Tertiary Care Hospital In Boston Research Articles

If you don’t test, they will not treat: Impact of stopping preoperative screening for asymptomatic bacteriuria

Screening for asymptomatic bacteriuria (ASB) is not recommended outside of patients undergoing invasive urological procedures and during pregnancy. Despite national guidelines recommending against screening for ASB, this practice is prevalent. We present outcomes from a quality-improvement intervention targeting patients undergoing cardiac artery bypass grafting surgery (CABG) at Massachusetts General Hospital, a tertiary-care hospital in Boston, Massachusetts, where preoperative testing checklists were modified to remove routine urinalysis and urine culture. This was a before-and-after intervention study. Prior to the intervention, screening for ASB was included in the preoperative check list for all patients undergoing CABG. We assessed the proportion of patients undergoing screening for ASB in the 6 months prior to and after the intervention. We estimated cost savings from averted laboratory analyses, and we evaluated changes in antibiotic prescriptions. We additionally examined the incidence of postoperative surgical-site infections (SSIs), central-line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs) and Clostridioides difficile infections (CDIs). Comparing the pre- and postintervention periods, urinalyses decreased by 76.5% and urine cultures decreased by 87.0%, with an estimated cost savings of $8,090.38. There were 50% fewer antibiotic prescriptions for bacteriuria after the intervention. Removal of urinalysis and urine culture from preoperative checklists for cardiac surgery led to a statistically significant decrease in testing without an increase in SSIs, CLABSIs, CAUTIs, or CDI. Challenges identified included persistence of checklists in templated order sets in the electronic health record.

Sources of exposure and risk among employees infected with severe acute respiratory coronavirus virus 2 (SARS-CoV-2) in a large, urban, tertiary-care hospital in the United States.

Hospital employees are at risk of SARS-CoV-2 infection through transmission in 3 settings: (1) the community, (2) within the hospital from patient care, and (3) within the hospital from other employees. We evaluated probable sources of infection among hospital employees based on reported exposures before infection. A structured survey was distributed to participants to evaluate presumed COVID-19 exposures (ie, close contacts with people with known or probable COVID-19) and mask usage. Participants were stratified into high, medium, low, and unknown risk categories based on exposure characteristics and personal protective equipment. Tertiary-care hospital in Boston, Massachusetts. Hospital employees with a positive SARS-CoV-2 PCR test result between March 2020 and January 2021. During this period, 573 employees tested positive, of whom 187 (31.5%) participated. We did not detect a statistically significant difference in the proportion of employees who reported any exposure (ie, close contacts at any risk level) in the community compared with any exposure in the hospital, from either patients or employees. In total, 131 participants (70.0%) reported no known high-risk exposure (ie, unmasked close contacts) in any setting. Among those who could identify a high-risk exposure, employees were more likely to have had a high-risk exposure in the community than in both hospital settings combined (odds ratio, 1.89; P = .03). Hospital employees experienced exposure risks in both community and hospital settings. Most employees were unable to identify high-risk exposures prior to infection. When respondents identified high-risk exposures, they were more likely to have occurred in the community.

Critical Care Transport of Patients With COVID-19.

Critical care transport is associated with a high rate of adverse events, and the risks and outcomes of transporting critically ill patients during the COVID-19 pandemic have not been previously described. We performed a retrospective review of transports of subjects with suspected or confirmed COVID-19 from sending hospitals to tertiary care hospitals in Boston. Follow-up data were obtained for patients transported between March 1st and April 20th, 2020. Of 254 charts identified, 250 patients were transported. Nine patients (3.5%) had cardiac arrest prior to transport. Twenty-nine (11.6%) had hypotension, 22 (8.8%) had a critical desaturation, and 4 (1.6%) had both en route. Hospital follow-up data were available for 189 patients. Of those intubated during their hospitalization, 44 (25.0%) had died, 59 (33.5%) had been extubated, and 13 (17.6%) had been discharged alive. For the subgroup with prior cardiac arrest, follow-up data available for 6. Of these 6, 2 died and 4 (66.7%) have been discharged alive. Few patients with COVID-19 had an adverse event in transport. The in-hospital mortality rate was 25%, with a 33.5% extubation rate. Patients resuscitated from cardiac arrest prior to transport had a 66.7% discharge rate among those transported to consortium hospitals.

Incidence of Hyponatremia in Patients With Indwelling Peritoneal Catheters for Drainage of Malignant Ascites

Indwelling peritoneal catheters (IPCs) are frequently used to drain tense, symptomatic, malignant ascites. Large-volume drainage may lead to hyponatremia owing to massive salt depletion. To date, no studies have examined the epidemiology of hyponatremia after placement of an IPC. To evaluate the incidence of hyponatremia after IPC placement, the risk factors associated with its development, and how it is managed. This cohort study retrospectively reviewed the medical records of 461 patients who had IPCs placed during the period between 2006 and 2016 at a tertiary care hospital in Boston, Massachusetts, of whom 309 patients met the inclusion criteria. Data analysis was performed from June to November 2019. Main outcomes were the incidence of hyponatremia (with a serum sodium level <135 mEq/L) after IPC placement, the risk factors for its development, and how it was managed. We also examined the clinical course of a subset of 21 patients with hypovolemic hyponatremia. Of the 309 eligible patients with laboratory results both before IPC placement and 2 days or more after IPC placement, 189 (72.1%) were female, and the mean (SD) age was 59 (12) years. The overall incidence of hyponatremia after IPC placement was 84.8% (n = 262), of whom 21 patients (8.0%) had severe hyponatremia. The mean (SD) decrease in serum sodium level before vs after IPC placement was 5 (5.1) mEq/L and decreased by 10 mEq/L or more among 52 patients (16.8%). Patients with hyponatremia prior to IPC placement had an 8-fold higher adjusted odds of having persistent hyponatremia after IPC placement (odds ratio, 7.9; 95% CI, 2.9-21.7). Patients with hepatopancreatobiliary malignant neoplasms were more likely to develop hyponatremia (78 of 262 patients with hyponatremia [29.8%] vs 7 of 47 patients without hyponatremia [14.9%]). Hyponatremia was either unrecognized or untreated in 189 patients (72.1%). Although the placement of an IPC is often a palliative measure, hyponatremia is common and is often untreated or unrecognized. Patients at highest risk, such as those with hyponatremia at baseline and those with hepatopancreatobiliary malignant neoplams, should be evaluated carefully prior to IPC placement and may warrant closer monitoring after placement. In all cases, hyponatremia should be evaluated and managed within the context of a patient's overall goals of care.

Endotracheal Intubation and In-Hospital Mortality after Intracerebral Hemorrhage

Background: Many patients with acute intracerebral hemorrhages (ICHs) undergo endotracheal intubation with subsequent mechanical ventilation (MV) for “airway protection” with the intent to prevent aspiration, pneumonias, and its related mortality. Conversely, these procedures may independently promote pneumonia, laryngeal trauma, dysphagia, and adversely affect patient outcomes. The net benefit of intubation and MV in this patient cohort has not been systematically investigated. Methods: We conducted a large single-center observational cohort study to examine the independent association between endotracheal intubation and MV, hospital-acquired pneumonia (HAP), and in-hospital mortality (HM) in patients with ICH. All consecutive patients admitted with a primary diagnosis of a spontaneous ICH to a tertiary care hospital in Boston, Massachusetts, from June 2000 through January 2014, who were ≥18 years of age and hospitalized for ≥2 days were eligible for inclusion. Patients with pneumonia on admission, or those having brain or lung neoplasms were excluded. Our exposure of interest was endotracheal intubation and MV during hospitalization; our primary outcomes were incidence of HAP and HM, ascertained using International Classification of Diseases-9 and administrative discharge disposition codes, respectively, in patients who underwent endotracheal intubation and MV versus those who did not. Multivariable logistic regression was used to control for confounders. Results: Of the 2,386 hospital admissions screened, 1,384 patients fulfilled study criteria and were included in the final analysis. A total of 507 (36.6%) patients were intubated. Overall 133 (26.23%) patients in the intubated group developed HAP versus 41 (4.67%) patients in the non-intubated group (p < 0.0001); 195 (38.5%) intubated patients died during hospitalization compared to 48 (5.5%) non-intubated patients (p < 0.0001). After confounder adjustments, OR for HAP and HM, were 4.23 (95% CI 2.48–7.22; p < 0.0001) and 4.32 (95% CI 2.5–7.49; p < 0.0001) with c-statistics of 0.79 and 0.89, in the intubated versus non-intubated patients, respectively. Conclusion: In this large hospital-based cohort of patients presenting with an acute spontaneous ICH, endotracheal intubation and MV were associated with increased odds of HAP and HM. These findings urge further examination of the practice of intubation in prospective studies.

Elevated ischemic stroke risk among women living with HIV infection.

To determine if the greater risk of ischemic stroke observed in women living with HIV infection (WLWH) compared with HIV-uninfected women persists after accounting for both traditional and sex-specific stroke risk factors. We performed an observational cohort study of WLWH (n = 1214) and demographics-matched HIV-uninfected women (n = 12 041) seen between 1996 and 2011 at two tertiary care hospitals in Boston. We used Cox proportional hazards regression analyses to model time to ischemic stroke, adjusting first for demographics and traditional stroke risk factors and then for sex-specific stroke risk factors, including menopause and estrogen use. We also constructed demographics-adjusted Cox models to identify HIV-related risk factors associated with ischemic stroke among WLWH. The incidence of ischemic stroke was higher among WLWH compared with HIV-uninfected women [incidence rate ratio 2.39, 95% confidence interval (CI) 1.62-3.43]. After adjusting for demographics and traditional stroke risk factors, HIV infection was associated with almost twice the risk of ischemic stroke (hazard ratio 1.93, 95% CI 1.31-2.85). The association of HIV with ischemic stroke persisted after inclusion of sex-specific stroke risk factors in the model (hazard ratio 1.89, 95% CI 1.28-2.81). Among WLWH, longer duration of antiretroviral therapy was associated with lower ischemic stroke risk (hazard ratio 0.86 per year, 95% CI 0.76-0.96). The increased risk of ischemic stroke among WLWH compared with HIV-uninfected women persisted after adjusting for both traditional and sex-specific stroke risk factors. Further investigation into the mechanisms of elevated stroke risk among WLWH, including immunologic factors, will be key for developing targeted preventive strategies for this at-risk population.

AUTOMATED IDENTIFICATION OF HOSPITAL-ACQUIRED VENOUS THROMBOEMBOLISM

Introduction Venous thromboembolism (VTE) as a hospital-acquired condition (HAC) – i.e. not ‘present on admission’ (POA) – is a potentially preventable complication. A decrease of HAC VTE events indicates success of efforts to prevent VTE in hospitalized patients. However, so far, costly chart reviews were needed to identify patients with HAC VTE. We investigated whether electronic health record data such as medication orders and their temporal relations allow for differentiating between HAC and POA. Therefore, we modeled a tree and two random forests and evaluated the automated classification of HAC VTE. Methods All inpatients with a length of stay of ≥24 hours (h), discharged from the Brigham and Women’s Hospital, a large tertiary care hospital in Boston, MA, between January 2009 and April 2014 were searched for ICD-9 diagnosis codes of acute venous thrombosis or pulmonary embolism. Patients were included who had VTE in the admitting diagnosis field – defined as POA VTE – or in one of up to 50 discharge diagnoses. Of those, only patients who received heparin, dalteparin, enoxaparin, alteplase, rivaroxaban or fondaparinux were considered, and the time from admission to the first order was calculated for each drug. Additionally included predictors: dose information, demographics (age, gender, race, language), length of stay, admission service, discharge service, transfer destination of the patient after discharge, and whether the patient was alive or died during the hospitalization or within 30 days after discharge. A single tree and two random forests (each with 5,000 trees) were generated to analyze the predictors and to assess the predictive power of the chosen approach. Since medication orders are electronically available in real time, such prospective predictors may have implications for clinical decision support – therefore, prospective predictors (i.e. demographics, admission service, time to order a drug, route and dose information for each drug) were separately analyzed in the first random forest. Half of the data served as calibration set, half as validation set. Statistical computing was performed using the software R version 3.1.0 (R Foundation for Statistical Computing, Vienna, Austria). Results A total of 5,374 patient stays featured a VTE diagnosis with a defined drug order. If VTE was POA (n=1,262; 23.5%), the median time to order one of the aforementioned drugs was 2.5h (IQR 1.3-5.0h). Among HAC VTE cases without an admitting diagnosis of VTE (n=4,112; 76.5%), the median time to order the drug was 4.2h (IQR 1.7-18.2h). Unsurprisingly, a single tree – after cross-validation and pruning – identified the time from admission to the ordering of intravenous (IV) heparin as the most significant predictor (Fig. 1). This tree’s validation resulted in an accuracy of 78.8% and a positive predictive value (PPV) of 83.3% for the classification of HAC VTE. The first validated random forest used predictors which are available in real time: the forest had an accuracy of 79.7% and a PPV of 85.3% for the classification of HAC VTE. The second validated random forest considered all variables and resulted in an accuracy of 81.7% and a PPV of 87.8% (variables’ importance is shown in Fig. 2). Discussion We modeled a tree and two random forests using structured data predictors to differentiate between HAC and POA VTE. Our validated tree (Fig. 1), considering the first order for IV heparin and the length of stay, could immediately be implemented as a first step to identifying HAC VTE patients. However, the random forests performed better, even when exclusively prospective predictors were used – and such real time models may have implications for clinical decision support tools. In conclusion, our random forests could help to evaluate interventions to improve thromboprophylaxis regimens for inpatients, where costly chart reviews are needed to differentiate between POA VTE and potentially preventable complications.

An Educational and Administrative Intervention to Promote Rational Laboratory Test Ordering on an Academic General Medicine Service

BackgroundOveruse of clinical laboratory testing in the inpatient setting is a common problem. The objective of this project was to develop an inexpensive and easily implemented intervention to promote rational laboratory use without compromising resident education or patient care. MethodsThe study comprised of a cluster-randomized, controlled trial to assess the impact of a multifaceted intervention of education, guideline development, elimination of recurring laboratory orders, unbundling of laboratory panels, and redesign of the daily progress note on laboratory test ordering. The population included all patients hospitalized “general medicine” was duplicated during 2 consecutive months on a general medicine teaching service within a 999-bed tertiary care hospital in Boston, Massachusetts. The primary outcome was the total number of commonly used laboratory tests per patient day during 2 months in 2008. Secondary outcomes included a subgroup analysis of each individual test per patient day, adverse events, and resident and nursing satisfaction. ResultsA total of 5392 patient days were captured. The intervention produced a 9% decrease in aggregate laboratory use (rate ratio, 0.91; P = .021; 95% confidence interval, 0.84-0.98). Six instances of delayed diagnosis of acute kidney injury and 11 near misses were reported in the intervention arm. ConclusionsA bundled educational and administrative intervention promoting rational ordering of laboratory tests on a single academic general medicine service led to a modest but significant decrease in laboratory use. To our knowledge, this was the first study to examine the daily progress note as a tool to limit excessive test ordering. Unadjudicated near misses and possible harm were reported with this intervention. This finding warrants further study.

Factors associated with fractures in HIV-infected persons: which factors matter?

Growing evidence suggests that tenofovir disoproxil fumarate decreases bone density among patients with HIV, but there are conflicting reports as to whether this decrease in bone density translates to higher fracture risk. We aimed to determine what factors were associated with an increased risk of fracture for patients with HIV, in particular whether tenofovir is associated with elevated fracture risk. We conducted a retrospective cohort study at two tertiary care hospitals in Boston, MA, between 2001 and 2012 to determine whether tenofovir use is associated with elevated all-site fracture risk, as compared to other antiretroviral medications. We also examined other potential factors associated with fracture among patients with HIV. We identified 1981 HIV-infected patients who had at some point used tenofovir and 682 patients who had not. The mean age was 43years, and 72% were male. The hepatitis C co-infection rate was 28%, about 40% had nadir CD4 count <200, and about 40% had a history of an AIDS-defining illness. We did not find an association between risk of fracture and tenofovir disoproxil fumarate (TDF) (adjusted RR (aRR) 0.8, 95% CI 0.6-1.1). However, co-infection with hepatitis C did increase risk of fracture (aRR 1.6, 95% CI 1.1-2.3), as did nadir CD4 count <200 (aRR 3.1, 95% CI 1.9-5.0) and history of AIDS-defining illness (aRR 1.6, 95% CI 1.1-2.2). There was no association found between fracture and tenofovir use, but there were associations between co-infection with hepatitis C and markers of advanced HIV disease and fracture.

Drug allergies documented in electronic health records of a large healthcare system.

The prevalence of drug allergies documented in electronic health records (EHRs) of large patient populations is understudied. We aimed to describe the prevalence of common drug allergies and patient characteristics documented in EHRs of a large healthcare network over the last two decades. Drug allergy data were obtained from EHRs of patients who visited two large tertiary care hospitals in Boston from 1990 to 2013. The prevalence of each drug and drug class was calculated and compared by sex and race/ethnicity. The number of allergies per patient was calculated and the frequency of patients having 1, 2, 3…, or 10+ drug allergies was reported. We also conducted a trend analysis by comparing the proportion of each allergy to the total number of drug allergies over time. Among 1 766 328 patients, 35.5% of patients had at least one reported drug allergy with an average of 1.95 drug allergies per patient. The most commonly reported drug allergies in this population were to penicillins (12.8%), sulfonamide antibiotics (7.4%), opiates (6.8%), and nonsteroidal anti-inflammatory drugs (NSAIDs) (3.5%). The relative proportion of allergies to angiotensin-converting enzyme (ACE) inhibitors and HMG CoA reductase inhibitors (statins) have more than doubled since early 2000s. Drug allergies were most prevalent among females and white patients except for NSAIDs, ACE inhibitors, and thiazide diuretics, which were more prevalent in black patients. Females and white patients may be more likely to experience a reaction from common medications. An increase in reported allergies to ACE inhibitors and statins is noteworthy.

PTU-240 Comparison of outcomes of abdominal and colorectal surgery in patients with left ventricular assist devices versus heart transplants

<h3>Introduction</h3> As survival of patients with left ventricular assist devices (LVADs) and cardiac transplantation improves, surgeons must increasingly decide whether and when to operate on them. <h3>Method</h3> We conducted a retrospective review of abdominal and colorectal operations performed on patients with heart transplants or LVADs at a tertiary care hospital in Boston, MA between 2003–2013. Data were collected on comorbidities, anticoagulation and immunosuppression status, intra-and post-operative complications, need for blood product transfusion, type of surgery performed, 24-hr and thirty day mortality, and time post-transplant or LVAD insertion. Statistical testing for significance was done using the two-sided Fisher’s exact test. <h3>Results</h3> Over the 11-year period, 13 patients with LVADs and 32 patients with heart transplants underwent a total of 67 colorectal (22%) and other abdominal (78%) operations. The median time between LVAD insertion or heart transplant and abdominal surgery was 175 days and 765 days respectively. There was a tendency towards a higher proportion of elective (vs emergency) cases in heart transplant (74%) vs LVAD patients (53%) (p = 0.13). LVAD patients were more likely to be anticoagulated, and had an 18% incidence of postoperative bleeding, with a significantly greater proportion of patients requiring blood transfusion within the first postoperative week (47%) compared to transplant patients (8%) (p = 0.001). Venous thromboembolic (VTE) events were also significantly more common in the LVAD group (21%) vs transplant group (0%) (p = 0.01). Subgroup analysis revealed the incidence of VTE was significantly decreased in the LVAD group bridged for surgery (p = 0.0008). Despite all transplant patients being on immunosuppression medication, and 46% on steroids, there was no statistically significant difference in surgical site infections between the transplant (6%) and LVAD (12%) groups (p = 0.59). Mortality within 24 h tended to be higher in the LVAD group (13%) vs transplant group (0%), with borderline significance (p = 0.06). 30-day mortality was significantly higher in the LVAD group (21%) vs transplant group (0%) (p = 0.01). <h3>Conclusion</h3> Surgical outcomes were better in patients who had undergone heart transplantation compared to those with LVADs, especially with respect to the need for postoperative transfusion, the incidence of VTE, and 24-hr and 30-day mortality. The observed tendency to perform fewer elective cases in LVAD patients compared to transplant patients may be a reflection of clinical intuition of this finding. Surgeons should assess these higher-risk patients on a case-by-case basis. Surgeons should also bridge anticoagulation for LVAD patients whenever possible to reduce the risk of VTE. <h3>Disclosure of interest</h3> None Declared.

Comparative Risk of Fracture in Men and Women with HIV

Men and women with HIV have an increased risk of fracture compared with individuals without HIV; however, it is unknown if women with HIV fracture at higher rates than men. We aimed to compare the incidence rates (IR) of fractures between men and women with HIV. The study was designed as a cohort study, examining medical records from November 2001 to August 2012. The study was performed using records from two tertiary-care hospitals in Boston, Massachusetts. The study patients were adults with HIV: this was defined by diagnosis codes for HIV on two visits, at least one prescription for antiretroviral therapy, and at least 18 years of age. IRs per 1000 person-years of all fractures and fractures at osteoporotic sites were calculated. We calculated IRs within age and gender strata and estimated IR ratios (IRR) between men and women. The main outcome measure was fracture at any site. We identified a cohort of 3161 HIV-infected patients (869 women and 2292 men) with a total of 587 fractures. The IRR of all fractures was 1.00 (95% confidence interval [CI] 0.83-1.19) between men and women. The IR of fractures at osteoporotic sites among men was 15.2 (95% CI 12.7-17.6) per 1000 person-years compared with 12.1 (95% CI 8.6-15.6) in women, with IRR of 1.26 (95% CI 0.90-1.75). Men had similar or higher IRs than women for osteoporotic site fractures across most age groups. This study found similar rates of fracture in men and women with HIV. Further studies validating these findings are required to determine whether men with HIV should be screened for osteoporosis.

Autoimmune, Atopic, and Mental Health Comorbid Conditions Associated With Alopecia Areata in the United States

To evaluate the prevalence of comorbid conditions among patients with alopecia areata (AA) seen at tertiary care hospitals in Boston, Massachusetts, during an 11-year period. Retrospective cross-sectional study. Tertiary care hospitals in Boston, including Brigham and Women's Hospital and Massachusetts General Hospital. We identified 3568 individuals with AA seen in the Partners health care system in Boston between January 1, 2000, and January 1, 2011. We performed comprehensive searches of the Research Patient Data Repository using International Classification of Diseases, Ninth Revision code 704.01. We randomly selected 350 patients and manually reviewed their medical records to train and validate a novel artificial intelligence program. This program then used natural language processing to review free-text medical records and confirm a diagnosis of AA. To confirm the algorithm, we manually reviewed a subset of records and found 93.9% validity. The prevalence of comorbid conditions was assessed. Common comorbid conditions included autoimmune diagnoses (thyroid disease in 14.6%, diabetes mellitus in 11.1%, inflammatory bowel disease in (2.0%) [corrected], systemic lupus erythematosus in 4.3%, rheumatoid arthritis in 3.9%, and psoriasis and psoriatic arthritis in (6.3%) [corrected], atopy (allergic rhinitis, asthma, and/or eczema in 38.2% and contact dermatitis and other eczema in 35.9%), and mental health problems (depression or anxiety in 25.5%). We also found high prevalences of hyperlipidemia (24.5%), hypertension (21.9%), and gastroesophageal reflux disease (17.3%). This profile was different from that seen in a comparison psoriasis and psoriatic arthritis group. We found a high prevalence of comorbid conditions among individuals with AA presenting to academic medical centers in Boston. Physicians caring for patients with AA should consider screening for comorbid conditions.

Association between hyperkalemia at critical care initiation and mortality

To investigate the association between potassium concentration at the initiation of critical care and all-cause mortality. We performed a retrospective observational study on 39,705 patients, age ≥18 years, who received critical care between 1997 and 2007 in two tertiary care hospitals in Boston, Massachusetts. The exposure of interest was the highest potassium concentration on the day of critical care initiation and categorized a priori as 4.0-4.5, 4.5-5.0, 5.0-5.5, 5.5-6.0, 6.0-6.5, or ≥6.5 mEq/l. Logistic regression examined death by days 30, 90, and 365 post-critical care initiation, and in-hospital mortality. Adjusted odds ratios were estimated by multivariable logistic regression models. The potassium concentration was a strong predictor of all-cause mortality 30 days following critical care initiation with a significant risk gradient across potassium groups following multivariable adjustment: K = 4.5-5.0 mEq/l OR 1.25 (95 % CI, 1.16-1.35; P < 0.0001); K = 5.0-5.5 mEq/l OR 1.42 (95 % CI, 1.29-1.56; P < 0.0001); K = 5.5-6.0 mEq/l OR 1.67 (95 % CI, 1.47-1.89; P < 0.0001); K = 6.0-6.5 mEq/l OR 1.63 (95 % CI, 1.36-1.95; P < 0.0001); K > 6.5 mEq/l OR 1.72 (95 % CI, 1.49-1.99; P < 0.0001); all relative to patients with K = 4.0-4.5 mEq/l. Similar significant associations post multivariable adjustments are seen with in-hospital mortality and death by days 90 and 365 post-critical care initiation. In patients whose hyperkalemia decreases ≥1 mEq/l in 48 h post-critical care initiation, the association between high potassium levels and mortality is no longer significant. Our study demonstrates that a patient's potassium level at critical care initiation is robustly associated with the risk of death even at moderate increases above normal.

Lower short- and long-term mortality associated with overweight and obesity in a large cohort study of adult intensive care unit patients.

IntroductionTwo thirds of United States adults are overweight or obese, which puts them at higher risk of developing chronic diseases and of death compared with normal-weight individuals. However, recent studies have found that overweight and obesity by themselves may be protective in some contexts, such as hospitalization in an intensive care unit (ICU). Our objective was to determine the relation between body mass index (BMI) and mortality at 30 days and 1 year after ICU admission.MethodsWe performed a cohort analysis of 16,812 adult patients from MIMIC-II, a large database of ICU patients at a tertiary care hospital in Boston, Massachusetts. The data were originally collected during the course of clinical care, and we subsequently extracted our dataset independent of the study outcome.ResultsCompared with normal-weight patients, obese patients had 26% and 43% lower mortality risk at 30 days and 1 year after ICU admission, respectively (odds ratio (OR), 0.74; 95% confidence interval (CI), 0.64 to 0.86) and 0.57 (95% CI, 0.49 to 0.67)); overweight patients had nearly 20% and 30% lower mortality risk (OR, 0.81; 95% CI, 0.70 to 0.93) and OR, 0.68 (95% CI, 0.59 to 0.79)). Severely obese patients (BMI ≥ 40 kg/m2) did not have a significant survival advantage at 30 days (OR, 0.94; 95% CI, 0.74 to 1.20), but did have 30% lower mortality risk at 1 year (OR, 0.70 (95% CI, 0.54 to 0.90)). No significant difference in admission acuity or ICU and hospital length of stay was found across BMI categories.ConclusionOur study supports the hypothesis that patients who are overweight or obese have improved survival both 30 days and 1 year after ICU admission.

Use of a Transitional Minimum Data Set (TMDS) to Improve Communication Between Nursing Home and Emergency Department Providers

To study the adoption of a transitional minimum data set (TMDS) and its effectiveness in conveying essential clinical data elements between skilled nursing facility (SNF) and emergency department (ED) staff. Retrospective medical record review of patients transferred from one SNF to one ED over a 14-month period before and after the implementation of the TMDS, to determine whether it improved data transfer compared with prior practice. One urban 140-bed SNF, averaging 17 ED transfers per month, and their affiliated ED at a major tertiary care hospital in Boston, MA. The medical records of 74 residents transferred from the SNF to the ED comprised the study data. A Transition of Care Minimum Data Set necessary for ED care was developed based on a literature review and expert panel consensus. From this, a TMDS tool was derived. The nursing facility staff was trained on the use of the TMDS tool (Resident Transfer Form and transfer packet), which was sent with each patient at the time of transfer from the SNF to the ED. Effectiveness of data transfer was determined by the proportion of TMDS items received by the ED following implementation of the TMDS in comparison with prior care. Adoption rate of the TMDS tool was determined by the proportion of hospital medical records that contained a paper copy of the resident transfer form. Following the implementation of the TMDS there was statistically significant improvement in data transfer of 15 of 30 TMDS items. Among these items were the following: patient's family notified of transfer, contact information for the MD/NP at the SNF, contact information for obtaining more patient information from the SNF, resuscitation status, baseline cognitive and functional status, isolation precautions and risk alerts, and whether the SNF could accept the patient back after treatment in the ED. The Resident Transfer Form was found in the hospital medical record of 73% of patients. There were anecdotal reports of hospital provider satisfaction with the TMDS and RTF. The TMDS was associated with marked improvement in the transfer of essential clinical information. Educational efforts are warranted to increase consistency of usage.

The Effect of Hospital Bed Occupancy on Throughput in the Pediatric Emergency Department

Although it has been suggested that high hospital occupancy leads to emergency department (ED) overcrowding and impedes ED throughput, there are limited data defining this relationship. The objective of this study is to examine whether high inpatient hospital occupancy negatively affects throughput in a pediatric ED. This cross-sectional analysis evaluated patient visits to an urban pediatric ED and hospital occupancy rates. Data were collected from a 347-bed pediatric tertiary care hospital in Boston, MA, between January and December 2006. Primary outcome measure was ED length of stay; secondary outcomes were percentages of patients who left without being seen or had a hallway bed used for treatment. Throughout the study period, there were 56,335 patient visits to the pediatric ED; 9,687 (17%) patients were hospitalized. High hospital occupancy directly correlated with longer length of stay for all patients treated in the ED. When inpatient occupancy was at or more than 80% capacity, every 5% increase in hospital occupancy was associated with an increase in length of stay of 17.7 minutes for discharged patients (95% confidence interval [CI] 2.2 to 33.2 minutes) and 34.3 minutes for admitted patients (95% CI 11.4 to 57.2 minutes). With the same 5% increase in inpatient occupancy, there were increases in the odds of either a patient leaving without being seen (odds ratio 1.21; 95% CI 1.12 to 1.31) or being treated in a hallway bed (odds ratio 1.18; 95% CI 1.15 to 1.22). High hospital occupancy has a significant and quantifiable negative influence on ED throughput, affecting patients both discharged and hospitalized.

Antibiotic Exposure and Room Contamination Among Patients Colonized With Vancomycin-Resistant Enterococci

To determine whether total and antianaerobic antibiotic exposure increases the risk of room contamination among vancomycin-resistant enterococci (VRE)-colonized patients. A 14-month study in 2 intensive care units at an academic tertiary care hospital in Boston, Massachusetts. All patients who acquired VRE or were VRE-colonized on admission and who had environmental cultures performed. We performed weekly environmental cultures (2 sites per room) and considered a room to be contaminated if there was a VRE-positive environmental culture during the patient's stay. We determined risk factors for room contamination by use of the Cox proportional hazards model. Of 142 VRE-colonized patients, 35 (25%) had an associated VRE-positive environmental culture. Patients who contaminated their rooms were more likely to have diarrhea than those who did not contaminate their rooms (23 [66%] of 35 vs 41 [38%] of 107; P = .005) and more likely to have received antibiotics while VRE colonized (33 [94%] of 35 vs 86 [80%] of 107; P = .02). There was no significant difference in room contamination rates between patients exposed to antianaerobic regimens and patients exposed to nonantianaerobic regimens or between patients with and patients without diarrhea, but patients without any antibiotic exposure were unlikely to contaminate their rooms. Diarrhea and antibiotic use were strongly confounded; although two-thirds of room contamination occurred in rooms of patients with diarrhea, nearly all of these patients received antibiotics. In multivariable analysis, higher mean colonization pressure in the ICU increased the risk of room contamination (adjusted hazard ratio per 10% increase, 1.44 [95% confidence interval, 1.04-2.04]), whereas no antibiotic use during VRE colonization was protective (adjusted hazard ratio, 0.21 [95% confidence interval, 0.05-0.89]). Room contamination with VRE was associated with increased mean colonization pressure in the ICU and diarrhea in the VRE-colonized patient, whereas no use of any antibiotics during VRE colonization was protective.

Managing anticoagulant related coagulopathy

There are several parenteral anticoagulants in use currently in the US. These include unfractionated heparin (UFH) commonly referred to as heparin, low-molecular weight heparins (LMWHs), synthetic pentasaccharide (fondaparinux), vitamin K antagonists (VKA) and direct thrombin inhibitors. The properties including mode of elimination, half-life, antidote and dose adjustment in renal failure of these drugs are listed in Table 1. VKA are the only orally approved anticoagulants with warfarin being the most commonly used in the United States with approximately three million users. This number of chronic warfarin users continues to increase annually as the baby boomers age and as patients over the age of 65 increase. It is estimated that approximately 26,000 major bleeding events occur annually in the United States. According to a recent study the incidence of anticoagulant associated intracerebral hemorrhage, the most feared and morbid bleeding complication, has quintupled in the US population in the 1990s [1]. The majority of this change can be explained by increasing warfarin use. A recent prospective study of 101 consecutive inpatients admitted to a tertiary care hospital in Boston [2] that looked at a cohort of patients with anticoagulation-associated hemorrhage suggested that excessive anticoagulation contributed independently to increased morbidity and mortality in hospitalized patients. The overall mortality at 60 days was 26% (13/50) in the excessive group compared with 10% (5/51) in the nonexcessive group (P = .03). Excessive warfarin therapy was associated with an increased 60-day mortality (P = .049), in contrast to excessive anticoagulation with UFH or LMWH alone (P = .27) or UFH or LMWH as a ‘‘bridge’’ to warfarin therapy (P = .10). Multivariate regression identified excessive anticoagulation as an independent predictor of 60-day mortality (adjusted hazard ratio [HR], 4.17; 95% confidence interval [CI], 1.39–12.49; P = .01), along with intracranial hemorrhage (adjusted HR, 6.16; 95% CI, 1.75– 21.67; P = .005) and active cancer (adjusted HR, 3.79; 95% CI, 1.13–12.70; P = .03).

Preventing the influx of vancomycin-resistant enterococci into health care institutions, by use of a simple validated prediction rule.

The goal of this study was to develop a validated prediction rule for identification of patients harboring vancomycin-resistant enterococci (VRE) at hospital admission. A model for the prediction of patients harboring VRE at admission was created and validated by assigning weighted point values to independent risk factors associated with harboring VRE at admission, in 2 different cohorts of patients from 2 tertiary care hospitals in Boston, Massachusetts. Patients with VRE isolated from clinical culture samples collected within 48 h of hospital admission were compared with patients not harboring VRE. To assess the diagnostic accuracy of the prediction rule, the main outcome measures were patient demographic characteristics, comorbid illnesses, hospitalizations, and antibiotic exposure. A total of 412 patients were enrolled. A risk index score was derived by using the following 6 independent risk factors associated with VRE recovery within 48 h of hospital admission: previous isolation of methicillin-resistant Staphylococcus aureus (MRSA), whether the patient was receiving long-term hemodialysis, transfer from a long-term care facility, antibiotic exposure, prior hospitalization, and age >60 years. On the basis of a point score >or=10, the sensitivity, specificity, and positive and negative predictive values of this prediction rule were 44%, 98%, 81%, and 90%, respectively. This validated clinical prediction rule provides a novel strategy for the identification of patients at high risk of harboring VRE at hospital admission. Implementation of this rule may reduce the influx of VRE into health care institutions and the overall prevalence of VRE, by targeting VRE-screening measures and contact isolation precautions for these high-risk patients.