission in acute decompensated heart failure (ADHF) patients. Hypothesis: POCUS-based estimation of RAP at the time of discharge can predict 30-day readmission in patients with ADHF. Methods: In this prospective cohort study, consecutive patients admitted with ADHF were screened for eligibility. POCUS images of the RIJV at end-expiration and at maximal expansion during Valsalva were collected daily during the patient’s stay. To assess compliance, the change in cross-sectional area (CSA) of the RIJV induced by Valsalva was calculated using ImageJ and referred to as the distensibility index (DI). From ROC analysis, a DI≥66% was considered negative for elevated RAP while a DI<66% was considered positive (PPV 87%). 30 days post-discharge, readmission data were collected from patients’ EMR and a follow-up phone call. Sensitivity/specificity and predictive value analyses were conducted based on readmission data for those discharged with positive and negative tests. Results: A total of 237 admitted patients were eligible for this analysis. Patients discharged with a POCUS-estimated elevated RAP had a 30 day readmission rate 3.5 times greater than those discharged with normal POCUS-estimated RAP (26.7% vs 7.6%). POCUS-based normal RAP at discharge had a 92.4% negative predictive value (NPV) for avoiding 30-day readmission (P<.001). A subset of patients in this cohort (n=81) were admitted to a local community hospital. In this setting, POCUS estimation of RAP at discharge had a 95.7% NPV (P<.001) for avoiding 30-day readmission, and patients discharged with a POCUS-based elevated RAP had a 30-day readmission rate 9.6 times greater than those discharged with a normal POCUS test (41.2% vs 4.3%) . Conclusions: POCUS estimation of RAP strongly predicts avoidance of 30-day readmission for ADHF. Using this technique to guide discharge planning, potentially to reduce readmission for ADHF, deserves further investigation in a prospective randomized trial.

Effects of COVID-19 hospitalization rates on the incidence of hospital-acquired Candida central line-associated bloodstream infection

An increase in central line-associated bloodstream infections (CLABSIs) has been reported during the Coronavirus (COVID-19) pandemic; however, few studies have documented causative pathogens, particularly Candida species associated with candidemia. This was a retrospective study based on the National Health Care Safety Network surveillance definitions of CLABSI caused by Candida species during pre-COVID-19 (October 2017 to February 2020) and COVID-19 (March 2020 to December 2021) periods within a local community hospital. Candida CLABSI incidence per 1,000 central line days was compared between periods using the χ2 test and correlated with COVID-19 inpatient hospitalization rates using Pearson correlation. Overall CLABSI (0.68 vs 1.98 per 1,000, P=.004) and Candida CLABSI incidence (0.06 vs 0.77 per 1,000, P=.003) significantly increased from pre-COVID-19 to COVID-19 periods. There was a significant correlation between COVID-19 ICU hospitalizations and CLABSIs (R=0.18, P=.048), but not acute care hospitalizations and CLABSIs (R=0.065, P=.250). Conversely, there was a significant association between COVID-19 acute care hospitalizations and Candida CLABSIs (R=0.50, P<.001), but not COVID-19 ICU hospitalizations and Candida CLABSIs (R=0.01, P=.631). During the COVID-19 pandemic, our facility experienced a significant increase in Candida CLABSI and a significant correlation of Candida CLABSIs with acute care COVID-19 hospitalizations.

Prenatal vs postnatal diagnosis of 22q11.2 deletion syndrome: cardiac and noncardiac outcomes through 1 year of age

The 22q11.2 deletion syndrome is the most common microdeletion syndrome and is frequently associated with congenital heart disease. Prenatal diagnosis of 22q11.2 deletion syndrome is increasingly offered. It is unknown whether there is a clinical benefit to prenatal detection as compared with postnatal diagnosis. This study aimed to determine differences in perinatal and infant outcomes between patients with prenatal and postnatal diagnosis of 22q11.2 deletion syndrome. This was a retrospective cohort study across multiple international centers (30 sites, 4 continents) from 2006 to 2019. Participants were fetuses, neonates, or infants with a genetic diagnosis of 22q11.2 deletion syndrome by 1 year of age with or without congenital heart disease; those with prenatal diagnosis or suspicion (suggestive ultrasound findings and/or high-risk cell-free fetal DNA screen for 22q11.2 deletion syndrome with postnatal confirmation) were compared with those with postnatal diagnosis. Perinatal management, cardiac and noncardiac morbidity, and mortality by 1 year were assessed. Outcomes were adjusted for presence of critical congenital heart disease, gestational age at birth, and site. A total of 625 fetuses, neonates, or infants with 22q11.2 deletion syndrome (53.4% male) were included: 259 fetuses were prenatally diagnosed (156 [60.2%] were live-born) and 122 neonates were prenatally suspected with postnatal confirmation, whereas 244 infants were postnatally diagnosed. In the live-born cohort (n=522), 1-year mortality was 5.9%, which did not differ between groups but differed by the presence of critical congenital heart disease (hazard ratio, 4.18; 95% confidence interval, 1.56-11.18; P<.001) and gestational age at birth (hazard ratio, 0.78 per week; 95% confidence interval, 0.69-0.89; P<.001). Adjusting for critical congenital heart disease and gestational age at birth, the prenatal cohort was less likely to deliver at a local community hospital (5.1% vs 38.2%; odds ratio, 0.11; 95% confidence interval, 0.06-0.23; P<.001), experience neonatal cardiac decompensation (1.3% vs 5.0%; odds ratio, 0.11; 95% confidence interval, 0.03-0.49; P=.004), or have failure to thrive by 1 year (43.4% vs 50.3%; odds ratio, 0.58; 95% confidence interval, 0.36-0.91; P=.019). Prenatal detection of 22q11.2 deletion syndrome was associated with improved delivery management and less cardiac and noncardiac morbidity, but not mortality, compared with postnatal detection.

Exploring a social pragmatic approach to overcoming barriers to interprofessional communication and across functional boundaries: A qualitative case study

BackgroundCommunication and collaboration are essential for high-quality patient care, especially in the context of global pandemics. PurposeThis study explored doctors’ knowledge-sharing behaviors in a local community hospital and the techniques they use to overcome communication barriers across functional boundaries. MethodThis study used a qualitative research design over three phases. Phases I (documentation review) and II (non-participatory observations) were iterative and informed the conceptualization of semi-structured interviews in Phase III. Through purposeful, non-random sampling, 14 doctors were recruited. Data were interpreted using thematic analysis, resulting in four emergent themes. DiscussionThe findings revealed that (1) communication skills allowed doctors to ensure accurate interpretation when collaborating across functions, (2) organizational culture and leadership influenced knowledge-sharing behaviors and reflective learning across the organization, and (3) social conversation benefited working relationships, creating personal communication channels. ConclusionsA social pragmatic approach helps doctors overcome communication barriers when collaborating with other healthcare professionals.

2022 Survey on the Developmental Trend of Smart eHealth in Taiwan

&lt;p&gt;世界衛生組織不僅將智慧醫療（eHealth）定義為資通訊科技在醫療及健康領域的應用 ，亦認為數位科技（Digital technologies）有助於推進全民健康覆蓋以及健康福祉相關的永續發展目標 ，衛生福利部第九期醫療網，亦將創造具韌性且智能的醫療照護體系訂為總目標之一。財團法人醫院評鑑暨醫療品質策進會持續於本（2022）年度進行全國醫院智慧醫療發展問卷普查。在疫情影響下，視訊診療、數位學習系統及遠距教學等導入比率較高，而環境管理智慧化導入則相較門急住診等應用要來得低。AI技術的應用是醫學中心未來一年的發展重點，非醫學中心則放在資訊安全。醫院政策、醫療人員需求及衛生政策分別為前三項推動的關鍵因素，差別在於地區醫院更看重醫院政策與衛生政策。&lt;/p&gt; &lt;p&gt;&amp;nbsp;&lt;/p&gt;&lt;p&gt;The World Health Organization defined eHealth as &amp;ldquo;the use of information and communications technology in support of health and health-related fields&amp;rdquo;, and it considered digital technologies conducive to promoting universal health coverage as well as to sustainable development goals related to health and welfare. The ninth phase of the medical network of the Ministry of Health and Welfare has established one of its overall goals as establishing a healthcare system that is resilient and smart. As in the past, in 2022, the Joint Commission of Taiwan continued to conduct a census of the development of eHealth in medical institutions in Taiwan. Affected by the COVID-19 pandemic, video teleconferencing for disease diagnosis and treatment, digital learning systems, and distant teaching have been more widely introduced compared to the application of environmental smart management in outpatient clinics, emergency departments, and inpatient clinics. In the following year, the application of artificial intelligence technology will be a key development point for medical centers; by contrast, the focus of non-medical centers will be information security. The top three key factors for promoting eHealth among medical institutions will be hospital policies, medical personnel demands, and health policies, with the only difference being that local community hospitals will focus more on hospital policies and health policies.&lt;/p&gt; &lt;p&gt;&amp;nbsp;&lt;/p&gt;

Implementation of an evidence-based accidental tracheostomy dislodgement bundle in a community hospital critical care unit.

Tracheostomy dislodgment can lead to catastrophic neurological injury or death. A fresh tracheostomy amplifies the risk of such events, where an immature tract predisposes to false passage. Unfortunately, few resources exist to prepare healthcare professionals to manage this airway emergency. To create and implement an accidental tracheostomy dislodgement (ATD) bundle to improve knowledge and comfort when responding to ATD. A multidisciplinary team with expertise in tracheostomy developed a 3-part ATD bundle including (1) Tracheostomy Dislodgement Algorithm, (2) Head of Bed Tracheostomy Communication Tool and (3) Emergency Tracheostomy Kit. The team tested the bundle during the COVID-19 pandemic in a community hospital critical care unit with the engagement of nurses and Respiratory Care Practitioners. Baseline and post-implementation knowledge and comfort levels were measured using Dorton's Tracheotomy Education Self-Assessment Questionnaire, and adherence to protocol was assessed. Reporting follows the revised Standards for Quality Improvement Reporting Excellence (SQUIRE). Twenty-four participants completed pre-test and post-test questionnaires. The median knowledge score on the Likert scale increased from 4.0 (IQR=1.0) pre-test to 5.0 (IQR=1.0) post-test. The median comfort level score increased from 38.0 (IQR=7.0) pre-test to 40.0 (IQR=5.0) post-test). In patient rooms, adherence was 100% for the Head of Bed Tracheostomy Communication Tool and Emergency Tracheostomy Kit. The adherence rate for using the Dislodgement Algorithm was 55% in ICU and 40% in SCU. This study addresses the void of tracheostomy research conducted in local community hospitals. The improvement in knowledge and comfort in managing ATD is reassuring, given the knowledge gap among practitioners demonstrated in prior literature. The ATD bundle assessed in this study represents a streamlined approach for bedside clinicians - definitive management of ATD should adhere to comprehensive multidisciplinary guidelines. ATD bundle implementation increased knowledge and comfort levels with managing ATD. Further studies must assess whether ATD bundles and other standardised approaches to airway emergencies reduce adverse events. Relevance to Clinical Practice A streamlined intervention bundle employed at the unit level can significantly improve knowledge and comfort in managing ATD, which may reduce morbidity and mortality in critically ill patients with tracheostomy.

P81. Effect of psychiatric comorbidities on outcomes following anterior cervical discectomy and fusion

<h3>BACKGROUND CONTEXT</h3> The incidence and prevalence of psychiatric disorders is increasing both domestically and internationally. Numerous studies have linked psychiatric comorbidities to increased health risks, poor treatment outcomes and higher use of health care resources. <h3>PURPOSE</h3> To assess the relationship between psychiatric comorbidities and medication use with outcomes following anterior cervical discectomy and fusion. <h3>STUDY DESIGN/SETTING</h3> Retrospective chart review of all patients undergoing anterior cervical discectomy and fusion over the course of 8 months at a local community hospital. <h3>PATIENT SAMPLE</h3> A total of 79 patients underwent anterior cervical discectomy and fusion. The mean age was 55.7 years. <h3>OUTCOME MEASURES</h3> Length of stay, disposition. <h3>METHODS</h3> Seventy-nine patient charts were reviewed retrospectively over the course of 8 months at Monmouth Medical Center. The procedure as well as age were recorded. DSM-V psychiatric diagnoses were noted in the patients' problem list or admission diagnoses. Psychiatric medications from the admission medical reconciliation were recorded. Lastly, disposition was noted (rehabilitation facility versus home) for each patient. <h3>RESULTS</h3> Of the 79 patients included in this study, 31 had a diagnosed DSM-V psychiatric disorder. Of the patients with psychiatric diagnoses, 15 had anxiety, 11 had depression, 1 had bipolar disorder, 1 had obsessive compulsive disorder, 4 with both anxiety and depression and 1 had diagnosed with anxiety and bipolar disorder. The average length of stay for all patients was 1.4 +/- 1.0 days. For those with depression, the average length of stay was 1.5 +/- 0.9 days. In patients with anxiety, the average length of stay was 1.6 +/- 1.5 days. Lastly in patients with bipolar disorder, the average length of stay was 3 +/- 0 days. When compared to patients without psychiatric diagnoses, the difference in length of stay was statisically significant only for patients with bipolar disorder (p = .000408). In addition, patients with psychiatric diagnoses had a higher rate of nonroutine disposition compared to those without psychiatric diagnoses (OR 15.9, p 0.0471). Lastly, the difference in length of stay in patients taking psychoactive medications (1.7 +/-1.4 days) versus those that did not (1.23 +/- 0.6 days) was statistically significant (p 0.021523). <h3>CONCLUSIONS</h3> Patients with bipolar disorder and those that take psychiatric medications may be at risk for increased length of stay following anterior cervical discectomy and fusion. Additionally, patients with psychiatric diagnoses are at a higher risk for discharge to a rehabilitation facility compared to home. Patients undergoing anterior cervical discectomy and fusion may benefit from presurgical screening for psychiatric comorbidities. This may lead to improved patient expectations regarding discharge and a better understanding of outcomes in this population. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Prostate-specific Antigen (PSA) Screening and a Lifesaving Cardiac Transplant

A 61-year-old man with known history of prostatic hypertrophy was transferred from a local community hospital with an acute myocardial infarction. Urgent cardiac transplantation (CTA) evaluation was initiated due to ischemia-induced ventricular septal injury. Pretransplant work-up on hospital day 1 notable for serum PSA of 232 ng/mL. Most recent PSA, 2.5 years prior to hospitalization, was 6.8 ng/mL. A rectal examination revealed an asymmetrically enlarged, smooth prostate.

Today We Walk. Tomorrow We Dance.

Today We Walk. Tomorrow We Dance Allen Callaci Roughly 10 years ago I was helicoptered from my local community hospital to Cedars-Sinai with less than a 25% chance of surviving the brief flight. I left work early, not feeling well that afternoon, and shortly after arriving home, blacked out across my bathroom floor. The heart that had been beating inside me for 40-plus years was in complete collapse. After more than 40 years, it was discovered that the circumflex branch of my left coronary artery had been underdeveloped since birth. My other arteries overcompensated over the ensuing decades, which slowly wore my heart down. I was tired in the years leading up to my transplant but I attached that weariness to my rich and active life, which was filled to the rim with working two jobs, being a grad student and occasionally singing in a rock ’n’ roll band. They say life changes in an instant. Mine changed quicker than that. I left work that afternoon thinking I’d be back in a day or so and catching a Bruce Springsteen concert I had tickets to the following week. Instead I woke up in a hospital bed hooked to oxygen and the symphony of a beeping heart monitor, connected to 27 IVs and two heart assist devices attached to each side of my heart. I woke in a medicated fog with my sister mentioning I was going to be having a heart transplant. I wondered if my situation was real or if I was dreaming and had been swept to a hospital located in Oz. The most positive and painful moments of my recovery and quest to get back home could sometimes be part of the same moment. There were excruciatingly painful moments as I balanced myself on a walker surrounded by a pit crew of nurses helping me balance all the IVs and an oxygen tank. One of the crew followed close behind me with a wheelchair if I should tire on my trek around the nurse’s station and should need a rest. Having not walked in weeks and weeks, each step was excoriatingly painful. My legs felt like a pair of wet flimsy noodles as I stood up for the first [End Page 120] time in a month and a half. My mind knew exactly what it was supposed to do, but the body wasn’t getting the message But as painful as these steps were (and they really were), I saw each step as one step closer to home. The staff at Cedars-Sinai were not just staff taking another patient on a walk—they made me feel like they were my crew with their reassuring and positive attitude as they guided me. I’ll be forever grateful to the nurse who, on one of my first brutally painful walks around the nurse’s station, lightheartedly told me that “today we walk, tomorrow we’ll dance.” I’ve known fewer moments as hopeful, humorous, and humanizing as that one. That mindset transferred onto me as we made our daily walks around the nursing station. Those walks became less and less painful with each passing day. I saw my progress as I graduated from walker, to cane, to being able to walk independently again. I have not stopped thinking of my donor and their family in the years since returning home from Cedars-Sinai, although I only know minimal details about them. I know they were 25 years old and a male. I have reached out to the family with written expressions of my enduring and unending gratitude over the years through the proper channels but have yet to hear back. When I sent out my initial note to the family, I was told that the odds were that I would likely not hear back as it can be an overwhelming emotional experience for donor families to meet the donor. This is more than understandable. My hope is only that my donor family found some small comfort and a sense of closure in my messages. I am often told by others what a journey I have been on. And it has been a journey...

Predicting 31- to 60-Day Heart Failure Rehospitalization Among Older Women.

The current study sought to identify social, hemodynamic, and comorbid risk factors associated with 31-to 60-day heart failure (HF) rehospitalization in African American and Caucasian older (aged >65 years) women. A non-equivalent, case-control, quantitative design study using secondary data analysis of medical records from a local community hospital in the Southeast region of the United States was performed over a 3-year period. Relationships between predictor variables and the outcome variable, 31- to 60-day HF rehospitalization, were explored. The full model containing all predictors was not able to distinguish between predictors (χ2[21, N = 188] = 35.77, p = 0.12). However, a condensed model showed that body mass index (BMI) level 1 (<25 kg/m2), BMI level 2 (>25 and <30 kg/m2), age 75 to 80 years, and those taking lipid-lowering agents were significant predictors. Subtype of HF (reduced or preserved) and race did not predict HF rehospitalization within the specified time period. Multiple comorbid risk factors failed to consistently predict rehospitalization, which may reflect dated HF-specific approaches and therapies. Future studies should evaluate contributions of current targeted post-discharge methods or therapies. [Research in Gerontological Nursing, 15(4), 179-191.].

A Review of Radiology Reports From Hip Surveillance Radiographs for Children With Cerebral Palsy.

Measurement of migration percentage (MP) is fundamental to successful hip surveillance for children with cerebral palsy (CP). In British Columbia, Canada, children enrolled in the province's hip surveillance program get radiographs at the province's tertiary care pediatric hospital or their local community hospital. This study aimed to review the radiology reporting of images completed as part of hip surveillance. Pelvis radiographs completed between September 2015 and December 2019 of 960 children enrolled in the province's hip surveillance program were included. MP values measured by the program coordinator and corresponding value measured by the facility's radiologist, when present, were retrieved. Agreement in MP between the program coordinator and the radiologist was measured using Bland-Altman plots and intraclass correlation coefficients. Radiology reports for images completed at community facilities that prompted a referral to a pediatric orthopaedic surgeon, when reviewed by the hip surveillance team, were further reviewed for qualitative comments. In total, 1849 radiographs were reviewed with 69.3% (1282) completed at the pediatric hospital and 30.7% (567) at 64 different hospitals or clinics. MP was reported for 20.6% (264/1282) of radiographs completed at the pediatric hospital and 3.0% (17/567) of the radiographs completed at community hospitals. Bland-Altman plot analyses found a MP mean difference of 1.2% (95% confidence interval=0.6%-1.8%) between the program coordinator and all radiologist reports with an intraclass correlation coefficient of 0.88 (95% confidence interval=0.86-0.90). There were 47 radiographs completed at community hospitals that resulted in a referral to a pediatric orthopaedic surgeon after review by the hip surveillance team. Eleven of these reports stated normal or unremarkable findings. Radiologic reporting of images completed for hip surveillance for children with CP was inadequate to allow for the detection of hip displacement. Reporting of MP was rare, particularly in community hospitals. If radiology reporting will be utilized for hip surveillance in children with CP, education of radiologists is required.

Impact of Palliative Care on Interhospital Transfers to the Intensive Care Unit.

Community hospitals will often transfer their most complex, critically ill patients to intensive care units (ICUs) of tertiary care centers for specialized, comprehensive care. This population of patients has high rates of morbidity and mortality. Palliative care involvement in critically ill patients has been demonstrated to reduce over-utilization of resources and hospital length of stays. We hypothesized that transfers from community hospitals had low rates of palliative care involvement and high utilization of ICU resources. In this single-center retrospective cohort study, 848 patients transferred from local community hospitals to the medical ICU (MICU) and cardiac care unit (CCU) at a tertiary care center between 2016-2018 were analyzed for patient disposition, length of stay, hospitalization cost, and time to palliative care consultation. Of the 848 patients, 484 (57.1%) expired, with 117 (13.8%) having expired within 48 hours of transfer. Palliative care consult was placed for 201 (23.7%) patients. Patients with palliative care consult were statistically more likely to be referred to hospice (p<0.001). Over two-thirds of palliative care consults were placed later than 5 days after transfer. Time to palliative care consult was positively correlated with length of hospitalization among MICU patients (r=0.79) and CCU patients (r=0.90). Time to palliative consult was also positively correlated with hospitalization cost among MICU patients (r=0.75) and CCU patients (r=0.86). These results indicate early palliative care consultation in this population may result in timely goals of care discussions and optimization of resources.

Todani type III: like biliary dilatation with duodenal prolapse—a case report

BackgroundBiliary dilatation is a rare disease involving intrahepatic and extrahepatic biliary tract abnormalities. With the development of imaging technology, an increasing number of special cases have been diagnosed, which poses a challenge to the traditional classification method.Case presentationA 50-year-old woman was admitted to the hospital due to right upper quadrant pain for more than 10 days. The patient had previous episodes of similar symptoms, which were relieved after symptomatic treatment at a local community hospital. After the symptoms developed, she underwent a computed tomography scan at the local hospital, which showed biliary dilatation; thus, she was referred to our hospital for further treatment. After admission, her magnetic resonance imaging examination also suggested biliary dilatation, but abnormal signals were found in her duodenum. First, a duodenal diverticulum was considered. Later, endoscopic ultrasonography was conducted, and the results suggested that the dilated biliary tract had herniated into the duodenum. This type of lesion is most closely classified as a Todani type III lesion. The patient finally underwent choledochectomy and Roux‑en‑Y hepaticojejunostomy, and the postoperative pathology was consistent with our preoperative diagnosis. The patient was followed up for approximately 2 years, and no obvious postoperative complications were found.ConclusionsThe manifestations of this case are relatively rare and involve one of the undiscussed categories of the Todani classification system; therefore, this case has certain clinical value. Moreover, there is no report similar to this experience in the previous literature.

Retrospective Cross-Sectional Analysis of COVID-19 Patients in a Local Hospital during Delta Surge

Many community members believe the vaccine is not effective against COVID-19 and that local hospitals are full of vaccinated patients with severe COVID-19. Furthermore, they feel national figures do not reflect local numbers. We aimed to analyze the profile of COVID-19 patients in our local community hospital in Sacramento, California to see if indeed most COVID-19 hospitalized patients are vaccinated. This is a retrospective cross-sectional study of COVID-19 patients that were admitted to a community hospital on August 26, 2021, during the delta variant surge. We analyzed the profile of patients in the hospital who had a positive COVID-19 test by PCR. A total of 96 COVID-19 patients were studied of which 20 are vaccinated and 76 are unvaccinated. The average age of hospitalized vaccinated patients with COVID-19 is 69 while unvaccinated patients is 52.6. Additionally, 24 patients were on high flow oxygen with only 3 of them being fully vaccinated. There are 26 patients in the ICU with COVID-19 of which only 3 are fully vaccinated. 21 of these ICU patients are on mechanical ventilation with only 2 being fully vaccinated. Our data is consistent with national trends. While breakthrough infections are inevitable, analysis shows that the elderly population is most significantly impacted. However, breakthrough infections tend to also be less severe. Importantly, the unvaccinated population with COVID-19 disease and hospitalization tend to be of younger age. Altogether, this data from our local hospital highlights and emphasizes the need for our community to be fully vaccinated to prevent COVID-19 disease and hospitalizations.

Development of a Centralized Antimicrobial Stewardship Program Across a Diverse Health System and Early Antimicrobial Usage Trends.

BackgroundExpanding antimicrobial stewardship to community hospitals is vital and now required by regulatory agencies. UPMC instituted the Centralized Health system Antimicrobial Stewardship Efforts (CHASE) Program to expand antimicrobial stewardship to all UPMC hospitals regardless of local resources. For hospitals with few local stewardship resources, we used a model integrating local non-Infectious Diseases (ID) trained pharmacists with centralized ID experts.MethodsThirteen hospitals were included. Eleven were classified as robust (4) or nonrobust (7) depending on local stewardship resources and fulfillment of Centers for Disease Control and Prevention core elements of hospital antimicrobial stewardship. In addition to general stewardship oversight at all UPMC hospitals, the centralized team interacted regularly with nonrobust hospitals for individual patient reviews and local projects. We compared inpatient antimicrobial usage rates at nonrobust versus robust hospitals and at 2 UPMC academic medical centers.ResultsThe CHASE Program expanded in scope between 2018 and 2020. During this period, antimicrobial usage at these 13 hospitals decreased by 16% with a monthly change of −4.7 days of therapy (DOT)/1000 patient days (PD) (95% confidence interval [CI], −5.5 to −3.9; P < .0001). Monthly decrease at nonrobust hospitals was −3.3 DOT/1000 PD per month (−4.5 to −2.0, P < .0001), similar to rates of decline at both robust hospitals (−3.3 DOT/1000 PD) and academic medical centers (−4.8 DOT/1000 PD) (P = .167).ConclusionsCoordinated antimicrobial stewardship can be implemented across a large and diverse health system. Our hybrid model incorporating a central team of experts with local community hospital pharmacists led to usage decreases over 3 years at a rate comparable to that seen in larger hospitals with more established stewardship programs.

Intensive care unit to unit capacity transfers are associated with increased mortality: an observational cohort study on patient transfers in the Swedish Intensive Care Register

BackgroundTransfers from one intensive care unit (ICU) to another ICU are associated with increased length of intensive care and hospital stay. Inter-hospital ICU transfers are carried out for three main reasons: clinical transfers, capacity transfers and repatriations. The aim of the study was to show that different ICU transfers differ in risk-adjusted mortality rate with repatriations having the least risk.ResultsObservational cohort study of adult patients transferred between Swedish ICUs during 3 years (2016–2018) with follow-up ending September 2019. Primary and secondary end-points were survival to 30 days and 180 days after discharge from the first ICU. Data from 75 ICUs in the Swedish Intensive Care Register, a nationwide intensive care register, were used for analysis (89% of all Swedish ICUs), covering local community hospitals, district general hospitals and tertiary care hospitals. We included adult patients (16 years or older) admitted to ICU and subsequently discharged by transfer to another ICU. Only the first admission was used. Exposure was discharge to any other ICU (ICU-to-ICU transfer), whether in the same or in another hospital. Transfers were grouped into three predefined categories: clinical transfer, capacity transfer, and repatriation. We identified 15,588 transfers among 112,860 admissions (14.8%) and analysed 11,176 after excluding 4112 repeat transfer of the same individual and 300 with missing risk adjustment. The majority were clinical transfers (62.7%), followed by repatriations (21.5%) and capacity transfers (15.8%). Unadjusted 30-day mortality was 25.0% among capacity transfers compared to 14.5% and 16.2% for clinical transfers and repatriations, respectively. Adjusted odds ratio (OR) for 30-day mortality were 1.25 (95% CI 1.06–1.49 p = 0.01) for capacity transfers and 1.17 (95% CI 1.02–1.36 p = 0.03) for clinical transfers using repatriation as reference. The differences remained 180 days post-discharge.ConclusionsThere was a large proportion of ICU-to-ICU transfers and an increased odds of dying for those transferred due to other reasons than repatriation.

Mentoring First-Generation and Underrepresented in Medicine Physician-Scientists by Expanding Conversations.

Mentoring First-Generation and Underrepresented in Medicine Physician-Scientists by Expanding Conversations.