University-affiliated Community Hospital Research Articles

An initiative to improve adherence to evidence-based guidelines in the treatment of URIs, sinusitis, and pharyngitis

BackgroundUpper respiratory infections, acute sinus infections, and sore throats are common symptoms that cause patients to seek medical care. Despite well-established treatment guidelines, studies indicate that antibiotics are prescribed far more frequently than appropriate, raising a multitude of clinical issues.MethodsThe primary goal of this study was to increase guideline adherence rates for acute sinusitis, pharyngitis, and upper respiratory tract infections (URIs). This study was the first Plan-Do-Study-Act (PDSA) cycle in a quality improvement program at an internal medicine resident faculty practice at a university-affiliated community hospital internal medicine residency program. To improve guideline adherence for respiratory infections, a package of small-scale interventions was implemented aimed at improving patient and provider education regarding viral and bacterial infections and the necessity for antibiotics. The data from this study was compared with a previously published study in this practice, which evaluated the adherence rates for the treatment guidelines before the changes, to determine effectiveness of the modifications. After the first PDSA cycle, providers were surveyed to determine barriers to adherence to antibiotic prescribing guidelines.ResultsAfter the interventions, antibiotic guideline adherence for URI improved from a rate of 79.28 to 88.58% with a p-value of 0.004. The increase of adherence rates for sinusitis and pharyngitis were 41.7–57.58% (p=0.086) and 24.0–25.0% (p=0.918), respectively. The overall change in guideline adherence for the three conditions increased from 57.2 to 78.6% with the implementations (p<0.001). In planning for future PDSA cycles, a fishbone diagram was constructed in order to identify all perceived facets of the problem of non-adherence to the treatment guidelines for URIs, sinusitis, and pharyngitis. From the fishbone diagram and the provider survey, several potential directions for future work are discussed.ConclusionsPassive interventions can result in small changes in antibiotic guideline adherence, but further PDSA cycles using more active methodologies are needed.

Gender differences in reasons for methamphetamine use in an ethnically diverse population in Hawaii

Objectives: This preliminary study examined methamphetamine (MA) use behaviors and motivators for MA use among 46 ethnically diverse participants from an university-affiliated community hospital and narcotics anonymous groups in Hawaii.Method: Data were collected among 46 participants using an anonymous survey.Results: Results showed that both women and men use MA primarily to get high and to get more energy. Women were more likely than men to use MA to cope with negative feelings and for increased energy. Men were more likely than women to use MA for sexual reasons and due to peer pressure.Conclusion: These results suggest that some women may be self-medicating with MA. Studying these behaviors may guide in developing future prevention and treatment strategies.

Frequency of Blood Cultures Performed in a Community Hospital

Background: Blood cultures (BCs) are obtained to identify etiologic organisms, demonstrate antibiotic efficacy, determine duration of treatment, and/or suggest further interventions. Published guidelines do not clearly state indications and timing for obtaining BCs. As a result, clinicians may obtain too many BCs, increasing cost and patient discomfort. Objective: To determine frequency of BCs performed at our hospital as part of a quality improvement project. Design: Retrospective review of all BCs submitted during a randomly selected month. Setting: A New York City 535-bed, university-affiliated community hospital. Measurements: Patient demographics and BC data were obtained from medical and laboratory records. Results: During the selected month, 2280 BCs were performed for 379 patients. Negative BCs were seen in 221 patients (58%) with one-half having multiple BCs performed within 48 hours of admission and prior to obtaining results of initial BCs. Repeat BCs frequently did not reveal further pathogens among patients with either negative or positive initial BCs. Conclusions: Two-thirds of BCs were obtained from less than one-half of patients without added clinical utility. Often, BCs were repeated prior to results of initial BCs or repeated in patients receiving antibiotics in spite of known low yield following antibiotic initiation. Clinical assessment and review of initial BCs prior to obtaining further BCs is necessary. Staff education regarding appropriate clinical setting for BCs and indications for repeat BCs is required to maximize utilization of resources, improve diagnostic yield, and limit patient discomfort.

Empirical Antimicrobial Prescriptions in Patients withClostridium difficileInfection at Hospital Admission and Impact on Clinical Outcome

To determine, among patients with Clostridium difficile infection (CDI) at hospital admission, the impact of concurrent use of systemic, non-CDI-related antimicrobials on clinical outcomes and the risk factors associated with unnecessary antimicrobial prescribing. Retrospective cohort study. University-affiliated community hospital. We reviewed computerized medical records for all patients with CDI at hospital admission during a 24-month period (January 1, 2008, through December 31, 2009). Colectomy, discharge to hospice, and in-hospital mortality were considered to be adverse outcomes. Antimicrobial use was considered unnecessary in the absence of physical signs and laboratory or radiological findings suggestive of an infection other than CDI or in the absence of antimicrobial activity against the organism(s) recovered from clinical cultures. Among the 94 patients with CDI at hospital admission, 62% received at least one non-CDI-related antimicrobial during their hospitalization for CDI. Severe complicated CDI (odds ratio [OR], 7.1 [95% confidence interval {CI}, 1.8-28.5]; [Formula: see text]), duration of non-CDI-related antimicrobial exposure (OR, 1.2 [95% CI, 1.03-1.36]; [Formula: see text]), and age (OR, 1.1 [95% CI, 1.0-1.1]; [Formula: see text]) were independent risk factors for adverse clinical outcomes. One-third of the patients received unnecessary antimicrobial therapy. Sepsis at hospital admission (OR, 5.3 [95% CI, 1.8-15.8]; [Formula: see text]) and clinical suspicion of urinary tract infection (OR, 9.7 [95% CI, 2.9-32.3]; [Formula: see text]) were independently associated with unnecessary antimicrobial prescriptions. Empirical use of non-CDI-related antimicrobials was common. Prolonged exposure to non-CDI-related antimicrobials was associated with adverse clinical outcomes, including increased in-hospital mortality. Minimizing non-CDI-related antimicrobial exposure in patients with CDI seems warranted.

Is It Possible to Identify Risks for Injurious Falls in Hospitalized Patients?

Patient falls are among the most commonly reported adverse hospital events with more than one million occurring annually in the United States; approximately 10% result in serious injury. A retrospective study was conducted to determine predictors and outcomes of fall injuries among a cohort of adult hospitalized patients. Data were obtained regarding patients who sustained an initial fall in hospital during a 26-month period from 16 adult general medical and surgical units in an urban university-affiliated community hospital. Data on intrinsic (individual) factors, extrinsic (environmental) factors, and situational activities were collected via nurse and patient interviews, patient examinations, and audits of incident reports and electronic health records. Fall injuries were classified as none/any for analyses. Unadjusted odds ratios [ORs] and 95% confidence intervals [CIs] for each of the variables of interest with fall injury were generated using logistic regressions. The 784 patients had a median age of 63.5 years (range, 20 to > 90 years), 390 (50%) were women, and 526 (67%) were black. Some 228 (29%) fallers sustained injury; patients who were white (OR: 2.23; 95% CI: 1.62, 3.08), or were administered a selective serotonin reuptake inhibitor (OR: 1.04; 95% CI: 1.04, 2.67), two antipsychotic agents (OR: 3.26; 95% CI: 1.20, 8.90), an opiate (OR: 1.59; 95%; CI: 1.14, 2.20), or a diuretic non-antihypertensive agent (OR: 1.53; 95% CI: 1.03, 2.26) were more likely to sustain an injury. Home-based wheelchair use was protective of fall injury (OR: 0.20; 95% CI: 0.05, 0.84). Seventy-nine percent of the patients had been designated as "high" fall risk within 24 hours before the fall. Few variables were able to distinguish patients who sustained injury after a hospital fall, further challenging clinicians' efforts to minimize hospital-related fall injury.

Intravenous iron replacement for persistent iron deficiency anemia after Roux-en-Y gastric bypass

BackgroundIron deficiency is a major postoperative complication of Roux-en-Y gastric bypass surgery. Oral replacement can fail to correct the deficiency. Thus, recourse to parenteral iron administration might be necessary. Our objective was to evaluate the effectiveness and safety of a standardized 2 g intravenous iron dextran infusion in the treatment of iron deficiency after Roux-en-Y gastric bypass surgery. The setting was a university-affiliated community hospital in the United States. MethodsWe reviewed the medical records of 23 patients at our institution who had received 2 g of iron dextran intravenously for recalcitrant iron deficiency after Roux-en-Y gastric bypass surgery. We obtained the demographic data and the complete blood count and serum iron studies obtained before treatment and at outpatient visits after infusion. ResultsBefore treatment, all 23 patients were iron deficient (average ferritin 6 ng/mL) and anemic (average hemoglobin 9.4 g/dL). By 3 months, the average ferritin and hemoglobin had increased to 269 ng/mL and 12.3 g/dL, respectively. The hemoglobin levels remained stable throughout the follow-up period. The iron stores were adequately replaced in most patients. Four patients required a repeat infusion by 1 year, because the ferritin levels had decreased to <15 ng/mL. The probability of remaining in an iron replete state was 84.6% (95% confidence interval 78–91.2%). One patient required warm compresses for superficial phlebitis. No other significant adverse events were reported. ConclusionIntravenous administration of 2 g of iron dextran corrects the anemia and repletes the iron stores for ≥1 year in most patients. This therapy is safe, tolerable, efficient, and effective.

Abstract 214: Multidisciplinary Approach to Improve Process Measures and Prevent Heart Failure Readmissions

Background: Approximately 5.2 million Americans have heart failure (HF). HF morbidity and mortality is high, and 27% of patients are readmitted at 1 month and 50% at six months. Objective: To determine the effect of a multidisciplinary approach on Hospital Quality Alliance (HQA) performance and 30-day HF readmission rates. Methods: A one year, prospective, observational study on the effect of a multidisciplinary approach on 30-day HF readmissions was performed and compared to the prior year’s readmission rate at a University affiliated community hospital. HF patients were identified by case and unit nurse managers, who also screened for intravenous diuretic use to determine if patients had HF but were admitted under another diagnosis. HF patients were clustered geographically where daily multidisciplinary rounds with the unit nurse and care manager, pharmacist, social worker, nutritionist, medical and nursing staff took place. The goal was to ensure compliance with the established HQA Performance Measures, initiate appropriate discharge planning, and assess functional status. Patients were educated on 2 gram sodium diet, 2 liter fluid restriction, daily weight monitoring, and smoking cessation. Follow-up appointments with their PCP or cardiologist were scheduled. Upon discharge, nursing and medical staff provided medication and home management instructions. The patient’s PCP was called by the attending physician or cardiovascular fellow as well as the Skilled Nurse Facility, Rehabilitation, and Home Care staff, when applicable. Targeted in-home support immediately following discharge from the hospital was provided. High risk patient had an in-home 2-3 day post discharge visit by VNA and a Pharmacist to access their weight, medications, and physical activity progress. Results: During the intervention year, 355 CHF patients were discharged and compared to 318 patients in the year prior. The 30 day readmissions were reduced from 79 (24.8 %) to 64 (18.03%), p = 0.04 by Wilcoxon Signed-Rank Test. The Heart Failure National Inpatient Quality Measures performance increased from 95% ± 3.8% (2010) to 99.6% ± 0.5% (2011) - p = 0.008 . Conclusions: With implementation of penalties by Medicare in 2013 for 30 day HF readmissions, strategies to reduce them are critical. A comprehensive intervention involving multiple specialties and appropriate patients’ disposition can reduce 30-day readmission rates as well as improve Heart Failure National Inpatient Quality Performance Measures. Further evaluation of this treatment approach, including an assessment of cost-effectiveness, is warranted.

Results From a Transitional-Year Program Director Survey: Identifying Crucial Issues and Concerns

Transitional Year (TY) programs meet an important need by preparing residents for specialties that accept individuals after an initial preparatory year. To our knowledge, no surveys to date have been conducted to identify attributes of TY programs and concerns of TY program directors. The purpose of this study was to review TY program characteristics and identify critical issues and concerns of TY program directors (TYPDs). A web-based, 22-question survey was sent to all 114 TYPDs of programs accredited by the Accreditation Council for Graduate Medical Education between January and April 2011. The survey included open-formatted and closed-formatted questions addressing program and institution demographics, program director time, administrative support, satisfaction, and future plans. The survey response rate was 86%. The median age of TY programs was 28years, with few new programs. More than 80% of TY programs were conducted at community hospitals and university-affiliated community hospitals. Of the responding TYPDs, 17% had served less than 2years, and 32% had served 10years or more. Common sponsoring TY programs included internal medicine (88%), general surgery (42%), family medicine (25%), emergency medicine (24%), and pediatrics (18%). Overall, TYPDs were satisfied with their positions. They expressed concerns about inadequate time to complete duties, salary support, and administrative duties assigned to program coordinators. Forty-nine percent of TYPDs reported they planned to leave the position within the next 5 years. Our survey provides useful information to assist institutions and the graduate medical education community in meeting the needs of TYPDs and strengthening TY programs.

Abstract 4017: Safety of Intra-Arterial Bolus and Intravenous Infusion of Eptifibatide as an Adjunct to Intravenous Alteplase in Acute Ischemic Stroke: A Prospective Registry

Background and Purpose: Eptifibatide, a competitive platelet glycoprotein IIb-IIIa receptor inhibitor with high selectivity for platelet glycoprotein IIb-IIIa receptors and a short half-life, has been shown to reduce the risk of ischemic events associated with coronary interventions. However, its role in conjunction with full dose intravenous alteplase in neurointerventional procedures needs to be determined. We report the results of an open-label prospective registry to evaluate the safety (in terms of avoiding hemorrhagic complications) and effectiveness (in terms of recannalization rates and clinical improvement) of administering eptifibatide. Method: Patients data was prospectively maintained at a University-affiliated community hospital from January 2010 to June 2011. Consecutive patients with moderate to severe stroke who received intravenous Alteplase and failed to improve were studied. Femoral artery access was established and site of cerebral occlusion crossed with microcatheter. Each patient was administered 135 mcg/kg intraarterial bolus followed by intravenous eptifibatide infusion (0.5-microg/kg/min) for 20 hours. The outcome analysis was done to look at recannalization rates, clinical improvement within 24 hours and mRS at discharge. The primary safety end point was symptomatic intracranial or major extra-cranial bleeding. Result: Sixteen patients (Mean Age 72.7, Range 30-93, Male-5(31.25%), Female-11(68.75%)) underwent treatment with this strategy. Recannalization was achieved in 93.75%(n=16)(Complete Recannalization in 43.75%, Partial Recannalization in 50%). There was immediate clinical improvement in 68.75% and good outcomes in 31.25%. One symptomatic and one asymptomatic intracerebral hemorrhage occurred during the follow-up period. Minor femoral site bleeding without requiring transfusion occurred in one patient. Conclusions: In conclusion, eptifibatide administered as an adjunct to thrombectomy for bridging after intravenous Alteplase appears to be safe and promotes recannalization in patients with acute ischemic stroke. Further studies are required to analyze eptifibatide efficacy after intravenous alteplase and its role in neurointerventional procedures.

Abstract 4013: The Hydration Influence on the Risk of Ischemic Stroke Outcome (THIRST-O) Study

Background: Alterations in electrolyte balance and other basic elements such as serum osmolarity have been claimed to play a role in the pathophysiology of ischemic cerebrovascular disease. However, the relationship between the serum osmolarity pattern, clinical severity and outcome after an acute ischemic stroke is not fully understood. Acute ischemic stroke may be due to heperviscosity that is commonly secondary to dehydration. Also, there is a decreased sensation of thirst and ability to swallow fluids in post stroke patients. It is unclear whether these changes contribute to cerebral ischemic events. This study may add to our understanding of previously published findings of THIRST study. Objective: The aim of the present study was to test whether the calculated serum osmolarity on admission and discharge have correlation with severity, as measured by National Institute of Health Stroke Scale(NIHSS); and outcome of ischemic stroke patients, as measured by Discharge Modified Rankin Scale (DCmRS). Methods: Consecutive patients presenting to a university affiliated community hospital within 24 hour of symptom onset, and a discharge diagnosis of acute ischemic stroke were identified. Their serum BUN level and calculated plasma Osmolality at the time of presentation and before discharge was compared. Correlation coefficient (Spearsman’s rho) and Mann Whitney test were performed. SPSS version 11 was utilized for data analysis. Results: A total of 540 patients met the study criteria. We divided the patients into two groups, Osmolarity more than 295 (group A= 217 patients) and less than 295 (group B=323 patients). The initial NIHSS (p=0.036) and DCmRS (p=0.19) were statistically different in both groups. We found a similar trend between day of discharge serum osmolarity and DCmRS. Conclusion: Our study suggests that high initial and discharge serum osmolarity has a negative impact on stroke severity and outcome especially in elderly patients. A future prospective randomized study is warranted.

Abstract 3980: Early Results of Stenting for Acute Stroke Intervention Following Full Dose IV Alteplase (SASI-1 Study)

Background and Purpose: Strategies for rapid restoration of flow using fibrinolytic therapy followed by acute stenting have been well studied for myocardial infarction. Previously reported data, on older stent designs, suggested that there may be an unacceptably high risk of Intracerebral Hemorrhage (ICH). Also reported were high rates of technical failure when using this strategy for ischemic stroke treatment. The SAS-1 study was designed to address this safety concern and look into the technical feasibility of the procedure. Methods: Patients were enrolled prospectively at a university-affiliated community hospital for this phase I trial from November 2009 to June 2011. Standard angiographic techniques, self expanding stents (SES) and anti-GIIb-IIIa were used following lack of improvement after administration of IV Alteplase. Angiographic recannalization (R) was recorded using modified TIMI and Qureshi grading scales. CT scans were performed immediate post procedure and at 24 hours. Clinical evaluations were performed at presentation, 24 hours, 7 to 10 days and/or at discharge, and 3 months after the treatment. All adverse events were noted. Safety stopping rules were prespecified. Results were analyzed using SPSS (11.0) software. Results: Of the 1012 ischemic stroke patients 64 were screened for the study. Nineteen patients met the study criteria (Mean Age 68.9, Range 38-93, Males = 7(36.84%), Females - 12(63.16%)). For this early analysis primary outcomes of interest were: (1) Technical feasibility (2) Recannalization Rates (Complete and Partial); and (3) serious adverse events within 72 hours (4) neurologic outcome within the first week. Fifteen patients had intracranial stenting (MCA n=12, basilar n=1, IC n=1) and 5 had extracranial carotid stents. There were no technical failures. In 2 patients stents were retrieved following complete recannalization. Comparison with historical studies suggests high recannalization rates (Complete Recannalization - 47.37%, Partial Recannalization - 47.37%), low occurrence of symptomatic ICH (n=1, 5%) and asymptomatic ICH (n=3, 15%). No other serious adverse events were noted. Early Neurological Improvement was seen in 63.16% (n=19). Three month follow-up are still not complete for all patients. Conclusion: The observed proportions of neurologic deterioration and serious adverse events were below the prespecified safety thresholds. There were no technical failures. The results form the basis of a larger randomized trial addressing the efficacy of full dose intravenous alteplase followed by acute stenting.

Resident Training in Robotic Assisted Gynecologic Surgery

Abstract Objective: The educational objective is to teach physicians who are in training effective surgical techniques and options for minimally invasive surgery by performing robotic surgery. Design: Several educators influenced the authors' design for robotic-assisted gynecologic surgery training. It was posited that surgical education should be innovative and should include at least five aspects: (1) knowledge; (2) basic skills; (3) experience; (4) decision-making skills; and (5) quality performance and evaluation. Materials and Methods: The obstetric and gynecologic residency training program used for this study involved a total of 24 residents (6 residents per year), with ∼70% of the surgical training being performed at a large tertiary care university-affiliated community hospital. The gynecologic surgery rotation included 4 residents (one each postgraduate year 1–4) and had a duration of 8 weeks. Training was instituted when patients who were scheduled for robotic surgery consented, and the residen...

Risk of acquired methemoglobinemia with different topical anesthetics during endoscopic procedures

IntroductionMethemoglobinemia is a recognized complication of the use of topical anesthetic sprays. The true scope of the problem or the risk with different topical anesthetic sprays and endoscopic procedures is unknown.MethodsWe retrospectively identified all cases of methemoglobinemia that occurred in a university affiliated community hospital from 2001 to 2007.ResultsEleven cases of methemoglobinemia were identified over the 6-year period. Nine (82%) occurred with use of benzocaine spray during transesophageal echocardiography (TEE). Patients who developed methemoglobinemia secondary to the topical anesthetic spray compared to other causes were more likely to be older, have lower mean hemoglobin levels (10.5 ± 0.5 g/dL vs 11.3 ± 0.0 g/dL), and a higher mean methemoglobin concentration at diagnosis (40.8% ± 5.2% vs 24% ± 10%). However, only age reached statistical significance (P = 0.004).ConclusionIn a university-affiliated community hospital, topical anesthetic sprays account for most of the burden of methemoglobinemia. Benzocaine use in the context of TEE caused more methemoglobinemia compared to lidocaine and other endoscopic procedures. This observation supports previous data and findings deserve further study.

Prophylactic glycopyrrolate prevents bradycardia after spinal anesthesia for Cesarean section: a randomized, double-blinded, placebo-controlled prospective trial with heart rate variability correlation

Study Objective To determine if prophylactic glycopyrrolate prevents bradycardia after spinal anesthesia. Design Prospective, randomized, double-blinded, placebo-controlled study. Setting Large university-affiliated community hospital. Patients 81 consecutive term parturients (not in active labor) who were scheduled for elective Cesarean section. Interventions Parturients received 1.0 to 1.5 L of intravenous Ringer's lactate and either glycopyrrolate 0.4 mg or an equal volume of saline, with caregivers blinded to the immediate sequelae of study drug. Each patient received intrathecal bupivacaine (12 to 14 mg) with morphine sulfate (0.1 to 0.2 mg). Measurements Continuous heart rate (HR) and blood pressure monitoring occurred for 20 minutes, with the minimum HR recorded for each 5-minute epoch. Heart rates < 60 beats per minute defined bradycardia. Heart rate variability (HRV) analysis occurred offline. Main Results None of 34 patients administered glycopyrrolate and 6 of 35 (17%) patients receiving saline experienced bradycardia ( P = 0.02476). Time domain, frequency domain, and nonlinear and embedded spectrum entropy analyses all reflected the decrease in HRV accompanying administration of glycopyrrolate. Conclusion Bradycardia after spinal anesthesia occurs commonly. Prophylactic glycopyrrolate may prevent the bradycardia, but not necessarily the hypotension.

Laparoscopic-Assisted Vaginal Hysterectomy vs Laparoscopic Supracervical Hysterectomy for Treatment of Nonprolapsed Uterus

Study Objective To compare perioperative outcomes between laparoscopic-assisted vaginal hysterectomy (LAVH) and laparoscopic supracervical hysterectomy (LSH) for the nonprolapsed uterus. Design Retrospective chart analysis (Canadian Task Force classification II-2). Setting Three university-affiliated community hospitals. Patients Women undergoing LAVH or LSH because of benign indications without concomitant pelvic organ prolapse. Intervention Laparoscopic hysterectomy with or without adnexectomy. Measurements and Main Results Data from 265 LAVH procedures and 181 LSH procedures performed at 3 university-affiliated community hospitals were included in the analysis from January 2001 to December 2007. The cases were successive. Exclusion criteria included surgery performed to treat malignancy or pelvic organ prolapse, and procedures that were converted to laparotomy. Two hundred forty-eight LAVH procedures and 173 LSH procedures were completed successfully. There was no significant difference in mean (SD) operating time between the 2 groups (145.1 [45.6] minutes for LAVH vs 143 [51.7] minutes for LSH; p = .66). Hospital stay was significantly shorter in the LSH group (1.6 [0.6] days vs 1.2 [0.5] days; p = .001). Patients in the LAVH group had significantly larger uterine weight (147.7 [84.8] g vs 121.5 [105.5] g; p = .005). Postoperative hemoglobin change and febrile morbidity were similar between the groups, as were overall perioperative complications (19% vs 15%, respectively; p = .36) and conversion rate to laparotomy (6.9% vs 4.6%; p = .27). Conclusion Compared with LAVH, LSH offers the benefits of a shorter hospital stay when performed in patients without uterine prolapse. Other perioperative outcomes studied were not significantly different between groups.

Nasal Swabs Collected Routinely To Screen for Colonization by Methicillin-Resistant Staphylococcus aureus in Intensive Care Units Are a Sensitive Screening Test for the Organism in Clinical Cultures

Many hospitals screen patients for methicillin-resistant Staphylococcus aureus (MRSA) on admission to the intensive care unit (ICU). We hypothesized that this screening information could be used to assist with empiric antibiotic decisions. The medical records of patients admitted to a university-affiliated community hospital as well as a tertiary-care university hospital were reviewed. Patients admitted to the ICU were screened for MRSA colonization with a nasal swab that was analyzed with either chromogenic medium (hospital 1) or polymerase chain reaction (PCR) (hospital 2). The results of the nasal swab were compared with clinical culture results. There were 141 patients, and 167 cultures were obtained. The majority of the cultures (70%) were performed on sputum specimens in an effort to diagnose pneumonia. The remaining cultures were performed on blood (10.1%), incisions (21.5%), and urine (3.4%). The overall sensitivity of nasal swab results was 69.5%. However, the sensitivity was significantly higher for nasal swab screening performed within six days of clinical cultures compared with screening performed seven days or more before cultures were obtained. (79% vs. 46%; p < 0.0001). Sensitivity also differed significantly depending on the surveillance method, being significantly higher among patients screened with PCR within six days of developing an infection than in patients screened with chromogenic medium (88% vs. 65.5%; p = 0.006). Screening with PCR analysis of nasal swab specimens is a highly sensitive test for MRSA in clinical cultures. Clinicians may be able to use the swab results to tailor more appropriate empiric antimicrobial regimens. The results with chromogenic medium screening are markedly poorer, which suggests that clinicians should view them with caution.

Pre–Lap-Band group education in Medicaid population: does it really make a difference?

BackgroundThe effect of group education classes before a Lap-Band procedure has not been well defined. We hypothesized that in a Medicaid population, the completion of a standardized 12-week multidisciplinary preoperative program (SMPP) would significantly improve the preoperative and early postoperative weight loss. All procedures were performed at a University-affiliated community hospital from 2006 to 2007. MethodsA prospectively collected database of 292 patients who underwent Lap-Band placement was retrospectively reviewed. All patients in the study cohort were encouraged to participate in the SMPP, which included medical, psychological, and nutritional interventions. The patients were divided into 2 groups according to their participation in the SMPP program: SMPP compliant and non-SMPP compliant. The postoperative weight loss of these 2 groups was then compared using the general linear models for repeated measures statistical analysis. ResultsNo significant difference was found in the mean baseline excess body weight between the 2 groups (74 ± 20 kg in the SMPP-compliant and 76 ± 20 kg in the non–SMPP-compliant participants). The mean baseline body mass index (47 ± 7 versus 48 ± 72 kg/m2 for the SMPP-compliant and non–SMPP-compliant participants) was also similar in the 2 groups. The postoperative follow-up rate was 94.5% at 1 month, 72.3% at 6 months, and 52.7% at 12 months. The excess weight loss was significantly greater in the SMPP compliant group than in the noncompliant group during the observed 12-month follow-up period (P = .04, by general linear models for repeated measures). ConclusionIn a Medicaid population, implementation of an intensive preoperative SMPP resulted in a significant improvement in the short-term weight loss after Lap-Band placement.

Peripherally inserted central catheter use in the hospitalized patient: Is there a role for the hospitalist?

Peripherally-inserted central venous catheters (PICCs) are frequently used in hospitals for central intravenous access. These catheters may offer advantages over traditional central catheters with respect to ease of placement and decreased complication rates. However, hospital physicians have not traditionally been trained to place PICCs. We trained 3 of 5 hospitalists to place PICCs in our small university-affiliated community hospital as we converted from a house physician model to a hospitalist model for inpatient care. We then looked retrospectively at the rates of all PICC and other central catheter placements as well as the number of femoral and nonfemoral catheter days for the 18-month period prior to and after the inception of the hospitalist program. Comparing the periods prior to and after the inception of the hospitalist program, the total number of central catheter placements doubled and the PICC rate rose from 20% to 80% of all central catheters. The rate of femoral and subclavian catheter placements decreased by approximately 50% and the rate of internal jugular catheter placement was roughly unchanged. There was also a fall in the number of femoral catheter days and a great increase in the number of total nonfemoral catheter days. The rate of catheter-related bacteremia remained low and did not appear to increase. PICCs may be a safe and easy alternative to centrally placed catheters for the hospital physician attempting to secure central intravenous access and may lead to a decrease in the need for more risky central venous catheter (CVC) insertions.

Selection Criteria for Residency: Results of a National Program Directors Survey

To assess the relative importance of criteria used for residency selection in 21 medical specialties given current available data and competitiveness of specialties. In 2006, questionnaires were distributed to 2,528 program directors in university hospital or university-affiliated community hospital residency programs across 21 medical specialties. Responses were recorded using a five-point Likert scale of importance. Mean values for each item were calculated within and across all specialties. Mean scores for item responses were used to create rank orders of selection criteria within the specialties. To facilitate comparisons, specialties were grouped according to the percentages of positions filled with U.S. medical school graduates. The overall response rate was 49%. With the data from all specialties pooled, the top five selection criteria were (1) grades in required clerkships, (2) United States Medical Licensing Examination (USMLE) Step 1 score, (3) grades in senior electives in specialty, (4) number of honors grades, and (5) USMLE Step 2 Clinical Knowledge (CK) score. The top academic selection criteria are based on clinical performance, with the exception of USMLE Step 1 score. Indicators that reflect excellence in clinical performance are valued across the specialties by residency program directors regardless of competitiveness within the specialty. USMLE Step 2 CK ranks higher in the less competitive specialties, whereas research experience is more prominent in the most competitive specialties. The Medical Student Performance Evaluation was ranked lowest of all criteria by the program directors.

Poster 241: Epidural Air Causing Pain and Weakness Following a Placement of Temporary Spinal Cord Stimulator Leads: A Case Report

Setting: Tertiary care university-affiliated community hospital. Patient: 83 year-old-woman with diabetes, chronic obstructive pulmonary disease, cardiac pacemaker, chronic low back pain (LBP), baseline right foot drop, and prior history of L45 lumbar laminectomy. Case Description: The patient was admitted to the hospital 2 days after a placement of temporary spinal cord stimulator leads because of excruciating LBP far above and beyond her baseline. Patient also complained of bilateral quadriceps weakness.