Vanderbilt University Hospital Research Articles

Severity of illness scores at presentation predict ICU admission and mortality in COVID-19.

Background:The COVID-19 pandemic has overwhelmed hospital systems in multiple countries and necessitated caring for patients in atypical healthcare settings. The goal of this study was to ascertain if the conventional critical care severity scores qSOFA, SOFA, APACHE-II, and SAPS-II could predict which patients admitted to the hospital from an emergency department would eventually require intensive care.Methods:This single-center, retrospective cohort study enrolled patients admitted to Vanderbilt University Hospital from the emergency room with symptomatic, confirmed COVID-19 infection between March 8, 2020 through May 15, 2020. Clinical phenotyping was performed by chart abstraction, and the correlation of the qSOFA, SOFA, APACHE-II, and SAPS-II scores for the primary endpoint of ICU admission and secondary endpoint of in-hospital mortality was evaluated.Results:During the study period, 128 patients were admitted to Vanderbilt University Hospital from the emergency room with COVID-19. Of these, 39 patients eventually required intensive care; the remaining 89 were discharged from the medical ward. All severity of illness scores demonstrated at least moderate ability to identify patients who would die or require ICU admission. Of the three severity of illness scores assessed, the APACHE-II score performed best with an AUC of 0.851 (95% CI: 0.786 to 0.917) for identifying patient that would require ICU admission. No patient with an APACHE-II score at the time of presentation less than 8 or qSOFA of 0 required intensive care unit (ICU) admission. All patients with an APACHE-II score less than 10 or qSOFA score of 0 survived to hospital discharge.Conclusions:The APACHE-II score accurately predicts the eventual need for ICU admission. This may allow for risk-stratification of patients safe to treat in alternative health care settings and prognostic enrichment to accelerate clinical trials of COVID-19 therapies.

Comparison of Leadless Pacing and Temporary Externalized Pacing Following Cardiac Implanted Device Extraction.

Pacemaker-dependent (PD) patients undergoing implantable cardiac electronic device extraction often must be subjected to temporary pacing interventions. We sought to determine the safety and utility of a leadless pacing system (Micra™; Medtronic, Minneapolis, MN, USA) in patients undergoing system extraction as compared with externalized temporary transvenous right ventricular lead (temp-perm) placement. We performed a retrospective cohort analysis of all patients receiving either permanent Micra™ or temp-perm systems following system extraction from October 2013 to September 2017 at Vanderbilt University Hospital. The Micra™ and temp-perm cohorts included nine and 27 patients meeting the inclusion criteria, respectively. System infection was the most common indication for extraction (67% Micra™, 84% temp-perm), but no patients had active bacteremia at the time of permanent system reimplantation. There was no difference in system type (p = 0.09) or mean lead dwell time extracted (109 versus 81 months; p = 0.93). Procedure times were comparable between the two groups (180 versus 194 minutes; p = 0.74). Patients receiving Micra™ systems had shorter hospital stays after extraction (two versus eight days; p < 0.005), with no difference in major complications (11% versus 15%; p = 0.78) or 30-day (11% versus 7%; p = 0.77) or 90-day (11% versus 11%; p = 0.45) mortality. No reinfections were observed in either group at 90 days. Implantation of the Micra™ pacing system in select PD patients after system extraction is feasible and appears to reduce the hospital length of stay as compared with the use of temp-perm systems.

A method for analyzing inpatient care variability through physicians' orders.

Administrators assess care variability through chart review or cost variability to inform care standardization efforts. Chart review is costly and cost variability is imprecise. This study explores the potential of physician orders as an alternative measure of care variability. The authors constructed an order variability metric from adult Vanderbilt University Hospital patients treated between 2013 and 2016. The study compared how well a cost variability model predicts variability in the length of stay compared to an order variability model. Both models adjusted for covariates such as severity of illness, comorbidities, and hospital transfers. The order variability model significantly minimized the Akaike information criterion (superior outcome) compared to the cost variability model. This result also held when excluding patients who received intensive care. Order variability can potentially typify care variability better than cost variability. Order variability is a scalable metric, calculable during the course of care.

2061. Impact of a Penicillin-Binding Protein 2a Rapid Diagnostic Test on Patients Who Present with Staphylococcus aureus Orthopedic Hardware Infections

BackgroundWaiting for culture availability from orthopedic hardware (HW) infections delays patient discharge and time to definitive antimicrobial therapy. In February 2017, Vanderbilt University Hospital (VUH) implemented a penicillin-binding protein 2a-based rapid diagnostic, Alere®, to differentiate methicillin-susceptible S. aureus (MSSA) and methicillin-resistant S. aureus (MRSA) from tissue sample growth. In other settings, use of Alere® demonstrated decreased time to definitive therapy with and without stewardship intervention. However, no studies to date have examined the impact of Alere® in the orthopedic HW infection population.MethodsWe performed a retrospective study of patients ≥18 years of age admitted to VUH with a culture-positive, monomicrobial, S. aureus orthopedic HW infection. Select ICD-10 codes related to orthopedic HW infections were used to identify potential patients. Exclusion criteria included concomitant bacteremia or polymicrobial infections. Patients with sterile site cultures obtained from August 2016 to January 2017 were included in the pre-Alere® group and February 2017 to September 2017 in the post-Alere® group. The primary outcome was time to appropriate antibiotic, defined as cefazolin or nafcillin for MSSA, and vancomycin for MRSA. Daptomycin and linezolid were acceptable alternatives in the case of prior vancomycin failure, or severe, documented reaction to vancomycin.ResultsICD-10 codes identified a total of 331 patients, with 29 (8.7%) demonstrating monomicrobial S. aureus HW infections (52% MSSA). There were 11 (38%) and 18 (62%) patients in pre- and post-Alere® groups, respectively. Alere® results provided definitive methicillin susceptibility 31.9 (range 19.5–46.1) hours before standard culture results. Time to appropriate antibiotic was 41.8 hours less in post-Alere® group (P = 0.009). Duration of empiric Gram-negative coverage was significantly reduced in the post-Alere® group (P = 0.029). Overall length of stay was unchanged between the groups (P = 0.873).ConclusionIntroduction of Alere® reduced time to appropriate therapy and reduced empiric Gram negative coverage in patients being treated for orthopedic hardware infections.Disclosures All authors: No reported disclosures.

Health Literacy and 1-Year Mortality: Mechanisms of Association in Adults Hospitalized for Cardiovascular Disease

ObjectiveTo test theorized patient-level mediators in the causal pathway between health literacy (HL) and 1-year mortality in adults with cardiovascular disease (CVD). Patients and MethodsA total of 3000 adults treated at Vanderbilt University Hospital from October 11, 2011, through December 18, 2015, for acute coronary syndrome or acute decompensated heart failure (ADHF) participated in the Vanderbilt Inpatient Cohort Study. Participants completed a bedside-administered survey and consented to health record review and longitudinal follow-up. Multivariable mediation models examined the direct and indirect effects of HL (a latent variable with 4 indicators) with 1-year mortality after discharge (dichotomous). Hypothesized mediators included social support, health competence, health behavior, comorbidity index, type of CVD diagnosis, and previous-year hospitalizations. ResultsOf the 2977 patients discharged from the hospital (60% male; mean age, 61 years; 83% non-Hispanic white, 37% admitted for ADHF), 17% to 23% had inadequate HL depending on the measure, and 10% (n=304) died within 1 year. The total effect of lower HL on 1-year mortality (adjusted odds ratio [AOR]=1.31; 95% CI, 1.01-1.69) was decomposed into an indirect effect (AOR=1.50; 95% CI, 1.35-1.67) via the mediators and a nonsignificant direct effect (AOR=0.87; 95% CI, 0.66-1.14). Each SD decrease in HL was associated with an absolute 3.2 percentage point increase in the probability of 1-year mortality via mediators admitted for ADHF, comorbidities, health behavior, health competence, and previous-year hospitalizations (listed by contribution to indirect effect). ConclusionPatient-level factors link low HL and mortality. Health competence and health behavior are modifiable mediators that could be targeted by interventions post hospitalization for CVD.

Interactive medical word sense disambiguation through informed learning.

Medical word sense disambiguation (WSD) is challenging and often requires significant training with data labeled by domain experts. This work aims to develop an interactive learning algorithm that makes efficient use of expert's domain knowledge in building high-quality medical WSD models with minimal human effort. We developed an interactive learning algorithm with expert labeling instances and features. An expert can provide supervision in 3 ways: labeling instances, specifying indicative words of a sense, and highlighting supporting evidence in a labeled instance. The algorithm learns from these labels and iteratively selects the most informative instances to ask for future labels. Our evaluation used 3 WSD corpora: 198 ambiguous terms from Medical Subject Headings (MSH) as MEDLINE indexing terms, 74 ambiguous abbreviations in clinical notes from the University of Minnesota (UMN), and 24 ambiguous abbreviations in clinical notes from Vanderbilt University Hospital (VUH). For each ambiguous term and each learning algorithm, a learning curve that plots the accuracy on the test set against the number of labeled instances was generated. The area under the learning curve was used as the primary evaluation metric. Our interactive learning algorithm significantly outperformed active learning, the previous fastest learning algorithm for medical WSD. Compared to active learning, it achieved 90% accuracy for the MSH corpus with 42% less labeling effort, 35% less labeling effort for the UMN corpus, and 16% less labeling effort for the VUH corpus. High-quality WSD models can be efficiently trained with minimal supervision by inviting experts to label informative instances and provide domain knowledge through labeling/highlighting contextual features.

Effectiveness of the Malnutrition Quality Improvement Initiative on Practitioner Malnutrition Knowledge and Screening, Diagnosis, and Timeliness of Malnutrition-Related Care Provided to Older Adults Admitted to a Tertiary Care Facility: A Pilot Study

BackgroundMalnutrition is present in 30% to 50% of hospitalized patients aged 60 years or older. As few as 3.2% of patients identified as high risk have a malnutrition diagnosis documented by medical providers. The Malnutrition Quality Improvement Initiative (MQii) aims to reduce the burden of hospital malnutrition by improving the process and delivery of care. ObjectiveTo evaluate implementing the MQii toolkit of best practice resources for screening, diagnosis, documentation, and timeliness of malnutrition care. DesignThis 6-month prospective pilot included a 3-month intervention with training and education modules tailored to type of practitioner and integrated into existing teaching and clinical workflow. Participants/settingForty-five health care professionals from geriatric, general medicine, and general surgery units at Vanderbilt University Hospital during January to June 2016. Main outcome measuresMalnutrition knowledge by 30-item questionnaire; electronic medical record (EMR) documentation; and timeliness of malnutrition screening, diagnosis, intervention, and discharge planning. Statistical analysesAnalysis of variance was used to test change over time. ResultsMalnutrition knowledge score increased 14%, from 39% to 53% (P=0.009). All patients whose nutrition screen indicated they were malnourished/high risk had registered dietitian nutritionist diagnosis of malnutrition documented in the EMR. The proportion who had medical provider (physician, nurse practitioner, or physician assistant) malnutrition diagnosis documented in the EMR increased 11.6%, from 26.7% to 38.3% (P=0.08). About 95% of malnourished/high risk patients had a documented intervention addressing malnutrition. Inclusion of malnutrition care in the discharge plan increased 4.8%, from 70.0% to 74.8% (P=0.13). ConclusionsThis pilot study demonstrated feasibility of implementing the MQii resources to improve malnutrition knowledge and professionals’ skills relevant to screening, diagnosis, intervention, and timeliness of malnutrition care. By optimizing the process and delivery of malnutrition care, it is expected that the quality of clinical care provided to older adults with malnutrition or at high malnutrition risk will improve.

Assessment of Knowledge, Attitudes, and Practices (KAP) of Providers Towards Internal Reporting of Antimicrobial Use

BackgroundSurveillance of antimicrobials is important to ensure appropriate practices. National mandatory reporting of antimicrobial utilization (AU) is anticipated. As feedback drives change, we surveyed providers to gain input on their perceptions about attribution, barriers to feedback, and preferences on AU feedback.MethodsA 20-question, IRB-approved survey was emailed to providers who prescribe antimicrobials at Vanderbilt University Hospital. Demographics, methods of and barriers to feedback, and case scenarios addressing attribution upon admission from the emergency department (ED), transfer between inpatient teams and consultant interactions were collected. Levels of concern were rated on a scale of 1 to 5 regarding barriers. Participants were stratified by service line. Chi-square and Fisher’s exact test for categorical variables and analysis of variance for intergroup mean differences were conducted.ResultsA total of 211 (27.5%) of 766 providers completed the survey. Upon admission, 83% of providers attributed to the ED team that ordered the antimicrobial with no between group differences, P = 0.21. After ICU transfer and broadening of therapy, 91% attributed to the ICU team that changed therapy, P = 0.39 between groups. After a new ICU team came on service, 73.9% attribute the antibiotic changed the day prior to the new team, P = 0.98. A significant difference was seen in the consult scenario of attribution to Infectious Disease (ID) team (critical care 50%, ED 43.5%, ID 37.5%, other medicine specialties 60.2%, and surgery 77.8%, P = 0.01). Providers wanted reporting to be based on service (62%) and to be notified via email (73%) as opposed to an online dashboard (36%). Levels of concern on following another provider’s recommendations varied (ED 3.1 vs. ID 2.3, P < 0.001 across all groups) as well as unaccounted patient severity (ED 4.4 vs. Surgery 2.8, P < 0.001 across all groups). Services also differed in likelihood to change practice based on feedback (ED 3.8 vs. Medicine 3.2, P = 0.047 across all groups).ConclusionThere is a general agreement on attribution throughout a hospitalization with varying levels of concern between services regarding feedback of utilization data. This is important to take into consideration prior to implementation of feedback distribution to providers.Disclosures T. Lines, National Institutes of Health: Investigator, Clinical and Translational Science Award grant obtained only to provide survey participants with $5 incentive in completing the survey

FDA starts showing its plans for oversight of pharmacy compounding

This spring and summer, FDA revealed in several guidance documents what the agency thinks pharmacy compounding should look like now that the relevant provisions in federal law are firmly in place and the agency has a budget for oversight. Some of FDA’s ideas, if incorporated into the final versions of the guidances, could be challenging for hospitals and health systems to implement, said Mark Sullivan, executive director of pharmacy operations for Vanderbilt University Hospital and Clinics (VUHC), based in Nashville. Other hospitals and health systems, such as Tufts Medical Center in Boston, may not be immediately concerned about FDA’s ideas. But as hospitals continue to affiliate or form multihospital systems, said Melissa Ortega, director of the medical center’s inpatient pharmacy operations, a plan to centralize compounding activities may need to be reconsidered. Other than removing the unconstitutional prohibition on advertisements about specific compounded drug products, the Drug Quality and Security Act (DQSA) did not change section 503A of the federal Food, Drug, and Cosmetic Act (FDCA).

What Patient Characteristics Influence Nurses’ Assessment of Health Literacy?

Overestimation of patients’ health literacy skills is common among nurses and physicians. At Vanderbilt University Hospital, nurses routinely ask patients the 3 Brief Health Literacy Screen (BHLS) questions. Data from 2 studies that recruited patients at Vanderbilt University Hospital—the Health Literacy Screening (HEALS) study and the Vanderbilt Inpatient Cohort Study (VICS)—were analyzed to compare the BHLS score recorded by nurses during clinical care with the score recorded by trained research assistants during the same hospitalization. Logistic regression models determined which patient characteristics were associated with nurses documenting higher health literacy scores than research assistants. Overall, the majority (60%) of health literacy scores were accurate, though nurses recorded meaningfully higher health literacy scores in 28.4% of HEALS patients and 35.6% of VICS patients. In the HEALS cohort, patients who were male and had less education were more likely to have higher health literacy scores recorded by nurses (odds ratio [OR] = 1.93, 95% confidence interval [CI] [1.24, 3.00]; and OR = 0.80, 95% CI [0.74, 0.88], respectively). In the VICS cohort, patients who were older, were male, and had less education were more likely to have higher health literacy scores recorded by nurses (OR = 1.01, 95% CI [1.003, 1.02]; OR = 1.49, 95% CI [1.20, 1.84]; and OR = 0.87, 95% CI [0.83, 0.90], respectively). These findings suggest that health literacy scores recorded by nurses for male patients and patients with less education could be overestimated. Thus, health care professionals should be aware of this tendency and should verify the results of routine health literacy screening tests, especially in certain patient groups.

Utility of the Richmond Agitation-Sedation Scale in evaluation of acute neurologic dysfunction in the intensive care unit.

Utility of the Richmond Agitation-Sedation Scale in evaluation of acute neurologic dysfunction in the intensive care unit.

MP31-16 THE IMPACT OF HEALTH LITERACY ON SURGICAL OUTCOMES FOLLOWING RADICAL CYSTECTOMY

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Practice Patterns, Quality of Life and Shared Decision Making III1 Apr 2016MP31-16 THE IMPACT OF HEALTH LITERACY ON SURGICAL OUTCOMES FOLLOWING RADICAL CYSTECTOMY Kristen Scarpato, Stephen Kappa, Kathryn Goggins, Sam Chang, Michael Cookson, Joseph Smith, Peter Clark, David Penson, Matthew Resnick, Dan Barocas, Kamran Idrees, Sunil Kripalani, and Kelvin Moses Kristen ScarpatoKristen Scarpato More articles by this author , Stephen KappaStephen Kappa More articles by this author , Kathryn GogginsKathryn Goggins More articles by this author , Sam ChangSam Chang More articles by this author , Michael CooksonMichael Cookson More articles by this author , Joseph SmithJoseph Smith More articles by this author , Peter ClarkPeter Clark More articles by this author , David PensonDavid Penson More articles by this author , Matthew ResnickMatthew Resnick More articles by this author , Dan BarocasDan Barocas More articles by this author , Kamran IdreesKamran Idrees More articles by this author , Sunil KripalaniSunil Kripalani More articles by this author , and Kelvin MosesKelvin Moses More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.1269AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Health literacy is the ability to obtain, comprehend and act on medical information, and is an independent predictor of health outcomes in patients with chronic health conditions. The relationship between health literacy and surgical outcomes has not been studied in detail. Radical cystectomy (RC) necessitates significant patient self-care post-operatively and patients are given detailed verbal and written instructions. We sought to determine the association between health literacy and surgical outcomes, including unplanned healthcare utilization and complications, after RC. We hypothesized that patient complications after RC are associated with health literacy. METHODS All patients admitted to Vanderbilt University Hospital are administered the Brief Health Literacy Survey (BHLS), a validated 3-question instrument that reflects patient health literacy, since 2010. Patient, tumor, and operative details are consistently abstracted from the medical record. Post-operative complications were graded according to the Clavien-Dindo Classification and grouped according to “any”, “major” (Grade III, IV, and V), and “minor” (Grade I and II) complications. Bivariate analyses and logistic and Cox regression analyses were performed using SPSS version 22. RESULTS A total of 368 patients who underwent RC had complete literacy data. The median BHLS score was 13 (IQR=10-15). The percentage of patients having any complication after surgery was 42.7%, and 8.4% and 34.2% of patients had a major and minor complication, respectively. Higher BHLS scores are associated with decreased odds of developing minor complications (OR=0.90, 95% CI: 0.83,0.97) or any complication in this patient population (OR=0.92, 95% CI: 0.84,0.99). In the logistic regression models, health literacy was the only variable significantly associated with developing a minor or any post-operative complication. CONCLUSIONS Lower health literacy is associated with an increased likelihood of having any complication or a minor complication among patients undergoing RC. This may be due to the inability to perform complex self-care or reduced access to resources necessary for optimal outcomes. Health literacy should be considered when caring for these patients in an effort to decrease complications following surgery. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e425-e426 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Kristen Scarpato More articles by this author Stephen Kappa More articles by this author Kathryn Goggins More articles by this author Sam Chang More articles by this author Michael Cookson More articles by this author Joseph Smith More articles by this author Peter Clark More articles by this author David Penson More articles by this author Matthew Resnick More articles by this author Dan Barocas More articles by this author Kamran Idrees More articles by this author Sunil Kripalani More articles by this author Kelvin Moses More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Effect of Pharmacist Counseling Intervention on Health Care Utilization Following Hospital Discharge: A Randomized Control Trial.

Reduction in 30-day readmission rates following hospitalization for acute coronary syndrome (ACS) and acute decompensated heart failure (ADHF) is a national goal. The aim of this study was to determine the effect of a tailored, pharmacist-delivered, health literacy intervention on unplanned health care utilization, including hospital readmission or emergency room (ER) visit, following discharge. Randomized, controlled trial with concealed allocation and blinded outcome assessors Two tertiary care academic medical centers Adults hospitalized with a diagnosis of ACS and/or ADHF. Pharmacist-assisted medication reconciliation, inpatient pharmacist counseling, low-literacy adherence aids, and individualized telephone follow-up after discharge The primary outcome was time to first unplanned health care event, defined as hospital readmission or an ER visit within 30 days of discharge. Pre-specified analyses were conducted to evaluate the effects of the intervention by academic site, health literacy status (inadequate versus adequate), and cognition (impaired versus not impaired). Adjusted hazard ratios (aHR) and 95% confidence intervals (CI) are reported. A total of 851 participants enrolled in the study at Vanderbilt University Hospital (VUH) and Brigham and Women's Hospital (BWH). The primary analysis showed no statistically significant effect on time to first unplanned hospital readmission or ER visit among patients who received interventions compared to controls (aHR = 1.04, 95% CI 0.78-1.39). There was an interaction of treatment effect by site (p = 0.04 for interaction); VUH aHR = 0.77, 95% CI 0.51-1.15; BWH aHR = 1.44 (95% CI 0.95-2.12). The intervention reduced early unplanned health care utilization among patients with inadequate health literacy (aHR 0.41, 95% CI 0.17-1.00). There was no difference in treatment effect by patient cognition. A tailored, pharmacist-delivered health literacy-sensitive intervention did not reduce post-discharge unplanned health care utilization overall. The intervention was effective among patients with inadequate health literacy, suggesting that targeted practice of pharmacist intervention in this population may be advantageous.

Abstract 293: Clinical Predictors of Endothelial Function in Human Saphenous Vein

BACKGROUND: Human saphenous vein (HSV) remains the most widely utilized conduit for vascular bypass procedures. Outcomes remain limited by vein graft failure and intimal hyperplasia. Endothelial function is considered an important determinant of vein graft failure. We have observed significant variability in endothelial function in freshly isolated HSV samples. We therefore evaluated clinical predictors of endothelial function in HSV. Methods: We obtained freshly isolated HSV samples from the operating room immediately following harvest from patients undergoing coronary artery bypass procedures from Vanderbilt University Hospital and the Nashville VA Hospital. We obtained HSV samples prior to any intraoperative manipulations. HSV viability, smooth muscle function, and endothelial-dependent relaxation (EDR) were measured in a muscle bath. We collected the following clinical and demographic information: age, height, weight, gender, ethnicity, medical comorbidities, laboratory values (creatinine, HbA1c, lipids), ejection fraction, preoperative medication regimen, and method of vein graft harvest. We performed a univariate and multivariate analysis of predictors of endothelial function in HSV. Results: HSV samples were obtained from 149 patients. HSV EDR varied from -11% to 63%. Open harvest was employed for 39 HSV samples, compared with endoscopic harvest in 110 HSV samples. On univariate analysis, only open harvest was a statistically significant predictor of endothelial function (p=0.02): mean HSV EDR was 21.5% in HSV samples harvested open, compared with 15.4% in HSV harvested with an endoscopic technique. HSV EDR was also improved with preoperative aspirin use: mean HSV EDR was 18% in patients with preoperative aspirin use compared with 11.6% in patients who were not administered preoperative aspirin in a multivariate model when controlling for method of vein graft harvest (p=0.05). Conclusions: Endoscopic vein graft harvest is associated with endothelial dysfunction in HSV, while preoperative aspirin use is associated with improved endothelial function. Further work will be necessary to determine whether these factors are associated with development of intimal hyperplasia and vein graft failure.

Quality and Financial Impact of Adding Nurse Practitioners to Inpatient Care Teams

The purpose of this project was to examine the financial impact of adding nurse practitioners (NPs) to inpatient care teams at Vanderbilt University Hospital. National initiatives targeting quality, safe, and cost-effective healthcare have created the optimal environment for NPs to showcase their abilities and contributions. Identifying outcomes that are directly affected by NPs and quantifying data in terms of dollars can be affirmation for the contribution of the NP practice. Value can be garnered in terms of revenue generation and cost-effectiveness of hiring NP providers; however, a considerable financial impact can be in cost avoidance and cost savings through NP-associated outcomes of care. This was a retrospective, secondary analysis of return on investment after adding NPs to 5 teams. Software was used to abstract billing, acuity, and length of stay (LOS) data and NP-associated quality metrics. Billing data, LOS, and risk-adjusted LOS data for designated years before and after adding NPs were compared. Gross collections compared with expenses for 4 NP-led teams for 2 year time periods were 62%, 36%, and 47%, and +32%. Average risk-adjusted LOS for the 5 time periods after adding NPs decreased and charges decreased, thus demonstrating less resource use. Most clinical outcomes improved beyond preproject baselines. This project demonstrated the value of adding NPs to inpatient care teams by means of generated revenue, reduction in LOS, and standardization of quality care.

Use of Multiple Imputation Method to Improve Estimation of Missing Baseline Serum Creatinine in Acute Kidney Injury Research

Baseline creatinine (BCr) is frequently missing in AKI studies. Common surrogate estimates can misclassify AKI and adversely affect the study of related outcomes. This study examined whether multiple imputation improved accuracy of estimating missing BCr beyond current recommendations to apply assumed estimated GFR (eGFR) of 75 ml/min per 1.73 m(2) (eGFR 75). From 41,114 unique adult admissions (13,003 with and 28,111 without BCr data) at Vanderbilt University Hospital between 2006 and 2008, a propensity score model was developed to predict likelihood of missing BCr. Propensity scoring identified 6502 patients with highest likelihood of missing BCr among 13,003 patients with known BCr to simulate a "missing" data scenario while preserving actual reference BCr. Within this cohort (n=6502), the ability of various multiple-imputation approaches to estimate BCr and classify AKI were compared with that of eGFR 75. All multiple-imputation methods except the basic one more closely approximated actual BCr than did eGFR 75. Total AKI misclassification was lower with multiple imputation (full multiple imputation + serum creatinine) (9.0%) than with eGFR 75 (12.3%; P<0.001). Improvements in misclassification were greater in patients with impaired kidney function (full multiple imputation + serum creatinine) (15.3%) versus eGFR 75 (40.5%; P<0.001). Multiple imputation improved specificity and positive predictive value for detecting AKI at the expense of modestly decreasing sensitivity relative to eGFR 75. Multiple imputation can improve accuracy in estimating missing BCr and reduce misclassification of AKI beyond currently proposed methods.

Infection Reduction Strategies Including Antibiotic Stewardship Protocols in Surgical and Trauma Intensive Care Units Are Associated with Reduced Resistant Gram-Negative Healthcare-Associated Infections

Resistance to broad-spectrum antibiotics by gram-negative organisms is increasing. Resistance demands more resource utilization and is associated with patient morbidity and death. We describe the implementation of infection reduction protocols, including antibiotic stewardship, and assess their impact on multi-drug-resistant (MDR) healthcare-acquired gram-negative infections. Combined infection reduction and antibiotic stewardship protocols were implemented in the surgical and trauma intensive care units at Vanderbilt University Hospital beginning in 2002. The components of the program were: (1) Protocol-specific empiric and therapeutic antibiotics for healthcare-acquired infections; (2) surgical antibiotic prophylaxis protocols; and (3) quarterly rotation/limitation of dual antibiotic classes. Continuous healthcare-acquired infection surveillance was conducted by independent practitioners using National Heath Safety Network criteria. Linear regression analysis was used to estimate trends in MDR gram-negative healthcare-acquired infections. A total of 1,794 gram-negative pathogens were isolated from healthcare-acquired infections during the eight-year observation period. The proportion of healthcare-acquired infections caused by MDR gram-negative pathogens decreased from 37.4% (2001) to 8.5% (2008), whereas the proportion of healthcare-acquired infections caused by pan-sensitive pathogens increased from 34.1% to 53.2%. The rate of total healthcare-associated infections per 1,000 patient-days that were caused by MDR gram-negative pathogens declined by -0.78 per year (95% confidence interval [CI] -1.28, -0.27). The observed rate of healthcare-acquired infections per 1,000 patient days attributable to specific MDR gram-negative pathogens decreased over time: Pseudomonas -0.14 per year (95% CI -0.20, -0.08), Acinetobacter-0.49 per year (95% CI -0.77, -0.22), and Enterobacteriaceae -0.14 per year (95% CI -0.26, -0.03). Implementation of an antibiotic stewardship protocol as a component of an infection reduction campaign was associated with a decrease in resistant gram-negative healthcare-acquired infections in intensive care units. These results further support widespread implementation of such initiatives.

Rationale and Design of the Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL-CVD) Study

Medication errors and adverse drug events are common after hospital discharge due to changes in medication regimens, suboptimal discharge instructions, and prolonged time to follow-up. Pharmacist-based interventions may be effective in promoting the safe and effective use of medications, especially among high-risk patients such as those with low health literacy. The Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL-CVD) study is a randomized controlled trial conducted at 2 academic centers-Vanderbilt University Hospital and Brigham and Women's Hospital. Patients admitted with acute coronary syndrome or acute decompensated heart failure were randomly assigned to usual care or intervention. The intervention consisted of pharmacist-assisted medication reconciliation, inpatient pharmacist counseling, low-literacy adherence aids, and tailored telephone follow-up after discharge. The primary outcome is the occurrence of serious medication errors in the first 30 days after hospital discharge. Secondary outcomes are health care utilization, disease-specific quality of life, and cost-effectiveness. Enrollment was completed September 2009. A total of 862 patients were enrolled, and 430 patients were randomly assigned to receive the intervention. Analyses will determine whether the intervention was effective in reducing serious medication errors, particularly in patients with low health literacy. The PILL-CVD study was designed to reduce serious medication errors after hospitalization through a pharmacist-based intervention. The intervention, if effective, will inform health care facilities on the use of pharmacist-assisted medication reconciliation, inpatient counseling, low-literacy adherence aids, and patient follow-up after discharge. Clinical Trial Registration- clinicaltrials.gov. Identifier: NCT00632021.

Commonly used surrogates for baseline renal function affect the classification and prognosis of acute kidney injury

Studies of acute kidney injury usually lack data on pre-admission kidney function and often substitute an inpatient or imputed serum creatinine as an estimate for baseline renal function. In this study, we compared the potential error introduced by using surrogates such as (1) an estimated glomerular filtration rate of 75 ml/min per 1.73 m(2) (suggested by the Acute Dialysis Quality Initiative), (2) a minimum inpatient serum creatinine value, and (3) the first admission serum creatinine value, with values computed using pre-admission renal function. The study covered a 12-month period and included a cohort of 4863 adults admitted to the Vanderbilt University Hospital. Use of both imputed and minimum baseline serum creatinine values significantly inflated the incidence of acute kidney injury by about half, producing low specificities of 77-80%. In contrast, use of the admission serum creatinine value as baseline significantly underestimated the incidence by about a third, yielding a low sensitivity of 39%. Application of any surrogate marker led to frequent misclassification of patient deaths after acute kidney injury and differences in both in-hospital and 60-day mortality rates. Our study found that commonly used surrogates for baseline serum creatinine result in bi-directional misclassification of the incidence and prognosis of acute kidney injury in a hospital setting.

Detection and Identification of Ehrlichia Species in Blood by Use of PCR and Electrospray Ionization Mass Spectrometry

Rapid detection and identification of Ehrlichia species improves clinical outcome for patients suspected of ehrlichiosis. We describe an assay that employs multilocus PCR and electrospray ionization mass spectrometry (PCR/ESI-MS) to detect and identify Ehrlichia species directly from blood specimens. The results were compared to those of a colorimetric microtiter PCR enzyme immunoassay (PCR-EIA) used as a diagnostic assay. Among 213 whole-blood samples collected from patients who were clinically suspected of ehrlichiosis from 1 May to 1 August 2008 at Vanderbilt University Hospital, 40 were positive for an Ehrlichia species by PCR/ESI-MS, giving a positive rate of 18.8%. In comparison to the PCR-EIA, PCR/ESI-MS possessed a sensitivity, a specificity, and positive and negative predictive values of 95.0%, 98.8%, 95.0%, and 98.8%, respectively. The 38 specimens that were positive for Ehrlichia by both PCR/ESI-MS and the PCR-EIA were further characterized to the species level, with 100% agreement between the two assays. In addition, Rickettsia rickettsii was detected by PCR/ESI-MS from four specimens that were confirmed retrospectively by serology and PCR-EIA. In three specimens, the PCR/ESI-MS assay identified Pseudomonas aeruginosa, Neisseria meningitidis, and Staphylococcus aureus; these were confirmed by culture and/or clinical diagnosis as being clinically relevant. From specimen processing to result reporting, the PCR/ESI-MS assay can be completed within 6 h, providing another laboratory tool for the diagnosis of ehrlichiosis. Moreover, this system may provide rapid detection and identification of additional pathogens directly from blood specimens.