Multihospital System Research Articles

53: Evaluation of a quality improvement intervention to decrease post-cesarean opioid use across a multi-hospital system

To determine the effect of an order-set change incorporating standing acetaminophen and nonsteroidal anti-inflammatory drug (NSAID) use on oral opioid consumption post-cesarean delivery across a multi- hospital system. We implemented a quality improvement intervention across a network of six hospitals comprised of two large tertiary care centers, two mid-sized community hospitals, and two small community hospitals. The network- wide electronic post-cesarean delivery order set was changed to alter the timing of acetaminophen and NSAID orders from as-needed to standing, and to optimize the dosage of these medications. As-needed opioid orders remained the same before and after the intervention. Using generalized linear regression models, we assessed the impact of this intervention on the average milligrams of morphine equivalent (MME) of oral opioids consumed per patient during the 8 months prior to the intervention and the 8 months following the intervention. We evaluated a total of 4666 women delivered via cesarean at 6 network hospitals. The two large tertiary care centers delivering a total of 1808 and 1254 patients, respectively, demonstrated a significant decrease in mean oral opioid consumption before and after the intervention (118.0 to 81.6 MME p<0.001, and 186.4 to 136.3 MME p=0.01). The four community hospitals delivering a total of 997, 480, 29 and 27 patients, respectively, showed no significant change in mean oral opioid consumption before and after the intervention (93.1 to 86.3 MME, p=0.66, 210.3 to 218.5 MME p=0.72, 55.5 to 63.1 MME p=0.77, and 50.0 to 23.7 MME p=0.06). There was a trend towards less opioid use post-intervention in the smallest community hospital. Order sets incorporating standing acetaminophen and NSAID use after cesarean is associated with decreased oral opioid consumption post-operatively in some settings. Our intervention was associated with the greatest impact in tertiary care centers where multiple initiatives have heightened awareness of the risks associated with opioid use.

Development of an antimicrobial stewardship program in an integrated healthcare system.

The development of an inpatient antimicrobial stewardship program (ASP) in an integrated healthcare system is described. With increasing national focus on reducing inappropriate antimicrobial use, state and national regulatory mandates require hospitals to develop ASPs. In 2015, BJC HealthCare, a multihospital health system, developed a system-level, multidisciplinary ASP team to assist member hospitals with ASP implementation. A comprehensive gap analysis was performed to assess current stewardship resources, activities and compliance with CDC core elements at each facility. BJC system clinical leads facilitated the development of hospital-specific leadership support statements, identification of hospital pharmacy and medical leaders, and led development of staff and patient educational components. An antimicrobial-use data dashboard was created for reporting and tracking the impact of improvement activities. Hospital-level interventions were individualized based on the needs and resources at each facility. Hospital learnings were shared at bimonthly system ASP meetings to disseminate best practices. The initial gap analysis revealed that BJC hospitals were compliant in a median of 6 ASP elements (range, 4-8) required by regulatory mandates. By leveraging system resources, all hospitals were fully compliant with regulatory requirements by January 2017. BJC's ASP model facilitated the development of broad-based stewardship activities, including education modules for patients and providers and clinical decision support, while allowing hospitals to implement activities based on local needs and resource availability.

Are Medicare's Nursing Home Compare Ratings Accurate Predictors of 90-Day Complications, Readmission, and Bundle Cost for Patients Undergoing Primary Total Joint Arthroplasty?

BackgroundNursing Home Compare (NHC) ratings, created and maintained by Medicare, are used by both hospitals and consumers to aid in the skilled nursing facility (SNF) selection process. To date, no studies have linked NHC ratings to actual episode-based outcomes. The purpose of this study was to evaluate whether NHC ratings are valid predictors of 90-day complications, readmission, and bundle costs for patients discharged to an SNF after primary total joint arthroplasty (TJA). MethodsAll SNF-discharged primary TJA cases in 2017 at a multihospital academic health system were queried. Demographic, psychosocial, and clinical variables were manually extracted from the health record. Medicare NHC ratings were then collected for each SNF. For patients in the Medicare bundle, postacute and total bundle cost was extracted from claims. ResultsFour hundred eighty-eight patients were discharged to a total of 105 unique SNFs. In multivariate analysis, overall NHC rating was not predictive of 90-day readmission/major complications, >75th percentile postacute cost, or 90-day bundle cost exceeding the target price. SNF health inspection and quality measure ratings were also not predictive of 90-day readmission/major complications or bundle performance. A higher SNF staffing rating was independently associated with a decreased odds for >75th percentile 90-day postacute spend (odds ratio, 0.58; P = .01) and a 90-day bundle cost exceeding the target price (odds ratio = 0.69; P = .02) but was similarly not predictive of 90-day readmission/complications. ConclusionResults of our study suggest that Medicare's NHC tool is not a useful predictor of 90-day costs, complications, or readmissions for SNFs within our health system.

Distance, Quality, or Relationship? Interhospital Transfer of Heart Attack Patients

We empirically investigate the pattern of where heart attack patients are transferred between hospitals. Using 2011 Florida State Emergency Department and Inpatient Databases, we demonstrate the relative importance of three key factors in determining transfer destinations: (1) the distance between sending and receiving hospitals, (2) publicly reported quality measures of receiving hospitals, and (3) the relationship between sending and receiving hospitals as indicated by whether they are affiliated with the same multihospital system. Our conditional logit analysis shows that hospital relationship plays a more dominant role in determining transfer destinations than distance and quality. This result is robust to three alternative specifications of choice sets using distance ranking, radius circles, and Hospital Referral Regions, and also robust to alternative measures of distance and quality. Using 30‐day readmission rate to evaluate the health outcome of transferred patients, we find that relationship‐based transfers led to worse outcome than distance‐based and quality‐based transfers. We also find that nonprofit hospitals are more likely to conduct quality‐based transfers and less likely to conduct relationship‐based transfers than their for‐profit counterparts. Our study calls for reevaluating the current practice of relationship‐driven routing of heart attack patients—selecting transfer destinations based on quality or distance can potentially decrease hospital readmission rate.

Variation in Tympanoplasty Cost in a Multihospital Network.

Identify costs and operative times for tympanoplasty, and evaluate factors influencing cost and time variation. Retrospective cohort study. Multihospital network. Patients undergoing tympanoplasty from 2008 to 2016. Subjects with additional procedures were excluded. A multihospital network's standardized activity-based accounting system was used to determine costs and operative times of tympanoplasty. Correlation between variable factors and cost was calculated by Spearman correlation coefficients. Statistical comparisons of cost and time were made between surgeons and hospitals using an ANOVA test (Kruskal-Wallis) followed by Dunn's test to correct for multiple comparisons. All providers or hospitals with single cases were excluded for statistical comparison. The study cohort included 487 tympanoplasties performed by 44 surgeons at 13 hospitals. Mean patient age was 18.2 ± 17.4 years. Mean cut-to-close time was 85.8 ± 56.7 minutes. Mean total encounter cost was $3491 ± $1,627. Substantial factors associated with total encounter cost were anesthesia cost (r = 0.8782; 95% CI 0.852-0.900, p < 0.001) and cut-to-close time (r = 0.7543; 95% CI 0.707-0.7949, p < 0.001). The total itemized supply cost was less correlated with total encounter cost (r = 0.3176; 95% CI 0.2128-0.4151, p < 0.001). Laser utilization (mean cost $541 ± $343) and artificial graft material (mean cost $199 ± $94) were the major supply costs. Significant variation in tympanoplasty costs exists among different surgeons and hospitals within a multihospital network. Reducing variation in costs while maintaining outcomes may improve healthcare value and eliminate waste.

1134. Novel T2Candida Panel Assay Compared With Blood Cultures for Detection of Candidemia in Transplant and Non-Transplant Patients

BackgroundBlood culture (BC) the current “gold” standard for detection of candidemia has a sensitivity of ~50% and turnaround time (TAT) of 2–5 days. T2Candida Panel (T2) a magnetic resonance nano-diagnostic test done directly on blood samples detects C. albicans/C. tropicalis, C. krusei/C. glabrata, and C. parapsilosis. Clinical trials of T2 showed good sensitivity, specificity, NPV 99% and TAT of 3–5 hours. The performance of T2 in high-risk transplant (Tx) population is unknown. T2 was implemented at our institution in October 2015. We evaluated the performance characteristics of T2 and BC in our Tx and non-transplant (non-Tx) patient populations.MethodsThis was an observational, retrospective, cross-sectional evaluation of patients with suspected candidemia that had T2 done from October 2015 to October 2017 at a multihospital healthcare system in Detroit, MI. Performance characteristics of the T2 and BC in Tx and non-Tx patients were compared. BC obtained within 7 days before or after the T2 test were included in the analysis. TAT, sensitivity, specificity, PPV and NPV were calculated using positive BC as the standard. Differences between groups were assessed using two sample proportions testing at α = 0.05.ResultsA total of 1,272 patients with suspected candidemia had T2 done: 1,162 (91%) non-Tx and 110 (9%) Tx patients. Average TAT for T2 was 13 hours (5–41) vs. 34 hours (21–109) to initial positive BC result and 4 days (3–13) to species-specific BC result. In four non-Tx patients with negative T2, C. lusitaniae, C. dubliniensis, and C. kefyr were isolated in BC. Performance characteristics of T2 and BC in the two groups is shown (Table 1). Of the T2+/BC− cases (n = 102), 9% had retinitis and 9% had invasive candidiasis.ConclusionThe rapid TAT, good sensitivity, and high NPV of T2 in Tx patients has clinical implications and can help support antifungal stewardship efforts in this population. The clinical significance of T2 positivity in the presence of negative BC needs further investigation.Table1: Performance Characteristics of T2 Compared with BC (N = 1,272)Tx (n = 110)Non-Tx (n = 1162) P-valueT2 + and blood culture +5 (4.5%)35 (3.01%)0.3917T2 + and blood culture −19 (17.3%)86 (7.4%)0.0003T2 - and blood culture +1 (0.9%)41 (3.5%)0.1431Sensitivity83.3%46.1%Specificity81.9%92.4%PPV20.8%28.9%NPV98.8%96.2%Disclosures G. Alangaden, T2 Biosystems: Speaker’s Bureau, Educational grant and Speaker honorarium.

1120. Clostridium difficile Infection Risk Factors, Severity, and Outcomes in Patients Infected with NAP1/027 Strain in a Non-Epidemic Setting

BackgroundEvidence surrounding outcomes with the North American pulsed-field gel electrophoresis type 1 (NAP1) Clostridium difficile (CDI) strain remains conflicting. We compared risk factors, severity of illness, and mortality of patients infected with NAP1 strain compared with patients with non-NAP1 strains in our multihospital health system.MethodsThis is a retrospective case–control analysis of patients admitted to one of five hospitals (one academic and four community hospitals) and diagnosed with CDI from April 2014 through July 2017. CDI definition included three or more stools per day with positive stool sample polymerase chain reaction (PCR) testing for C. difficile.ResultsA total of 490 patients met inclusion, of which 155 had the NAP1 strain and 335 patients were infected with non-NAP1 strains. More patients with NAP1 were older, female, had CHF, and presented from a healthcare facility as opposed to from the community (all P < 0.05). No difference in 90-day antibiotic class use was found. NAP1 patients had increased ICU admission (12.3 vs. 6.0%, P = 0.016), a shorter length of stay (10.8 vs. 13.4 days, P = 0.037), abnormal CT findings (P < 0.023), and trend toward more ID consults (P = 0.067). Per IDSA classification, 61.9% in the NAP1 CDI group had severe CDI as opposed to 49.6% in the non-NAP1 study group. (P ≤ 0.038). There was no observed difference in inpatient mortality (7.7 vs. 5.7%, P = 0.381).ConclusionCDI caused by NAP1 strain did result in increased severity but did not result in increased mortality compared with CDI caused by non-NAP1 strains. Evidence continues to mount that while the NAP1 strain may affect severity, its effect on mortality remains in question.Disclosures All authors: No reported disclosures.

Robotic Inguinal Hernia Repair: A Large Health System's Experience With the First 300 Cases and Review of the Literature

BackgroundOver the past 5 y, robotic surgery has expanded within general surgery, especially in regard to hernia repairs. We aimed to evaluate the outcomes of the early experience of over 300 consecutive robotic inguinal hernia repairs performed in an academic multihospital system. MethodsConsecutive robotic inguinal hernia repairs performed between December 2015 and June 2017 were analyzed. Retrospective chart review was performed, and hospital records were queried. Descriptive statistics were performed. A surgical learning curve case study is presented, breakdown of operative time is delineated, and review of the literature performed. ResultsOver a period of 19 mo, 335 robotic inguinal hernia repairs were performed across seven hospitals by 18 surgeons. The mean patient age was 59 y (standard deviation [SD] 14), 93% were male, and the mean body mass index was 27 (SD 4.6). Bilateral hernia repairs were performed on 131 patients (39%). The mean operative time was 102 min (SD 38) and a resident or fellow trainee was present in the operating room for 119 cases (36%). Minor postoperative complications occurred in 54 patients (16%), including 14 with urinary retention (4.2%) and 13 with scrotal swelling (3.9%). The learning curve of the first adopted surgeon was 11-12 cases. ConclusionsIn the largest case series of robotic inguinal hernia repairs to date reporting short-term outcomes, early experience in an academic multihospital system produced safe outcomes including no open conversions, reoperations, and one readmission. In addition, the learning curve is manageable showing improvement in operating time with experience.

The Current Look of MAC in a Large Multihospital System

The Current Look of MAC in a Large Multihospital System

Hospital resource utilization and presence of advance directives at the end of life for adults with congenital heart disease.

Overall health care resource utilization by adults with congenital heart disease has increased dramatically in the past two decades, yet little is known about utilization patterns at the end of life. The objective of this study is to betterunderstand the patterns and influences on end-of-life care intensity for adults with congenital heart disease. We identified a sample of adults with congenital heart disease (n=65), cancer (n=10784), or heart failure (n=3809) who died between January 2010 and December 2015, cared for in one multi-hospital health care system. We used multivariate analysis to evaluate markers of resource utilization, location of death, and documentation of advance care planning among patients with congenital heart disease versus those with cancer and those with heart failure. Approximately 40% of adults with congenital heart disease experienced inpatient and intensive care unit (ICU) hospitalizations in the last 30days of life; 64% died in the hospital. Compared to patients with cancer, patients with adult congenital heart disease (ACHD) were more likely to have inpatient (adjusted risk ratio 1.57; 95% CI 1.12-2.18) and ICU admissions in the last 30days of life (adjusted risk ratio 2.56; 95% CI 1.83-3.61), more likely to die in the hospital (adjusted risk ratio 1.75; 95% CI 1.43-2.13), and more likely to have documentation of advance care planning (adjusted risk ratio 1.46; 95% CI 1.09-1.96). Compared to patients with heart failure (HF), patients with ACHD were less likely to have an ICU admission in the last 30days of life (adjusted risk ratio 0.73; 95% CI 0.54-0.99). Adults with congenital heart disease have significant hospital resource utilization near the end of life compared to patients with cancer, notable for more hospitalizations and a higher likelihood of death in the hospital. This population represents an important opportunity for the application of palliative and supportive care.

A Mixed Methods Study of Tele-ICU Nursing Interventions to Prevent Failure to Rescue of Patients in Critical Care.

Background:Failure to rescue (FTR) is a benchmark of quality care. Limited evidence exists examining the influence of telemedicine intensive care units (tele-ICU) nursing interventions in preventing FTR. The purpose of this study was to characterize tele-ICU nursing interventions and to determine which combination of documented tele-ICU nursing interventions (DTNI) best predicts prevention of FTR in ICU patients with hospital-acquired conditions (HACs).Materials and Methods:We used convergent parallel mixed methods design to conduct qualitative interviews with a purposive sample of tele-ICU nurses (n = 19) from 11 US tele-ICU centers. Quantitative data, including demographics, DTNIs, severity of illness scores, and video assessment times from January 2016 to December 2016 were retrieved for ICU patients discharged from a multihospital health system with a tele-ICU center (n = 861). Findings from both qualitative and quantitative analyses were merged, compared, and contrasted.Results:FTR patients had higher severity of illness, longer video assessment by tele-ICU nurses, and were more likely to have DTNIs related to hemodynamic instability. Four themes emerged from qualitative analysis: fundamental tele-ICU nurse attributes, proactive clinical practice, effective collaborative relationships, and strategic use of advanced technology. Mixed methods analysis revealed convergence between DTNIs and tele-ICU nurses' characterizations of their practice.Conclusions:Tele-ICU nurses' characterizations of their practice closely align with DTNIs. Tele-ICU nursing practice to prevent FTR involves systems thinking and integration of many complex factors. Tele-ICU nurses can reduce the odds of FTR with focus on support and clinical coordination interventions that avoid hemodynamic instability in ICU patients with a diagnosed HAC.

Development and Implementation of a Standardized Sterile Compounding Training Program.

Purpose: The purpose of the study is to develop and implement a standardized sterile compounding training program in a multihospital system that incorporates sterile compounding best practice recommendations and ensures compliance with United States Pharmacopeia (USP) Chapters 797 and 800 standards. Methods: Baseline sterile compounding training data were collected and reviewed for sterile compounding facilities across a multihospital health system, which included 37 distinct sterile compounding operations. Current sterile compounding personnel across the system completed preintervention assessments consisting of a written, knowledge-based exam; media-fill challenge test; and an observed assessment of aseptic technique. The personnel then completed refresher training of sterile compounding concepts by completing online and in-person courses. A postintervention assessment was then conducted to evaluate training methods and topics. Based on the intervention data, a training program for new sterile compounding personnel was developed and implemented. A program to provide annual, ongoing training to existing sterile compounding personnel was also developed and implemented. Results: There was a statistically significant improvement in sterile compounding written exam scores (P < .0001) and aseptic technique observation scores (P < .0001) after implementation of refresher training. The validated training program was then included in the development and implementation of standardized training for all new and existing sterile compounding personnel across a multihospital health system. Conclusion: A standardized and consistent, sterile compounding training program was developed for all new and existing sterile compounding personnel incorporating a live, in-person training course, as well as online and hands-on training.

Association of Lowering Default Pill Counts in Electronic Medical Record Systems With Postoperative Opioid Prescribing

Reliance on prescription opioids for postprocedural analgesia has contributed to the opioid epidemic. With the implementation of electronic medical record (EMR) systems, there has been increasing use of computerized order entry systems for medication prescriptions, which is now more common than handwritten prescriptions. The EMR can autopopulate a default number of pills prescribed, and 1 potential method to alter prescriber behavior is to change the default number presented via the EMR system. To investigate the association of lowering the default number of pills presented when prescribing opioids in an EMR system with the amount of opioid prescribed after procedures. A prepost intervention study was conducted to compare postprocedural prescribing patterns during the 3 months before the default change (February 18 to May 17, 2017) with the 3 months after the default change (May 18 to August 18, 2017). The setting was a multihospital health care system that uses Epic EMR (Hyperspace 2015 IU2; Epic Systems Corporation). Participants were all patients in the study period undergoing 1 of the 10 most common operations and discharged by postoperative day 1. The default number of opioid pills autopopulated in the EMR when prescribing discharge analgesia was lowered from 30 to 12. Linear regression estimating the change in the median number of opioid pills and the total dose of opioid prescribed was performed. Opioid doses were converted into morphine milligram equivalents (MME) for comparison. The frequency of patients requiring analgesic prescription refills was also evaluated. There were 1447 procedures (mean [SD] age, 54.4 [17.3] years; 66.9% female) before the default change and 1463 procedures (mean [SD] age, 54.5 [16.4] years; 67.0% female) after the default change. After the default change, the median number of opioid pills prescribed decreased from 30 (interquartile range, 15-30) to 20 (interquartile range, 12-30) per prescription (P < .001). The percentage of prescriptions written for 30 pills decreased from 39.7% (554 of 1397) before the default change to 12.9% (183 of 1420) after the default change (P < .001), and the percentage of prescriptions written for 12 pills increased from 2.1% (29 of 1397) before the default change to 24.6% (349 of 1420) after the default change (P < .001). Regression analysis demonstrated a decrease of 5.22 (95% CI, -6.12 to -4.32) opioid pills per prescription after the default change, for a total decrease of 34.41 (95% CI, -41.36 to -27.47) MME per prescription. There was no statistical difference in opioid refill rates (3.0% [4 of 135] before the default change vs 1.5% [2 of 135] after the default change, P = .41). Lowering the default number of opioid pills prescribed in an EMR system is a simple, effective, cheap, and potentially scalable intervention to change prescriber behavior and decrease the amount of opioid medication prescribed after procedures.

The association between outpatient follow-up visits and all-cause non-elective 30-day readmissions: A retrospective observational cohort study.

BackgroundAs an effort to reduce hospital readmissions, early follow-up visits were recommended by the Society of Hospital Medicine. However, published literature on the effect of follow-up visits is limited with mixed conclusions. Our goal here is to fully explore the relationship between follow-up visits and the all-cause non-elective 30-day readmission rate (RR) after adjusting for confounders.Methods and resultsTo conduct this retrospective observational study, we extracted data for 55,378 adult inpatients from Advocate Health Care, a large, multi-hospital system serving a diverse population in a major metropolitan area. These patients were discharged to Home or Home with Home Health services between June 1, 2013 and April 30, 2015. Our findings from time-dependent Cox proportional hazard models showed that follow-up visits were significantly associated with a reduced RR (adjusted hazard ratio: 0.86; 95% CI: 0.82–0.91), but in a complicated way because the interaction between follow-up visits and a readmission risk score was significant with p-value < 0.001. Our analysis using logistic models on an adjusted data set confirmed the above findings with the following additional results. First, time matter. Follow-up visits within 2 days were associated with the greatest reduction in RR (adjusted odds ratio: 0.72; 95% CI: 0.63–0.83). Visits beyond 2 days were also associated with a reduction in RR, but the strength of the effect decreased as the time between discharge and follow-up visit increased. Second, the strength of such association varied for patients with different readmission risk scores. Patients with a risk score of 0.113, high but not extremely high risk, had the greatest reduction in RR from follow-up visits. Patients with an extremely high risk score (> 0.334) saw no RR reduction from follow-up visits. Third, a patient was much more likely to have a 2-day follow-up visit if that visit was scheduled before the patient was discharged from the hospital (30% versus < 5%).ConclusionsFollow-up visits are associated with a reduction in readmission risk. The timing of follow-up visits can be important: beyond two days, the earlier, the better. The effect of follow-up visits is more significant for patients with a high but not extremely high risk of readmission.

When the General Meets the Particular: The Practices and Challenges of Interorganizational Knowledge Reuse

A large literature addresses the practices and challenges surrounding knowledge reuse within organizations. Yet organizations frequently attempt to reuse knowledge from outside their boundaries, which may be even more challenging. The practice is so prevalent that an entire industry—the consulting industry—has developed to support it. Unfortunately, we understand little about how knowledge embedded in one organization is used to intervene in another and about what challenges follow from the attempt to do so. In this paper, we aim to address these questions. On the basis of an analysis of four months of ethnographic fieldwork and extensive archival data surrounding an engagement between a leading consulting firm and a multihospital healthcare system, we find that partners and senior executives created generalizations based on their experience and encouraged junior consultants and hospital employees to apply these generalizations and reuse old solutions. Yet junior consultants, who had different backgrounds and were embedded in particular contexts, struggled to reuse solutions, and they instead developed novel insights through the engagement. We argue, moreover, that the ultimate success of consulting engagements lies in this division of labor within and across firms. Our work contributes to the literatures on knowledge reuse, organizational learning, and consulting by illuminating how knowledge is (or is not) reused and how differences between junior and senior consultants, and between consultants and clients, shape both the reuse of existing solutions and the development of new ones.

Obstetric Nurses Lead the Way in the Professional Nursing Advancement Program

To describe the innovative changes made to a multihospital system’s professional nursing advancement program (PNAP) under the leadership of a bedside obstetric nurse and its effect on obstetric nurses’ participation and practice.

PC040. Disease-Based Observational Cohort Study of Patients With Thoracoabdominal Aortic Aneurysm

Current understanding of patients with thoracoabdominal aortic aneurysms (TAAA) is limited to institutional case series and administrative data describing patients selected to undergo surgical repair. The purpose of this study is to describe a disease-based cohort of patients with TAAA, including those undergoing repair by various methods and those not having surgery. Data on patients with TAAA within a multihospital academic medical system were obtained from 2009 to 2017. This hospital system serves as the primary regional referral center for a population of 11 million. Patients were identified by two methods: an administrative database was screened by diagnosis codes for ruptured or nonruptured TAAA, and individual surgeons in our group identified their operative and nonoperative patients. The diagnosis of TAAA was then confirmed based on the computed tomography finding of aneurysmal degeneration >3.2 cm of the paravisceral aorta in continuity with aneurysmal aorta meeting standard criteria for repair. Patients under the age of 18 and those with mycotic aneurysms were excluded. The primary outcome measure among those operated upon was a composite measure of good outcome at 1 year, indicating survival with a return to preoperative functional status and freedom from permanent loss of organ system function. Statistical analysis was performed using StataIC version 14 (StataCorp, College Station, Tex). A total of 342 patients with TAAA were identified. Demographic details are reported in Table I. Patients demographics are similar to those in published operative case series. Patient outcomes are reported in Table II. There were 160 patients (47%) deemed ineligible for or declined treatment. At 1 year, a good outcome was achieved in 63%, 72%, 83%, and 53% of those undergoing open, endovascular, hybrid, and partial repairs, respectively. Reintervention was common, and occurred most frequently in the hybrid group. This inclusive cohort study of patients with TAAA shows that one-half of patients with TAAA did not undergo treatment, and an additional 16% had incomplete repair. Overall, two-thirds of patients with TAAA never went on to have definitive repair of the perivisceral aorta despite access to all treatment options, suggesting that data from operated case series are achieved among highly selected patient cohorts and do not reflect the overall outcomes of patients with TAAA. A majority of patients with TAAA never undergo repair, and that among those who are repaired, similar results are achieved with different techniques in appropriately selected patients.Table IKey demographics of thoracoabdominal aortic aneurysm (TAAA)a patientsOpenEndovascularbHybridcPartial repairdNonoperativeeTotalPn41661956160342Age, median617563707272<.001Sex, %.002 Male68.374.263.271.449.460.9 Female31.725.836.828.650.639.1Diameter, mean, cm6.56.86.96.56.36.5.038Presentation, %.19 Asymptomatic78.081.884.266.181.379.6 Symptomatic17.116.715.821.413.315.0 Ruptured4.91.5-12.55.35.4 Dissection41.54.538.948.224.527.3<.001Crawford, %<.001 Extent I7.315.210.535.710.615.7 Extent II34.124.268.453.636.238.8 Extent III19.519.75.35.49.411.6 Extent IV34.139.415.85.437.531.6 Extent V4.91.5--3.82.7CTD, %26.8-31.67.12.57.3<.001Preoperative exercise tolerance, %<.001 High44.422.26.722.77.618.1 Moderate25.042.973.347.719.532.8 Low30.634.920.029.572.949.1Previous aortic surgery, %46.343.947.442.943.844.2.99Significant comorbidity, %f10.016.75.629.151.027.5<.001CTD, Connective tissue disease.aTAAA is defined as aneurysmal dilatation of the paravisceral aorta of at least 3.2 cm in continuity with aneurysmal aorta that exceeds a maximum diameter of 5.5 cm or aortic size index of 2.75 (defined as body surface area divided by maximum diameter of aneurysmal aorta), causes symptoms, or grows more than 5 mm within 6 months.bEndovascular repair includes those repairs that treat the paravisceral aorta. Nearly all endovascular repairs were conducted with a physician-modified branched thoracic endovascular aortic repair endograft under a Food and Drug Administration-approved investigative device exemption trial.cHybrid repair is defined as visceral debranching and subsequent bypass from the iliac arteries to the paravisceral arteries followed by coverage of the paravisceral segment with thoracic endovascular aortic repair.dPartial repair is defined as any intervention that incompletely addresses the paravisceral aorta.eNonoperative group includes those patients who refused intervention, remained undecided, had yet to follow-up on a recommendation for intervention, or received a recommendation against intervention.fSignificant comorbidity is defined as the presence of one or more of the following: dependent functional status, untreated cancer, chronic obstructive pulmonary disease on home oxygen, active substance abuse, unintentional weight loss > 10% of body weight, dementia or significant cognitive impairment, and/or body mass index <18.5 or >40 kg/m2. Open table in a new tab Table IIKey outcome measures after thoracoabdominal aortic aneurysm (TAAA) repairOpenEndovascularHybridPartial repairAll operativeIndex hospitalization n41661956182 Mortality, %2051179 Permanent spinal cord injury, %17145511 RF requiring dialysis at discharge, %721144 Discharged home, %5173637167Follow-up Composite “good” outcome at one- year follow-up, %a (nb)63 (27)72 (47)83 (12)53 (41)65 (127) Any aortic reintervention, %1729422537RF, Renal failure.aComposite “good” outcome is defined as freedom from permanent spinal cord injury or renal failure and return to previous functional status at the 1-year follow-up (6-18 months). For patients who had staged repairs in either the open, endovascular, or hybrid groups, a “good” result also implies that all stages were completed. On the other hand, partial repairs are by definition incomplete and thus a "good outcome" for this group excludes completeness as a criterion.bIncludes all uncensored patients. 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Disruptive Technology: Saving Money and Inspiring Engagement in Professional Staff.

Competent, efficient, and cost-effective delivery of professional development is a challenge in health care. Collaboration of teaching methodologies with academia and acute care offers fresh perspectives and delivery methods that can facilitate optimal outcomes. One multihospital system introduced the academic "flipped classroom" model to its acute care setting and integrated it into professional development requirements. The concept of the flipped classroom requires independent student engagement prior to classroom activities versus the traditional classroom lecture model. Results realized a cost savings in 2 years of $28,737 in addition to positive employee engagement.

Success of a Colorectal Surgical Site Infection Prevention Bundle in a Multihospital System.

Surgical site infections, readmissions, and extended hospital stays are risks for patients undergoing colon surgeries. These procedures are often urgent, and patients may have multiple comorbidities. Preoperative and postoperative steps to reduce the number of complications provide substantial benefits clinically, economically, and psychologically. We used a multidisciplinary, collaborative approach to identify best practices when developing and implementing a standardized approach to the management of patients undergoing elective colon surgery. Interventions included nutrition supplements and preoperative and postoperative protocols. Our management project showed a 74.6% reduction in readmissions, a 22.73% reduction in length of stay, an 85% reduction in colon surgical site infections measured by incidence (84.5% reduction) and standard infection ratio (54.55% reduction), and 95% compliance with the use of both order sets during an 18-month period. Applying standardized order sets for assessing and addressing patient comorbidities before colorectal surgery can result in a substantial and sustainable reduction in complications.

Hospitals get serious about pharmacy technician training.

Hospitals are starting to take a do-it-yourself approach by developing their own accredited pharmacy technician training programs with the goal of hiring these skilled workers and advancing pharmacy practice. John Armitstead, system director of pharmacy services at Lee Health in Fort Myers and Cape Coral, Florida, said the multihospital system recently hired all 7 graduates of the organization’s inaugural pharmacy technician class. “We’ve already got another class started, and that’s got 6 students in it,” Armitstead said. Lee Health’s technician training program is one of 15 in the state with full or candidate accreditation status from ASHP and the Accreditation Council for Pharmacy Education (ACPE). It’s the only such pharmacy technician training program in Florida that’s operated by a health system. Nationally, just 5 of the 261 ASHP–ACPE-accredited or candidate-status technician training programs are classified as operated by a health system or hospital, said Lisa Lifshin, director of pharmacy technician accreditation and residency services in ASHP’s Accreditation Services Division.