Suburban Hospital Research Articles

A Single Center Study on Guideline Adherence to H. pylori Testing

Introduction: It is well documented that PPI therapy decreases the sensitivity of all common methods of testing for H. pylori infection. This leads to decreased detection of colonization in patients hospitalized for GI bleeding, so routine follow up and re-testing is indicated 1-2 weeks after the withdrawal of PPI therapy. The aim of this study is to evaluate how often adequate follow up occurs in patients who were tested for H. pylori infection by EGD with biopsy during hospitalization for GI bleeding. Methods: A chart review of 240 patients admitted to a large suburban community hospital from January 2017 to April 2018 was conducted in search of individuals whose clinical course met the following criteria: patients had to have an ICD 10 code related to GI bleeding, been on PPI therapy for at least 2.5 hours prior to EGD with biopsy, survived to discharge, and been referred to a provider within the hospital's network. 36 patients met the criteria and we mathematically determined the proportion of patients who received adequate follow up based on records obtained from the outpatient providers. Results: Of the 36 patients included, 6 (16.7%) patients received adequate follow up. 8 (22.2%) were positive for H. pylori infection and of these patients, only 3 (37.5%) received treatment. Of the 28 patients with a negative test as an inpatient, only 3 (10.7%) had any record of ever being retested. Conclusion: The prevalence of H. pylori infection of the adult population in the Western world is estimated to be about 45%, however, studies have shown a prevalence of greater than 70% in patients treated for GI bleeding. Using a modest estimate of 45%, it is likely that several cases of H. pylori were not detected in this study, and most patients were never retested. The most common reason for not retesting was patient non-compliance, 50% of patients never returned for follow up. While patient non-compliance will always be a barrier to delivery of care, improved patient education on the importance of follow up would curb this issue. Of the 8 patients who tested positive for H. pylori, the 3 who sought further evaluation were treated and retested for eradication. Failure to detect H. pylori infection in patients with GI bleeding leads to further episodes of re-bleeding, and thus increased morbidity and mortality as well as increased healthcare costs. More must be done to ensure retesting in as many patients as possible. We are continuing this study across other healthcare networks for more data.

Examination of How the Affordable Care Act Influenced Use of Lower-Acuity Emergency Department Services

CONTEXTThe Affordable Care Act (ACA) was implemented to make insurance accessible and reduce healthcare costs. The purpose of this study was to examine for changes in the use of lower-acuity types of Emergency Department (ED) services at two suburban Detroit facilities before, and after implementation of the ACA.METHODSA retrospective chart review of patients presenting to the ED at a two-campus suburban hospital system was performed over two 18-month pre- and post-ACA periods. The authors completed a review of electronic health record data and used ICD-9 code and ED visit billing and collections data. Sample patients included those who had received lower-acuity ED care within the two designated time periods. A total of 16 lower-acuity ICD-9 codes were included to gauge pre and post changes in use of ED services.RESULTSThe authors identified 2,099 patients meeting study criteria during the pre-ACA period and 2,158 patients within the post-ACA period. A subgroup of 166,483 ED patients received care during the pre-ACA time period and 179,879 post-ACA. There was no statistically significant difference between the volume of lower-acuity ED visits during the two analytic periods (i.e., 1.26% seen pre-ACA implementation and 1.20% seen post-ACA). (p = 0.420) Neither did the absolute number of all ED visits significantly change. As could be anticipated, however, the proportion of self-pay patients pre-ACA significantly decreased from 506 (24.1%) to 191 (8.9%) post-ACA. (p < 0.001) Medicaid HMO payments also increased significantly from 824 visits pre-ACA to 1,086 visits post-ACA. (p < 0.001) In addition, Blue Cross coverage increased from 54 visits pre-ACA to 98 visits post-ACA. (p < 0.001)CONCLUSIONSIn summary, our results revealed no significant change in the absolute volume of all ED visits or proportions of lower-acuity ED visits between the pre- and post-ACA periods. As the authors had anticipated, pre and post changes in the number of self-pay patients and those with certain types of insurance coverage were dramatic. The authors conclude that changes in lower-acuity visits to the ED in these study settings had not decreased as envisioned by ACA developers. Future studies with larger longitudinal samples are warranted to more fully investigate the longer-term implications of the ACA on use of ED services.

375 Comparison of Electronic Clinical Decision Support for the Diagnosis of Suspected Pulmonary Embolism in Three Health Care Systems

Clinical decision support (CDS) for the diagnosis of acute pulmonary embolism (PE) has been recommended by multiple professional societies, yet its use remains uncommon. We sought to compare the CTPA positive rate at 4 hospitals where electronic CDS is optional, 1 hospital where eCDS was mandatory, and 1 hospital where eCDS was not available. We performed a retrospective cohort study at 6 hospital emergency departments (EDs), 3 academic level 1 trauma centers and 3 large suburban community hospitals with combined visits of 286,096 from January-December 2016. Included patients were age >17, with suspected PE determined by the treating emergency physician. Patients were excluded if age <18, or pregnant at the time of enrollment. eCDS consisted of PE Rule-out Criteria (PERC), Revised Geneva Score (RGS) or Wells score followed by age-adjusted d-dimer when appropriate and was implemented in 5 hospitals electronic medical record; 4 where the use of eCDS was optional and 1 where it was mandatory prior to ordering CTPA. We compared the relative risk and percent relative risk of having a positive CTPA using combined eCDS utilization data from the mandatory use hospital plus the cases where eCDS was used at the 4 optional use hospitals, to the hospital where eCDS was not available and cases where eCDS was not utilized at the optional hospitals. At the 5 hospitals with eCDS available 1147 CTPA’s were performed using the eCDS tools with 184 PE diagnoses for a CTPA positive rate of 16% (95% CI: 14-18%). At the hospitals where eCDS was not used or not available, 4560 CTPA were performed with 302 PE’s diagnosed for a CTPA positive rate of 6.6% (95% CI: 5.9-7.4%). With eCDS use, relative risk of having a positive CTPA is 2.42 (95% CI: 2.04-2.88; p<0.001), compared to no use of eCDS. Percent relative risk shows CTPA’s are 142% more likely to be positive with eCDS utilization. eCDS utilization is associated with a higher CTPA positive rate.Tabled 1CTPA positive rate with eCDSCTPAN=PE Diagnoses N=% Positive (95% CI)eCDS114718416% (14.1-18.3)No eCDS45603026.6% (5.9-7.4) Open table in a new tab

244 Opiate Use for Headaches in Five Emergency Departments

It is generally accepted that opiates should not be used for patients with primary headaches in the emergency department (ED), especially as first-line agents. Monitoring the use of opiates in such circumstances has become a common quality measure for physicians and EDs. Our primary objective was to describe opiate use for headaches in 5 different EDs, and also to examine whether there was significant variation between sites. As part of a quality improvement project in 2017, each emergency physician in a 5-hospital system was asked to review 10 charts of 1 colleague. Patients who had a discharge diagnosis of headache over the previous year were grouped by treating physician and included in the analysis. Each physician’s charts were then randomly assigned to a colleague who was instructed to review 10 charts. For each chart, the reviewing physician determined if an opiate was used to treat the patient's headache. If an opiate was given, it was noted whether it was the first medication given, or whether a non-opiate medication was given first. There were 5 hospitals included in the analysis. The majority of visits were at an urban adult and pediatric level-1 trauma center with an emergency medicine residency program. The other 4 sites were rural and suburban community hospitals with annual visit volumes between 8,000 and 14,000. The percentages of patients receiving opiates at the 5 sites were compared using a Fisher exact 3x2 contingency table. A total of 583 charts were reviewed by 52 physicians and included in the analysis (Table 1). Opiates were used in 54/583 (9%) patients overall, and were the first medication given in 29/583 (5%) patients. There were small variations in the rate of opiate use between the sites, but none of the variation between any of the sites was statistically significant (p=0.56). Overall, use of opiates for headache in these 5 EDs was low, and there was no significant difference between the 5 sites. This could serve as a baseline rate of opiate use for headaches for future monitoring and studies. These results also suggest clinicians from varied ED settings are already minimizing opiate use for ED patients with headaches.Table 1Site (annual visits)Charts reviewedOpiates given (%)Opiates given first (%)Academic tertiary care center with EM residency (88,000)33433 (10%)21 (6%)Suburban community hospital (11,000)1058 (8%)3 (3%)Suburban community hospital (14,000)828 (10%)5 (6%)Rural community hospital (8,000)341 (3%)0 (0%)Rural community hospital (8,000)284 (14%)0 (0%)Total58354 (9%)29 (5%) Open table in a new tab

Symptoms of Depression and Preterm Birth Among Black Women.

To investigate the relationship between depressive symptoms and preterm birth (PTB) while adjusting for social support, both general and from the father of the baby. Retrospective study design. Participants of the Life-course Influences of Fetal Environments (LIFE) study were recruited from a suburban hospital in Metropolitan Detroit, Michigan. The LIFE data consisted of 1,410 self-identified Black women age 18 to 45 years; 1,207 women were included in this analysis. Women were interviewed using a structured questionnaire administered 24 to 48 hours after birth during their postpartum hospitalization. Data on the newborns and their mothers' health were collected through medical record abstraction. The Center for Epidemiologic Studies Depression Scale (CES-D) was used to measure symptoms of depression. The CES-D scores ≥23 were considered severe symptoms of depression. Modified Poisson regression models were built using a stepwise approach to assess association between symptoms of depression and PTB. Approximately, 17% of women had a PTB and 20% of women in the sample had a CES-D scores ≥23. Women who had CES-D score ≥23 were about 70% more likely to have a PTB compared with women with CES-D scores <23 (PR = 1.68, 95% CI: 1.24-2.16) after adjustment for both general social support and father of the baby support. Women with CES-D scores ≥23 were almost twice more likely to have PTB compared with women with CES-D scores <23. Referrals for mental healthcare providers might benefit women with symptoms of depression and improve birth outcomes. Nurses should encourage women to seek support beyond the father of the baby.

Laparoscopic-Assisted Myomectomy with Bilateral Uterine Artery Occlusion/Ligation

Conventional laparoscopic myomectomy (CLM) and robotic-assisted myomectomy (RAM) are limited in the number and size of myomas that can be removed, whereas abdominal myomectomy (AM) is associated with increased complications and morbidity. Here we evaluated the surgical outcomes of these myomectomy techniques compared with those of laparoscopic-assisted myomectomy (LAM), a hybrid approach that combines laparoscopy and minilaparotomy with bilateral uterine artery occlusion or ligation to control blood loss. Retrospective chart review (Canadian Task Force classification II-1). Suburban community hospital. Women age ≥18 years with nonmalignant indications. A total of 1313 consecutive CLMs, RAMs, AMs, and LAMs performed between January 2011 and December 2013. Our review included 163 CLMs (12%), 156 RAMs (12%), 686 AMs (52%), and 308 LAMs (23%). Although the average number, size, and total weight of leiomyomas removed were comparable in the LAM and AM groups (9.1, 8.13 cm, and 391 g, respectively, vs 9.0, 7.5 cm, and 424 g; p < .0001), the number and weight of myomas were significantly greater in those 2 groups compared with the CLM and RAM groups (2.9 and 217 g, respectively, and 2.9 and 269 g; p < .0001). The intraoperative complication rate was highest in the RAM group, and the postoperative complication rate was highest in the AM group, both of which were approximately 3 times greater than the rates in the LAM group. There was no statistically significant difference in postoperative complication rates between the CLM and LAM groups. LAM with uterine artery occlusion/ligation is a viable approach for removing large tumor loads while minimizing blood loss and precluding the need for power morcellation.

Wednesday, September 26, 2018 7:35 AM–9:00 AM ePosters: P51. The efficacy of spinal cord stimulators: a comparison of success in the trial period versus after permanent stimulator placement

BACKGROUND CONTEXT Spinal cord stimulators (SCS) have often seen success in scenarios where medication and surgical interventions have failed. The literature suggests that patients tend to develop tolerance to these stimulating therapies often resulting in reduced efficacy of symptom relief as early as 2years after permanent implantation; however, to date no study has addressed the commonly reported discrepancies in pain reduction between the trial period and after permanent device insertion in the short term. PURPOSE This study aims to address and characterize the immediate discrepancies in outcomes between the stimulator trial period versus permanent device placement in the acute postoperative period (less than 6 weeks). STUDY DESIGN/SETTING This retrospective chart review included patients who underwent SCS placement at our suburban hospital over a 5-year period. PATIENT SAMPLE A total of 100 patient charts were included in our cohort. Only patients with lumbar radiculopathy who were treated with an SCS placed by a fellowship trained orthopaedic surgeon or neurosurgeon were included in our study. Patients who had a previous SCS placed, were having other surgeries while having their SCS placed, or did not have documented notes of their trial period or permanent stimulator placement were excluded. OUTCOME MEASURES Numerical rating system pain scores, Oswestry Disability Index (ODI) scores, and narcotic medication usage as reported by our online state narcotic drug monitoring program. METHODS Stimulator candidates who underwent a successful percutaneous stimulator trial (reporting greater than 50% in pain relief) subsequently underwent permanent SCS placement. For each patient, demographic information and outcome measures were recorded at baseline, during the trial period, and after permanent stimulator placement. Differences from baseline were analyzed and compared. RESULTS A total of 100 patient charts were included in our cohort. Sixty percent of our population was female, with a roughly even age distribution ranging from 37 to 90years of age. Patients reported significantly increased pain reduction in the trial period (median=4) from baseline compared to after permanent stimulator placement (median=2) (p=.00). A significant difference was not seen when comparing the difference in ODI scores between the trial period and baseline (median=4) versus after permanent stimulator placement and baseline (median=6) (p=.64). Finally, a significantly higher decrease in opioid medication usage (milli-morphine equivalents or day) was seen during the trial period (median=0) from baseline compared to after permanent spinal cord stimulator placement to baseline (median=0) (p=.028). CONCLUSIONS Spinal cord stimulators remain an effective treatment option to treat lumbar back pain and radiculopathy in chronic pain and post-laminectomy syndrome patients. However, patients may receive more pain and symptom relief during their percutaneous stimulator trial than they do after their permanent stimulator is placed, leaving patients hoping and expecting long term relief that might not always arrive.

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Developing Data to Support Effective Coordination of Nonprofit Hospital Community Benefit Investments.

Nonprofit hospitals achieve tax exemption through community benefit investments. The objective of this study was to characterize urban and suburban nonprofit hospitals' community benefit expenditures and to estimate regional per capita community benefit spending relative to community need. Community benefit expenditures, both overall and by subtype, were compared for urban versus suburban nonprofit hospitals in a large metropolitan area, the greater Philadelphia region. Estimated zip code-level per capita expenditures were mapped in the urban core area. We found that urban hospitals report higher overall community benefit expenditures than suburban hospitals yet invest less in community health improvement services, both proportionally and absolutely, despite spending similar proportions on charity care. There is an overlap in hospital-identified community benefit service areas in the urban core, but the degree of overlap is not related to community poverty levels. There is significant variation in zip code-level per capita community benefit expenditures, which does not correlate with community need. Community benefit investments offer the potential to improve community health, yet without regional coordination, the ability to maximize the potential of these investments is limited. This study's findings highlight the need to implement policies that increase transparency, accountability, and regional coordination of community benefit spending.

Epidemic spread of OXA-48 beta-lactamase in Croatia.

A dramatic increase in OXA-48 β-lactamase was observed recently not only in large hospital centres, but also in smaller suburban hospital centres in geographic areas bordering Croatia. The aim of the study was to analyse the epidemiology, the mechanisms of antibiotic resistance and the routes of spread of OXA-48 carbapenemase in Croatia. Carbapenemase and other β-lactamase and fluoroquinolone resistance genes were detected by PCR and sequencing. Whole-genome sequencing (WGS) was performed on five representative isolates. The isolates were genotyped by PFGE. Forty-eight isolates positive for OXA-48, collected from seven hospital centres in Croatia from May 2016 to May 2017, were analysed (40 Klebsiella pneumoniae, 5 Enterobacter cloacae, 2 Escherichia coli and one Citrobacter freundii). Thirty-three isolates were ESBL positive and harboured group 1 CTX-M 1 β-lactamases. In addition to the β-lactam resistance genes detected by PCR (blaSHV-1, blaOXA-48 and blaOXA-1), WGS of five representative isolates revealed the presence of genes encoding aminoglycoside resistance, aadA2 and aph3-Ia, fluoroquinolone resistance determinants aac(6)Ib-c, oqxA and oqxB, the sulfonamide resistance gene sul1, and fosA (fosfomycin resistance). IncL plasmid was found in all isolates. Two K. pneumoniae isolates belonged to ST16, two E. cloacae to ST66 and E. coli to ST354. K. pneumoniae isolates were allocated to five clusters by PFGE which occured in different hospitals, indicating epidemic spread. The OXA-48-positive organisms found in this study showed wide variability in antibiotic susceptibility, β-lactamase content and PFGE banding patterns. This study revealed a switch from the predominance of VIM-1 in 2012-2013 to that of OXA-48 in the 2015 to 2017.

Educating Emergency Department Staff on the Identification and Treatment of Human Trafficking Victims

IntroductionHospitalization is one of the few circumstances in which the lives of trafficking victims intersect with the general population. Based on survivor testimonies, the majority of human trafficking victims may receive medical treatment in a hospital’s emergency department while in captivity. With evidenced-based training, ED personnel have a better opportunity to screen persons who are being trafficked and intervene on their behalf. MethodsThis project examined the efficacy of an innovative, evidence-based online training module (HTEmergency.com) created by the project team. Participants completed a pre-survey to determine learning needs and a post-survey to determine the effectiveness of the online education. The learning module contained a PowerPoint presentation, identification and treatment guidelines, and 2 realistic case studies. ResultsData were collected among ED personnel in 2 suburban hospitals located near a northeast metropolitan city. Seventy-five employees participated in the survey and education. Staff completing the education included nurses, physicians, nurse practitioners/physician assistants, registration, and ED technicians. Results indicated that 89% of participants had not received previous human trafficking training. Less than half of the participants stated that they had a comprehensive understanding of human trafficking before the intervention, with an increase to 93% after education. The training module significantly increased confidence in identification (from an average confidence level of 4/10 to 7/10) and treatment (from an average confidence level of 4/10 to 8/10) of human trafficking victims within the emergency department; 96% found the educational module to be useful in their work setting. DiscussionParticipants reported that they are more confident in identifying a possible trafficking victim and are more likely to screen patients for human trafficking after participation in the online training module. The proposed general guideline for care provided ED personnel with a useful tool in perpetuity. The results of this project, coupled with the growth of worldwide human trafficking, highlights the need for focused human trafficking education within the hospital setting.

Use of Massive Transfusion Protocol: Maternal Outcomes in Patients With Severe Obstetric Hemorrhage [22K

INTRODUCTION: Obstetrical hemorrhage represents the single-most significant cause of maternal mortality. As hemorrhage rates increase, Massive Transfusions Protocols (MTP) have been adopted for maternal resuscitation. We explored maternal outcomes associated with MTP utilization. METHODS: We retrospectively studied women who delivered with Class III-IV hemorrhage (estimated blood loss [EBL] ≥1,500 mL) at either an urban teaching-hospital serving high-risk patients (HOSP1) or a suburban hospital serving average-risk patients (HOSP2) during 2012–2015. Patient groups included: 1) no transfusion, 2) transfusion without MTP, and 3) transfusion via MTP (implemented at HOSP1 only). Between-group differences in maternal characteristics and outcomes by year and hospital were described. RESULTS: Women totaled 109 at HOSP1 (no transfusion: 30 [28%], transfusion: 56 [51%], MTP: 23 [21%]) and 42 at HOSP2 (no transfusion: 18 [43%], transfusion: 24 [57%]). Transfusion reactions (n=2) occurred in the transfusion group only, and no maternal deaths occurred. No statistically significant patterns were detected in length of stay (LOS) or renal, hematologic, or coagulation indices. However, notable patterns were observed at HOSP1 in mean EBL (no transfusion: 1,720 mL, transfusion: 2,048 mL, MTP: 3,417 mL) and postpartum LOS (no transfusion: 3.0 days, transfusion: 3.2 days, MTP: 4.3 days). Thrombocytopenia improved annually with MTP. Total units transfused were greater with MTP (Total 10.2, PRBC 6.6, FFP 2.6, Platelet 0.9) than transfusion (Total 3.6, PRBC 3.0, FFP 0.4, Platelet 0.1). MTP accounted for the only wasted units (mean 0.52, range 0–4). CONCLUSION: MTP uses more blood products. However, in class III–IV hemorrhages, MTP use may be beneficial without significant adverse outcome.

Changes In Hospital Utilization Three Years Into Maryland's Global Budget Program For Rural Hospitals.

In a substantial shift in payment policy, the State of Maryland implemented a global budget program for acute care hospitals in 2010. Goals of the program include controlling hospital use and spending. Eight rural hospitals entered the program in 2010, while urban and suburban hospitals joined in 2014. Prior analyses, which focused on urban and suburban hospitals, did not find consistent evidence that Maryland's program had contributed to changes in hospital use after two years. However, these studies were limited by short follow-up periods, may have failed to isolate impacts of Maryland's payment change from other state trends, and had limited generalizability to rural settings. To understand the effects of Maryland's global budget program on rural hospitals, we compared changes in hospital use among Medicare beneficiaries served by affected rural hospitals versus an in-state control population from before to after 2010. By 2013-three years after the rural program began-there were no differential changes in acute hospital use or price-standardized hospital spending among beneficiaries served by the affected hospitals, versus the within-state control group. Our results suggest that among Medicare beneficiaries, global budgets in rural Maryland hospitals did not reduce hospital use or price-standardized spending as policy makers had anticipated.

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Development of a Risk Tool to Support Discussions of Care for Older Adults Admitted to the ICU With Pneumonia.

Early, data-driven discussion surrounding palliative care can improve care delivery and patient experience. To develop a 30-day mortality prediction tool for older patients in intensive care unit (ICU) with pneumonia that will initiate palliative care earlier in hospital course. Retrospective Electronic Health Record (EHR) review. Four urban and suburban hospitals in a Western New York hospital system. A total of 1237 consecutive patients (>75 years) admitted to the ICU with pneumonia from July 2011 to December 2014. Data abstracted included demographics, insurance type, comorbidities, and clinical factors. Thirty-day mortality was also determined. Logistic regression identified predictors of 30-day mortality. Area under the receiver operating curve (ROC) was calculated to quantify the degree to which the model accurately classified participants. Using the coordinates of the ROC, a predicted probability was identified to indicate high risk. A total of 1237 patients were included with 30-day mortality data available for 100% of patients. The mortality rate equaled 14.3%. Age >85 years, having active cancer, Congestive Heart Failure (CHF), Chronic Obstructive Pulmonary Disease (COPD), sepsis, and being on a vasopressor all predicted mortality. Using the derived index, with a predicted probability of mortality >0.146 as a cutoff, sensitivity equaled 70.6% and specificity equaled 65.6%. The area under the ROC was 0.735. Our risk tool can help care teams make more informed decisions among care options by identifying a patient group for whom a careful review of goals of care is indicated both during and after hospitalization. External validation and further refinement of the index with a larger sample will improve prognostic value.

CE: Original Research: An Investigation into the Safety of Oral Intake During Labor.

This was a quantitative retrospective observational cross-sectional study. The initial data set consisted of all closed medical records for 2,817 women who were admitted to a suburban community hospital in the northeastern United States between January 2008 and December 2012. Some subjects' records were missing either covariate data or outcomes data, resulting in final sample sizes of 2,797 women (for comparison across covariates) and 2,784 women (for comparison across outcomes). A deidentified limited data set was extracted from the electronic health record for descriptive and inferential comparisons between groups. Demographics and maternal comorbidities present on admission were compared between groups before data analysis. Outcome comparisons were obtained with traditional between-groups analysis and propensity score matching. The groups were found to be sufficiently equivalent for comparison. The group permitted nothing by mouth was significantly more likely to have unplanned cesarean section births than the group permitted ad lib oral intake. There were no significant differences in unplanned maternal ICU admissions postpartum, in neonate condition as determined by Apgar scores, or in the need for a higher level of care. Allowing women ad lib oral intake during labor caused no increase in morbidity, and there were no mortalities in either group. Allowing women ad lib oral intake during labor does not increase adverse maternal or neonatal outcomes. It stands to reason that allowing such intake could increase patient satisfaction. Further study is needed to determine what types of food and drink are most beneficial as well as what types are preferred.

Primary care professionals providing non-urgent care in hospital emergency departments.

In many countries emergency departments (EDs) are facing an increase in demand for services, long waits, and severe crowding. One response to mitigate overcrowding has been to provide primary care services alongside or within hospital EDs for patients with non-urgent problems. However, it is unknown how this impacts the quality of patient care and the utilisation of hospital resources, or if it is cost-effective.This is the first update of the original Cochrane Review published in 2012. To assess the effects of locating primary care professionals in hospital EDs to provide care for patients with non-urgent health problems, compared with care provided by regularly scheduled emergency physicians (EPs). We searched the Cochrane Central Register of Controlled Trials (the Cochrane Library; 2017, Issue 4), MEDLINE, Embase, CINAHL, PsycINFO, and King's Fund, from inception until 10 May 2017. We searched ClinicalTrials.gov and the WHO ICTRP for registered clinical trials, and screened reference lists of included papers and relevant systematic reviews. Randomised trials, non-randomised trials, controlled before-after studies, and interrupted time series studies that evaluated the effectiveness of introducing primary care professionals to hospital EDs attending to patients with non-urgent conditions, as compared to the care provided by regularly scheduled EPs. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. We identified four trials (one randomised trial and three non-randomised trials), one of which is newly identified in this update, involving a total of 11,463 patients, 16 general practitioners (GPs), 9 emergency nurse practitioners (NPs), and 69 EPs. These studies evaluated the effects of introducing GPs or emergency NPs to provide care to patients with non-urgent problems in the ED, as compared to EPs for outcomes such as resource use. The studies were conducted in Ireland, the UK, and Australia, and had an overall high or unclear risk of bias. The outcomes investigated were similar across studies, and there was considerable variation in the triage system used, the level of expertise and experience of the medical practitioners, and type of hospital (urban teaching, suburban community hospital). Main sources of funding were national or regional health authorities and a medical research funding body.There was high heterogeneity across studies, which precluded pooling data. It is uncertain whether the intervention reduces time from arrival to clinical assessment and treatment or total length of ED stay (1 study; 260 participants), admissions to hospital, diagnostic tests, treatments given, or consultations or referrals to hospital-based specialist (3 studies; 11,203 participants), as well as costs (2 studies; 9325 participants), as we assessed the evidence as being of very low-certainty for all outcomes.No data were reported on adverse events (such as ED returns and mortality). We assessed the evidence from the four included studies as of very low-certainty overall, as the results are inconsistent and safety has not been examined. The evidence is insufficient to draw conclusions for practice or policy regarding the effectiveness and safety of care provided to non-urgent patients by GPs and NPs versus EPs in the ED to mitigate problems of overcrowding, wait times, and patient flow.

Reducing Hypotension and Acute Kidney Injury in the Elective Total Joint Arthroplasty Population: A Multi-Disciplinary Approach

BackgroundWhen critically analyzing our hospital system's rate of hypotension and acute kidney injury (AKI) after total joint arthroplasty, our incidence rates (14.54%, 6.02%) were much higher than our peers (7.17%, 2.03%) and national rates (2.0%, 3.3%). We present a multi-disciplinary management intervention that aimed to decrease overall complication rates. MethodA multi-disciplinary team implemented a protocol at our suburban hospital to limit complication rates after joint replacement surgery. Hypotension, AKI, length of stay (LOS), re-admission rates, and mortality rates were compared before the protocol was implemented, after protocol implementation, and after protocol integration into our EMR (electronic medical record). ResultsIn total, 1233 patients over 36 months were followed. Hypotension rates after protocol implementation into EMR (group 3) were significantly lower than rates before the protocol (group 1) (P = .002), with rates after protocol implementation without EMR (group 2) trending toward a significant decrease from group 1 (P = .064). AKI rates in group 3 were significantly lower than group 1 (P = .000) and group 2 (P = .006). No difference was seen in hypotension rates between group 2 and 3 (P = .792) or AKI rates between group 1 and 2 (P = .533). Finally, no significant difference was seen between groups in LOS (P = .560), re-admission rates (P = .378), and mortality rates (all 0.0%). ConclusionBy implementing a comprehensive electronic protocol consisting of pre-operative risk stratification, multi-disciplinary medical optimization, and an evolving post-operative management plan, significant decreases in hypotension and AKI can be seen.

Short-term and long-term survival probabilities among first-ever ischaemic and haemorrhagic stroke patients at a hospital in the suburban east coast of Peninsular Malaysia.

AimThis study aimed to determine the 28‐day, 1‐year, and 5‐year survival probabilities in first‐ever stroke patients in a relatively understudied setting: a suburban hospital that serves a predominantly rural population in the east coast of Peninsular Malaysia.Methods and resultsA retrospective record review was conducted among 432 first‐ever stroke patients admitted to the Hospital Universiti Sains Malaysia, Kelantan, Malaysia. Data from between January 1, 2005 and December 31, 2011, were extracted from the medical records. The Kaplan‐Meier product limit estimator was applied to determine the 28‐day, 1‐year, and 5‐year survival probabilities. Log‐rank test was used to test the equality of survival time between different groups. A total of 101 patients died during the study period. The 28‐day, 1‐year, and 5‐year survival probabilities were 78.0% (95% confidence interval [CI]: 73.5–81.9), 74.2% (95% CI: 69.4–78.4), and 70.9% (95% CI: 65.1–75.9), respectively. There were significant differences in the survival time based on the types of stroke, Glasgow Coma Scale, hyperlipidaemia, atrial fibrillation, fasting blood glucose, and diastolic blood pressure.ConclusionThis study, though retrospective, highlights several clinical parameters that influenced the survival probabilities among first‐ever stroke patients managed in a suburban setting in Malaysia, and compared them to those reported in more urban regions. Our data emphasise the need for wider establishment of specialized stroke units and teams, as well as for prospective multi‐centre studies on first‐ever stroke patients to better inform the development of stroke care provision in Malaysia.

Neuroimaging Rates for Closed Head Trauma in a Community Hospital.

We aimed to characterize the utility of neuroimaging for head trauma in a suburban community hospital and determine whether imaging practices conform to most recent pediatric guidelines. The electronic medical record was surveyed for computed tomographic and magnetic resonance imaging head scans on patients aged 1 to 18 years who were evaluated for trauma. The query included the following: date, sex, type of scan (computed tomography or magnetic resonance imaging), age, patient location, reason for scan, Glasgow Coma Scale (GCS) score (if entered), result, and text from physician's notes. A total of 2679 patients were identified. Within this cohort was a maximum of 29 surgical patients, of whom 8 required a surgical procedure but not neurosurgery among the 592 patients who had a GCS score of 14-15 entered, 2 were confirmed/possible neurosurgical patients, giving a neurosurgical rate of 0.34%. When the GCS 3-13 patient group was analyzed, the relative risk of requiring neurosurgery climbed to 52. Using an established algorithm for pediatric head trauma imaging would have reduced the number of scanned patients to 533. The individual cost of identifying the 29 surgical patients in our population exceeded $31,000. Our rate of serious lesions in GCS 14-15 patients was identical to a larger prospective study in urban teaching hospitals. Using their previously described algorithm might have reduced the number of patients scanned by more than 70% and saved close to $750,000 for the study period.