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PURPOSE - We aimed to determine trends in postoperative opiate management among urological patients, identify associations with opiate keeping and foster appropriate opiate disposal after surgery via introduction of an educational handout.
MATERIALS AND METHODS - We retrospectively analyzed opiate practices in 68 patients who had undergone urological surgery. In a separate consecutive cohort of 59 patients we distributed a handout detailing FDA (Food and Drug Administration) approved disposal methods. Patient opiate obtainment, use and disposal were assessed via telephone interviews with prescription filling data verified using the Tennessee CSMD (Controlled Substances Monitoring Database). Opiate keeping was defined as possessing any opiates more than 3 weeks after surgery or more than 4 times the duration of the postoperative prescription, whichever was longer.
RESULTS - Opiate keeping was observed in 41 patients (72%) in our initial cohort. Of these patients 68% left the medication unsecured at home. Major barriers to opiate disposal included concern for return of disease specific pain in 44% of patients and unrelated pain in 29%. As assessed on a short test, opiate keepers were less knowledgeable about safe disposal practices compared to nonkeepers (72% vs 85%, p = 0.005). Among opiate keepers there was an improvement in knowledge scores after the intervention (66% to 77%, p = 0.03). When comparing pre-education to post-education, there was no detectable improvement in the rate of opiate keeping (72% vs 68%, p = 0.66) or proper disposal (9% vs 8%, p = 1.0).
CONCLUSIONS - Opiate keeping is common following urological surgery and a major barrier to disposal is concern for the return of disease specific pain. Future interventions aimed at limiting opiate keeping should combine evidence-based prescription practices and targeted patient education.
Pregnant women have been called therapeutic orphans because data supporting common interventions, medications, health teaching, and models of care are meager. The generation of quality evidence benefits from proactive approaches that ensure ethical standards are met to protect participants. The purpose of this article is to differentiate among health care, quality improvement, and research and to discuss ethical involvement of women who are pregnant and potentially childbearing in these initiatives. Health care is provided to protect and improve individual health. Quality improvement aims to enhance delivery of care for all those receiving care in particular settings. Research, whether retrospective or prospective, is designed to contribute to generalizable knowledge. This review includes vignettes to distinguish between research, quality improvement, and case study dissemination and to highlight the value of publication of information with applicability beyond a single site. As a community, perinatal care providers will be able to contribute more evidence to guide care if they err on the side of seeking institutional review board approval for activities that examine the care and outcomes of pregnant women and the fetus. Traditional research activities, including clinical trials, remain crucial. However, to fill gaps in knowledge, we must expedite our ability to report informative cases, examine clinical data, share lessons learned during quality improvement campaigns, and publish and disseminate these findings. Accelerating improvements in care demands expansion of the evidence base.
© 2017 by the American College of Nurse-Midwives.
The risk profile of extraoperative electrocorticography (ECoG) is documented almost exclusively by case series from a limited number of academic medical centers. These studies tend to underreport minor complications, like urinary tract infections (UTIs) and deep venous thromboses (DVTs), that nevertheless affect hospital cost, length of stay, and the patient's quality of life. Herein, we used data from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) to estimate the rate of adverse events in extraoperative ECoG surgeries. NSQIP is a validated dataset containing nearly 3 million procedures from over 600 North American hospitals, and uses strict criteria for the documentation of complications. Major complications occurred in 3.4% of 177 extraoperative ECoG cases, while minor complications occurred in 9.6%. The most common minor complication was bleeding requiring a transfusion in 3.4% of cases, followed by sepsis, DVT, and UTI each in 2.3% of cases. No mortality was reported. Overall, in a national database containing a heterogeneous population of hospitals, major complications of extraoperative ECoG were rare (3.4%). Complications such as UTI and DVT tend to be underreported in retrospective case series, yet make up a majority of minor complications for ECoG patients in this dataset.
Copyright © 2016 Elsevier B.V. All rights reserved.
UNLABELLED - ♦
BACKGROUND - In general, efforts to standardize care based on group consensus practice guidelines have resulted in lower morbidity and mortality. Although there are published guidelines regarding insertion and perioperative management of peritoneal dialysis (PD) catheters, variation in practice patterns between centers may exist. The objective of this study is to understand variation in PD catheter insertion practices in preparation for conducting future studies. ♦
METHODS - An electronic survey was developed by the research committee of the International Society for Peritoneal Dialysis - North American Research Consortium (ISPD-NARC) to be completed by physicians and nurses involved in PD programs across North America. It consisted of 45 questions related to 1) organizational characteristics; 2) PD catheter insertion practices; 3) current quality-improvement initiatives; and 4) interest in participation in PD studies. Invitation to participate in the survey was given to nephrologists and nurses in centers across Canada and the United States (US) identified by participation in the inaugural meeting of the ISPD-NARC. Descriptive statistics were applied to analyze the data. ♦
RESULTS - Fifty-one ISPD-NARC sites were identified (45% in Canada and 55% in the US) of which 42 responded (82%). Center size varied significantly, with prevalent PD population ranging from 6 - 300 (median: 60) and incident PD patients in the year prior to survey administration ranging from 3 - 180 (median: 20). The majority of centers placed fewer than 19 PD catheters/year, with a range of 0 - 50. Availability of insertion techniques varied significantly, with 83% of centers employing more than 1 insertion technique. Seventy-one percent performed laparoscopic insertion with advanced techniques (omentectomy, omentopexy, and lysis of adhesions), 62% of sites performed open surgical dissection, 10% performed blind insertion via trocar, and 29% performed blind placement with the Seldinger technique. Use of double-cuff catheters was nearly universal, with a near even distribution of catheters with pre-formed bend versus straight inter-cuff segments. There was also variation in the choice of perioperative antibiotics and perioperative flushing practices. Although 86% of centers had quality-improvement initiatives, there was little consensus as to appropriate targets. ♦
CONCLUSIONS - There is marked variability in PD catheter insertion techniques and perioperative management. Large multicenter studies are needed to determine associations between these practices and catheter and patient outcomes. This research could inform future trials and guidelines and improve practice. The ISPD-NARC is a network of PD units that has been formed to conduct multicenter studies in PD.
Copyright © 2016 International Society for Peritoneal Dialysis.
BACKGROUND - Coordinating efforts across disciplines in the intensive care unit is a key component of quality improvement (QI) efforts. Spontaneous awakening trials (SATs) and spontaneous breathing trials (SBTs) are considered key components of guidelines, yet unfortunately are often not done or coordinated properly.
OBJECTIVE - To determine if a pharmacist-driven awakening and breathing coordination (ABC) QI program would improve compliance (ie, process measures) as compared with the previous protocol, which did not involve pharmacists.
METHODS - The QI program included pharmacist-led education, daily discussion on rounds, and weekly performance reports to staff. Using a pre-QI versus during-QI versus post-QI intervention design, we compared data from 500 control ventilator-days (pre-QI period) versus 580 prospective ventilator-days (during-QI period). We then evaluated the sustainability of the QI program in 216 ventilator-days in the post-QI period.
RESULTS - SAT safety screens were performed on only 20% pre-QI patient-days versus 97% of during-QI patient-days (P < 0.001) and 100% of post-QI patient-days (P = 0.25). The rates of passing the SAT safety screen in pre-QI and during-QI periods were 63% versus 78% (P = 0.03) and 81% in the post-QI period (P = 0.86). The rates of SATs among eligible patients on continuous infusions were only 53% in the pre-QI versus 85% in the during-QI (P = 0.0001) and 87% in the post-QI (P = 1) periods.
CONCLUSIONS - In this QI initiative, a pharmacist-driven, interdisciplinary ABC protocol significantly improved process measures compliance, comparing the pre-QI versus during-QI rates of screening, performing, and coordinating SAT and SBTs, and these results were sustained in the 8-month follow-up period post-QI program.
© The Author(s) 2015.
Delivery of primary care preventative services can be significantly increased utilizing Six Sigma methods. Missed preventative service opportunities were compared in the study clinic with the community clinic in the same practice. The study clinic had 100% preventative services, compared with only 16.3% in the community clinic. Preventative services can be enhanced to Six Sigma quality when the nurse executive and medical staff agree on a single standard of nursing care executed via standing orders.
OBJECTIVES - Blood culture contamination is a common and preventable problem in the emergency department (ED). In a previous single-center study, changing the process of ED blood culture collection from the traditional "clean," nonsterile procedure to a fully sterile procedure with standardized use of sterile gloves, large-volume chlorhexidine skin antisepsis, and fenestrated sterile drapes resulted in a substantial reduction in contamination. The objective of the current study was to evaluate the effectiveness of this sterile blood culture collection process for reducing blood culture contamination in two community hospital EDs.
METHODS - The authors implemented the sterile blood culture collection process in the ED of two hospitals, including Hospital A, which historically had a contamination rate of approximately 5%, and Hospital B, with a 2.5% historical contamination rate. With an interrupted times-series design and segmented regression analysis to adjust for secular trends and autocorrelation, the monthly percentages of cultures contaminated at each hospital during an intervention period (sterile technique) were compared to a 10-month baseline period immediately preceding implementation (clean technique). At Hospital A, the full sterile blood culture collection process was used throughout the 16-month intervention period. At Hospital B, user feedback indicated poor adherence to the process due to difficulty implementing the fenestrated drape component; therefore, the process was simplified to the modified sterile collection process, in which the fenestrated drape component was dropped and sterile gloves and large-volume skin antisepsis were emphasized. Hence, at Hospital B, two intervention periods were compared to the baseline period: the 8-month intervention period 1 (full sterile process) and the subsequent 8-month intervention period 2 (modified sterile process).
RESULTS - At Hospital A, during the baseline period, 165 of 3,417 (4.83%) cultures were contaminated, while 142 of 5,238 (2.71%) were contaminated during the intervention period (p < 0.01). In the segmented regression model, the full sterile blood culture collection process was associated with an immediate 2.68% (95% confidence interval [CI] = 1.43% to 3.52%) absolute reduction in contamination and sustained reductions during the entire intervention period. At Hospital B, during the baseline, 63 of 2,509 (2.51%) cultures were contaminated. In intervention period 1 with the full sterile process, 51 of 1,865 (2.73%) cultures were contaminated (p = 0.65), with segmented regression results showing no changes compared to baseline. After simplification of the process to address poor adherence, the modified sterile process during intervention period 2 was associated with a significant reduction in contamination, with 17 of 1,860 (0.91%) cultures contaminated (p < 0.01 compared to baseline). The segmented regression model demonstrated the modified sterile process was associated with an immediate 1.53% (95% CI = 1.00% to 1.88%) absolute reduction in contamination with significant sustained reductions.
CONCLUSIONS - Changing the method of blood culture collection from the commonly used nonsterile technique to a sterile process resulted in significant reductions in blood culture contamination at two community hospital EDs, including one with low baseline contamination. Monitoring the implementation process at both sites was important to identify and overcome operational challenges. At one study site, simplification of the process by removing the fenestrated drape component was a key for successful implementation.
© 2014 by the Society for Academic Emergency Medicine.
BACKGROUND - Hematuria is a common clinical finding and represents the most frequent presenting sign of bladder cancer. The American Urological Association recommends cystoscopy and abdomino-pelvic imaging for patients aged more than 35 years. Nonetheless, less than half of patients presenting with hematuria undergo proper evaluation. We sought to identify clinical and nonclinical factors associated with evaluation of persons with newly diagnosed hematuria.
METHODS - We performed a retrospective cohort study, using claims data and laboratory values. The primary exposure was practice site, as a surrogate for nonclinical, potentially modifiable sources of variation. Primary outcomes were cystoscopy or abdomino-pelvic imaging within 180 days after hematuria diagnosis. We modeled the association between clinical and nonclinical factors and appropriate hematuria evaluation.
RESULTS - We identified 2455 primary care patients aged 40 years or more and diagnosed with hematuria between 2004 and 2012 in the absence of other explanatory diagnosis; 13.7% of patients underwent cystoscopy within 180 days. Multivariate logistic regression revealed significant variation between those who did and did not undergo evaluation in age, gender, and anticoagulant use (P < .001, P = .036, P = .028, respectively). Addition of practice site improved the predictive discrimination of each model (P < .001). Evaluation was associated with a higher rates of genitourinary neoplasia diagnosis.
CONCLUSIONS - Patients with hematuria rarely underwent complete evaluation. Although established risk factors for malignancy were associated with increasing use of diagnostic testing, factors unassociated with risk, such as practice site, also accounted for significant variation. Inconsistency across practice sites is undesirable and may be amenable to quality improvement interventions.
Copyright © 2014 Elsevier Inc. All rights reserved.