Morristown Medical Center Research Articles

P-261. Physician Attitude on Stethoscope Sanitization: A Quality Improvement Project

Abstract Background Literature has demonstrated that stethoscopes can harbor pathogenic bacteria (Staphylococcus aureus, Pseudomonas aeruginosa, vancomycin-resistant Enterococci and Clostridium difficile) and act as vectors of infection transmission between patients. Although it seems most healthcare professionals are aware of the potential of stethoscopes to transmit infections, the practice of stethoscope cleaning varies widely and is often not up to standard recommendations. This QI project aims to determine current stethoscope sanitization practices at our hospital, Morristown Medical Center (MMC), barriers that prevent more frequent cleaning, and whether education and easier access to sanitization methods changes practices of providers. Figure 1: Frequency of stethoscope sanitization pre- and post-intervention Methods Participants (physicians at MMC) were asked to complete a pre- and post-intervention survey about their stethoscope cleaning practices and barriers to more frequent cleaning. Intervention consisted of physician education and placement of alcohol wipes at physician workspaces for 3 weeks. Figure 2: Obstacles to stethoscope sanitization Results Of the 35 responses from the pre-intervention survey, 97% believed stethoscopes harbor harmful bacteria. 17% of physicians sanitized their stethoscopes after every patient encounter, 37% every day, 34% every week and 11.5% less than every week (Figure 1). Barriers to more frequent stethoscope cleaning included: inaccessibility of alcohol wipes (62.9%), difficult to remember (51.4%), too time-consuming (45.7%), and other (22.9%) (Figure 2). Post-intervention survey (25 responses) showed an increase from 17% to 48% for physicians that sanitize after every patient encounter. More importantly, 96% of participants agreed they would implement better stethoscope sanitization practices going forward. Conclusion Physicians are aware of the potential for stethoscopes to harbor bacteria and transmit infections, however, their stethoscope cleaning practices do not necessarily align with this knowledge, with only 17% sanitizing after every patient encounter. Allowing easier access to alcohol wipes as well as physician education served to increase frequency of stethoscope sanitization overall. Our conclusion is that ongoing education and reminders can help improve overall stethoscope sanitization practices in the hospital. Disclosures All Authors: No reported disclosures

A Phenomenological Analysis of Spiritual Counseling: The Case of Morristown Medical Center Healthcare Chaplaincy (USA)

Manevi danışmanlık uygulamasının temelinin atıldığı Amerika Birleşik Devletleri’nde (ABD) yıllar içerisinde profesyonel ve sistemli bir manevi danışmanlık alanı teşekkül etmiştir. Ancak, Türkiye’de manevi danışmanlık yeni gelişen bir uygulama alanı olması nedeniyle henüz sistematik bir yapı oluşmamıştır. Dolayısıyla, ABD manevi danışmanlık teori ve pratiği Türkiye için önem arz etmektedir. Bu çalışmanın amacı, köklü bir geçmişi olan ABD örneğindeki Healthcare Chaplaincy uygulayıcılarının perspektiflerini ve uygulamalarını incelemek, böylece ABD uygulamalarından faydalanarak Türkiye'deki manevi danışmanlık alanına ışık tutmaktır. Araştırma, nitel bir yaklaşım kullanarak yürütülmüş olup yarı yapılandırılmış görüşme tekniğine dayanmaktadır. 20-27 Temmuz 2018 tarihlerinde Morristown Tıp Merkezi Healthcare Chaplaincy biriminde, 14 chaplain ile derinlemesine görüşme gerçekleştirilmiş ve içerik analizi yöntemi ile katılımcıların deneyimleri görünür kılınmaya çalışılmıştır. Araştırmada veri toplama aracı olarak yarı yapılandırılmış görüşme formu uygulanmıştır. Bu görüşme formunda öncelikle katılımcıların demografik bilgileri ve chaplain olarak ne kadar süredir görev yaptığı hakkında bilgi edinilmektedir. Ardından, katılımcıların Healthcare Chaplaincy hakkındaki görüşler, Healthcare Chaplaincy’deki uygulama deneyimi ve chaplainlerin Türkiye’deki manevi danışmanlara önerileri olmak üzere üç bölüm yer almaktadır. Elde ettiğimiz bulgular, katılımcıların deneyimlerinin literatür ile örtüştüğünü göstermektedir. Öne çıkan önemli bulgulardan biri, klinik manevi danışmanlık eğitiminin manevi danışmanlık uygulamasında en temel standartlardan biri olduğu gerçeğidir. ABD'de uygulanan bu klinik manevi danışmanlık eğitim sisteminin, manevi danışmanlık alanında Türkiye'ye örnek olarak alınabilecek dikkate değer model olduğunu belirtmek mümkündür.

MakoTM robotic-arm-assisted total hip and total knee arthroplasty outcomes in an orthopedic oncology setting: A case series

BackgroundThe MAKO Robotic-Arm system is a cutting-edge technology which combines both computed tomography (CT) scanning and three-dimensional planning to determine the ideal size and orientation of implants prior to bone resection. It is typically utilized within a general orthopedic setting for joint replacement procedures, such as total joint arthroplasties. However, its use within orthopedic oncology, which contains a much more compromised patient population and more complex surgical treatment, is not well documented within the literature. Question/purposesTo determine the patient outcomes of those who underwent a total hip arthroplasty (THA) or total knee arthroplasty (TKA) at Morristown Medical Center using the MAKO Robotic-Arm System. Particularly, we aspired to delve into the use of the MAKO in an orthopedic oncology setting for patients with a degenerative hip or knee and a history of cancer or other orthopedic tumor, impending pathological fracture, PVNS, chondromatosis, radiation therapy, or other oncological related conditions. Patients and methodsOur institution monitored twenty-five individuals with unique orthopedic oncology conditions that underwent MAKO robotic-assisted total hip and knee arthroplasty. This was performed between 2020 and 2022 at Morristown Medical Center in New Jersey. During this time period, 52% (13/25) of the operations were performed on knees and 48% (12/25) were performed on hips. Data regarding patient demographics, body mass index (BMI), medications, hemoglobin, hematocrit, comorbidities, American Society of Anesthesiologists (ASA) Class, operative data, the length of stay (LOS), readmission rates due to infection or periprosthetic fractures, and complications were collected retrospectively. All confidence intervals were calculated at the 95% confidence level. ResultsPostoperatively, the average LOS was 3.2 days, and there were no complications after any of the MAKO-assisted joint arthroplasty procedures. Additionally, there were no readmissions at any of our recorded intervals - 1–30, 1–60, 1–90, and 1 year - however one patient presented to the emergency department after falling 4 days post-operatively. X-ray imaging ultimately revealed no periprosthetic fracture or malalignment of the prosthesis. ConclusionsThe utilization of the MAKO Robotic-Arm System for joint arthroplasty procedures (THAs and TKAs) on orthopedic oncology patients yielded exceptional outcomes, with no complications or readmissions directly attributed to the use of this innovative robotic technology. Thus, this newly emerging surgical system holds great promise, potentially revolutionizing the approach for selected orthopedic oncology patients undergoing total joint arthroplasty compared to the traditional manual techniques. It further demonstrates that its use in an orthopedic oncology setting - where the cohort of patients are often compromised, leading to more intricate surgeries with heightened risks - elicits safety and provides optimal outcomes for patients. Nevertheless, its role within the field is evolving, and in the coming years, as it gains further popularity and sees broader application by orthopedic oncology surgeons, its potential will become clearer. To solidify its position, future clinical investigations and prospective research should be conducted to support the preference of the MAKO system over traditional manual techniques. This will help provide the necessary evidence to advocate for its widespread adoption and continued advancements in orthopedic oncology procedures.

Social Media and Sports Cardiology: Potential Pitfalls and the Importance of Informed Communication

HomeCirculationVol. 147, No. 19Social Media and Sports Cardiology: Potential Pitfalls and the Importance of Informed Communication No AccessArticle CommentaryRequest AccessFull TextAboutView Full TextView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toNo AccessArticle CommentaryRequest AccessFull TextSocial Media and Sports Cardiology: Potential Pitfalls and the Importance of Informed Communication Jonathan H. Kim, Matthew W. Martinez and Michael J. Ackerman Jonathan H. KimJonathan H. Kim Correspondence to: Jonathan H. Kim, MD, MSc, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, 1750 Haygood Dr NE, HSRB II, Office N251, Atlanta, GA 30322. Email E-mail Address: [email protected] https://orcid.org/0000-0001-5885-0284 Emory University School of Medicine, Emory Clinical Cardiovascular Research Institute, Atlanta, GA (J.H.K.). Search for more papers by this author , Matthew W. MartinezMatthew W. Martinez Atlantic Health, Morristown Medical Center, NJ (M.W.M.). Search for more papers by this author and Michael J. AckermanMichael J. Ackerman https://orcid.org/0000-0002-8011-3333 Departments of Cardiovascular Medicine, Pediatric and Adolescent Medicine, and Molecular Pharmacology and Experimental Therapeutics; Divisions of Heart Rhythm Services and Pediatric Cardiology; Windland Smith Rice Genetic Heart Rhythm Clinic; and Windland Smith Rice Sudden Death Genomics Laboratory, Mayo Clinic, Rochester, MN (M.J.A.). Search for more papers by this author Originally published8 May 2023https://doi.org/10.1161/CIRCULATIONAHA.123.064082Circulation. 2023;147:1419–1421FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.For Sources of Funding and Disclosures, see page 1420–1421.Circulation is available at www.ahajournals.org/journal/circCorrespondence to: Jonathan H. Kim, MD, MSc, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, 1750 Haygood Dr NE, HSRB II, Office N251, Atlanta, GA 30322. Email jonathan.[email protected]edu

Editorial Commentary

No AccessUrology PracticeHealth Policy1 May 2021Editorial CommentaryThis article comments on the following:Underutilization of Surgical Standard of Care for Insured Men with Invasive Penile Cancer Sandip M. Prasad Sandip M. PrasadSandip M. Prasad Garden State Urology, Morristown Medical Center, Atlantic Health System, Morristown, New Jersey More articles by this author View All Author Informationhttps://doi.org/10.1097/UPJ.0000000000000214.02AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "Editorial Commentary." Urology Practice, 8(3), p. 354

The cost-effectiveness of antibiotic-loaded bone cement versus plain bone cement following total and partial knee and hip arthroplasty

BackgroundPostoperative infection is one of the most prevalent complications following total joint arthroplasty (TJA). As such procedures become more prevalent, it is imperative that we develop new prophylactic methods to prevent the need for revision procedures. In recent years, surgeons have opted to use antibiotic-loaded bone cement (ALBC) rather than plain bone cement (PBC) in primary hip and knee replacements due to its theoretical potential of lowering infection rates. However, the cost-effectiveness of this intervention remains in question.Questions/Purposes: To determine the rate of infection and cost-effectiveness of antibiotic-loaded bone cement as compared to plain bone cement in hip and knee arthroplasty. Patients and methodsWe reviewed 4116 primary hip and knee arthroplasty cases performed between 2016 and 2018 at Morristown Medical Center in New Jersey. Data regarding demographics, complications, and any readmissions due to deep infection were collected retrospectively. During that time period there were a total of 4016 knee cases (423 ALBC, 3593 PBC) and 123 hip cases (63 ALBC, 60 PBC). The average cost for one bag of antibiotic-loaded bone cement and plain bone cement for hip and knee arthroplasty was $336.42 and $72.14, respectively. A statistical analysis was performed using Fisher's exact test; the National Healthcare Safety Network (NHSN) surgical site infection guidelines were used to distinguish between superficial and deep infections. ResultsTen patients were readmitted due to deep infection, all of whom had undergone total knee arthroplasty. Of those cases, plain bone cement was used for the index procedure in seven instances and antibiotic-loaded cement was used in three. This resulted in an infection rate of 0.19% and 0.62%, respectively, p = 0.103. There was no statistically significant difference in infection rates between the two groups. A total of 778 bags of ALBC were used in 423 knee surgeries, and 98 bags of ALBC were used in 63 hip cases. The total cost for ALBC in TKA and THA procedures was $261,734.76 (778*336.42) and $32,969.16 (98*336.42), respectively. If PBC had been used during all index procedures, it would have resulted in a total savings of $231,509.28. ConclusionsAntibiotic-loaded cement did not significantly reduce the rate of infection for either knee or hip arthroplasty. Thus, the routine use of antibiotic-loaded cement in primary hip and knee arthroplasty may be an unnecessary financial burden to the healthcare system. A larger sample size and a randomized controlled trial would help confirm our findings and would provide further information on the cost-effectiveness of ALBC cement versus PBC.Significance/Clinical Relevance: In this review of cases performed from 2016 to 2018 there was no statistically significant difference between the rate of infection and the need for revision surgeries for patients treated with ALBC versus PBC. As hospital systems continue to transition towards a bundled payment model, it becomes imperative for providers to reduce any unnecessary costs in order to increase quality and efficiency. We estimate that our hospital system could save nearly $120,000/year by using plain bone cement instead of antibiotic-loaded cement.

Occupational Therapy’s Role with Ventricular Assist Devices and the Promotion of Travel Protocols

An option for individuals diagnosed with end-stage heart failure is to receive a ventricular assist device (VAD). In 2006, Shepherd and Wilding produced an article regarding occupational therapy’s role during the VAD process as they anticipated a growing need for this area of practice. Since that time, there continues to be a lack of supporting literature on occupational therapy’s important role with this population. Therefore, the purpose of this article is to explain an occupational therapist’s contribution on the VAD team, offer opportunities and interventions for enhancing quality of life for this unique population, and discuss an innovative travel protocol implemented at Morristown Medical Center.

The Effect of “Pathway” to Diagnosis for Childhood ITP on Caregiver Quality of Life at Time of Diagnosis

Background: Immune thrombocytopenia (ITP) is an immune mediated bleeding disorder characterized by isolated thrombocytopenia. ITP can have a variety of presentations from asymptomatic to life threatening bleeding. Although childhood ITP is most often a self-resolving illness which can be closely observed without intervention, it can be associated with significant impact on quality of life (QoL). Prospective studies of QoL in ITP patients show that there is not always a correlation with treatment or disease severity. The pathway from initial presentation to final diagnosis varies and may include encounters with emergency room, primary care or specialty providers. There have been no published studies to date showing the impact of factors prior to the diagnosis of ITP on treatment decision making and QoL. Objective: To identify the role of physician-patient and physician-caregiver interactions on the QoL and emotional well-being of patients and their families. Ascertaining the impact of pre-diagnosis factors may provide an opportunity to improve access and quality of care provided. Methods: The ITP Consortium of North America (ICON) "Pathways" study was a multicenter observational prospective cohort study focused on the pathways to diagnosis of ITP. The study was supported by a Foundation for Morristown Medical Center Research Fund Grant. Subjects were included if they had presumed primary ITP and were age >12 months to <18 years. Subjects were excluded if they had secondary ITP, including Evans syndrome. Treatment was determined by the physician. Subjects were consented and presented with questionnaires to be completed at the conclusion of the initial hematology visit. The hematologist also completed survey data at that time. Survey data forms included demographic form, physician form, Peds QL Family Impact Questionnaire, Kids ITP tools (KIT) Parent Impact Report and parent proxy report, and child (patient) KIT self-report. There was a parent questionnaire which included a question about worry with a scale from 0 to 10. Study data were collected and managed using REDCap electronic data capture tools hosted at Atlantic Health System. Correlation between variables were calculated using Pearson coefficient or Spearman's rho depending on the distribution of the data variables. Results: Sixty subjects and caregivers were enrolled at 6 ICON centers; 52 were eligible for inclusion. The majority (40%) had Grade 1 bleeding. Most patients (82%) were seen in outpatient hematology clinic by the hematologist and had been referred by the emergency room (73%). The median time to consultation with a hematologist from onset of symptoms was 7 days (1-199) and the median time to diagnosis by hematologist from initial contact with a health care provider was 5 days (0-154). Most subjects had seen 2 health care providers prior to the hematologist. KIT proxy report cumulative scores were a mean of 76.03 (SD 14.72). There was no significant difference between the time to diagnosis or the time from initial encounter with health care provider to hematologist and initial level of worry (p=0.70 and 0.90, respectively). There was also no significant difference between the time to diagnosis or the time from initial encounter with health care provider to hematologist and KIT proxy scores (p=0.96 and 0.50, respectively). However, there was a significant decline in level of worry (scale 0-10) prior to the hematologist visit (median 8, range 1-10) to after the visit (median 4, range 1-10). The association between number of medical providers encountered prior to diagnosis and KIT proxy scores was not significant (p=0.45) (Table). Conclusions: In this study at 6 teaching institutions, we were unable to detect a significant difference in proxy-reported KIT scores relative to the number of health care providers seen or time from diagnosis until the first encounter with the hematologist. We were, however, able to detect a significant change in the level of caregiver worry pre- and post- visit with the pediatric hematologist, supporting a benefit of specialist care to the caregivers of children with ITP. This study was limited by its small sample size and retrospective design. ITP is considered a benign disease but is associated with a significant amount of worry and impact on QoL for patients and caregivers which warrants further investigation. Disclosures Lambert: CSL Behring: Consultancy; Amgen: Consultancy, Other; Bayer: Other: Ad boards; Novartis: Other: Ad boards, Research Funding; Shionogi: Consultancy; Kedrion: Consultancy; Sysmex: Consultancy; AstraZeneca: Research Funding; PDSA: Research Funding. Grace:Agios Pharmaceuticals, Inc: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Novartis: Research Funding.

Updates in Hospital Palliative Care

Rachel D. Havyer (1*), Nauzley Abedini (2), Robert L. Jayes (3), Brenda Matti-Orozco (4), Daniel H. Pomerantz (5), Aziz A. Ansari (6); 1. Division of Community Internal Medicine, Mayo Clinic. 2. Division of Palliative Medicine, University of California San Francisco. 3. Division of Geriatrics and Palliative Medicine, George Washington University Medical Faculty Associates. 4. Division of General Internal Medicine and Palliative Medicine, Morristown Medical Center, Atlantic Health System. 5. Department of Medicine, Montefiore New Rochelle Hospital. 6. Division of Hospital Medicine, Loyola University Medical Center

Stoma Bridge Types and Their Impact on Patient Outcomes: A Retrospective Analysis and Prospective Global Survey of Surgical Practice.

The purpose of this study was to describe the effect of rigid or flexible stoma bridges used for loop ostomy diversions on peristomal skin integrity. Additional aims were to describe surgeon practices related to stoma bridges, and determine the availability of an ostomy nurse specialist. Retrospective chart review and cross-sectional survey. The sample used to address the first aim (effect of stoma bridges) comprised 93 adult patients cared for at Morristown Medical Center, Atlantic Health System, Morristown, New Jersey, an acute care facility. Data provided by 355 colorectal surgeons from 30 countries were used to describe surgeon practice in this area and determine the availability of an ostomy nurse specialist. Respondents were invited from an international roster of colorectal surgeons obtained with permission from the American Society of Colon and Rectal Surgeons (ASCRS). In order to accomplish the initial aim, we retrospectively reviewed medical records of patients who underwent ostomy surgery from 2008 to 2015 and met inclusion criteria. In order to meet our additional aims, analyzed data were obtained from a survey of colorectal surgeons that queried practices related to stoma bridges, and availability of an ostomy nurse specialist. Patients managed with a rigid bridge were significantly more likely to experience leakage beneath the pouching system faceplate than were patients managed by a flexible bridge (42% vs 11%, P < .001). Slightly less than one quarter of patients who developed leakage (n = 22, 24%) experienced pressure and moisture-related peristomal skin complications. Peristomal wounds, inflammation, and infection were significantly higher when a rigid bridge was used (χ test, P < .003). The surgeon's survey (N = 355) showed variability in the use of bridges. Ninety-three percent of all surgeons indicated an ostomy nurse specialist was part of their health care team. Rigid ostomy bridges were associated with a higher likelihood of leakage from underneath the faceplate of the pouching system and impaired peristomal skin integrity. Analysis of colorectal surgeon responses to a survey indicated no clear consensus related to bridge use in patients undergoing loop ostomies.

A DISCHARGE CARE BUNDLE REDUCES READMISSIONS IN PATIENTS WITH ACUTE EXACERBATION OF COPD

SESSION TITLE: Late Breaking Abstracts SESSION TYPE: Original Investigations PRESENTED ON: 10/08/2018 04:30 PM - 05:30 PM PURPOSE: Chronic obstructive pulmonary disease (COPD) remains the third most common cause of readmission among Medicare beneficiaries, occurring in 60% of patients within one year of hospital discharge and in 30% within 3 months of discharge. Decreasing readmissions in this patient population improves patient health and decreases healthcare utilization of resources. The purpose of this study was to determine if a COPD care bundle delivered by a multidisciplinary health care team will reduce hospital readmission rates for acute exacerbations of COPD (AECOPD). METHODS: A prospective cohort design study with pre and post intervention arms was conducted. From April to September of 2016, patients admitted with AECOPD at Morristown Medical Center (MMC) were enrolled in the pre-intervention group. Subsequently an evidence-based COPD care bundle was developed with three primary objectives: (1) Patient education on COPD by healthcare providers prior to discharge; (2) Completion of an individualized self-management COPD action plan to be used by patients after hospital discharge; and (3) Timely outpatient follow-up with a pulmonologist. After this COPD care bundle was implemented in April of 2017, patients admitted with AECOPD at MMC from April to September of 2017 were enrolled in the post-intervention group. Patient characteristics, hospital length of stay (LOS), discharge location, and readmission rates for both groups were collected. Statistical analysis were carried out using Pearson chi-square test or Fisher exact test for categorical variables and 2-sample t-test or Mann Whitney test for continuous variables. The primary outcome was 30-day readmission rates. Secondary outcome was hospital LOS. RESULTS: 150 patients were enrolled in the pre-intervention group and 221 patients were enrolled in the post-intervention group. The two groups were similar in clinically relevant patient characteristics. 30-day readmission rate was lower in the post-intervention group, 22.2% vs. 32.7% (p=0.024). 60-day and 90-day readmission rates were also lower in the post-intervention group, 30.3% vs. 56.0% (p< 0.001) and 35.3% vs. 62.6% (p<0.001), respectively. Hospital length of stay was similar between the two groups, 8 days vs. 7 days (p=0.322). CONCLUSIONS: Implementation of a discharge care bundle in patients admitted with AECOPD significantly and consistently reduced 30 day hospital readmission rates in our patient population without increasing hospital length of stay. This reduction in readmissions was sustained through 60 and 90 days. CLINICAL IMPLICATIONS: A multidisciplinary discharge program can be easily implemented and can improve patient outcomes in those admitted with AECOPD. Such a program should be considered in all hospitals. DISCLOSURES: No relevant relationships by Federico Cerrone, source=Web Response No relevant relationships by Stephanie Chiu, source=Web Response No relevant relationships by Joan Corasaniti, source=Web Response No relevant relationships by Krystal Fitzpatrick, source=Web Response No relevant relationships by Moira Kendra, source=Web Response No relevant relationships by Lisa Landry, source=Web Response No relevant relationships by Beverly Natale, source=Web Response No relevant relationships by Natalie Reyes, source=Web Response No relevant relationships by Chirag Shah, source=Web Response

Post-Surgical Outcomes in Patients with Ventricular Assist Devices

Morristown Medical Center, Morristown, NJ; RWJ Barnabas Health, Livingston, NJ; Rutgers New Jersey Medical School, Newark, NJ

Outcome and Cost Analysis of Hand-Sewn and Stapled Anastomoses in the Reversal of Loop Ileostomy

Diverting loop ileostomies are common procedures for protecting high-risk anastomoses. There is little consensus on the most ideal technique both in terms of cost efficiency and outcome. Data for this study were collected from 101 patients who underwent loop ileostomy reversal between 2009 and 2014 at Morristown Medical Center. Of the 101 patients included in the review, 57 received a hand-sewn anastomosis (HS-A) and 44 received a stapled anastomosis (S-A). Average total hospital charges for stapled anastomoses were significantly greater than that for hand-sewn anastomoses, as were total operating room supply costs. When the total cost of the operation itself was considered, S-A cases were still found to be significantly greater than HS-A cases. Hospital room charges, total lab charges, pathology charges, and EKG/ECG charges were all greater for S-A cases than HS-A cases. Overall costs were greater for S-As than hand-sewn anastomoses and because of a lack of difference in procedure length, stapler supply costs were not offset. Complication rates and length of stay were also similar between the techniques. We found S-A cases to be more costly and have a greater cost/hour than HS-A cases.

Cost and efficacy examination of alvimopan for the prevention of postoperative ileus

Opioid analgesics exacerbate ileus through peripheral μ-opioid receptor action. Alvimopan, a μ-opioid receptor antagonist, has been proposed to alleviate postoperative ileus, leading to decreased time to return of gastrointestinal function...

The effects of Hurricane Sandy on trauma center admissions.

Hurricane Sandy was a particularly unusual storm with regard to both size and location of landfall. The storm landed in New Jersey, which is unusual for a tropical storm of such scale, and created hazardous conditions which caused injury to residents during the storm and in the months following. This study aims to describe differences in trauma center admissions and patterns of injury during this time period when compared to a period with no such storm. Data were collected for this study from patients who were admitted to the trauma center at Morristown Medical Center during Hurricane Sandy or the ensuing cleanup efforts (patients admitted between 29 October 2012 and 27 December 2012) as well as a control group consisting of all patients admitted to the trauma center between 29 October 2013 and 27 December 2013. Patient information was collected to compare the admissions of the trauma center during the period of the storm and cleanup to the control period. A total of 419 cases were identified in the storm and cleanup period. 427 were identified for the control. Striking injuries were more common in the storm and cleanup group by 266.7% (p=0.0107); cuts were more common by 650.8% (p=0.0044). Medical records indicate that many of these injuries were caused by Hurricane Sandy. Self-inflicted injuries were more common by 301.3% (p=0.0294). There were no significant differences in the total number of patients, mortality, or injury severity score between the two cohorts. The data we have collected show that the conditions caused by Hurricane Sandy and the following cleanup had a significant effect on injury patterns, with more patients having been injured by being struck by falling or thrown objects, cut while using tools, or causing self-inflicted injuries. These changes, particularly during the cleanup period, are indicative of environmental changes following the storm which increase these risks of injury.

Experience of General Surgery Residents in the Creation of Small Bowel and Colon Anastomoses

With the introduction of stapling devices (SDs), the proportion of hand-sewn (HS) intestinal anastomoses (IAs) has declined. As more IAs are constructed with SDs, there are fewer opportunities for general surgery residents (GSRs) to acquire the skills for HS techniques during their training. Data for this study were extracted from an existing database of all IAs performed at the Department of Surgery of the Morristown Medical Center since 2003. For the purposes of this study, a 5.5-year timeframe was used between July 2006 and 2011, which contained 1659 IA operations on adult patients with resident involvement. GSRs of the 5-year general surgery residency program were grouped by postgraduate year (PGY) for further analysis. The number of all IAs created by each resident during the 5-year training was 67.2 on average. Most of these operations were done in the last 2 years of the training: 45.1% of all IAs in PGY5 and 37.3% of all IAs in PGY4. Of all, 1659 IAs performed in the study period, 711 (42.9% of total) were done laparoscopically and 948 (57.1% of all IAs) were done as open operations. Laparoscopic operations had a proportionally higher rate of SD use when compared to open cases (90.9% vs 82.4%). On average, each resident constructed 9.4 HS IAs (13.98% of all IAs) and 57.8 SD IAs (86.02% of total). Out of all anastomoses, ostomy reversals (30.7%) had the highest percentage of HS suturing followed by right colectomies (27.5%), ileal pouch-anal anastomoses and total colectomies and proctocolectomies (23.3%), small bowel resection (17.0%), and left colectomies (5.5%). Regardless of the location of the operation, stapled and sutured anastomoses had similar outcomes measured by the rate of anastomotic leaks. Residents used significantly more SDs in the creation of anastomoses than HS suturing in the PGY3, PGY4, and PGY5 years. We also documented that attending surgeons who are older more often used HS suturing than their younger colleagues when creating IAs. The experiences of GSRs in IA operations are heavily weighted toward the use of SDs. There are select cases, however, when HS suturing can have an advantage over stapler use in anastomosis creation. Therefore, we believe that GSRs should continue learning, perfecting, and using the both techniques.

Visual Diagnosis: 15-Year-Old Girl With Fever, Extremity Pain, and Unusual Rash

1. David Toturgul, MD* 2. Megan Yunghans, MD† 3. Jessica Kosut, MD† 1. *Atlantic Health Sports Medicine, Morristown Medical Center, Morristown, NJ. 2. †Division of Hospital Medicine, John A Burns School of Medicine, Honolulu, HI. A 15-year-old girl presents to the clinic with fever, rash, and extremity pain associated with difficulty walking. The patient had been in her usual state of health until 6 days before admission, when she developed diffuse abdominal pain, nonbilious and nonbloody emesis, and subjective fever. The patient initially had been seen in the emergency department (ED) 2 days before presentation and underwent abdominal computed tomography (CT), blood work, and urine studies. The abdominal CT revealed a normal-appearing appendix and no evidence of gastrointestinal obstruction. The blood work was notable for the following: white blood cell (WBC) count, 18,700/μL (18.7 × 109/L) with 39% band cells; hemoglobin, 15 g/dL (150 g/L); hematocrit, 43.1; platelet count, 94.0 × 103/μL (94.0 × 109/L); erythrocyte sedimentation rate, 30 mm/h; and C-reactive protein, 111 mg/L (1057 nmol/L). The urinalysis revealed 0 to 5 WBCs, 2 to 5 red blood cells, a protein level of greater than 300 mg/dL (3.0 g/L), and moderate bacteria (10-30 casts) but normal pH and negative leukocyte esterase and nitrite test results. A rapid streptococcal test result was negative. The patient was given a single dose of ceftriaxone and sent home with a prescription for a 10-day course of cephalexin for presumed urinary tract infection. The next day she followed up with her pediatrician and by that time had developed chills, extremity pain that began in her lower extremities with progression to her upper extremities, and a new rash on her palms and soles. She had not filled the cephalexin prescription and was given a new prescription for amoxicillin by her pediatrician. Later, a …

Treatment of Obstructive Sleep Apnea Syndrome with Nasal Positive Airway Pressure Improves Golf Performance

Obstructive sleep apnea syndrome (OSAS) is associated with impairment of cognitive function, and improvement is often noted with treatment. Golf is a sport that requires a range of cognitive skills. We evaluated the impact of nasal positive airway pressure (PAP) therapy on the handicap index (HI) of golfers with OSAS. Golfers underwent a nocturnal polysomnogram (NPSG) to determine whether they had significant OSAS (respiratory disturbance index > 15). Twelve subjects with a positive NPSG were treated with PAP. HI, an Epworth Sleepiness Scale (ESS), and sleep questionnaire (SQ) were submitted upon study entry. After 20 rounds of golf on PAP treatment, the HI was recalculated, and the questionnaires were repeated. A matched control group composed of non-OSAS subjects was studied to assess the impact of the study construct on HI, ESS, and SQ. Statistical comparisons between pre- and post-PAP treatment were calculated. The control subjects demonstrated no significant change in HI, ESS, or SQ during this study, while the OSAS group demonstrated a significant drop in average HI (11.3%, p = 0.01), ESS, (p = 0.01), and SQ (p = 0.003). Among the more skilled golfers (defined as HI ≤ 12), the average HI dropped by an even greater degree (31.5%). Average utilization of PAP was 91.4% based on data card reporting. Treatment of OSAS with PAP enhanced performance in golfers with this condition. Treatment adherence was unusually high in this study. Non-medical performance improvement may be a strong motivator for selected subjects with OSAS to seek treatment and maximize adherence.

Use of tincture of opium compared to oral morphine for the treatment of neonatal abstinence syndrome

To evaluate the difference in time until medical clearance when comparing tincture of opium (TO) to oral morphine (OM) in the treatment of neonatal abstinence syndrome (NAS). Retrospective chart review conducted from May 2007 to July 2011. Level III Neonatal Intensive Care unit at Morristown Medical Center in Morristown, New Jersey. Clinical Drug Utilization reports identified 26 neonates who were treated with TO and 25 neonates who were treated with OM for NAS. No patients were excluded. Patients were treated with either TO or OM for the indication of NAS. The primary outcome is to compare the time it takes for a baby being treated with TO versus OM for NAS to be medically cleared for discharge. The median time until medical clearance for those treated with TO was 29.5 days compared to 37 days for those treated with OM (p = 0.14). There was no statistically significant difference in the time it takes for a baby being treated with TO versus OM for NAS to be medically cleared for discharge. There are a number of safety benefits in using OM compared to TO. Until further data are collected, it is appropriate to continue treatment of neonates with NAS with OM.

Partners in Caring

Nursing leadership at Morristown Medical Center, a Magnet-designated, 600-plus bed tertiary care center, in response to forces, such as health care reform, and recommendations, such as those outlined in the Institute of Medicine report The Future of Nursing, developed an innovative model of care delivery called the Partners in Caring. This model of care delivery is an approach built on a functional unit of registered nurse-nurse assistant partnership supported by a patient care facilitator. The nursing partners are accountable for the coordination of patient care with an emphasis on patient and organizational goal achievement of (1) improving the health of our patients, (2) developing and maintaining an improved and responsive health care system, and (3) lowering costs while delivering quality care. The model of care was developed and is being implemented and evaluated using a knowledge translation methodology to ensure its evidence base and outcome achievement. Transforming workforce roles and communication patterns, incorporating technology to benefit time management and maintaining a keen focus on achieving patient outcomes are hallmarks of this new model.