Tertiary Care Veterans Affairs Research Articles

2257. Cost-Benefit Analysis of Fidaxomicin (FDX) as First Line Treatment for Initial Episode of Clostridioides difficile Infection (CDI) during the COVID-19 Pandemic: A Quality Control/Improvement (QC/QI) Project at a Tertiary Care Veterans Affairs Medical Center (VAMC) over a 4-year period

Abstract Background In 2021, Clostridioides difficile infection treatment guidelines were updated to recommend fidaxomicin over oral vancomycin as first-line therapy for initial and recurrent episodes of CDI. The aim of this analysis is to evaluate the cost benefit advantage of using fidaxomicin as first line therapy for the first episode of CDI. Methods A retrospective review of outpatient oral vancomycin and fidaxomicin use at the VAMC in Detroit, Michigan was conducted by evaluating total prescription fills per 1000 unique patients from 2019 to 2022. This study was done during the COVID-19 pandemic when there was an increased use of antibiotics for respiratory infections, and after the updated IDSA guidelines recommending fidaxomicin as first line therapy for initial and first recurrence of CDI. Diagnosis of CDI was based on clinical presentation and a positive stool C diff PCR test. Despite substantial cost of FDX, the expectation was that there would be a significant reduction in recurrent CDI, hospitalizations, length of stay, all of which would offer a cost-benefit advantage. Results There was a 5-fold increase in the use of fidaxomicin in 2021-2022 compared to 2018-2019. Its use was directly proportional to the increased use of respiratory quinolones and Beta lactam antibiotics for respiratory infections during the COVID-19 pandemic in 2020. Insurance co-pays were high and the FDX company support programs failed to cover veterans with Medicaid/Medicare coverage. Veterans were unable to complete the 10-day course of FDX as it was unaffordable. They had to be transitioned to oral vancomycin to complete the 10-day course for CDI. Conclusion Reduction of recurrent CDI may not offset the higher up-front cost of fidaxomicin ($2,400/10 days), compared to oral vancomycin ($30/10 days). This QC/QI analysis over a 4-year period revealed that increased use of fidaxomicin as first-line treatment for CDI did not translate into a cost advantage through decreases in CDI recurrence, given the high cost of fidaxomicin. Reduction in cost of fidaxomicin to < $1,200 may be needed to achieve the expected cost benefit. Based on our data, starting November 2022, FDX has been restricted in our institution. Prescription for FDX requires ID approval, and is reserved for recurrent CDI and not for the first episode of CDI. Disclosures All Authors: No reported disclosures

2230. Consumption of Quinolones, Macrolides, and Beta-Lactam Antibiotics at a Tertiary Care Veterans Affairs Medical Center (VAMC) during COVID-19 Pre-pandemic and Pandemic periods: A 4-year Analysis and Implications for Antimicrobial Stewardship

Abstract Background During the coronavirus disease 2019 (COVID-19) pandemic, antimicrobial use increased tremendously. Evidence suggests that the pandemic has resulted in an increased rate of AMR due to inadvertent antibiotic use. This likely reflects difficulties in distinguishing COVID-19 from community-acquired pneumonia when patients first arrive at a hospital. Strengthening antimicrobial stewardship (AMS) efforts by formulating policies for the use of antibiotics is crucial to prevent emergence of AMR. Methods A retrospective analysis to assess changes in antibiotic use during the pandemic and pre-pandemic patterns was done. Results : In the inpatient setting, there was an overall decrease in antibiotic use (all units that follow are in DOT/1000 BDOC) from an average of 380 to 300, vancomycin from 90 to 62, cefazolin from 30 to 17, Linezolid from 5 to 2, Zosyn from 57 to 30 from pre-pandemic period (Jan 2019) to pandemic period (Dec 2022). Antimicrobials that showed an increase during the pandemic included ceftriaxone from 70 to 82, Cefepime from 5 to 8, Levofloxacin from 2 to 5, and fluconazole from 4 to 10 compared to pre-pandemic use. In the outpatient settings (units are in fills/1000 unique patients), levofloxacin use doubled from 3 to 6, cefuroxime use increased from 0.5 to 2 and Azithromycin use dropped from 80 to < 20, with concomitant increase in doxycycline use from 45 to 60. Outpatient antibiotic prescriptions were high for levofloxacin, doxycycline and cefuroxime and increases corresponded to peaks in cases of COVID-19. Conclusion Our analysis demonstrates that COVID-19 had shifted the antibiotic consumption curve towards treatment of pneumonia and invasive fungal infections (in seriously ill patients) which has key implications for AMS. Implementation of stringent AMS and mandatory Infectious disease consultation for all COVID 19 infections helped keep our antibiotic consumption well below the national average and curtail AMR. Disclosures All Authors: No reported disclosures

Operationalizing a Free Flap Program for Head and Neck Reconstruction at a Veterans Affairs Hospital.

We aimed to operationalize a head and neck microvascular free tissue transfer (MVFTT) program at a Veterans Affairs (VA) hospital with the emphasis on initiating radiotherapy within 6 weeks of surgery for cancer patients and minimizing readmissions. Case series. Tertiary care VA hospital. A retrospective analysis was performed on consecutive head and neck MVFTT patients from May 1, 2017 and April 30, 2022. Demographics, patient and disease characteristics, per-operative data and postoperative outcomes were recorded from the electronic medical record. We sought to compare our rate of 30-day readmissions with those published in the literature. One hundred and forty-one procedures were performed in the queried timeframe. Eighty-four percent (119) were performed after oncologic resections and 16% (22) were for nononcologic procedures. The rate of total flap loss was <1% and the rate of partial flap loss was 3.5%. For mucosal defects, the fistula rate was 2.3%. The rate of return to the OR for any reason within 30 days was 7.8%. The 30-day readmission rate was 6.4% while the rates reported in the literature range from 13% to 20%. One hundred and four patients required postoperative radiotherapy (PORT) and 76% started PORT within 42 days of surgery. Operationalizing a head and neck MVFTT program with a VA hospital is safe and allows for the successful delivery of multimodality treatment to cancer patients. These resources can be expanded for the care of head and neck cancer treatment sequelae, such as osteoradionecrosis, and other nononcologic patient needs.

Antimicrobial stewardship in solid organ transplantation: Perspective from a Veterans Affairs Medical Center.

The importance of antimicrobial stewardship (AMS) activities specifically focused on solid organ transplant (SOT) recipients is increasingly recognized. In 2014, the Veterans Health Administration (VHA) created national guidance and committed resources to establish AMS programs at Veterans Affairs (VA) medical centers across the country. However, the AMS implementation is at the discretion of individual VA centers. We undertook an environmental scan of AMS activities in a tertiary care VA medical center. We describe AMS activities focused on SOT recipients. Strategies based on local epidemiology that leverage the electronic medical record together with engagement by transplant infectious diseases personnel are likely to be beneficial. AMS in SOT recipients is challenging yet impactful. Strategies described here may be useful for AMS activities focused on the SOT population.

Interactive Evidence-Based Pressure Injury Education Program for Hospice Nursing: A Quality Improvement Approach.

PURPOSE:The purpose of this quality improvement (QI) project was to develop and implement an interactive, evidence-based pressure injury (PI) education program and evaluate the impact on frontline hospice nursing staff knowledge and practice.PARTICIPANTS AND SETTING:The QI setting was a 12-bed inpatient hospice unit in a tertiary care Veterans Affairs (VA) Medical Center in Cleveland, Ohio. Nineteen licensed and unlicensed hospice nursing staff participated in this pre-/postworkshop project.APPROACH:Chart audit determined baseline PI incidence and prevalence on the inpatient hospice unit. Interviews with key leaders informed the need to develop and implement innovative PI education opportunities. A literature review determined existing standards regarding the benefits of PI education for nursing staff but did not reveal measurable targets in hospice settings. We developed a PI education intervention based on Kolcaba's Theory of Comfort framework and a Plan-Do-Study-Act (PDSA) performance improvement model. Education was delivered in 7 workshops, lasting 2 hours each. Knowledge, practice, and comfort for inpatient hospice nursing staff were evaluated at baseline and 8 weeks following the final refresher visit. Workshop satisfaction was collected once using standard program evaluation forms after final workshop delivery.OUTCOMES:We observed a significant improvement in staff PI knowledge (P = .001) and practice (P = .001) after initial workshop attendance and repeat engagement (P = .001). There was a large magnitude of effect for overall knowledge change (d = 1.04); similarly PI care planning and practice showed a large magnitude of effect and significant improvement (P = .001, d = 2.64). Staff comfort with job duties was stable with low effect size (mean 4.52, d = 0.04), and satisfaction with the workshop education was high (100% agreement with trainer effectiveness).IMPLICATIONS FOR PRACTICE:We found that frontline hospice nursing staff knowledge and practice improved after attendance at our evidence-based PI education program. Results of this QI project have stimulated ongoing discussion on how to sustain this program in our hospice setting.

Nutritional status and outcomes of veterans undergoing curative surgery for colorectal cancer.

e18585 Background: Malnutrition is highly prevalent within the cancer population. Malnourishment has various negative surgical and oncologic impacts. The Veterans Health Administration (VHA) provides comprehensive care to patients in a single-payer system allowing for capture of peri-operative data and the opportunity for focused pre-operative (pre-op) interventions to improve outcomes. We sought to study the effect of pre-op weight and albumin on post-operative (post-op) complications in a contemporaneous group of veterans with colorectal cancer (CRC) at a tertiary care Veterans Affairs (VA) hospital. Methods: This is a retrospective review of 105 patients with colorectal malignancies treated with curative intent surgery at the VA Ann Arbor Healthcare System between January 2015 and January 2020. Patients with distant metastatic disease, neoadjuvant therapy, non-adenocarcinoma histology, or those receiving majority of care outside of the VHA were excluded. We examined BMI trends from one year prior to one year post surgery, rates of nutrition consults, and post-op complications defined as abnormal clinical developments such as, but not limited to, infection and delayed wound healing. Fisher’s exact test was used for analysis. Results: At time of CRC diagnosis, the mean age was 70.3 ± 9.1 and the median stage was T2N0. Surgical resections were 65% (n = 68) laparoscopic. Pre-op weight loss from 6 months prior to diagnosis to time of surgery was observed in the majority of patients (n = 47, 64%). Significant weight loss, defined as ≥3% weight reduction, was seen in 45% (n = 33) of patients. A quarter of patients were identified to have a low pre-op albumin of less than 3.5 (n = 25, 25%). Significant weight loss and low pre-op albumin were each independently associated with increased post-op complications (p &lt; 0.01). Post-op weight loss was seen in 81% (n = 73) and 69% (n = 48) of patients at 30- and 60-days post-op, respectively, and was not associated with post-op complications. Inpatient post-op nutrition consultation was performed in 96% (n = 101) of patients; nutritional supplements were recommended in only 23% (n = 23) of cases. In patients with significant weight loss, pre-op nutrition evaluation was performed in 15% (n = 5) of cases and post-op outpatient nutrition follow up occurred in 18% (n = 6) of cases. Conclusions: 45% of patients had ≥3% weight loss 6 months prior to diagnosis of CRC and 25% of patients had low albumin levels. These led to greater post-operative complications. An intensive nutrition pre-habilitation program to address weight loss and low albumin prior to surgery for CRC is needed and may reduce associated complications.

Coordinated-Transitional Care for Veterans with Heart Failure and Chronic Lung Disease.

Patients with congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD) account for most 30-day hospital readmissions nationwide. The Coordinated-Transitional Care (C-TraC) program is a telephone-based, nurse-driven intervention shown to decrease readmissions in Veterans Affairs (VA) and non-VA hospitals. The goal of this project was to assess the feasibility and efficacy of adapting C-TraC to meet the needs of complex patients with CHF and COPD in a large urban tertiary care VA medical center. We used the Replicating Effective Programs model to guide the implementation. The C-TraC nurse received intensive training in cardiology and pulmonology and worked closely with both inpatient and outpatient providers to coordinate care. Eligible patients were admitted with CHF or COPD and had at least one additional risk for readmission. The nurse met patients in the hospital, participated in their discharge planning, and then provided intensive case management for up to 4 weeks. Over its initial 14 months, the program successfully enrolled 299 veterans with good fidelity to the protocol. A total of 43 (15.8%) C-TraC participants were rehospitalized within 30 days compared with 172 (21.0%) of historical controls matched 3:1 on age, risk of 90-day hospital admission, and discharge diagnosis. Participants were 54% less likely to be rehospitalized (odds ratio = .46; 95% CI = .24-.89). The program was financially sustainable. The total cost of care in the 30-day postdischarge period was $1842.52 less per C-TraC patient than per controls, leading the medical center to sustain and expand the program.

1882. Resistance (R) Trends in Gram-Negative Bacilli (GNB) to Fluoroquinolones (FQ), [Ciprofloxacin (CIP), Levofloxacin (LEV), Moxifloxacin (MOX)], Trimethoprim–Sulfamethoxazole (TMP/SMX) and Nitrofurantoin (NFT) over a 7-Year Period: Pre- and Post-Implementation of FQ Restriction at a Tertiary Care Veterans Affairs Medical Center (VAMC)

BackgroundUnrestricted use of FQ has been associated with emergence of drug resistance in GNB. Active surveillance measures are essential components of antibiotic stewardship practice. The aim of this study was to evaluate antibiotic utilization, assess the impact of FQ restriction on resistance to FQ, TMP/SMX, and NFT, and identify quality improvement measures to prevent emergence of resistance in GNB.MethodsA retrospective records review and comparison of antimicrobial susceptibility data for GNB isolated at the Detroit VAMC over a 7-year period, pre- and post-FQ restriction, implemented in 2013. Susceptibility testing was performed by reference broth micro-dilution methods in a central laboratory. Antibiotic usage data were obtained from pharmacy computer records from 2011 to 2017. Antibiotic use in inpatients was expressed as days of therapy/1,000 patient-days (DOT/PD) and as number of prescriptions filled for outpatients. Data were analyzed using Pearson correlation coefficient score.ResultsIn 2016–2017, the most common GNB isolated in our institution were E. coli (n = 303), Klebsiella pneumoniae (n = 100), and P. aeruginosa (n = 70). Inpatient: During 2011–2012, DOT/1,000 PD for CIP, LEV and MOX were 34, 10, and 5 respectively, that dropped to 14, 5, and 3 during 2014–2017, post-FQ restriction initiated in 2013. Outpatient: During 2013–2017, outpatient CIP and MOX prescriptions decreased from 1936 to 781 and from 478 to 86, respectively; however, prescriptions for LEV, TMP/SMX, and NFT increased from 33 to 128, 680 to 1,074, and 95 to 322, respectively. Overall: resistance to CIP, LEV, and MOX had increased by 8% in E. coli (14–22%) and by 7% in P. aeruginosa (10–17%) during 2015–2017; FQ-R in K. pneumonia and NFT-R in E. coli stayed low at 7% and 2%, respectively. Also, isolates of TMP/SMX-resistant E. coli and NFT-resistant K. pneumonia increased from 20% to 27% and 40% to 51%, respectively.ConclusionUse of FQ among outpatients was still high (781 scripts in 2017) despite a 4-year restriction, resulting in high FQ-R in E. coli and P. aeruginosa; a concomitant increase in TMP/SMX and NFT resistance was noted, attributed to a compensatory increased use of these agents during the study period (P < 0.05). Reversal of resistance trends may take a few years. Antimicrobial stewardship activities need to be enhanced in both ambulatory and inpatient settings in order to achieve optimal results.Disclosures All authors: No reported disclosures.

Outcomes of Bloodstream Infections (BSI) Caused by Coagulase-Negative Staphylococcus (CoNS) With Elevated Minimum Inhibitory Concentration (MIC) to Vancomycin at a Tertiary Care Veterans Affairs (VA) Medical Center

Outcomes of Bloodstream Infections (BSI) Caused by Coagulase-Negative Staphylococcus (CoNS) With Elevated Minimum Inhibitory Concentration (MIC) to Vancomycin at a Tertiary Care Veterans Affairs (VA) Medical Center

Effect of Lean Processes on Surgical Wait Times and Efficiency in a Tertiary Care Veterans Affairs Medical Center

There are an increasing number of veterans in the United States, and the current delay and wait times prevent Veterans Affairs institutions from fully meeting the needs of current and former service members. Concrete strategies to improve throughput at these facilities have been sparse. To identify whether lean processes can be used to improve wait times for surgical procedures in Veterans Affairs hospitals. Databases in the Veterans Integrated Service Network 11 Data Warehouse, Veterans Health Administration Support Service Center, and Veterans Information Systems and Technology Architecture/Dynamic Host Configuration Protocol were queried to assess changes in wait times for elective general surgical procedures and clinical volume before, during, and after implementation of lean processes over 3 fiscal years (FYs) at a tertiary care Veterans Affairs medical center. All patients evaluated by the general surgery department through outpatient clinics, clinical video teleconferencing, and e-consultations from October 2011 through September 2014 were included. Patients evaluated through the emergency department or as inpatient consults were excluded. The surgery service and systems redesign service held a value stream analysis in FY 2013, culminating in multiple rapid process improvement workshops. Multidisciplinary teams identified systemic inefficiencies and strategies to improve interdepartmental and patient communication to reduce canceled consultations and cases, diagnostic rework, and no-shows. High-priority triage with enhanced operating room flexibility was instituted to reduce scheduling wait times. General surgery department pilot projects were then implemented mid-FY 2013. Planned outcome measures included wait time, clinic and telehealth volume, number of no-shows, and operative volume. Paired t tests were used to identify differences in outcome measures after the institution of reforms. Following rapid process improvement workshop project rollouts, mean (SD) patient wait times for elective general surgical procedures decreased from 33.4 (8.3) days in FY 2012 to 26.0 (9.5) days in FY 2013 (P = .02). In FY 2014, mean (SD) wait times were half the value of the previous FY at 12.0 (2.1) days (P = .07). This was a 3-fold decrease from wait times in FY 2012 (P = .02). Operative volume increased from 931 patients in FY 2012 to 1090 in FY 2013 and 1072 in FY 2014. Combined clinic, telehealth, and e-consultation encounters increased from 3131 in FY 2012 to 3460 in FY 2013 and 3517 in FY 2014, while the number of no-shows decreased from 366 in FY 2012 to 227 in FY 2014 (P = .02). Improvement in the overall surgical patient experience can stem from multidisciplinary collaboration among systems redesign personnel, clinicians, and surgical staff to reduce systemic inefficiencies. Monitoring and follow-up of system efficiency measures and the employment of lean practices and process improvements can have positive short- and long-term effects on wait times, clinical throughput, and patient care and satisfaction.

Dealing With No Shows: A Quality Improvement Initiative at a Tertiary Care Veterans Affairs Medical Center

Dealing With No Shows: A Quality Improvement Initiative at a Tertiary Care Veterans Affairs Medical Center

Systems Redesign: A Quality Improvement Initiative at a Tertiary-Care Veterans Affairs Medical Center

Systems Redesign: A Quality Improvement Initiative at a Tertiary-Care Veterans Affairs Medical Center

Impact of race on oropharyngeal squamous cell carcinoma presentation and outcomes among veterans.

Racial disparities in oropharyngeal squamous cell carcinoma (SCC) have been demonstrated and attributed to differences in human papillomavirus (HPV) status. The purpose of this study was to examine racial disparities in oropharyngeal SCC among veterans. Retrospective review of patients with oropharyngeal SCC at a tertiary-care Veterans Affairs (VA) hospital. Adjusted Cox proportional hazards models were conducted to examine the effect of race on oropharyngeal SCC outcomes. Of 158 patients, 126 (79.7%) were white and 32 (20.3%) were African American. No difference in p16 tumor expression was noted between the groups. Five-year disease-free survival (DFS) was 42.6% and 55.1% for African Americans and whites, respectively (p = .372). Five-year overall survival (OS) for African Americans and whites was 54.6% and 51.8%, respectively (p = .768). On multivariate analysis, there was no significant difference in risk of recurrence or death by race. Racial disparities are largely ameliorated in patients with oropharyngeal SCC treated within the VA, there were no racial differences in p16 tumor expression, and outcomes remain poor.

Patterns in Patient Safety with Computerized Consult Management and Clinical Documentation

Patient safety issues continue to be prevalent in delivering care with the electronic health record (EHR) and other health information technology (HIT) tools. Defining the unit of analysis for the study of clinical information systems is important based on the focus of the research. This study applies a conceptual framework with three levels of units of analysis for human-computer interaction (HCI) to identify and guide investigations at each level. Ethnographic observations and semi-structured, key-informant interviews were conducted with 40 healthcare workers across five primary care clinics, nine specialty clinics, and one inpatient ward at a tertiary-care Veterans Affairs Medical Center (VAMC). Two researchers recorded the interactions and interview responses of 40 healthcare workers related to their work with computerized consultations, clinical documentation, and the EHR in general. Patient safety issues from these data were categorized using three different units of analysis: EHR interface-, team coordination / workflow-, and organizational-levels. A total of 30 patient safety issues were identified; 17 emerged from the observation and interview data on computerized consults, 10 from the data on clinical documentation, and 3 were related to the EHR in general. Patient safety issues were organized by level of unit of analysis and mapped to specific methods that could be used for further investigation. Relevant concepts are discussed to help guide investigations at each level.

Impact of race/ethnicity on laryngeal cancer in patients treated at a Veterans Affairs Medical Center

Black patients generally present with advanced head and neck cancer resulting in decreased survival. The objective of this study was to determine whether equal access to laryngeal cancer care in a tertiary care Veterans Affairs (VA) Medical Center would result in similar survival for white and black patients. Retrospective chart review. Patient and tumor characteristics, compliance with National Comprehensive Cancer Network (NCCN) guidelines, and survival outcomes were collected for 205 male patients with squamous cell carcinoma of the larynx treated between 2000 and 2012 at the Michael E. DeBakey Veterans Affairs Medical Center. Black patients constituted 33% of the entire cohort, were older (mean age, 65.1 vs. 62.1 years), and consumed less tobacco (46.6 vs. 65.8 mean pack-years) than white patients. Disease stage and compliance with NCCN guidelines were not affected by race. Mean follow up time was 3.6 years. A higher recurrence rate was noted among white patients (24% vs. 15%, P < .05). Neither disease-free survival (DFS) nor overall survival (OS) was significantly different between black and white patients (DFS 69% vs. 68%, P = .7; OS 68% vs. 77%, P = .1). Utilization of a multidisciplinary approach to laryngeal cancer care at the VA medical center allows for high compliance with NCCN guidelines and excellent oncologic outcomes. Ethnicity did not impact stage at presentation, treatment selection, or treatment intensity in this patient cohort. Our data suggest that cancer care at a VA medical center results in clinical outcomes that do not significantly vary based on patient race.

Specialty Care Delivery: Bringing Infectious Disease Expertise to the Residents of a Veterans Affairs Long‐Term Care Facility

To initiate a long-term care facility (LTCF) infectious disease (LID) service that provides on-site consultations to LTCF residents to improve the care of residents with possible infections. Clinical demonstration project. A 160-bed LTCF affiliated with a tertiary care Veterans Affairs (VA) hospital. Residents referred to the LID team. The reason for and source of LTCF residents' referral to the LID team and their demographic characteristics, infectious disease diagnoses, interventions, and hospitalizations were determined. Between July 2009 and December 2010, the LID consultation service provided 291 consultations for 250 LTCF residents. Referrals came from LTCF staff (75%) or the VA hospital's ID consult service (25%). The most common diagnoses were Clostridium difficile infection (14%), asymptomatic bacteriuria (10%), and urinary tract infection (10%). More than half of referred residents were receiving antibiotic therapy when they first saw the LID team; 46% of residents required an intervention. The most common interventions, stopping (32%) or starting (26%) antibiotics, were made in accordance with principles of antibiotic stewardship. The LID team represents a novel and effective means to bring subspecialty care to LTCF residents.

Management of Acute Contrast Media Reactions: Assessing Preparedness of a Tertiary Care Veterans Affairs Medical Center

THE PROBLEM: HOSPITAL READINESS FOR CONTRAST MEDIA REACTIONS Acute contrast media reactions can range in severity from mild discomfort to life-threatening anaphylaxis. Three percent of all patients receiving intravenous (IV) contrast will experience reactions, although most will not require treatment. Severe, potentially life-threatening reactions occur in about 1 in 2,500 patients [1]. Overall, contrast reactions remain rare, particularly because of the widespread use of nonionic, lowosmolar contrast media. Because of the rarity of adverse reactions to contrast, many radiologists and hospital staff members remain unfamiliar with optimal treatments, appropriate medications, and their respective doses. Additionally, reaction training for nonradiology staff members covering after hours is not well established. Potential errors that commonly occur in the management of contrast reactions are a failure to recognize a contrast reaction; uncertainty regarding how to treat a reaction; failure to administer oxygen promptly; incorrect dosing or administration of epinephrine, atropine, and antihistamines; and an overall lack of advanced preparedness for the possibility of reactions [2,3]. Because of this concern for a lack f preparedness, other radiology epartments have performed local udit studies or surveys, and often any of these management errors re identified [4,5]. In our quality mprovement initiative, we assessed he readiness of our department nd medical center both during and after hours in responding to acute contrast media reactions and identified areas for improvement to ensure proper and efficient treatment should a contrast reaction occur.

Is heart failure guideline adherence being underestimated? The impact of therapeutic contraindications

Several studies based on claims data have reported underutilization of evidence-based heart failure (HF) therapies. The degree to which these estimates fail to account for therapeutic contraindications is unclear. We identified patients with HF and left ventricular ejection fraction ≤45% seen between January 1, 2010, and July 1, 2010, at a tertiary care Veterans Affairs Medical Center. Medical records were abstracted to evaluate utilization of and contraindications to β-blocker, angiotensin-converting enzyme inhibitor, aldosterone antagonist, anticoagulation for atrial fibrillation, implantable cardioverter-defibrillator, and cardiac resynchronization therapies. Of the 178 patients with HF and an ejection fraction ≤45%, 78 (44%) received every guideline-recommended therapy. After accounting for medical contraindications, 77 (72%) of 107 patients received every guideline-recommended therapy. Adherence to recommendations for β-blocker (98%), angiotensin-converting enzyme inhibitor/angiotensin blocker (95%), and anticoagulation (97%) were better than adherence to implantable cardioverter-defibrillator (82%), cardiac resynchronization therapy (59%), or aldosterone antagonist (51%) recommendations. In adjusted analysis, lower New York Heart Association functional class and care by a cardiologist were associated with improved guideline adherence (P < .001). Many patients with HF have therapeutic contraindications, and a failure to account for these may lead to a large underestimation of the true guideline adherence rates.

Agreement in Classifying Bloodstream Infections Among Multiple Reviewers Conducting Surveillance

Mandatory reporting of healthcare-associated infections (HAIs) is increasing. Evidence for agreement among different reviewers applying HAI surveillance criteria is limited. We aim to characterize agreement among infection preventionists (IPs) conducting surveillance for central line-associated bloodstream infection (CLABSI) with each other and as compared with simplified laboratory-based definitions. Abstracted electronic health records were assembled from inpatients with positive blood cultures at a tertiary-care Veterans Affairs (VA) hospital over a 5-year period. Identical patient records were made available to VA IPs from different facilities to report on CLABSI using their usual surveillance methods. Positive blood cultures were also evaluated using laboratory-based definitions. Standard indices of interrater agreement, expressed as a κ statistic, were computed between IPs, and between IPs and simplified laboratory-based methods. Overall, 114 patient records were reviewed by 18 IPs, the majority of whom specified they followed National Healthcare Safety Network criteria. The overall agreement among IPs by κ statistic was 0.42 (standard error [SE], 0.06). IPs had better agreement with a simple laboratory-based definition with an average κ of 0.55 (SE, 0.05). The proportion of patient records that 18 IPs reported with CLABSI ranged from 14% to 39% (overall mean, 28% with a coefficient of variation of 25%). When simple laboratory-based methods were applied to different sets of patient records, classification was more consistent with CLABSI assigned in a proportion ranging from 36% to 42% (overall mean, 39%). Reliability of IP-conducted surveillance to identify HAI may not be ideal for public reporting goals of interhospital comparisons.

Higher adenoma detection rates with cap-assisted colonoscopy: a randomised controlled trial

ObjectiveCap-assisted colonoscopy (CAC) uses a small plastic transparent cap attached to the tip of the colonoscope that can depress and flatten colonic folds and thus improve visualisation of their proximal...