Academic Tertiary Care Hospital Research Articles

Risk Factors and Outcomes of Invasive Candida Infections in Heart Transplant Recipients: A Case-Control Study.

Invasive Candida infections (ICI) are the most common invasive fungal infections in solid organ transplant recipients. There are limited contemporary data on the risk factors for infection in heart transplant (HT) recipients especially since the expansion of temporary mechanical circulatory support (MCS) use. This was a case-control study conducted at a tertiary care academic hospital of HT recipients from January 2022 to January 2024. All patients who developed ICI by the detection of Candida species from a normally sterile site were included as cases. Four controls who underwent HT, two before the case and two after the case, were selected. ​Fisher's exact or Mann-U-Whitney tests were used for the analysis. There were 12 cases and 48 controls out of a total of 117 transplants during the study period​. The proportion of ICI was 10.6%. The median time to ICI from transplant was 16 days (IQR 10, 83). The most common organisms isolated were Candida parapsilosis and Candida albicans. The majority of infections were mediastinitis. Risk factors for ICI included receipt of antibiotics for more than 7 days within 1 month prior to transplant (58.3%vs. 22.9%, p = 0.03), tracheostomy (41.7%vs. 10.4%, p = 0.02), prolonged chest tube placement (13vs. 9 days, p = 0.02), and temporary MCS (p = 0.042). Patients who developed ICI had increased 90-day all-cause mortality compared to controls (33.3% vs. 4.2%, p = 0.01). This study identified several risk factors for ICI following HT. Further research is essential to develop interventions that mitigate these risk factors in this patient population.

P-879. Predicting Antimicrobial Resistance and Empiric Treatment Failure in Hospital-Onset Sepsis Using Machine Learning on Electronic Health Records

Abstract Background Antimicrobial resistance (AMR) is a major cause of treatment failure in hospital-onset sepsis. Approaches to guide empiric antimicrobial therapy are urgently needed. We utilized machine learning to predict empiric treatment failure and AMR patterns within a high-risk hospital-onset sepsis cohort using electronic health records (EHRs). Methods We examined hospitalizations with documented bacterial infection from 2010 to 2023 at a tertiary-care academic hospital system. Hospital-onset sepsis was defined using CDC Adult Sepsis Event criteria. Empiric therapy was considered adequate if all pathogens isolated were susceptible to antimicrobials administered. AMR patterns included methicillin (MRSA), extended-spectrum beta-lactamase (ESBL), vancomycin (VRE), ceftriaxone, and carbapenem (CRE). Features for prediction were patient characteristics, hospitalization details, and clinical severity metrics measured within 24 hours prior to sepsis onset. Linear and non-linear machine learning models were evaluated using bootstrap validation and out-of-bag area under the receiver operating characteristic curve (AUC). Results Among 49,581 hospitalizations, 2019 (4%) hospital-onset sepsis encounters were identified. Mean (SD) age was 65 (16.4) years and 900 (45%) were female. At 24 hours after sepsis onset, 377 (19%) received inadequate empiric treatment and 911 (45%) infections expressed AMR. Those who received inadequate empiric treatment were 8.2 (95%CI: 6.2-10.9) times more likely to have an AMR infection. Random forest model was best-performing, with AUC (95%CI) for any AMR pattern, VRE, and CRE at 0.64 (0.63-0.64), 0.71 (0.69-0.72), and 0.70 (0.67-0.73), respectively. The AUC (95%CI) for predicting inadequate empiric antimicrobial treatment was 0.65 (0.64-0.66) with a sensitivity of 64% (58-69%) and specificity of 52% (46-68%) at optimal probability thresholds. Conclusion In a hospital-onset sepsis cohort with prevalent AMR, machine learning approaches utilizing limited EHR data accessible at initial sepsis recognition had moderate, but clinically insufficient, discriminatory ability in predicting AMR and empiric antimicrobial treatment failure. Future research will evaluate the utilization of large language models using unstructured EHRs. Disclosures All Authors: No reported disclosures

Outcomes of Cochlear Implantation in Adolescents With Auditory Neuropathy Spectrum Disorder: Scoping Review and Case Report.

To assess outcomes of CI in adolescent patients with ANSD, a population which has not yet been comprehensively reviewed through a scoping review. A scoping review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive search of MEDLINE, EMBASE, Cochrane DSR, Cochrane CENTRAL, CINAHL, and Web of Science was performed. Cohort and case studies evaluating outcomes of CI in adolescents with ANSD were selected. A case report of an adolescent ANSD patient who underwent CI from our tertiary care academic hospital setting is also reported. Our search identified a total of 17 articles after screening 488 articles. Among the 24 patients isolated from the selected articles, the vast majority showed some level of improvement in their hearing ability (n = 21, 87.5%). Additionally, of the 20 individuals whose hearing outcomes had a comparison cohort of subjects under 10 years old, nearly half showed better or similar levels of hearing improvement (n = 9, 45%). Adolescents with ANSD receiving CI have notable improvements in hearing outcomes, but to a lesser degree than younger cohorts with ANSD. As such, CI should be considered as a valid treatment option for adolescents with ANSD. However, the benefit of such intervention has a wide variability, presumably based on the different pathologies that can cause their hearing loss and not necessarily the age at implantation.

Exploring the quality of end-of-life care in the intensive care unit: a qualitative multiple case study approach with family members of Muslim patients

ObjectiveMuslim patients are an underrepresented community in end-of-life care research, with little evidence around factors that influence the quality and experience of care. The aim of this study was to...

Implementation of multidisciplinary team decisions on the management of complex bone and joint infections: an observational study

BackgroundMultidisciplinary team (MDT) management of prosthetic joint infections (PJI) and other bone and joint infections (BJI) is increasingly put into practice. However, studies evaluating the performance of MDTs in this field are scarce. We aimed to assess our MDT for complex BJI by determining the implementation rate of team decisions, analyzing factors associated with non-implementation and evaluating the clinical outcome of patients in whom MDT decisions were not implemented.MethodsAn observational study was conducted on all patients with a PJI or other BJI of which the management was discussed during MDT meetings between 2015 and 2022 in a tertiary care academic hospital. Patient characteristics and MDT data were obtained from electronic patient records. The multidisciplinary team consisted of orthopaedic surgeons, trauma surgeons, infectious diseases specialists and clinical microbiologists. A decision was considered not implemented if the patient did not receive the management that was decided by the MDT. Factors possibly associated with non-implementation were statistically analyzed using logistic regression.ResultsThe analysis included 1321 MDT decisions on 509 patients. The overall implementation rate of MDT decisions was 92%. Reasons for non-implementation were disagreement by the treating surgeon with the MDT regarding the optimal treatment (n = 24, 23%), patient preference for a different treatment (n = 19, 18%), new clinical information not yet available during the MDT meeting that made the physician change management (n = 17, 16%) or unknown (n = 45, 43%). Trauma surgeons were more likely to not implement an MDT decision (odds ratio 2.4, p = 0.01) The cure rate of patients who received a different surgical strategy than decided by the MDT was 33%. The cure rate was lower if a patient chose to deviate from the MDT decision (46%) than when the treating physician chose to deviate from the MDT decision (77%).ConclusionThe implementation rate of decisions made by our complex BJI MDT was high. Furthermore, the current study suggests that non-implementation of MDT decisions on surgical management and non-implementation initiated by the patient lead to poor clinical outcomes. An analysis of MDT decision implementation is a useful tool to evaluate the impact of MDTs and further improve its quality.

Sex Differences in Testing for Pulmonary Embolism Among Emergency Department Patients Aged 18–49 by Chief Complaint

BackgroundWomen undergo diagnostic testing for pulmonary embolism (PE) in greater numbers than men, despite the disease incidence being higher in men overall. It is unknown if testing for PE varies based on patient chief complaint. MethodsThis retrospective cohort study was conducted at two academic tertiary care hospitals. Nonpregnant adult patients (aged 18–49 years) were included if they presented to the ED between 1/1/2016 and 12/31/2018 with nontraumatic mechanisms and any of the following chief complaints: chest pain, shortness of breath, hemoptysis, or syncope AND had objective testing for PE. Data were obtained from the electronic medical record and analyzed descriptively. Four outcome variables were assessed: receipt of D-dimer testing, D-dimer positivity, receipt of pulmonary vascular imaging, and diagnosis of PE. ResultsWe studied 1,991 unique patient encounters, most of whom (63%; 1,256/1,991) were female. Overall, female patients had higher odds of receiving D-dimer testing than male patients (OR 1.30, CI 1.06–1.59, P = 0.015), while they had lower odds of being diagnosed with PE (OR 0.57, CI 0.36–0.90, P = 0.019). However, this trend varied by chief complaint. Among patients with chest pain, females had higher odds of having a D-dimer performed (OR 1.35, CI 1.01–1.80, P = 0.049) and lower odds of being diagnosed with PE (OR 0.36, CI 0.18–0.70, P = 0.003) than males. ConclusionsBoth patient sex and chief complaint were associated with trends in diagnostic testing for PE. Among patients with chest pain, females are significantly more likely to be tested with a D-dimer and less likely to be diagnosed with PE.

Deep learning to predict risk of lateral skull base cerebrospinal fluid leak or encephalocele.

Skull base features, including increased foramen ovale (FO) cross-sectional area, are associated with lateral skull base spontaneous cerebrospinal fluid (sCSF) leak and encephalocele. Manual measurement requires skill in interpreting imaging studies and is time consuming. The goal of this study was to develop a fully automated deep learning method for FO segmentation and to determine the predictive value in identifying patients with sCSF leak or encephalocele. A retrospective cohort study at a tertiary care academic hospital of 34 adults with lateral skull base sCSF leak or encephalocele were compared with 815 control patients from 2013-2021. A convolutional neural network (CNN) was constructed for image segmentation of axial computed tomography (CT) studies. Predicted FO segmentations were compared to manual segmentations, and receiver operating characteristic (ROC) curves were constructed. 295 CTs were used for training and validation of the CNN. A separate dataset of 554 control CTs was matched 5:1 on age and sex with the sCSF leak/encephalocele group. The mean Dice score was 0.81. The sCSF leak/encephalocele group had greater mean (SD) FO cross-sectional area compared to the control group, 29.0 (7.7) mm2 versus 24.3 (7.6) mm2 (P = .002, 95% confidence interval 0.02-0.08). The area under the ROC curve was 0.69. CNNs can be used to segment the cross-sectional area of the FO accurately and efficiently. Used together with other predictors, this method could be used as part of a clinical tool to predict the risk of sCSF leak or encephalocele.

Hypovolaemic phlebotomy in patients undergoing hepatic resection at higher risk of blood loss (PRICE-2): a randomised controlled trial.

Blood loss and subsequent red blood cell transfusions are common in liver surgery. Hypovolaemic phlebotomy is associated with decreased red blood cell transfusion in observational studies. This trial aimed to investigate whether hypovolaemic phlebotomy is superior to usual care in reducing red blood cell transfusions in patients undergoing liver resection. PRICE-2 was a multicentre, single-blind, superiority randomised controlled trial. Patients at a higher risk of blood loss undergoing liver resection for any indication at four Canadian academic tertiary-care hospitals were randomised to receive hypovolaemic phlebotomy or usual care. Hypovolaemic phlebotomy consisted of the removal of 7-10 mL/kg of whole blood, without volume replacement, before liver transection. Patients were randomised centrally using permuted blocks of randomly variable length, stratified by centre. The randomisation sequence was computer-generated by an independent statistician. Surgeons, patients, and outcome assessors were masked to treatment allocation. The primary outcome was perioperative red blood cell transfusion to 30 days post-randomisation, analysed in all randomly assigned patients who underwent liver resection. PRICE-2 trial was registered with ClinicalTrials.gov (NCT03651154) and is completed. Between Oct 1, 2018, and Jan 13, 2023, 486 individuals were randomly assigned to receive hypovolaemic phlebotomy (n=245) or usual care (n=241). 22 individuals in the hypovolaemic phlebotomy group and 18 in the usual care group did not undergo liver resection and were thus excluded from the primary analysis population. 223 patients were included in the hypovolaemic phlebotomy group (mean age 61·4 years [SD 13·0]; 137 [61%] men) and 223 in the control group (62·1 years [12·1]; 114 [51%]). 17 (8%) of 223 patients allocated to hypovolaemic phlebotomy and 36 (16%) of 223 patients allocated to usual care had a perioperative red blood cell transfusion by 30 days (difference -8·8 percentage points [95% CI -14·8 to -2·8]; adjusted risk ratio [aRR] 0·47 [95% CI 0·27 to 0·82]). Severe complications to 30 days occurred in 37 (17%) patients allocated to hypovolaemic phlebotomy and 36 (16%) allocated to usual care (aRR 1·06 [95% CI 0·70-1·61]). Overall complications to 30 days occurred in 135 (61%) of 223 patients allocated to hypovolaemic phlebotomy and 116 (52%) of 223 patients allocated to usual care (1·08 [0·92-1·25]). There was no postoperative mortality to 90 days. In patients undergoing liver resection, hypovolaemic phlebotomy reduced perioperative red blood cell transfusion and improved operative conditions, with no statistically significant increase in the incidence of complications compared with usual care. Hypovolaemic phlebotomy should be considered for routine use in patients undergoing liver resection at higher risk of bleeding. Canadian Institutes of Health Research (PJT-156108).

Canadian computed tomography head rule and New Orleans criteria in mild traumatic brain injury: Comparison at an urban tertiary care facility in Pakistan.

Traumatic brain injury (TBI) is a leading cause of mortality and morbidity worldwide, with road traffic accidents being the predominant cause in Pakistan. Computed tomography (CT) scans have become the cornerstone of investigation for all TBIs, but their widespread use raises concerns about cost-effectiveness, radiation exposure, and incidental findings. This study aimed to validate the applicability of the Canadian CT head rule (CCHR) and New Orleans Criteria (NOC) in the Pakistani population and compare their sensitivity and specificity. A cross-sectional study was conducted in a tertiary care academic hospital in Pakistan, including consecutive patients with acute, mild brain injury. The primary outcome was "clinically important brain injury," while the secondary outcome was "need for neurosurgical intervention." Univariate analysis using Chi square was performed for each variable to assess association with CT findings. Sensitivity, specificity, and accuracy were calculated to evaluate the performance of each decision rule. Most of the patients in our study had a Glasgow Coma Scale (GCS) score of 15 (92.6%). Headache was the most common parameter overall (61.7%). Clinically important CT was detected in 68 (6.7%) patients. Only 1 of the NOC and 4 CCHR variables demonstrated statistically significant association with clinically significant CT. The CCHR was 64% sensitive for detecting clinically important CTs in trauma patients with GCS of 13-15, and the NOC was 86% sensitive, with respective specificities of 70% and 33%. For predicting the need for neurosurgical intervention, the sensitivities of CCHR and NOC were 61% and 85%, and specificity was 68% and 32%, respectively. We concluded that the CCHR was more specific and accurate, and it has the potential to have a greater influence on CT ordering rates than the NOC. Further studies are recommended to validate the tools for the Pakistani population.

Gather "Round": An Integrated Care Model for the Emergency Department Multi-Visit Patient.

Emergency departments (EDs) are a vital component of the United States healthcare system and care for over 130 million patient visits annually. Nonurgent ED visits can contribute to crowding, delays in care, and adverse effects. Many high-utilizing ED patients may present with complex medical, behavioral, and social needs that are not necessarily emergent or urgent in nature. The authors created an Integrated Care Model, called the Multi-Visit Patient (MVP) program, for patients with 5 or more visits to the ED in a rolling 12-month period. The MVP program incorporated an interdisciplinary group of ED leadership and case management (CM) to identify, engage, and intervene with ED MVPs, aiming to improve their ED utilization. Patients received comprehensive screenings for depression, falls, alcohol use disorder, caregiver support, social determinants of health, and more. Based on these screenings, the CM team implemented interventions such as connecting patients with outpatient specialists and linking patients to community-based organizations to optimize stability, wellness, and reduce ED utilization. The collaboratively developed MVP program was implemented in the ED of a large, suburban, tertiary care academic hospital. The MVP program identified 221 MVP patients over a 20-month period and successfully connected with 89% of them. Of these 221 patients, 78% (172 patients) chose to engage in the MVP program, with 160 completing their engagement with an outcome. Among the patients who completed their engagement and for whom the study could match separate utilization data (151 patients), the study observed a 57% reduction in ED visits. Case managers play a crucial role in the effectiveness of the MVP program by coordinating comprehensive care for high-utilizing ED patients. The MVP program includes transition of care initiatives designed to improve patient outcomes. Through screenings and targeted interventions, case managers identify and address the complex medical, behavioral, and social needs of MVP patients. This collaborative, interdisciplinary approach underscores the importance of timely and coordinated care, benefiting both patients and the health system. The MVP program exemplifies the critical role of case managers in reducing unnecessary ED visits and enhancing overall patient care.

Abstract 4138686: Impact of Ejection Fraction on Incidence of Atrial Fibrillation Following Admission for Heart Failure

Introduction: Though the prevalence of atrial fibrillation (AF) is similar amongst heart failure (HF) with reduced, mildly reduced, and preserved ejection fractions, population-level data suggests a modestly increased prevalence in patients with HFpEF compared to those HFrEF. The development of atrial fibrillation is associated with increased risk of stroke, hospitalization, and cardiovascular death in all types of heart failure, though some data suggests morbidity and mortality is worse amongst those with HFpEF. Whether ejection fraction plays a role in development of AF following a HF hospitalization is unclear. Hypothesis: We hypothesized incidence of AF following heart failure hospitalization is increased in patients with preserved ejection fractions. Aim: The goal of this study is to assess the impact of ejection fraction on development of new atrial fibrillation following heart failure exacerbation. Methods: Patients admitted to an academic tertiary care hospital with a primary diagnosis of HF without a previous diagnosis of AF were identified and followed for up to one year for this retrospective study. Demographic, comorbidity, medications, and echocardiography of these patients were obtained from the medical record and analyzed. Consistent with the American Heart Association heart failure guidelines, we defined HFrEF as an EF less than 40%, HFmrEF as an EF between 40-50%, and HFpEF as an EF greater than 50%. This data was analyzed on SPSS using cox-regression and Kaplan-Meier survival analysis. Results: Of the 3,953 patients included in our study, 22.2% had HFrEF, 13.5% had HFmrEF, and 64.3% had HFpEF. At the end of one year 23.5% of those with HFrEF, 20.1% of those with HFmrEF, and 15.9% of those with HFpEF, developed atrial fibrillation. The difference in AF incidence was noted to be statistically significantly lower in HFpEF compared to HFrEF (p<0.001) and HFmrEF (p=0.019). The difference between HFmrEF and HFrEF did not reach statistical significance (p=0.144). Conclusion: In patients without atrial fibrillation, a reduced ejection fraction is associated with an increased incidence of atrial fibrillation one year following a hospitalization for heart failure compared to a preserved ejection fraction.

Outcomes of Universal Suicide Risk Screening in Medical Inpatients

Objectives Universal screening for suicide risk has not been shown to reduce suicide rates or reliably predict suicide, but there have been few studies assessing other potential benefits of this practice. We aimed to investigate the feasibility of implementing a universal inpatient suicide risk screening protocol and determine if a positive suicide screen was predictive of the need for psychiatric admission, and if it reduced the length of stay prior to psychiatric admission. Methods We conducted a retrospective chart review of non-psychiatric admissions over 1 year at a tertiary care academic hospital. We calculated the proportion of patients screening positive for suicidal ideation (SI), and among those screening positive, the proportion receiving a psychiatric consult and being admitted to psychiatry. Length of stay among groups was determined. We performed chi square analysis and adjusted multivariate logistic regression comparing different demographics. Results 97.2% of patients were screened, with 2.6% screening positive. Of these patients, 44.6% received a psychiatric consultation and 9.2% were admitted to psychiatry. Psychiatric admissions who screened positive for SI averaged 5.7 days until transfer to psychiatry, compared to 17.9 days for those who screened negative. Suicide risk screening had a sensitivity of 62.0%, specificity of 97.6%, positive predictive value of 9.2%, and a negative predictive value of 99.8% for psychiatric admission. Conclusions Universal suicide risk screening is feasible and may help identify patients requiring psychiatric care sooner, reducing length of stay of those requiring psychiatric admission.

Candida auris fungaemia outbreak in a tertiary care academic hospital and emergence of a pan-echinocandin resistant isolate, Greece, 2021 to 2023.

After the start of the COVID-19 pandemic, a rapid rise in reported numbers and wide geographic spread of Candida auris-related invasive infections has been observed globally. However, the contemporary epidemiology of C. auris fungaemias in Greece remains unknown. An outbreak of C. auris bloodstream infections has been ongoing for almost 3 years in a Greek tertiary care academic hospital, with 89 C. auris-driven episodes appearing in five waves every 6-7 months following peaks in colonisation rates by 3-4 months. All isolates clustered in clade I and were genetically related, 84% were fluconazole-resistant and all were non-resistant to amphotericin B and echinocandins, except one pan-echinocandin-resistant isolate (FKS1S639F mutant) recovered from a patient on empiric therapy with anidulafungin. Notably, C. auris was in 2023 the most prevalent (34%) cause of candidaemia in our hospital. The accelerated and long-term transmission dynamics of C. auris fungaemia underscore the need for rigorous infection control measures, while antifungal stewardship is warranted to contain the selection of echinocandin-resistant isolates.

Pediatric Early Warning Scores Before Rapid Response Poorly Predict Intensive Care Unit Transfers.

The Pediatric Early Warning Score (PEWS) is a clinical tool used to identify children at risk for clinical deterioration, but its utility remains debated, particularly in high-resource settings. Our objective with this study was to assess the predictive performance of the PEWS for unplanned PICU transfers after pediatric rapid response team (RRT) activation. A retrospective cohort study at a tertiary care academic children's hospital included all hospitalized patients up to 21 years old who had RRT activations between August 2021 and July 2022. Demographic and clinical data, the primary reason for RRT activation, and the modified Brighton PEWS were collected. The primary outcome was PICU transfer following RRT activation, and the secondary outcome was rapid escalation of care within 4 hours after RRT activation. Sensitivity, specificity, and area under the receiver operating characteristic curve (AUROC) were calculated at multiple PEWS thresholds. Of 297 RRT activations in 244 patients, 183 (63%) resulted in a PICU transfer, 75% of which were due to respiratory concerns. The PEWS was recorded in 89% of RRT activations within the preceding 4 hours. There was no significant difference in the PEWS between patients with or without PICU transfer or rapid escalation of care. The sensitivity, specificity, and AUROC of PEWS for predicting PICU transfer or rapid escalation of care were low (AUROC 0.495-0.613). PEWS within 4 hours before RRT activation was a poor predictor of PICU transfer or rapid escalation care. Further work is needed to develop a more sensitive and specific tool.

The Diagnostic Utility of Fever in Patients With Suspected Sepsis Secondary to Community-Acquired Bacteremia.

Background Community-acquired bacteremia is a potential source of infection and cause of fever in patients presenting to the emergency department (ED) with suspected sepsis. Ambiguous or false-positive blood culture results may lead to unnecessary testing and overtreatment with substantial implications on antimicrobial stewardship and associated healthcare costs. There is little clinical information available to determine with a high degree of certainty whether a patient may be febrile secondary to bacteremia. The primary aim of this study was to assess the diagnostic utility of fever in patients with suspected sepsis secondary to community-acquired bacteremia. Methodology A retrospective review of a consecutive sample of electronic health records of patients presenting to the ED of an academic tertiary care hospital with an annual census of approximately 100,000 visits was performed. Structured demographic and clinical data were summarized. Receiver operating characteristics of fever, defined as an initial recorded temperature≥38°C, in predicting bacteremia, defined as at least one positive blood culture result, were calculated. The associations between fever and bacteremia and admission and inpatient all-cause mortality rates were analyzed using multivariable logistic regression. Results A total of 100,270 pediatric and adult ED visits were screened for eligibility. Of the 10,220 (10.2%) patients who had at least one blood culture result and temperature recorded, 1,175 (11.5%) were febrile and 487 (4.8%) had bacteremia. Febrile patients were more likely to have blood cultures drawn than afebrile patients (34% vs. 10%, p < 0.001), and the median initial temperature was higher in patients with a positive blood culture result (37.1°C vs. 36.9°C, p < 0.001). Fever was not sensitive for bacteremia across pediatric, adult, and geriatric cohorts (25.0%, 21.6%, and 23.4%, respectively), but was more specific in adult and geriatric cohorts (90.2% and 92.1%, respectively) than the pediatric cohort (68.6%). A positive blood culture result was associated with an increased likelihood of admission (adjusted odds ratio (AOR) = 2.85, 95% confidence interval (CI) = 2.14-3.81, p < 0.001) and inpatient all-cause mortality (AOR = 3.67, 95% CI = 2.68-5.04, p < 0.001) while fever increased the likelihood of admission only (AOR = 1.58, 95% CI = 1.36-1.83, p < 0.001). Conclusions A strict definition of a fever of ≥38°C is specific but not sensitive for bacteremia. Febrile patients are 1.58 times as likely to be admitted when compared to afebrile patients while adjusting for age, sex, and the presence of a positive blood culture result. Bacteremia is associated with increased admission and mortality rates in patients with suspected sepsis presenting to the ED.

Blood component-associated acute transfusion reactions in pediatric patients: experience of a tertiary care hospital.

The transfusion of blood products is a life-saving clinical practice in patients with bleeding, hemoglobinopathy, and cancer. It was aimed herein to analyze the frequency and types of blood component-related acute transfusion reactions (ATRs) in pediatric patients. This retrospective study was conducted at a tertiary care academic pediatric hospital. During the study period, 30,811 transfusions were administered to 25,448 patients. There were 103 ATRs detected in 81 patients (0.33%; 3.34 reactions per 1000 transfusions, mean age 8.3 ± 5.98 years, 36 females and 45 males). All the reactions were observed within an average of 4 h after the transfusion began. The most common ATRs were allergic reactions (79; 76.6%) and febrile nonhemolytic transfusion reactions (12; 11.6%). All the allergic transfusion reactions occurred within the first hour after the start of the transfusion. Granulocyte concentrates were the blood component associated with the highest ATR rate (2.1%). Within our hospital, pediatric hematology-oncology wards and the stem cell transplantation unit had the most frequent ATR reports; therefore, when transfusions are carried out, increased attention should be given to these units. Educating health staff about the adverse effects of transfusion therapy should increase the awareness and reporting of ATRs in children.

The Effect of the Adoption of the National Accreditation Program for Rectal Cancer Process on Compliance Standards at a Single Institution.

Background: The National Accreditation Program for Rectal Cancer (NAPRC) was developed to enhance the quality of rectal cancer care in the United States. This project compared NAPRC compliance at a single tertiary care academic hospital before and after the institution adopted these standards in 2019. Methods: Rectal cancer patients from 2016 to 2023 who met NAPRC eligibility criteria were retrospectively reviewed for compliance with pre-selected patient care standards. Patients diagnosed prior to August 1, 2019 (pre-NAPRC) were compared with those diagnosed afterward (post-NAPRC) to determine whether compliance with these standards differed following the institution's adoption of new guidelines. Results: This study included 353 patients, 146 pre-NAPRC and 207 post-NAPRC. The post-NAPRC group demonstrated significantly higher compliance with pretreatment standards compared to the pre-NAPRC group, including attaining magnetic resonance imaging (MRI) (P = .015), computed tomography (CT) (P < .001), and a carcinoembryonic antigen (CEA) level (P < .001). Postoperative standards were more frequently met in the post-NAPRC group regarding the photographing of surgical specimens (P < .001). No significant differences were observed in confirming a tissue diagnosis, starting treatment within a 60-day timeframe, or completing surgical pathology reports. Prior to initiation of the NAPRC process, the institution had achieved accreditation-level compliance in 2 of the 7 standards. Within 2years of adopting NAPRC standards, complete compliance was met in 6 of the 7 measures. Conclusions: A single institution's adoption of NAPRC standards improved compliance with multiple rectal cancer care standards, achieving near-complete accreditation level compliance within 2years.

Usefulness of the 4A's test for detecting delirium in critically ill patients: a multicenter prospective observation study.

The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) is a robust and reliable instrument for discerning delirium within the specific context of the intensive care unit (ICU). Nonetheless, the CAM-ICU is burdened by various limitations, including a protracted learning curve and the need for frequent daily administration. The 4 A's Test (4AT) was formulated to assess delirium in hospitalized patients and may have distinct advantages over the CAM-ICU, particularly regarding practical applicability within the ICU bundle. This study was performed to assess the utility of the 4AT in detecting delirium in critically ill patients. This multicenter prospective observational study involved critically ill patients at four academic tertiary care hospitals in South Korea from June 2021 to September 2022. In total, 274 patients (median age, 64years; 56.9% men) were included, and 75 (27.4%) developed delirium. The 4AT showed good performance in detecting ICU delirium (area under the curve, 0.879; P < 0.001). The 4AT showed a sensitivity of 74.0%, specificity of 95.4%, positive predictive value of 77.5%, negative predictive value of 94.6%, and accuracy of 91.7% for ICU detection of delirium. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the CAM-ICU for detecting ICU delirium were 71.3%, 97.1%, 83.8%, 94.1%, and 92.6%, respectively. The 4AT showed acceptable reliability and validity for detecting ICU delirium in critically ill patients. Because the 4AT is simpler and easier to learn, this scale could be a useful alternative to the CAM-ICU for detecting delirium in critically ill patients.

Environmentally sustainable opportunities for health systems: Metered-dose inhaler prescribing, dispensing, use and waste at a tertiary academic centre.

The Canadian health sector's carbon footprint is among the highest in the world and is responsible for 4.6% of Canada's total greenhouse gas emissions, a quarter of which is linked to pharmaceuticals, with metered-dose inhalers (MDIs) contributing disproportionally high amounts. To describe MDI prescribing, dispensing, use and waste patterns at a Canadian tertiary care academic hospital. In a retrospective point-prevalence cohort study, 100 consecutive patients discharged from medical and surgical services who were prescribed at least 1 MDI during their admission were included. Data were collected to describe patient demographics, MDI prescribing, dispensing, use and waste patterns. Use and waste data were applied to annual purchasing data to estimate annual usage and waste. Financial cost was computed using local purchasing estimates and carbon cost was calculated using published estimates. In 100 consecutively discharged patients, 315 MDIs were dispensed in total, of which 96 were unused. This represents 61,440 actuations dispensed, with 56,773 (92%) of doses unused or wasted. Waste data were applied to annual estimates, with a calculated annual carbon footprint of 315.8 tons of carbon dioxide equivalent (tCO2e). We estimate that a 20% waste reduction would result in carbon savings of 68.5 tCO2e. If 20% of salbutamol prescriptions were switched to the dry powder inhaler alternative, terbutaline, a 14% reduction in waste would be required to offset the additional monetary cost. This study suggests that 92% of MDI doses are unused and wasted. Opportunities for waste reduction exist and would be associated with both financial and carbon savings.

Can a New, Satellite Inpatient Hospital Maintain the Efficiency of an Ambulatory Surgery Center with No Difference in Patient-reported Outcomes? A Prospective Study

BackgroundPrevious research has found that anterior cruciate ligament (ACL) reconstructions performed at ambulatory surgery centers (ASCs) are more time-efficient. However, recent literature investigating this phenomenon within the pediatric population is limited and primarily retrospective. The goal of this study was to prospectively compare the operating room (OR) efficiency of pediatric ACL reconstructions performed across different surgical settings. MethodsAdolescent patients (12–18 years) undergoing ACL reconstruction by a single surgeon were prospectively enrolled from 2020 to 2024. Patients were cohorted based on the location of their surgery at one of three sites: 1) a traditional, tertiary care academic hospital, 2) hospital-owned ASCs, or 3) a satellite inpatient hospital that was built and connected to an ASC in January 2022. Patient preoperative, surgical, and postoperative data were collected, and surgical efficiency was compared across surgical sites using a variety of metrics. Patient-reported outcomes (PROMs) were collected using the Pedi-FABS and Pediatric International Knee Documentation Committee questionnaires. ResultsA total of 115 patients (56.5% female, mean age: 15.4 ​± ​1.7 years) met inclusion criteria and were enrolled. Thirty-one patients (27.0%) had ACL reconstructions at the main inpatient hospital, 36 (31.3%) at hospital-owned ASCs, and 48 (41.7%) at the new satellite inpatient hospital. When controlling for concomitant procedures, regional anesthesia type, and staff, there was a significant difference in total OR in-room, anesthesia induction, surgery preparation, surgery duration, and dressing application/wake-up times among the three cohorts (P ​< ​.001). Both the ASCs and the satellite inpatient hospital had shorter total OR in-room and surgery duration times than the main inpatient hospital (P ​< ​.001). There were no differences in PROMs among the three cohorts (P ​> ​.05). ConclusionsAdolescent ACL reconstructions performed at either an ASC or a satellite inpatient hospital were more time-efficient than those performed at a traditional, main inpatient hospital, with no differences in PROMs. Institutions should consider implementing strategies used at ASCs, such as standardized surgical teams, at main hospitals to increase efficiency. Key Concepts(1)A satellite inpatient hospital and ambulatory surgery centers are more time-efficient for adolescent ACL reconstruction than a main, inpatient hospital.(2)There were no differences in patient-reported functional outcomes after adolescent ACL reconstruction among ASCs, a main inpatient hospital, and a satellite inpatient hospital.(3)A satellite inpatient hospital can be as efficient as an ASC, with no significant difference in quality. Level of EvidenceII (Prospective Cohort Study)