Urban University Hospital Research Articles

Does Beta-Blockade Reduce the Risk of Depression in Patients with Isolated Severe Extracranial Injuries?

BackgroundApproximately half of trauma patients develop post-traumatic depression. It is suggested that beta-blockade impairs trauma memory recollection, reducing depressive symptoms. This study investigates the effect of early beta-blockade on depression following severe traumatic injuries in patients without significant brain injury.MethodsPatients were identified by retrospectively reviewing the trauma registry at an urban university hospital between 2007 and 2011. Severe extracranial injuries were defined as extracranial injuries with Abbreviated Injury Scale score ≥3, intracranial Abbreviated Injury Scale score <3 and an Injury Severity Score ≥16. In-hospital deaths and patients prescribed antidepressant therapy ≤1 year prior to admission were excluded. Patients were stratified into groups based on pre-admission beta-blocker status. The primary outcome was post-traumatic depression, defined as receiving antidepressants ≤1 year following trauma.ResultsFive hundred and ninety-six patients met the inclusion criteria with 11.4% prescribed pre-admission beta-blockade. Patients receiving beta-blockers were significantly older (57 ± 18 vs. 42 ± 17 years, p < 0.001) with lower Glasgow Coma Scale score (12 ± 3 vs. 14 ± 2, p < 0.001). The beta-blocked cohort spent significantly longer in hospital (21 ± 20 vs. 15 ± 17 days, p < 0.01) and intensive care (4 ± 7 vs. 3 ± 5 days, p = 0.01). A forward logistic regression model was applied and predicted lack of beta-blockade to be associated with increased risk of depression (OR 2.7, 95% CI 1.1–7.2, p = 0.04). After adjusting for group differences, patients lacking beta-blockers demonstrated an increased risk of depression (AOR 3.3, 95% CI 1.2–8.6, p = 0.02).ConclusionsPre-admission beta-blockade is associated with a significantly reduced risk of depression following severe traumatic injury. Further investigation is needed to determine the beneficial effects of beta-blockade in these instances.

Learning from 2523 trauma deaths in India- opportunities to prevent in-hospital deaths

BackgroundA systematic analysis of trauma deaths is a step towards trauma quality improvement in Indian hospitals. This study estimates the magnitude of preventable trauma deaths in five Indian hospitals, and uses a peer-review process to identify opportunities for improvement (OFI) in trauma care delivery.MethodsAll trauma deaths that occurred within 30 days of hospitalization in five urban university hospitals in India were retrospectively abstracted for demography, mechanism of injury, transfer status, injury description by clinical, investigation and operative findings. Using mixed methods, they were quantitatively stratified by the standardized Injury Severity Score (ISS) into mild (1–8), moderate (9–15), severe (16–25), profound (26–75) ISS categories, and by time to death within 24 h, 7, or 30 days. Using peer-review and Delphi methods, we defined optimal trauma care within the Indian context and evaluated each death for preventability, using the following categories: Preventable (P), Potentially preventable (PP), Non-preventable (NP) and Non-preventable but care could have been improved (NPI).ResultsDuring the 18 month study period, there were 11,671 trauma admissions and 2523 deaths within 30 days (21.6%). The overall proportion of preventable deaths was 58%, among 2057 eligible deaths. In patients with a mild ISS score, 71% of deaths were preventable. In the moderate category, 56% were preventable, and 60% in the severe group and 44% in the profound group were preventable. Traumatic brain injury and burns accounted for the majority of non-preventable deaths. The important areas for improvement in the preventable deaths subset, inadequacies in airway management (14.3%) and resuscitation with hemorrhage control (16.3%). System-related issues included lack of protocols, lack of adherence to protocols, pre-hospital delays and delays in imaging.ConclusionFifty-eight percent of all trauma deaths were classified as preventable. Two-thirds of the deaths with injury severity scores of less than 16 were preventable. This large subgroup of Indian urban trauma patients could possibly be saved by urgent attention and corrective action. Low-cost interventions such as airway management, fluid resuscitation, hemorrhage control and surgical decision-making protocols, were identified as OFI. Establishment of clinical protocols and timely processes of trauma care delivery are the next steps towards improving care.

Outcomes of nighttime refusal of admission to the intensive care unit: The role of the intensivist in triage

PurposeTo compare outcomes of patients refused medical intensive care unit (MICU) admission overnight to those refused during the day and to examine the impact of the intensivist in triage. Materials and methodsRetrospective, observational study of patients refused MICU admission at an urban university hospital. ResultsOf 294 patients, 186 (63.3%) were refused admission overnight compared to 108 (36.7%) refused during the day. Severity-of-illness by the Mortality Probability Model was similar between the two groups (P=.20). Daytime triage refusals were more likely to be staffed by an intensivist (P=.01). After risk-adjustment, daytime refusals had a lower odds of subsequent ICU admission (OR 0.46, 95% CI 0.22–0.95, P=.04) than patients triaged at night. There was no evidence for interaction between time of triage and intensivist staffing of the patient (P=.99). ConclusionsPatients refused MICU admission overnight are more likely to be later admitted to an ICU than patients refused during the day. However, the mechanism for this observation does not appear to depend on the intensivist's direct evaluation of the patient. Further investigation into the clinician-specific effects of ICU triage and identification of potentially modifiable hospital triage practices will help to improve both ICU utilization and patient safety.

Validation of the Prognostic Utility of the Electrocardiogram for Acute Drug Overdose.

BackgroundWhile it is certain that some emergency department patients with acute drug overdose suffer adverse cardiovascular events (ACVE), predicting ACVE is difficult. The prognostic utility of the ECG for heterogeneous drug overdose patients remains to be proven. This study was undertaken to validate previously derived features of the initial ECG associated with ACVE in this population.Methods and ResultsWe performed a prospective validation cohort study to evaluate adult emergency department patients with acute drug overdose at 2 urban university hospitals over 5 years in whom an emergency department admission ECG was performed. Exclusion criteria were alternate diagnoses, anaphylaxis, chronic drug toxicity, and missing outcome data. ACVE was defined as any of the following: circulatory shock, myocardial injury, ventricular dysrhythmia, or cardiac arrest. Blinded cardiologists interpreted ECGs for previously derived predictors of ACVE (ectopy, QT prolongation, nonsinus rhythm, ischemia/infarction), QT dispersion, and prominent R wave in lead AVR. Of 589 patients who met inclusion criteria (48% male, mean age 42), there were 95 ACVEs (39 shock, 64 myocardial injury, 26 dysrhythmia, 16 cardiac arrest). The most common drug exposures were as follows: benzodiazepines, opioids, and acetaminophen. Previously derived criteria were highly predictive of ACVE, with QT correction >500 ms as the highest risk feature (OR 11.2, CI 4.6–27).ConclusionsThis study confirms that early ECG evaluation is essential to assess the cardiovascular prognosis and medical clearance of emergency department patients with acute drug overdose. Furthermore, this study validates previously derived high‐risk features of the admission ECG to risk stratify for ACVE in this patient population.

Investigation of Mycobacterium Pseudo-outbreak

Background A cluster of 8 Mycobacterium avium Complex (MAC) clinical acid-fast bacilli (AFB) cultures were identified in a 2-week period at an urban public university hospital system. A review of AFB cultures from the past year showed a surge of cases during the months of October to November from the typical 1-3 cases per month.Methods An internal evaluation demonstrated that the number of cultures growing MAC from 9/30/16-11/30/16 was considerably greater than it had been in preceding months. Chart review was performed to determine the clinical relevance of the MAC cultures. Of 8 initial patients identified 6 had no clinical syndrome consistent with MAC infection. In addition, there were no common collection locations to suggest contamination at collection. Microbiology laboratory practices were reviewed and AFB smear and culture preparation and genetic probe identification of AFB were observed. Reagents and stains were cultured and local laboratory and reagent manufacturers were contacted.ResultsMAC was identified in 22 cultures from October to December 2016. Culture sites included sputum (induced and bronchoalveolar lavage), tissue, body fluid and organ preservation fluid. Prior history of mycobacterial pulmonary disease was seen in 5 patients during this time. Providers did not start patients without a history of MAC on therapy. Species identification by rpoB gene sequencing was performed in 17 of 22 cultures. Nine (53%) isolates were M. chimaera followed by M. Avium with 5 (29%)isolates. One grew both M. Avium and Mycobacterium tuberculosis (MTB), while another isolate was identified as MTB. Review of laboratory practices, revealed opportunities for cross contamination when tasks were batched and alternated while awaiting incubation or amplification as all AFB processing took place under one hood. Culture of PANTA™ reagent grew M. chimera.Conclusion Increased MAC cultures above baseline incidence identified a contamination of laboratory reagent causing a pseudo-outbreak of M. chimera. The pseudo-outbreak did not have clinical implication as patients lacked clinical signs and were not treated. Separation of amplification and culture preparation tasks both spatially and temporally are recommended to decrease cross contamination.Disclosures All authors: No reported disclosures.

Imported Malaria in Travelers Presenting to a Tertiary Urban Hospital, 2000–2016

Background Due to increasing global travel and evolving epidemiologic factors, the number of incident cases of malaria imported into the United States has been growing in recent years.Methods We conducted a retrospective review of 90 cases of malaria seen at a single urban university hospital during 2000–2016.ResultsOf the 90 cases, 77% were Plasmodium falciparum, 14% were either P. ovale or P. vivax, 1% was P. malariae, and the rest were mixed or unknown. Eighty-one patients had traveled to Africa, four to Asia, four to more than one continent, and one to Haiti. Mean age was 41, and 59% were male. The main presenting symptoms were fever (92%), chills (78%), and headache (66%); 10% presented with cerebral malaria. Thirteen cases were managed as outpatients, 59 on a medical ward, and 18 in the ICU. Fourteen (16%) had severe malaria; these were more likely to present with hypotension, non-segmented neutrophilia, hyponatremia, metabolic acidosis, and acute kidney injury (all P < 0.01). Thrombocytopenia was more severe in patients with severe malaria (54,000 vs. 113,000, P < 0.01). Treatment included quinine-based therapy (38%), atovaquone/proguanil (31%), artemether/lumefantrine (19%), and chloroquine/primaquine (11%). Twenty (22%) required change of treatment regimen due to inadequate clinical response or adverse effects. The most common in-hospital complications were ARDS (8%), QT prolongation (7%), and nosocomial infection (4%). Two patients were pregnant at the time of presentation; one suffered severe malaria and fetal loss. Only 3% of patients reported being prescribed a prophylactic regimen and completing it; 20% reported taking an incomplete course, and the majority took no prophylaxis at all. Of 27 patients who had presented to another United States-based medical provider prior to hospitalization, 11 were initially misdiagnosed and treated for conditions other than malaria, including two who underwent extensive hematologic investigations. Inadequate experience and resources in treating malaria were the primary reasons cited for transfer to the tertiary hospital from community-based providers.Conclusion Malaria poses a substantial health risk to US travelers, particularly in light of under-utilization of prophylaxis, lack of familiarity with the disease by local providers, and delays to diagnosis.Disclosures All authors: No reported disclosures.

Healthcare Providers' Formative Experiences with Race and Black Male Patients in Urban Hospital Environments.

We explored health providers' formative personal and professional experiences with race and Black men as a way to assess their potential influence on interactions with Black male patients. Utilizing convenience sampling with snowballing techniques, we identified healthcare providers in two urban university hospitals. We compared Black and White providers' experiences based on race and level of training. We used the Gardener's Tale to conceptualize how racism may lead to racial health disparities. A semi-structured interview guide was used to conduct in-person interviews (n=16). Using the grounded theory approach, we conducted three types of coding to examine data patterns. We found two themes reflective of personally mediated racism: (1) perception of Black males accompanied by two subthemes (a) biased care and (b) fear and discomfort and (2) cognitive dissonance. While this latter theme is more reflective of Jones's internalized racism level, we present its results because its novelty is compelling. Perception of Black males and cognitive dissonance appear to influence providers' approaches with Black male patients. This study suggests the need to develop initiatives and curricula in health professional schools that address provider racial bias. Understanding the dynamics operating in the patient-provider encounter enhances the ability to address and reduce health disparities.

Does early beta-blockade in isolated severe traumatic brain injury reduce the risk of post traumatic depression?

IntroductionDepressive symptoms occur in approximately half of trauma patients, negatively impacting on functional outcome and quality of life following severe head injury. Pontine noradrenaline has been shown to increase upon trauma and associated β-adrenergic receptor activation appears to consolidate memory formation of traumatic events. Blocking adrenergic activity reduces physiological stress responses during recall of traumatic memories and impairs memory, implying a potential therapeutic role of β-blockers. This study examines the effect of pre-admission β-blockade on post-traumatic depression. MethodsAll adult trauma patients (≥18 years) with severe, isolated traumatic brain injury (intracranial Abbreviated Injury Scale score (AIS) ≥3 and extracranial AIS <3) were recruited from the trauma registry of an urban university hospital between 2007 and 2011. Exclusion criteria were in-hospital deaths and prescription of antidepressants up to one year prior to admission. Pre- and post-admission β-blocker and antidepressant therapy data was requested from the national drugs registry. Post-traumatic depression was defined as the prescription of antidepressants within one year of trauma. Patients with and without pre-admission β-blockers were matched 1:1 by age, gender, Glasgow Coma Scale, Injury Severity Score and head AIS. Analysis was carried out using McNemar's and Student's t-test for categorical and continuous data, respectively. ResultsA total of 545 patients met the study criteria. Of these, 15% (n=80) were prescribed β-blockers. After propensity matching, 80 matched pairs were analyzed. 33% (n=26) of non β-blocked patients developed post-traumatic depression, compared to only 18% (n=14) in the β-blocked group (p=0.04). There were no significant differences in ICU (mean days: 5.8 (SD 10.5) vs. 5.6 (SD 7.2), p=0.85) or hospital length of stay (mean days: 21 (SD 21) vs. 21 (SD 20), p=0.94) between cohorts. Conclusionβ-blockade appears to act prophylactically and significantly reduces the risk of post-traumatic depression in patients suffering from isolated severe traumatic brain injuries. Further prospective randomized studies are warranted to validate this finding.

Rehabilitation during congenital heart disease in pediatric patients.

Cardiac rehabilitation is an important part of daily routine for cardiac disorder patients in adults. However, pediatric rehabilitation is an emerging field, and is totally different and new field in case of pediatric patients. The main reason of variability is the Pediatric patients differ from adult patients in several ways. The main difference is they are dependent on their parents for meeting their needs, including for transportation and following of rehabilitation initiatives. Furthermore, rehabilitation initiatives are often connected to large urban university hospitals and unavailable to children whose parents cannot bring them for exercise training on a regular basis. The present review article is focused on these aspects of rehabilitation during congenital heart disease.

Teaching Dialectical Behavior Therapy to Psychiatry Residents: The Columbia Psychiatry Residency DBT Curriculum.

Dialectical behavior therapy (DBT) is an evidence-based psychosocial treatment with efficacy in reducing self-harm behaviors in borderline personality disorder (BPD). This study describes and evaluates a clinical curriculum to teach DBT to psychiatry residents, developed at a large urban university hospital. The curriculum objectives are to (1) have psychiatry residents achieve basic understanding of DBT theory and clinical skill, (2) increase residents' ability and confidence in treating self-harm behaviors (both suicidal behavior and non-suicidal self-injury), and (3) enhance residents' willingness to treat individuals with BPD. In addition to a 6-week didactic course on DBT offered to all residents (n = 62), 25 elected to enroll in a year-long DBT clinical training curriculum over the course of a 5-year period. The DBT clinical training consisted of 15h of additional didactics, ongoing conduct of individual therapy and group DBT skills training, videotaping of individual therapy sessions, and weekly supervision meetings utilizing videotape to provide feedback. Residents participating in the clinical training program videotaped baseline and later sessions, which were rated for DBT adherence. All 62 graduates of the program were surveyed regarding the impact of the training on their practice of psychiatry. Upon graduation, a high percentage (87% in the curriculum and 70% in the didactic course only) reported incorporating DBT into their psychiatry practice, as well as willingness and confidence in treating BPD and self-harm behaviors. Residents participating in the clinical training demonstrated significant improvement in their ability to utilize DBT interventions, particularly in structuring sessions, problem assessment, problem solving, and using validation and dialectical strategies. This DBT curriculum was effective in preparing psychiatrists-in-training to incorporate evidence-based practices for effective treatment of BPD and self-harm behaviors and can serve as a model for teaching DBT during psychiatry residency training. Limitations include a small sample size and lack of baseline survey measurement of attitudes for pre- and post-curriculum comparison.

Counseling About the Maternal Health Benefits of Breastfeeding and Mothers' Intentions to Breastfeed.

Objectives To evaluate the impact of counseling regarding the maternal health effects of lactation on pregnant women's intentions to breastfeed. Methods Women seeking prenatal care at an urban university hospital completed surveys before and after receiving a 5-min counseling intervention regarding the maternal health effects of breastfeeding. The counseling was delivered by student volunteers using a script and one-page infographic. Participants were asked the likelihood that breastfeeding affects maternal risk of multiple chronic conditions using 7-point Likert scales. We compared pre/post changes in individual item responses and a summary score of knowledge of the maternal health benefits of lactation (MHBL) using paired t tests. Multivariable logistic regression was used to examine the impact of increases in knowledge of MHBL on participants' intentions to breastfeed. Results The average age of the 65 participants was 24±6years. Most (72%) were African-American and few (9%) had college degrees. Half (50%) had previously given birth, but few (21%) had previously breastfed. Before counseling, few were aware of any benefits of lactation for maternal health. After counseling, knowledge of MHBL increased (mean knowledge score improved from 19/35 to 26/35, p<0.001). Improvement in MHBL knowledge score was associated with increased intention to try breastfeeding (aOR 1.20, 95% CI 1.02-1.42), of wanting to breastfeed (aOR 1.45, 95% CI 1.13-1.86), and feeling that breastfeeding is important (aOR 1.21, 95% CI 1.03-1.42). Conclusions for Practice Brief structured counseling regarding the effects of lactation on maternal health can increase awareness of the maternal health benefits of breastfeeding and strengthen pregnant women's intentions to breastfeed.

Digital rectal examination for initial assessment of the multi-injured patient: Can we depend on it?

BackgroundDigital rectal examination (DRE) is part of the assessment of trauma patients as recommended by ATLS®. The theory behind is to aid early diagnosis of potential lower intestinal, urethral and spinal cord injuries. Previous studies suggest that test characteristics of DRE are far from reliable. This study examines the correlation between DRE findings and diagnosis and whether DRE findings affect subsequent management.Materials and methodsPatients with ICD-10 codes for spinal cord, urethral and lower intestinal injuries were identified from the trauma registry at an urban university hospital between 2007 and 2011. A retrospective review of electronic medical records was carried out to analyse DRE findings and subsequent management.Results253 patients met the inclusion criteria with a mean age of 44 ± 20 years and mean ISS of 26 ± 16. 160 patients had detailed DRE documentation with abnormal findings in 48%. Sensitivity rate was 0.47. Correlational analysis between examination findings and diagnosis gave a kappa of 0.12. Subsequent management was not altered in any case due to DRE findings.ConclusionDRE in trauma settings has low sensitivity and does not change subsequent management. Excluding or postponing this examination should therefore be considered.

Predictive value of the National Early Warning Score–Lactate for mortality and the need for critical care among general emergency department patients

Study objectivesWhat is the predictive value of the National Early Warning Score–Lactate (NEWS-L) score for mortality and the need for critical care in general emergency department (ED) patients? MethodsIn this retrospective cohort study, we enrolled all adult patients who visited the ED of an urban academic tertiary-care university hospital in South Korea over 2 consecutive months. The primary outcome was 2-day mortality. The secondary outcomes were the need for critical care (advanced airway use, vasopressor or inotropic agent use, intensive care unit admission) during an ED stay; 2-day composite outcome (2-day mortality and the need for critical care); 7-day mortality; and in-hospital mortality. ResultsDuring the study period, 4624 adult patients visited the ED. Of these, 87 (1.9%) died within 2 days. In total, 481 patients (10.4%) required critical care during their ED stay. The 2-day composite outcome, 7-day mortality, and in-hospital mortality were 10.9% (503/4624), 2.5% (116/4624), and 3.9% (182/4624), respectively. The NEWS-L demonstrated excellent predictive value for 2-day mortality with an area under the receiver operating characteristic curve (AUROC) of 0.96 (95% confidence interval [CI], 0.94-0.98); this value was better than that of the NEWS alone (AUROC 0.94 [95% CI, 0.91-0.96], P=.002). The AUROC of the NEWS-L for the need for critical care was 0.83 (95% CI, 0.81-0.85); for the 2-day composite outcome, it was 0.84 (95% CI, 0.82-0.86); for 7-day mortality, it was 0.94 (95% CI, 0.92-0.96); and for in-hospital mortality, it was 0.87 (95% CI, 0.85-0.90). Logistic regression results confirmed that the ratio of the NEWS to the initial lactate level was 1:1. Similar results were obtained in the subgroup analyses (disease-infection, disease–vascular and heart, disease-others, and nondisease). The high-risk NEWS-L group (NEWS-L≥7, 9.4% of all patients) had an adjusted odds ratio of 28.67 (12.66-64.92) for 2-day mortality in the logistic regression model adjusted for basic characteristics. ConclusionThe NEWS-L can provide excellent discriminant value for predicting 2-day mortality in general ED patients, and it has the best discriminant value regarding the need for critical care and composite outcomes. The NEWS-L may be helpful in the early identification of at-risk general ED patients.

30-Day In-hospital Trauma Mortality in Four Urban University Hospitals Using an Indian Trauma Registry.

In India, half of the annual 200,000 road traffic deaths occur in hospitals, but the exact in-hospital trauma mortality rate remains unknown. A research consortium of universities, with a mandate to reduce trauma mortality, measured the baseline 30-day in-hospital mortality rate. Between September 2013 and February 2015, trained data collectors collected on-admission demographic, physiological vital signs, and health service performance indicators (time of injury to admission, investigation, or intervention) on all patients with traumatic injuries admitted to four public university hospitals in three Indian megacities. Of the 11,202 hospitalized trauma patients, 21.4% died within 30days of hospitalization. The median age was 30years for survivors and 37years for non-survivors. The on-admission systolic blood pressure and Glasgow Coma Score was near-normal in survivors, but was significantly lower in non-survivors and associated with both early and late mortality (p=0.001). In the absence of a trauma system, there were process-of-care delays from injury to reaching and being examined, investigated, or operated in the hospital. Using a multi-institutional Indian registry, this study is the first to systematically document that the 30-day in-hospital trauma mortality was twice that found in similar registries from high-income countries. Physiological scoring of on-admission vitals was clinically useful to predict mortality. More research is needed to understand the causes of high mortality and time delays in the process of delivering trauma care in India, which has no prehospital or trauma system.

Validation of a novel prediction model for early mortality in adult trauma patients in three public university hospitals in urban India.

BackgroundTrauma is one of the top threats to population health globally. Several prediction models have been developed to supplement clinical judgment in trauma care. Whereas most models have been developed in high-income countries the majority of trauma deaths occur in low- and middle-income countries. Almost 20 % of all global trauma deaths occur in India alone. The aim of this study was to validate a basic clinical prediction model for use in urban Indian university hospitals, and to compare it with existing models for use in early trauma care.MethodsWe conducted a prospective cohort study in three hospitals across urban India. The model we aimed to validate included systolic blood pressure and Glasgow coma scale. We compared this model with three additional models, which all have been designed for use in bedside trauma care, and two single variable models based on systolic blood pressure and Glasgow coma scale respectively. The outcome was early mortality, defined as death within 24 h from the time when vital signs were first measured. We compared the models in terms of discrimination, calibration, and potential clinical consequences using decision curve analysis. Multiple imputation was used to handle missing data. Performance measures are reported using their median and inter-quartile range (IQR) across imputed datasets.ResultsWe analysed 4440 patients, out of which 1629 were used as an updating sample and 2811 as a validation sample. We found no evidence that the basic model that included only systolic blood pressure and Glasgow coma scale had worse discrimination or potential clinical consequences compared to the other models. A model that also included heart had better calibration. For the model with systolic blood pressure and Glasgow coma scale the discrimination in terms of area under the receiver operating characteristics curve was 0.846 (IQR 0.841–0.849). Calibration measured by estimating a calibration slope was 1.183 (IQR 1.168–1.202). Decision curve analysis revealed that using this model could potentially result in 45 fewer unnecessary surveys per 100 patients.ConclusionsA basic clinical prediction model with only two parameters may prove to be a feasible alternative to more complex models in contexts such as the Indian public university hospitals studied here. We present a colour-coded chart to further simplify the decision making in early trauma care.

Frequency of early warning score assessment and clinical deterioration in hospitalized patients: A randomized trial

AimTo explore whether early warning score (EWS) measurements at 8h intervals is associated with better outcomes than 12h intervals. We hypothesized that the proportion of patients that deteriorated to a higher EWS at 24h after hospital admission would be lower with 8h interval than with 12h interval. MethodThis was a pragmatic, ward-level randomized, non-blinded, controlled trial at an urban University hospital. During two six weeks periods acutely admitted surgical and medical patients, with an initial EWS of 0 or 1, were monitored either every 8th hour or every 12th hour. The primary outcome was clinical deterioration 24h post-admission, estimated by the proportion of patients with an EWS≥2 at 24h after the initial EWS on admission. ResultsOf 3185 patients screened for eligibility, 1346 patients were included to the trial. Forty-nine percent were allocated to the 8h group and 51% to the 12h group; of these, 23% and 20% had an elevated EWS≥2 at 24h, respectively (p=0.456), OR 1.17 (0.78–1.76); 3.4% and 2.2%, respectively had an EWS≥5 (p=0.391), and one patient in each group had an EWS≥7 at 24h (p=1.0). Multiple logistic regression analysis showed no significant interactions for the primary outcome and the predefined variables: age, gender, ward type, and inclusion period, with an adjusted OR 1.20 (0.79–1.82). There were no significant differences in regard to the secondary outcomes: cardiac arrests, ICU admissions, review by medical emergency team (MET), length of hospital stay, or elevated EWS at 48h. Thirty-day mortality was 1.1% vs. 1.8% (p=0.357) in the 8h group and the 12h-group, respectively (OR=0.60 (0.23–1.50), p=0.279). ConclusionWe found no significant reduction in the proportion of clinical deterioration with monitoring frequencies of 3 vs. 2 times daily among patients acutely admitted to a surgical or medical ward and an initial EWS of 0–1.

Aggregation of Marginal Gains in Cardiac Surgery: Feasibility of a Perioperative Care Bundle for Enhanced Recovery in Cardiac Surgical Patients.

The aim of this pilot study was to assess the feasibility of a perioperative care bundle for enhanced recovery after cardiac surgery (ERACS). A prospective, observational study. A major urban teaching and university hospital and tertiary referral center. The study included 53 patients undergoing cardiac surgery before implementation of an ERACS protocol (pre-ERACS group) and 52 patients undergoing cardiac surgery after implementation of an ERACS protocol (ERACS group). Based on recommendations from a consensus review in colorectal surgery, the following enhanced recovery perioperative care bundle was applied: detailed preoperative information, avoidance of prolonged fasting periods preoperatively, preoperative carbohydrate beverages, optimization of analgesia with avoidance of long-acting opioids, prevention of postoperative nausea and vomiting, early enteral nutrition postoperatively, and early mobilization. The authors hypothesized that length of hospital stay would be reduced with ERACS. Secondary outcome variables included a composite of postoperative complications and pain scores. Whereas the length of stay in the group of patients receiving the bundle of enhanced recovery interventions remained unchanged compared with the non-ERACS group, there was a statistically significant reduction in the number of patients in the ERACS group presenting with one or more postoperative complications (including hospital-acquired infections, acute kidney injury, atrial fibrillation, respiratory failure, postoperative myocardial infarction, and death). In addition, postoperative pain scores were improved significantly in the ERACS group. This pilot study demonstrated that ERACS is feasible and has the potential for improved postoperative morbidity after cardiac surgery. A larger multicenter quality improvement study implementing perioperative care bundles would be the next step to further assess outcomes in ERACS patients.

Hospital wastewater genotoxicity: A comparison study between an urban and rural university hospital with and without metabolic activation

Abstract Background: Hospital wastewater is a major source of micropollutants and toxic chemicals. It ends up draining into many aquatic bodies, causing environmental hazards. The aim of the study was to perform

Azithromycin use and outcomes in severe sepsis patients with and without pneumonia

PurposeStudies investigating the association between macrolides and outcomes in both pulmonary and nonpulmonary critically ill patients are limited. We aimed to examine the association between azithromycin use and clinical outcomes in severe sepsis patients with and without pneumonia receiving mechanical ventilation. Materials and MethodsA retrospective cohort of 105 patients admitted to an adult intensive care unit (ICU) with severe sepsis in an urban university hospital were included in the study. Multivariable linear regression was performed to assess the relationship between azithromycin use and the following outcomes: 28-day ICU-free days and 28-day ventilator-free days. ResultsIn univariate analysis, patients receiving azithromycin had nearly 6 more ICU-free days on average than did patients not receiving azithromycin (P = .005). The increased ICU-free days remained in multivariable analysis adjusting for age, sex, race, ICU type, and presence of shock (P = .005). In stratified analysis examining the association of azithromycin use in severe sepsis patients without pneumonia (n = 74), the results were similar to the full cohort. ConclusionAzithromycin was associated with more ICU-free days in severe sepsis patients with and without pneumonia. Further investigations are warranted to better elicit the association of macrolide use on clinical outcomes in severe sepsis patients, especially those without pneumonia.

Sedative use: its association with harmful alcohol use, harmful tobacco use and quality of life among health care workers in Thailand

Background: Health care workers (HCWs) may be at higher risk for sedative misuse due to potential access and self-medication behavior.Objectives: To examine risk factors for harmful sedative use (HSedU) and its association with harmful alcohol use (HAlcU), harmful tobacco use (HTobU) and quality of life (QoL).Methods: A survey was conducted in 2013 at an urban university hospital in Northern Thailand. Risk of harm was measured using The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST). Harmful substance use defined as having at least moderate risk of harm. QoL was measured using SF-36 questionnaire.Results: A sample of 3204 HCWs (59.7% response) participated. The prevalence of HSedU in past 3 months was 4.2%. Health professionals involved with prescribing or dispensing medication were at higher risk of HSedU (OR 1.80, 95% CI 1.21–2.67). Adjusting for confounders, HSedU was associated with HAlcU (OR 3.35, 95% CI 1.81–6.20) but not associated with HTobU. HSedU was associated with lower QoL score which was 7.78 and 5.52 points lower for physical (95% CI −10.4 to −5.18) and mental QoL (95% CI −7.11 to −3.93), respectively.Conclusions: HCWs were at higher risk of HSedU. HSedU was associated with HAlcU and associated with lower physical and mental health QoL.