Michele G. Sullivan

WASHINGTON – A little bit of education can go a long way toward helping new parents understand the value of vaccines, according to Dr. Sarah E. Williams.

Parents who described themselves as worried about vaccine safety reported significantly greater confidence after they watched an 8-minute video about vaccine safety, she said at the annual meeting of the Pediatric Academic Societies.

Source: Vanderbilt University School of Medicine

"This is important because the study shows that it is possible to modify perceptions of vaccine-hesitant parents, which is likely the first step in the behavior change process," Dr. Williams said in an interview. "A larger sample size will be needed to see the actual change in vaccination rates."

Dr. Williams, a pediatrician who specializes in vaccinology and vaccine-preventable diseases at Vanderbilt University, Nashville, Tenn., conducted a randomized controlled trial of a vaccine education program in two pediatric offices. The study included parents of 2-week-old infants who were coming in for their first well-child check.

More than 450 parents completed the 15-item Parent Attitudes about Childhood Vaccines (PACV) survey, which examines parent behavior toward vaccines, their concerns about safety and efficacy, and other general questions about vaccines. Parents who scored 25 or higher were considered vaccine hesitant and invited to participate in the study; 369 agreed.

The control group received routine care and counseling. The intervention group received two short printed handouts and watched the video, which was narrated by Dr. Kathryn Edwards, professor of pediatrics at Vanderbilt. In it, Dr. Edwards touches on the safety of each of the infant vaccines; each discussion also includes a parent discussing his or her firsthand experience with an unvaccinated child falling seriously ill –or even dying.

The primary outcome was the change in PACV scores immediately after the video and at the 2-month well-child check. The secondary outcome was vaccine uptake.

Most of the parents (80%) were mothers; their mean age was 32 years. The majority were white (79%), and half reported an annual income of at least $75,000. The mean baseline PACV score was 28.

At the 2-month visit, the intervention group had a significant decrease in PACV score compared with the control group (median difference of 6.7). This finding remained significant after adjustment for baseline PACV score, race/ethnicity, and income.

There was not a significant between-group difference in on-time receipt of vaccines (control group, 82%; intervention group, 83%). However, Dr. Williams noted, the PACV scores in the intervention group remained stable from right after the video and reading until the 2-month visit. "This shows that brief education can improve vaccine attitudes in vaccine-hesitant parents and that these changes appear to be stable for at least 2 months."

She added that she is now developing a Web-based, interactive intervention that will allow parents to re-evaluate their feelings and ask their own questions. The project will continue to evolve along with public opinion about vaccines, she said.

"There’s a shifting hypothesis among these parents. As soon as we knock down one theory with research, another [one] crops up, so we need to have the opportunities to address these as they develop."

Dr. Williams said she had no relevant financial disclosures.

[email protected]

WASHINGTON – A little bit of education can go a long way toward helping new parents understand the value of vaccines, according to Dr. Sarah E. Williams.

Parents who described themselves as worried about vaccine safety reported significantly greater confidence after they watched an 8-minute video about vaccine safety, she said at the annual meeting of the Pediatric Academic Societies.

Source: Vanderbilt University School of Medicine

"This is important because the study shows that it is possible to modify perceptions of vaccine-hesitant parents, which is likely the first step in the behavior change process," Dr. Williams said in an interview. "A larger sample size will be needed to see the actual change in vaccination rates."

Dr. Williams, a pediatrician who specializes in vaccinology and vaccine-preventable diseases at Vanderbilt University, Nashville, Tenn., conducted a randomized controlled trial of a vaccine education program in two pediatric offices. The study included parents of 2-week-old infants who were coming in for their first well-child check.

More than 450 parents completed the 15-item Parent Attitudes about Childhood Vaccines (PACV) survey, which examines parent behavior toward vaccines, their concerns about safety and efficacy, and other general questions about vaccines. Parents who scored 25 or higher were considered vaccine hesitant and invited to participate in the study; 369 agreed.

The control group received routine care and counseling. The intervention group received two short printed handouts and watched the video, which was narrated by Dr. Kathryn Edwards, professor of pediatrics at Vanderbilt. In it, Dr. Edwards touches on the safety of each of the infant vaccines; each discussion also includes a parent discussing his or her firsthand experience with an unvaccinated child falling seriously ill –or even dying.

The primary outcome was the change in PACV scores immediately after the video and at the 2-month well-child check. The secondary outcome was vaccine uptake.

Most of the parents (80%) were mothers; their mean age was 32 years. The majority were white (79%), and half reported an annual income of at least $75,000. The mean baseline PACV score was 28.

At the 2-month visit, the intervention group had a significant decrease in PACV score compared with the control group (median difference of 6.7). This finding remained significant after adjustment for baseline PACV score, race/ethnicity, and income.

There was not a significant between-group difference in on-time receipt of vaccines (control group, 82%; intervention group, 83%). However, Dr. Williams noted, the PACV scores in the intervention group remained stable from right after the video and reading until the 2-month visit. "This shows that brief education can improve vaccine attitudes in vaccine-hesitant parents and that these changes appear to be stable for at least 2 months."

She added that she is now developing a Web-based, interactive intervention that will allow parents to re-evaluate their feelings and ask their own questions. The project will continue to evolve along with public opinion about vaccines, she said.

"There’s a shifting hypothesis among these parents. As soon as we knock down one theory with research, another [one] crops up, so we need to have the opportunities to address these as they develop."

Dr. Williams said she had no relevant financial disclosures.

[email protected]

WASHINGTON – A little bit of education can go a long way toward helping new parents understand the value of vaccines, according to Dr. Sarah E. Williams.

Parents who described themselves as worried about vaccine safety reported significantly greater confidence after they watched an 8-minute video about vaccine safety, she said at the annual meeting of the Pediatric Academic Societies.

Source: Vanderbilt University School of Medicine

"This is important because the study shows that it is possible to modify perceptions of vaccine-hesitant parents, which is likely the first step in the behavior change process," Dr. Williams said in an interview. "A larger sample size will be needed to see the actual change in vaccination rates."

Dr. Williams, a pediatrician who specializes in vaccinology and vaccine-preventable diseases at Vanderbilt University, Nashville, Tenn., conducted a randomized controlled trial of a vaccine education program in two pediatric offices. The study included parents of 2-week-old infants who were coming in for their first well-child check.

More than 450 parents completed the 15-item Parent Attitudes about Childhood Vaccines (PACV) survey, which examines parent behavior toward vaccines, their concerns about safety and efficacy, and other general questions about vaccines. Parents who scored 25 or higher were considered vaccine hesitant and invited to participate in the study; 369 agreed.

The control group received routine care and counseling. The intervention group received two short printed handouts and watched the video, which was narrated by Dr. Kathryn Edwards, professor of pediatrics at Vanderbilt. In it, Dr. Edwards touches on the safety of each of the infant vaccines; each discussion also includes a parent discussing his or her firsthand experience with an unvaccinated child falling seriously ill –or even dying.

The primary outcome was the change in PACV scores immediately after the video and at the 2-month well-child check. The secondary outcome was vaccine uptake.

Most of the parents (80%) were mothers; their mean age was 32 years. The majority were white (79%), and half reported an annual income of at least $75,000. The mean baseline PACV score was 28.

At the 2-month visit, the intervention group had a significant decrease in PACV score compared with the control group (median difference of 6.7). This finding remained significant after adjustment for baseline PACV score, race/ethnicity, and income.

There was not a significant between-group difference in on-time receipt of vaccines (control group, 82%; intervention group, 83%). However, Dr. Williams noted, the PACV scores in the intervention group remained stable from right after the video and reading until the 2-month visit. "This shows that brief education can improve vaccine attitudes in vaccine-hesitant parents and that these changes appear to be stable for at least 2 months."

She added that she is now developing a Web-based, interactive intervention that will allow parents to re-evaluate their feelings and ask their own questions. The project will continue to evolve along with public opinion about vaccines, she said.

"There’s a shifting hypothesis among these parents. As soon as we knock down one theory with research, another [one] crops up, so we need to have the opportunities to address these as they develop."

Dr. Williams said she had no relevant financial disclosures.

[email protected]

WASHINGTON – A pop-up on children’s electronic medical records was enough of a reminder to significantly increase influenza vaccine coverage in four large urban clinics, according to Dr. Melissa S. Stockwell.

"FluAlert" was built into the electronic medical record system and synchronized with the New York City vaccine registry. When it was activated during the winter flu season, children were 9% more likely to be fully vaccinated for influenza than when the reminder system wasn’t engaged, she said at the annual meeting of the Pediatric Academic Societies.

In addition to prompting physicians to vaccinate, the program allowed them to document reasons that the vaccine wasn’t given – a particularly valuable feature, said Dr. Stockwell, a pediatrician who is medical director of the New York–Presbyterian Hospital immunization registry.

"In this world of core measures, documentation of why a child is not vaccinated is becoming increasingly important," she said.

FluAlert was designed based on provider and parent focus groups, and implemented at four urban, community clinics that serve a primarily low-income Hispanic population. When the child’s electronic medical record opens, a FluAlert box appears at the upper-right-hand corner of the screen. The program searches both the provider registry and the larger vaccination registry and displays the vaccination status as having received no vaccine, having received one vaccine, or up to date. It asks, "Do you want to order the flu vaccine today?"

"Our providers wanted the alert to show up early in the visit, when the child’s record is opened, in order to integrate it into conversation with the parent," Dr. Stockwell said. "Doctors can ignore the message, order the vaccine, or document any reason why it wasn’t given. It’s not a forced action."

The alert also offers a look at the child’s overall immunization status, with the opportunity to order those vaccines. A "more info" button offers talking points that can be incorporated into a discussion about the importance of vaccinations.

The program was tested in a randomized study, with each clinic having an on and off period in two flu season phases (October through December and January through February).

When FluAlert was on, it fired for 8,630 visits, identifying the 62% of children who were not up to date on the vaccine. Most of those alerts (77%) came up during well-child and adolescent visits; 16% were acute care visits, 7% were visits specifically for vaccination, and the remaining visits were for Women, Infants, and Children program assessments. Providers acted on the alert 82% of the time: 53% ordered the vaccine. When they did not order the vaccine, providers noted the reason 98% of the time.

Overall, non–up-to-date children who were seen when FluAlert was on were 9% more likely to receive vaccine than children seen during an "off" period.

The program was also associated with significantly more documentation about why a child who needed the flu shot didn’t get it. In total, 625 children left the visit unvaccinated. When FluAlert was on, the reason for not vaccinating was noted for 68%; when it was off, documentation was present for only 41%.

The alert’s relative unobtrusiveness is probably one reason it was embraced as well as it was, Dr. Stockwell added. "What really annoys people is if something pops up and you can’t do anything else until you go through the entire process. So having it sit there as a gentle reminder is more appealing than something that’s always flashing and telling providers what to do."

Dr. Stockwell said she had no relevant financial disclosures

[email protected]

WASHINGTON – A pop-up on children’s electronic medical records was enough of a reminder to significantly increase influenza vaccine coverage in four large urban clinics, according to Dr. Melissa S. Stockwell.

"FluAlert" was built into the electronic medical record system and synchronized with the New York City vaccine registry. When it was activated during the winter flu season, children were 9% more likely to be fully vaccinated for influenza than when the reminder system wasn’t engaged, she said at the annual meeting of the Pediatric Academic Societies.

In addition to prompting physicians to vaccinate, the program allowed them to document reasons that the vaccine wasn’t given – a particularly valuable feature, said Dr. Stockwell, a pediatrician who is medical director of the New York–Presbyterian Hospital immunization registry.

"In this world of core measures, documentation of why a child is not vaccinated is becoming increasingly important," she said.

FluAlert was designed based on provider and parent focus groups, and implemented at four urban, community clinics that serve a primarily low-income Hispanic population. When the child’s electronic medical record opens, a FluAlert box appears at the upper-right-hand corner of the screen. The program searches both the provider registry and the larger vaccination registry and displays the vaccination status as having received no vaccine, having received one vaccine, or up to date. It asks, "Do you want to order the flu vaccine today?"

"Our providers wanted the alert to show up early in the visit, when the child’s record is opened, in order to integrate it into conversation with the parent," Dr. Stockwell said. "Doctors can ignore the message, order the vaccine, or document any reason why it wasn’t given. It’s not a forced action."

The alert also offers a look at the child’s overall immunization status, with the opportunity to order those vaccines. A "more info" button offers talking points that can be incorporated into a discussion about the importance of vaccinations.

The program was tested in a randomized study, with each clinic having an on and off period in two flu season phases (October through December and January through February).

When FluAlert was on, it fired for 8,630 visits, identifying the 62% of children who were not up to date on the vaccine. Most of those alerts (77%) came up during well-child and adolescent visits; 16% were acute care visits, 7% were visits specifically for vaccination, and the remaining visits were for Women, Infants, and Children program assessments. Providers acted on the alert 82% of the time: 53% ordered the vaccine. When they did not order the vaccine, providers noted the reason 98% of the time.

Overall, non–up-to-date children who were seen when FluAlert was on were 9% more likely to receive vaccine than children seen during an "off" period.

The program was also associated with significantly more documentation about why a child who needed the flu shot didn’t get it. In total, 625 children left the visit unvaccinated. When FluAlert was on, the reason for not vaccinating was noted for 68%; when it was off, documentation was present for only 41%.

The alert’s relative unobtrusiveness is probably one reason it was embraced as well as it was, Dr. Stockwell added. "What really annoys people is if something pops up and you can’t do anything else until you go through the entire process. So having it sit there as a gentle reminder is more appealing than something that’s always flashing and telling providers what to do."

Dr. Stockwell said she had no relevant financial disclosures

[email protected]

WASHINGTON – A pop-up on children’s electronic medical records was enough of a reminder to significantly increase influenza vaccine coverage in four large urban clinics, according to Dr. Melissa S. Stockwell.

"FluAlert" was built into the electronic medical record system and synchronized with the New York City vaccine registry. When it was activated during the winter flu season, children were 9% more likely to be fully vaccinated for influenza than when the reminder system wasn’t engaged, she said at the annual meeting of the Pediatric Academic Societies.

In addition to prompting physicians to vaccinate, the program allowed them to document reasons that the vaccine wasn’t given – a particularly valuable feature, said Dr. Stockwell, a pediatrician who is medical director of the New York–Presbyterian Hospital immunization registry.

"In this world of core measures, documentation of why a child is not vaccinated is becoming increasingly important," she said.

FluAlert was designed based on provider and parent focus groups, and implemented at four urban, community clinics that serve a primarily low-income Hispanic population. When the child’s electronic medical record opens, a FluAlert box appears at the upper-right-hand corner of the screen. The program searches both the provider registry and the larger vaccination registry and displays the vaccination status as having received no vaccine, having received one vaccine, or up to date. It asks, "Do you want to order the flu vaccine today?"

"Our providers wanted the alert to show up early in the visit, when the child’s record is opened, in order to integrate it into conversation with the parent," Dr. Stockwell said. "Doctors can ignore the message, order the vaccine, or document any reason why it wasn’t given. It’s not a forced action."

The alert also offers a look at the child’s overall immunization status, with the opportunity to order those vaccines. A "more info" button offers talking points that can be incorporated into a discussion about the importance of vaccinations.

The program was tested in a randomized study, with each clinic having an on and off period in two flu season phases (October through December and January through February).

When FluAlert was on, it fired for 8,630 visits, identifying the 62% of children who were not up to date on the vaccine. Most of those alerts (77%) came up during well-child and adolescent visits; 16% were acute care visits, 7% were visits specifically for vaccination, and the remaining visits were for Women, Infants, and Children program assessments. Providers acted on the alert 82% of the time: 53% ordered the vaccine. When they did not order the vaccine, providers noted the reason 98% of the time.

Overall, non–up-to-date children who were seen when FluAlert was on were 9% more likely to receive vaccine than children seen during an "off" period.

The program was also associated with significantly more documentation about why a child who needed the flu shot didn’t get it. In total, 625 children left the visit unvaccinated. When FluAlert was on, the reason for not vaccinating was noted for 68%; when it was off, documentation was present for only 41%.

The alert’s relative unobtrusiveness is probably one reason it was embraced as well as it was, Dr. Stockwell added. "What really annoys people is if something pops up and you can’t do anything else until you go through the entire process. So having it sit there as a gentle reminder is more appealing than something that’s always flashing and telling providers what to do."

Dr. Stockwell said she had no relevant financial disclosures

[email protected]

A universal decolonization strategy reduced the risk of methicillin-resistant Staphylococcus aureus infections by 37% in intensive care units – a significant improvement over the recommended strategy of targeting only carriers.

The protocol was easy – daily intranasal mupirocin and chlorhexidine skin washing – and cheap, with a total cost of about US$40 per patient, Dr. Susan S. Huang and her colleagues wrote in the May 29 issue of the New England Journal of Medicine.

But the finding should also be viewed with a note of caution, wrote Dr. Huang of the University of California Irvine.

Courtesy Janice Haney Carr/CDC

"Widespread use of chlorhexidine and mupirocin could possibly engender resistance," which has been reported in some prior studies of MRSA decolonization," she noted. A MRSA gene conferring chlorhexidine resistance has been found, but it’s still unclear whether it is clinically significant. "It will therefore be important for surveillance programs to monitor mupirocin and chlorhexidine resistance" (N. Engl. J. Med. 2013 [doi:10.1056/NEJMoa1207290])

The team studied three protocols designed to tamp down nosocomial MRSA infections: MRSA screening with isolation for positive patients; targeted isolation, with screening, isolating, and decolonizing of patients with MRSA; and universal decolonization of all patients.

The universal approach does not incorporate screening. Instead, commencing with admission to the ICU, every patient receives twice-daily intranasal mupirocin for 5 days and daily bathing with chlorhexidine-impregnated cloths for the entire ICU stay.

The study’s primary outcome was ICU-attributable MRSA positive cultures. Secondary outcomes were ICU-attributable MRSA bloodstream infections, and bloodstream infections caused by any other pathogen.

The authors randomized 43 hospitals (comprising 74 ICUs) to the protocols, which were employed in a total of 74,256 patients. These were a median of 65 years, with a variety of coexisting conditions, including diabetes (about 31%), renal failure (about 20%), cancer (about 11%), and liver failure (about 4%). About 10% had a past history of MRSA infection. The median ICU stay was 3 days, and the median hospital stay, 7 days.

The risk analysis compared each hospital’s results with its own baseline data. Universal decolonization was the most effective means of preventing MRSA-positive cultures, significantly reducing the risk of a MRSA-positive culture by 37% (odds ratio, 0.63). This result was significantly better than either the targeted screening protocol, which reduced the risk by 25% (OR, 0.75) or the screening/isolation protocol, which reduced the risk by 8% (OR 0.92).

There were no significant differences in the risk of MRSA bloodstream infections in any of the groups. However, the authors noted, universal decolonization was associated with a greater reduction than either screening/isolation or targeted decolonization’s (OR, 0.74 vs. 1.20 and 1.19, respectively).

Both universal and targeted decolonization significantly reduced the risk of a bloodstream infection caused by any pathogen (OR, 0.55 and 0.77, respectively). Screening/isolation did not significantly affect this outcome (OR, 0.98).

There were seven adverse events – two in the targeted decolonization and five in the targeted decolonization groups. All of these were skin reactions to the chlorhexidine bath and resolved when that was discontinued.

Although the authors said the intervention was inexpensive, they recommended a more-detailed cost analysis. Such a study would examine the US$40 per patient cost in light of cost reductions associated with cessation of screening, reduced isolation precautions, and reduced infections, and of the potentially increased costs associated with any emergence of resistant MRSA strains.

"It remains to be seen whether universal decolonization can obviate the need for all contact precautions for carriers of MRSA or other multidrug-resistant organisms," they added.

The study was funded by the U.S. Agency for Healthcare Research and Quality and the U.S. Centers for Disease Control and Prevention. Dr. Huang did not report having any financial disclosures, but several of the coauthors stated they had financial ties with Sage Products and Express Scripts.

A universal decolonization strategy reduced the risk of methicillin-resistant Staphylococcus aureus infections by 37% in intensive care units – a significant improvement over the recommended strategy of targeting only carriers.

The protocol was easy – daily intranasal mupirocin and chlorhexidine skin washing – and cheap, with a total cost of about US$40 per patient, Dr. Susan S. Huang and her colleagues wrote in the May 29 issue of the New England Journal of Medicine.

But the finding should also be viewed with a note of caution, wrote Dr. Huang of the University of California Irvine.

Courtesy Janice Haney Carr/CDC

"Widespread use of chlorhexidine and mupirocin could possibly engender resistance," which has been reported in some prior studies of MRSA decolonization," she noted. A MRSA gene conferring chlorhexidine resistance has been found, but it’s still unclear whether it is clinically significant. "It will therefore be important for surveillance programs to monitor mupirocin and chlorhexidine resistance" (N. Engl. J. Med. 2013 [doi:10.1056/NEJMoa1207290])

The team studied three protocols designed to tamp down nosocomial MRSA infections: MRSA screening with isolation for positive patients; targeted isolation, with screening, isolating, and decolonizing of patients with MRSA; and universal decolonization of all patients.

The universal approach does not incorporate screening. Instead, commencing with admission to the ICU, every patient receives twice-daily intranasal mupirocin for 5 days and daily bathing with chlorhexidine-impregnated cloths for the entire ICU stay.

The study’s primary outcome was ICU-attributable MRSA positive cultures. Secondary outcomes were ICU-attributable MRSA bloodstream infections, and bloodstream infections caused by any other pathogen.

The authors randomized 43 hospitals (comprising 74 ICUs) to the protocols, which were employed in a total of 74,256 patients. These were a median of 65 years, with a variety of coexisting conditions, including diabetes (about 31%), renal failure (about 20%), cancer (about 11%), and liver failure (about 4%). About 10% had a past history of MRSA infection. The median ICU stay was 3 days, and the median hospital stay, 7 days.

The risk analysis compared each hospital’s results with its own baseline data. Universal decolonization was the most effective means of preventing MRSA-positive cultures, significantly reducing the risk of a MRSA-positive culture by 37% (odds ratio, 0.63). This result was significantly better than either the targeted screening protocol, which reduced the risk by 25% (OR, 0.75) or the screening/isolation protocol, which reduced the risk by 8% (OR 0.92).

There were no significant differences in the risk of MRSA bloodstream infections in any of the groups. However, the authors noted, universal decolonization was associated with a greater reduction than either screening/isolation or targeted decolonization’s (OR, 0.74 vs. 1.20 and 1.19, respectively).

Both universal and targeted decolonization significantly reduced the risk of a bloodstream infection caused by any pathogen (OR, 0.55 and 0.77, respectively). Screening/isolation did not significantly affect this outcome (OR, 0.98).

There were seven adverse events – two in the targeted decolonization and five in the targeted decolonization groups. All of these were skin reactions to the chlorhexidine bath and resolved when that was discontinued.

Although the authors said the intervention was inexpensive, they recommended a more-detailed cost analysis. Such a study would examine the US$40 per patient cost in light of cost reductions associated with cessation of screening, reduced isolation precautions, and reduced infections, and of the potentially increased costs associated with any emergence of resistant MRSA strains.

"It remains to be seen whether universal decolonization can obviate the need for all contact precautions for carriers of MRSA or other multidrug-resistant organisms," they added.

The study was funded by the U.S. Agency for Healthcare Research and Quality and the U.S. Centers for Disease Control and Prevention. Dr. Huang did not report having any financial disclosures, but several of the coauthors stated they had financial ties with Sage Products and Express Scripts.

A universal decolonization strategy reduced the risk of methicillin-resistant Staphylococcus aureus infections by 37% in intensive care units – a significant improvement over the recommended strategy of targeting only carriers.

The protocol was easy – daily intranasal mupirocin and chlorhexidine skin washing – and cheap, with a total cost of about US$40 per patient, Dr. Susan S. Huang and her colleagues wrote in the May 29 issue of the New England Journal of Medicine.

But the finding should also be viewed with a note of caution, wrote Dr. Huang of the University of California Irvine.

Courtesy Janice Haney Carr/CDC

"Widespread use of chlorhexidine and mupirocin could possibly engender resistance," which has been reported in some prior studies of MRSA decolonization," she noted. A MRSA gene conferring chlorhexidine resistance has been found, but it’s still unclear whether it is clinically significant. "It will therefore be important for surveillance programs to monitor mupirocin and chlorhexidine resistance" (N. Engl. J. Med. 2013 [doi:10.1056/NEJMoa1207290])

The team studied three protocols designed to tamp down nosocomial MRSA infections: MRSA screening with isolation for positive patients; targeted isolation, with screening, isolating, and decolonizing of patients with MRSA; and universal decolonization of all patients.

The universal approach does not incorporate screening. Instead, commencing with admission to the ICU, every patient receives twice-daily intranasal mupirocin for 5 days and daily bathing with chlorhexidine-impregnated cloths for the entire ICU stay.

The study’s primary outcome was ICU-attributable MRSA positive cultures. Secondary outcomes were ICU-attributable MRSA bloodstream infections, and bloodstream infections caused by any other pathogen.

The authors randomized 43 hospitals (comprising 74 ICUs) to the protocols, which were employed in a total of 74,256 patients. These were a median of 65 years, with a variety of coexisting conditions, including diabetes (about 31%), renal failure (about 20%), cancer (about 11%), and liver failure (about 4%). About 10% had a past history of MRSA infection. The median ICU stay was 3 days, and the median hospital stay, 7 days.

The risk analysis compared each hospital’s results with its own baseline data. Universal decolonization was the most effective means of preventing MRSA-positive cultures, significantly reducing the risk of a MRSA-positive culture by 37% (odds ratio, 0.63). This result was significantly better than either the targeted screening protocol, which reduced the risk by 25% (OR, 0.75) or the screening/isolation protocol, which reduced the risk by 8% (OR 0.92).

There were no significant differences in the risk of MRSA bloodstream infections in any of the groups. However, the authors noted, universal decolonization was associated with a greater reduction than either screening/isolation or targeted decolonization’s (OR, 0.74 vs. 1.20 and 1.19, respectively).

Both universal and targeted decolonization significantly reduced the risk of a bloodstream infection caused by any pathogen (OR, 0.55 and 0.77, respectively). Screening/isolation did not significantly affect this outcome (OR, 0.98).

There were seven adverse events – two in the targeted decolonization and five in the targeted decolonization groups. All of these were skin reactions to the chlorhexidine bath and resolved when that was discontinued.

Although the authors said the intervention was inexpensive, they recommended a more-detailed cost analysis. Such a study would examine the US$40 per patient cost in light of cost reductions associated with cessation of screening, reduced isolation precautions, and reduced infections, and of the potentially increased costs associated with any emergence of resistant MRSA strains.

"It remains to be seen whether universal decolonization can obviate the need for all contact precautions for carriers of MRSA or other multidrug-resistant organisms," they added.

The study was funded by the U.S. Agency for Healthcare Research and Quality and the U.S. Centers for Disease Control and Prevention. Dr. Huang did not report having any financial disclosures, but several of the coauthors stated they had financial ties with Sage Products and Express Scripts.

Guidelines for fertility preservation in newly diagnosed cancer patients have been updated to include oocyte preservation as a standard practice rather than an experimental option, according to the American Society of Clinical Oncology.

With the exception of the recommendation on oocyte preservation, however, the update is essentially comparable to the one that ASCO issued in 2006. The latest guidelines also include literature updates used to create a framework for physician-patient discussions of fertility preservation. The guidelines appear in the May 28 online edition of the Journal of Clinical Oncology (doi: 10.1200/JCO.2013.49.2678).

The discussion of fertility preservation needs to occur early, as part of education and informed consent before treatment. "Current evidence suggests that discussions about fertility and fertility preservation are of great importance to patients with cancer," wrote Dr. Alison Loren, cochair of the guidelines update panel, and her colleagues. "Discussing infertility and introducing the possibility of fertility preservation lead to improved quality of life and diminished distress in all patient populations."

"It may be difficult for physicians to know how important fertility preservation is to their patients unless they ask, because many patients may not bring up the topic," wrote Dr. Loren of the University of Pennsylvania, Philadelphia, and her colleagues. "They may be overwhelmed by and focused exclusively on the cancer diagnosis, they may be unaware that potential fertility loss may occur, or they may be concerned that pursuing fertility preservation will delay their treatment, leading to increased morbidity or mortality."

"There is evidence to suggest that, at least among women, patients may make cancer treatment decisions based on fertility concerns. ... [In a recent study,] 29% of women with breast cancer reported that infertility concerns influenced their treatment decisions," the panel wrote.

The panel examined 18 recent randomized controlled trials; 6 systematic reviews, meta-analyses, and previous guidelines; and dozens of narrative reviews, case series, case studies, and editorials. From this review, they produced guidelines for fertility preservation in men, women, and post- and prepubertal children.

Such discussions should occur with all cancer patients of reproductive age (and with parents or guardians of children and adolescents) before treatment starts when infertility is a potential risk of therapy. Discussions should address whether fertility preservation might have an impact on successful cancer treatment. Those interested in fertility preservation, including ambivalent patients, should be referred to reproductive specialists and the discussion documented in the medical record. Distress about potential infertility warrants a referral to a psychosocial provider. Those who opt for fertility preservation should be encouraged to participate in registries and clinical studies.

For men

Men who choose to move ahead with sperm cryopreservation can usually do so expeditiously with no cancer treatment delay.

Sperm cryopreservation is the only established fertility preservation method; sperm is usually easy to obtain, and samples can be recovered every 24 hours. Testicular hormone suppression and testicular tissue or spermatogonial freezing for later transplanting – including testis xenografting – are experimental and unproven in humans. Men should be advised of a potentially higher risk of genetic damage in sperm collected after initiation of chemotherapy.

For women

"Fertility preservation options in females depend on patient age, diagnosis, type of treatment, presence or participation of a male partner, and/or patient preferences regarding the use of banked donor sperm, time available, and likelihood that cancer has metastasized to her ovaries," the panel wrote. Timing is an issue: Oocyte and embryo cryopreservation are proven methods, but the ovarian stimulation needed to accomplish these generally takes at least 2-4 weeks. Prior worries about hormonal stimulation and its possible effect on hormone-sensitive cancers have been somewhat allayed.

Letrozole combined with standard fertility drugs can induce ovulation without spiking estrogen; the number of eggs and embryos from these inductions appears no different from those obtained with traditional drugs.

Ovarian transposition (oophoropexy) is an option when pelvic radiation therapy is performed as cancer treatment.

Ovarian suppression with gonadotropin-releasing hormone agonists doesn’t seem to have any significant benefit in fertility preservation, according to the panel. No differences have been noted in post-treatment resumption of menstruation or in hormonal or imaging markers of fertility.

Ovarian tissue cryopreservation for the purpose of future transplantation is still experimental. At least 19 live births have been reported using frozen ovarian tissue transplanted after treatment. "There is a theoretic concern with re-implanting ovarian tissue and the potential for reintroducing cancer cells depending on the type and stage of cancer, although so far there have been no reports of cancer recurrence in humans."

For teens and children

Postpubertal adolescents can choose to freeze eggs or sperm, a process that requires consent from both the teen and the parents.

There are no standard options for preserving the fertility of prepubertal children; all approaches are experimental. There are some reports of oocyte cryopreservation in girls aged 13 years and older, but no reports of live births associated with later re-implantation.

Testicular tissue has also been frozen, but again, there are no reports of re-implantation.

"Efforts to preserve the fertility of children using experimental methods should be attempted only under institutional review board–approved protocols," the panel cautioned.

Data are lacking on the fertility impact of new biologic and targeted treatments, with the exceptions of bevacizumab and tyrosine kinase inhibitors.

In 2011, the Food and Drug Administration reported a 34% rate of ovarian failure in women who got bevacizumab as part of a colorectal cancer treatment regimen; 1 in 5 women regained ovarian function. This possible complication should be addressed with women.

Young patients taking tyrosine kinase inhibitors for chronic myeloid leukemia may also face later fertility problems, the panel noted, including an increased risk of complications in pregnancy or congenital anomalies. Data on these findings are incomplete, but patients should understand the possible risks, the panel wrote.

Supplements and clinical tools and resources can be found at www.asco.org/guidelines/fertility. Patient information is also available at www.cancer.net.

Neither Dr. Loren nor any of the other panel members had any financial disclosures.

[email protected]

Guidelines for fertility preservation in newly diagnosed cancer patients have been updated to include oocyte preservation as a standard practice rather than an experimental option, according to the American Society of Clinical Oncology.

With the exception of the recommendation on oocyte preservation, however, the update is essentially comparable to the one that ASCO issued in 2006. The latest guidelines also include literature updates used to create a framework for physician-patient discussions of fertility preservation. The guidelines appear in the May 28 online edition of the Journal of Clinical Oncology (doi: 10.1200/JCO.2013.49.2678).

The discussion of fertility preservation needs to occur early, as part of education and informed consent before treatment. "Current evidence suggests that discussions about fertility and fertility preservation are of great importance to patients with cancer," wrote Dr. Alison Loren, cochair of the guidelines update panel, and her colleagues. "Discussing infertility and introducing the possibility of fertility preservation lead to improved quality of life and diminished distress in all patient populations."

"It may be difficult for physicians to know how important fertility preservation is to their patients unless they ask, because many patients may not bring up the topic," wrote Dr. Loren of the University of Pennsylvania, Philadelphia, and her colleagues. "They may be overwhelmed by and focused exclusively on the cancer diagnosis, they may be unaware that potential fertility loss may occur, or they may be concerned that pursuing fertility preservation will delay their treatment, leading to increased morbidity or mortality."

"There is evidence to suggest that, at least among women, patients may make cancer treatment decisions based on fertility concerns. ... [In a recent study,] 29% of women with breast cancer reported that infertility concerns influenced their treatment decisions," the panel wrote.

The panel examined 18 recent randomized controlled trials; 6 systematic reviews, meta-analyses, and previous guidelines; and dozens of narrative reviews, case series, case studies, and editorials. From this review, they produced guidelines for fertility preservation in men, women, and post- and prepubertal children.

Such discussions should occur with all cancer patients of reproductive age (and with parents or guardians of children and adolescents) before treatment starts when infertility is a potential risk of therapy. Discussions should address whether fertility preservation might have an impact on successful cancer treatment. Those interested in fertility preservation, including ambivalent patients, should be referred to reproductive specialists and the discussion documented in the medical record. Distress about potential infertility warrants a referral to a psychosocial provider. Those who opt for fertility preservation should be encouraged to participate in registries and clinical studies.

For men

Men who choose to move ahead with sperm cryopreservation can usually do so expeditiously with no cancer treatment delay.

Sperm cryopreservation is the only established fertility preservation method; sperm is usually easy to obtain, and samples can be recovered every 24 hours. Testicular hormone suppression and testicular tissue or spermatogonial freezing for later transplanting – including testis xenografting – are experimental and unproven in humans. Men should be advised of a potentially higher risk of genetic damage in sperm collected after initiation of chemotherapy.

For women

"Fertility preservation options in females depend on patient age, diagnosis, type of treatment, presence or participation of a male partner, and/or patient preferences regarding the use of banked donor sperm, time available, and likelihood that cancer has metastasized to her ovaries," the panel wrote. Timing is an issue: Oocyte and embryo cryopreservation are proven methods, but the ovarian stimulation needed to accomplish these generally takes at least 2-4 weeks. Prior worries about hormonal stimulation and its possible effect on hormone-sensitive cancers have been somewhat allayed.

Letrozole combined with standard fertility drugs can induce ovulation without spiking estrogen; the number of eggs and embryos from these inductions appears no different from those obtained with traditional drugs.

Ovarian transposition (oophoropexy) is an option when pelvic radiation therapy is performed as cancer treatment.

Ovarian suppression with gonadotropin-releasing hormone agonists doesn’t seem to have any significant benefit in fertility preservation, according to the panel. No differences have been noted in post-treatment resumption of menstruation or in hormonal or imaging markers of fertility.

Ovarian tissue cryopreservation for the purpose of future transplantation is still experimental. At least 19 live births have been reported using frozen ovarian tissue transplanted after treatment. "There is a theoretic concern with re-implanting ovarian tissue and the potential for reintroducing cancer cells depending on the type and stage of cancer, although so far there have been no reports of cancer recurrence in humans."

For teens and children

Postpubertal adolescents can choose to freeze eggs or sperm, a process that requires consent from both the teen and the parents.

There are no standard options for preserving the fertility of prepubertal children; all approaches are experimental. There are some reports of oocyte cryopreservation in girls aged 13 years and older, but no reports of live births associated with later re-implantation.

Testicular tissue has also been frozen, but again, there are no reports of re-implantation.

"Efforts to preserve the fertility of children using experimental methods should be attempted only under institutional review board–approved protocols," the panel cautioned.

Data are lacking on the fertility impact of new biologic and targeted treatments, with the exceptions of bevacizumab and tyrosine kinase inhibitors.

In 2011, the Food and Drug Administration reported a 34% rate of ovarian failure in women who got bevacizumab as part of a colorectal cancer treatment regimen; 1 in 5 women regained ovarian function. This possible complication should be addressed with women.

Young patients taking tyrosine kinase inhibitors for chronic myeloid leukemia may also face later fertility problems, the panel noted, including an increased risk of complications in pregnancy or congenital anomalies. Data on these findings are incomplete, but patients should understand the possible risks, the panel wrote.

Supplements and clinical tools and resources can be found at www.asco.org/guidelines/fertility. Patient information is also available at www.cancer.net.

Neither Dr. Loren nor any of the other panel members had any financial disclosures.

[email protected]

Guidelines for fertility preservation in newly diagnosed cancer patients have been updated to include oocyte preservation as a standard practice rather than an experimental option, according to the American Society of Clinical Oncology.

With the exception of the recommendation on oocyte preservation, however, the update is essentially comparable to the one that ASCO issued in 2006. The latest guidelines also include literature updates used to create a framework for physician-patient discussions of fertility preservation. The guidelines appear in the May 28 online edition of the Journal of Clinical Oncology (doi: 10.1200/JCO.2013.49.2678).

The discussion of fertility preservation needs to occur early, as part of education and informed consent before treatment. "Current evidence suggests that discussions about fertility and fertility preservation are of great importance to patients with cancer," wrote Dr. Alison Loren, cochair of the guidelines update panel, and her colleagues. "Discussing infertility and introducing the possibility of fertility preservation lead to improved quality of life and diminished distress in all patient populations."

"It may be difficult for physicians to know how important fertility preservation is to their patients unless they ask, because many patients may not bring up the topic," wrote Dr. Loren of the University of Pennsylvania, Philadelphia, and her colleagues. "They may be overwhelmed by and focused exclusively on the cancer diagnosis, they may be unaware that potential fertility loss may occur, or they may be concerned that pursuing fertility preservation will delay their treatment, leading to increased morbidity or mortality."

"There is evidence to suggest that, at least among women, patients may make cancer treatment decisions based on fertility concerns. ... [In a recent study,] 29% of women with breast cancer reported that infertility concerns influenced their treatment decisions," the panel wrote.

The panel examined 18 recent randomized controlled trials; 6 systematic reviews, meta-analyses, and previous guidelines; and dozens of narrative reviews, case series, case studies, and editorials. From this review, they produced guidelines for fertility preservation in men, women, and post- and prepubertal children.

Such discussions should occur with all cancer patients of reproductive age (and with parents or guardians of children and adolescents) before treatment starts when infertility is a potential risk of therapy. Discussions should address whether fertility preservation might have an impact on successful cancer treatment. Those interested in fertility preservation, including ambivalent patients, should be referred to reproductive specialists and the discussion documented in the medical record. Distress about potential infertility warrants a referral to a psychosocial provider. Those who opt for fertility preservation should be encouraged to participate in registries and clinical studies.

For men

Men who choose to move ahead with sperm cryopreservation can usually do so expeditiously with no cancer treatment delay.

Sperm cryopreservation is the only established fertility preservation method; sperm is usually easy to obtain, and samples can be recovered every 24 hours. Testicular hormone suppression and testicular tissue or spermatogonial freezing for later transplanting – including testis xenografting – are experimental and unproven in humans. Men should be advised of a potentially higher risk of genetic damage in sperm collected after initiation of chemotherapy.

For women

"Fertility preservation options in females depend on patient age, diagnosis, type of treatment, presence or participation of a male partner, and/or patient preferences regarding the use of banked donor sperm, time available, and likelihood that cancer has metastasized to her ovaries," the panel wrote. Timing is an issue: Oocyte and embryo cryopreservation are proven methods, but the ovarian stimulation needed to accomplish these generally takes at least 2-4 weeks. Prior worries about hormonal stimulation and its possible effect on hormone-sensitive cancers have been somewhat allayed.

Letrozole combined with standard fertility drugs can induce ovulation without spiking estrogen; the number of eggs and embryos from these inductions appears no different from those obtained with traditional drugs.

Ovarian transposition (oophoropexy) is an option when pelvic radiation therapy is performed as cancer treatment.

Ovarian suppression with gonadotropin-releasing hormone agonists doesn’t seem to have any significant benefit in fertility preservation, according to the panel. No differences have been noted in post-treatment resumption of menstruation or in hormonal or imaging markers of fertility.

Ovarian tissue cryopreservation for the purpose of future transplantation is still experimental. At least 19 live births have been reported using frozen ovarian tissue transplanted after treatment. "There is a theoretic concern with re-implanting ovarian tissue and the potential for reintroducing cancer cells depending on the type and stage of cancer, although so far there have been no reports of cancer recurrence in humans."

For teens and children

Postpubertal adolescents can choose to freeze eggs or sperm, a process that requires consent from both the teen and the parents.

There are no standard options for preserving the fertility of prepubertal children; all approaches are experimental. There are some reports of oocyte cryopreservation in girls aged 13 years and older, but no reports of live births associated with later re-implantation.

Testicular tissue has also been frozen, but again, there are no reports of re-implantation.

"Efforts to preserve the fertility of children using experimental methods should be attempted only under institutional review board–approved protocols," the panel cautioned.

Data are lacking on the fertility impact of new biologic and targeted treatments, with the exceptions of bevacizumab and tyrosine kinase inhibitors.

In 2011, the Food and Drug Administration reported a 34% rate of ovarian failure in women who got bevacizumab as part of a colorectal cancer treatment regimen; 1 in 5 women regained ovarian function. This possible complication should be addressed with women.

Young patients taking tyrosine kinase inhibitors for chronic myeloid leukemia may also face later fertility problems, the panel noted, including an increased risk of complications in pregnancy or congenital anomalies. Data on these findings are incomplete, but patients should understand the possible risks, the panel wrote.

Supplements and clinical tools and resources can be found at www.asco.org/guidelines/fertility. Patient information is also available at www.cancer.net.

Neither Dr. Loren nor any of the other panel members had any financial disclosures.

[email protected]

WASHINGTON – New Zealand mothers who attended childbirth classes during pregnancy were 58% less likely to delay their infants’ first-year immunizations than were those who didn’t take the classes, Dr. Cameron Grant said at the annual meeting of the Pediatric Academic Societies.

The findings of his large prospective cohort study show that early engagement with a maternity clinician is important not only for mothers’ health, but for babies’ as well, said Dr. Grant of the University of Auckland (New Zealand).

The data were drawn from "Growing Up in New Zealand," a large, ongoing study of children’s health from birth to age 21 years; Dr. Grant is also the associate director of this project.

The birth cohort is culturally, racially, and economically diverse, and includes about one-third of the New Zealand births that occurred from April 2009 to March 2010. Mothers were contacted during their pregnancy and had face-to-face interviews when the infant was 6 weeks and 9 months old. There were also phone interviews at 16, 24, and 31 months. Four-year interviews started this year.

The immunization study included 6,822 mothers and their 6,846 children. It examined the links between infant immunization and the maternity care provided in the country. Typically, women attend childbirth preparation classes and their prenatal care is provided by a maternity clinician, usually a midwife. After birth, a community nurse provides well-child visits, but the mother and child return to their family doctor for immunizations. The New Zealand infant immunization series consists of the DTaP, hepatitis B/Hib, and conjugate pneumococcal vaccine, which are given at 6 weeks, 3 months, and 5 months. Delayed immunization was considered as not getting the 6-week immunizations by 8 weeks, or not getting the 3- or 5-month immunizations within 30 days of the due dates.

Mothers in the study are a diverse group, with 52% being white, 16% Maori, 14% Pacific Islanders, 14% Asian, and 4% other. Nearly a third was in the country’s lowest socioeconomic group. The pregnancy was the first for 42%.

Immunizations were delayed for 1,353 (20%) of the infants. Immunizations were on time for 88% of the women who attended childbirth classes, compared with 74% of those who did not, translating to a 62% risk reduction (odds ratio, 0.38).

A univariate analysis found several other significant predictors. Having a midwife significantly reduced the risk of delayed immunizations (OR, 0.43), as did going to any of the three infant well child visits (OR, 0.45).

However, after researchers adjusted for maternal ethnicity, age, and household income, only class attendance and well-child visits with a physician remained significantly associated with immunizations. Those who went to the class were 58% less likely to delay immunizations than were those who didn’t go to the class (OR, 0.42), and 24% less likely to delay than were those who had not gone to the class, but said they intended to (OR, 0.76). Women who visited their doctor for all three well-child visits were 55% less likely to delay immunizations (OR, 0.45).

During the discussion, Dr. Simon Hambidge, a professor at the Colorado School of Public Health, Denver, asked if the association could be a proxy for overall engagement with the health care system or an indicator of some more fundamental force influencing the decision to vaccinate.

"I really do think the health care system has a big role on whether immunization occurs or not," Dr. Grant said. "Moms from the poorest households had the highest intention to immunize their children, but the lowest actual immunization timeliness. I think that points to a number of barriers in health care that we should work hard to overcome, rather than just telling women it’s all up to them to get themselves organized and make sure it happens. We just have to make this more available."

The study is sponsored by a number of New Zealand and Pacific Island government agencies. Dr. Grant had no financial disclosures.

[email protected]

WASHINGTON – New Zealand mothers who attended childbirth classes during pregnancy were 58% less likely to delay their infants’ first-year immunizations than were those who didn’t take the classes, Dr. Cameron Grant said at the annual meeting of the Pediatric Academic Societies.

The findings of his large prospective cohort study show that early engagement with a maternity clinician is important not only for mothers’ health, but for babies’ as well, said Dr. Grant of the University of Auckland (New Zealand).

The data were drawn from "Growing Up in New Zealand," a large, ongoing study of children’s health from birth to age 21 years; Dr. Grant is also the associate director of this project.

The birth cohort is culturally, racially, and economically diverse, and includes about one-third of the New Zealand births that occurred from April 2009 to March 2010. Mothers were contacted during their pregnancy and had face-to-face interviews when the infant was 6 weeks and 9 months old. There were also phone interviews at 16, 24, and 31 months. Four-year interviews started this year.

The immunization study included 6,822 mothers and their 6,846 children. It examined the links between infant immunization and the maternity care provided in the country. Typically, women attend childbirth preparation classes and their prenatal care is provided by a maternity clinician, usually a midwife. After birth, a community nurse provides well-child visits, but the mother and child return to their family doctor for immunizations. The New Zealand infant immunization series consists of the DTaP, hepatitis B/Hib, and conjugate pneumococcal vaccine, which are given at 6 weeks, 3 months, and 5 months. Delayed immunization was considered as not getting the 6-week immunizations by 8 weeks, or not getting the 3- or 5-month immunizations within 30 days of the due dates.

Mothers in the study are a diverse group, with 52% being white, 16% Maori, 14% Pacific Islanders, 14% Asian, and 4% other. Nearly a third was in the country’s lowest socioeconomic group. The pregnancy was the first for 42%.

Immunizations were delayed for 1,353 (20%) of the infants. Immunizations were on time for 88% of the women who attended childbirth classes, compared with 74% of those who did not, translating to a 62% risk reduction (odds ratio, 0.38).

A univariate analysis found several other significant predictors. Having a midwife significantly reduced the risk of delayed immunizations (OR, 0.43), as did going to any of the three infant well child visits (OR, 0.45).

However, after researchers adjusted for maternal ethnicity, age, and household income, only class attendance and well-child visits with a physician remained significantly associated with immunizations. Those who went to the class were 58% less likely to delay immunizations than were those who didn’t go to the class (OR, 0.42), and 24% less likely to delay than were those who had not gone to the class, but said they intended to (OR, 0.76). Women who visited their doctor for all three well-child visits were 55% less likely to delay immunizations (OR, 0.45).

During the discussion, Dr. Simon Hambidge, a professor at the Colorado School of Public Health, Denver, asked if the association could be a proxy for overall engagement with the health care system or an indicator of some more fundamental force influencing the decision to vaccinate.

"I really do think the health care system has a big role on whether immunization occurs or not," Dr. Grant said. "Moms from the poorest households had the highest intention to immunize their children, but the lowest actual immunization timeliness. I think that points to a number of barriers in health care that we should work hard to overcome, rather than just telling women it’s all up to them to get themselves organized and make sure it happens. We just have to make this more available."

The study is sponsored by a number of New Zealand and Pacific Island government agencies. Dr. Grant had no financial disclosures.

[email protected]

WASHINGTON – New Zealand mothers who attended childbirth classes during pregnancy were 58% less likely to delay their infants’ first-year immunizations than were those who didn’t take the classes, Dr. Cameron Grant said at the annual meeting of the Pediatric Academic Societies.

The findings of his large prospective cohort study show that early engagement with a maternity clinician is important not only for mothers’ health, but for babies’ as well, said Dr. Grant of the University of Auckland (New Zealand).

The data were drawn from "Growing Up in New Zealand," a large, ongoing study of children’s health from birth to age 21 years; Dr. Grant is also the associate director of this project.

The birth cohort is culturally, racially, and economically diverse, and includes about one-third of the New Zealand births that occurred from April 2009 to March 2010. Mothers were contacted during their pregnancy and had face-to-face interviews when the infant was 6 weeks and 9 months old. There were also phone interviews at 16, 24, and 31 months. Four-year interviews started this year.

The immunization study included 6,822 mothers and their 6,846 children. It examined the links between infant immunization and the maternity care provided in the country. Typically, women attend childbirth preparation classes and their prenatal care is provided by a maternity clinician, usually a midwife. After birth, a community nurse provides well-child visits, but the mother and child return to their family doctor for immunizations. The New Zealand infant immunization series consists of the DTaP, hepatitis B/Hib, and conjugate pneumococcal vaccine, which are given at 6 weeks, 3 months, and 5 months. Delayed immunization was considered as not getting the 6-week immunizations by 8 weeks, or not getting the 3- or 5-month immunizations within 30 days of the due dates.

Mothers in the study are a diverse group, with 52% being white, 16% Maori, 14% Pacific Islanders, 14% Asian, and 4% other. Nearly a third was in the country’s lowest socioeconomic group. The pregnancy was the first for 42%.

Immunizations were delayed for 1,353 (20%) of the infants. Immunizations were on time for 88% of the women who attended childbirth classes, compared with 74% of those who did not, translating to a 62% risk reduction (odds ratio, 0.38).

A univariate analysis found several other significant predictors. Having a midwife significantly reduced the risk of delayed immunizations (OR, 0.43), as did going to any of the three infant well child visits (OR, 0.45).

However, after researchers adjusted for maternal ethnicity, age, and household income, only class attendance and well-child visits with a physician remained significantly associated with immunizations. Those who went to the class were 58% less likely to delay immunizations than were those who didn’t go to the class (OR, 0.42), and 24% less likely to delay than were those who had not gone to the class, but said they intended to (OR, 0.76). Women who visited their doctor for all three well-child visits were 55% less likely to delay immunizations (OR, 0.45).

During the discussion, Dr. Simon Hambidge, a professor at the Colorado School of Public Health, Denver, asked if the association could be a proxy for overall engagement with the health care system or an indicator of some more fundamental force influencing the decision to vaccinate.

"I really do think the health care system has a big role on whether immunization occurs or not," Dr. Grant said. "Moms from the poorest households had the highest intention to immunize their children, but the lowest actual immunization timeliness. I think that points to a number of barriers in health care that we should work hard to overcome, rather than just telling women it’s all up to them to get themselves organized and make sure it happens. We just have to make this more available."

The study is sponsored by a number of New Zealand and Pacific Island government agencies. Dr. Grant had no financial disclosures.

[email protected]

WASHINGTON – Children with hypertension performed worse on tests of attention, and verbal and visual recall, according to some early findings of an ongoing study.

A low socioeconomic status seemed to amplify those problems, putting some children at an even higher risk, Dr. Marc Lande said at the annual meeting of the Pediatric Academic Societies.

"These baseline data don’t tell us why these differences occur," he said in an interview. "It is possible that the hypertension itself is causing a problem since we know that the brain is a target organ of hypertension. However, it is also possible that children with cognitive problems are more prone to develop hypertension."

He and his colleagues shared some baseline data from their prospective, multicenter study of neurocognition in children with primary hypertension. The study will eventually enroll 75 children with newly diagnosed primary hypertension and 75 matched normotensive controls. At baseline, both groups will have the same neurocognitive tests. During the following year, the hypertensive children will be treated with lifestyle management and angiotensin-converting enzyme inhibitors, if needed. After a year, all of the children will repeat the same neurocognitive tests.

So far, the cohort includes 37 children with hypertension and 24 controls. Their mean age is 15 years; about half of each group has mothers with less than a high school education – a measure used to indicate lower socioeconomic status. Obesity is present in 70% of the hypertensive group and 58% of the normotensive group. There are no significant differences in IQ, said Dr. Lande, a pediatric nephrologist at University of Rochester (N.Y.) Medical Center.

All of the children had 24-hour ambulatory blood pressure monitoring at baseline. The mean 24-hour systolic blood pressure load was 50% in the hypertensive group and 7% in the normotensive group. The mean 24-hour diastolic load was 22% in the hypertensive group and 5% in the normotensive group – despite the fact that almost 60% of these children were obese.

Dr. Lande presented his baseline data, showing that children in the hypertensive group were already experiencing some neurocognitive differences, compared with the control group.

On the baseline neurocognitive tests, children with hypertension scored worse than the controls on the Rey Auditory Verbal Learning Test (RAVLT) and the Conners’ Continuous Performance Test II (CPT II), although scores on the Spatial Span Forward (SSF) test were not markedly different.

When the comparison was limited to those children with less-educated mothers, the CPT II and SSF performance differences were amplified. The RAVLT performance was largely unaffected.

Findings were similar on three tests of executive function - the CPT II Commissions, Digit Span Backward, and Parent BRIEF Global Executive Composite – with hypertensive children performing worse on all three. When the analysis was limited to children of lower socioeconomic status, the difference was amplified, increasing from a small to moderate or moderate to large effect size.

There were four tests of memory: the RAVLT Short and Long Delay tests, the RAVLT List A Recognition test, and the CogState Maze Long Delay Recall. Overall, children with hypertension had worse performance, with effect sizes ranging from small to large. And again, when the investigators looked only at those children with low maternal education, the effect size between the groups increased. The impact seemed strongest on the RAVLT Recognition Test, in which the effect size increased from small to large.

The baseline findings were unadjusted for any other factors that might influence cognition, Dr. Lande noted. However, they do speak to the need for physicians who treat these children to be aware of the potential for learning problems, especially among children with lower socioeconomic status.

"These results are preliminary findings, which will be further elucidated as the study enrollment goes forward," he said. "We don’t know their clinical significance yet. Until they become more clear, though, clinicians should be aware of the possibility of increased learning problems in their patients with hypertension."

Dr. Lande said he had no financial disclosures

[email protected]

WASHINGTON – Children with hypertension performed worse on tests of attention, and verbal and visual recall, according to some early findings of an ongoing study.

A low socioeconomic status seemed to amplify those problems, putting some children at an even higher risk, Dr. Marc Lande said at the annual meeting of the Pediatric Academic Societies.

"These baseline data don’t tell us why these differences occur," he said in an interview. "It is possible that the hypertension itself is causing a problem since we know that the brain is a target organ of hypertension. However, it is also possible that children with cognitive problems are more prone to develop hypertension."

He and his colleagues shared some baseline data from their prospective, multicenter study of neurocognition in children with primary hypertension. The study will eventually enroll 75 children with newly diagnosed primary hypertension and 75 matched normotensive controls. At baseline, both groups will have the same neurocognitive tests. During the following year, the hypertensive children will be treated with lifestyle management and angiotensin-converting enzyme inhibitors, if needed. After a year, all of the children will repeat the same neurocognitive tests.

So far, the cohort includes 37 children with hypertension and 24 controls. Their mean age is 15 years; about half of each group has mothers with less than a high school education – a measure used to indicate lower socioeconomic status. Obesity is present in 70% of the hypertensive group and 58% of the normotensive group. There are no significant differences in IQ, said Dr. Lande, a pediatric nephrologist at University of Rochester (N.Y.) Medical Center.

All of the children had 24-hour ambulatory blood pressure monitoring at baseline. The mean 24-hour systolic blood pressure load was 50% in the hypertensive group and 7% in the normotensive group. The mean 24-hour diastolic load was 22% in the hypertensive group and 5% in the normotensive group – despite the fact that almost 60% of these children were obese.

Dr. Lande presented his baseline data, showing that children in the hypertensive group were already experiencing some neurocognitive differences, compared with the control group.

On the baseline neurocognitive tests, children with hypertension scored worse than the controls on the Rey Auditory Verbal Learning Test (RAVLT) and the Conners’ Continuous Performance Test II (CPT II), although scores on the Spatial Span Forward (SSF) test were not markedly different.

When the comparison was limited to those children with less-educated mothers, the CPT II and SSF performance differences were amplified. The RAVLT performance was largely unaffected.

Findings were similar on three tests of executive function - the CPT II Commissions, Digit Span Backward, and Parent BRIEF Global Executive Composite – with hypertensive children performing worse on all three. When the analysis was limited to children of lower socioeconomic status, the difference was amplified, increasing from a small to moderate or moderate to large effect size.

There were four tests of memory: the RAVLT Short and Long Delay tests, the RAVLT List A Recognition test, and the CogState Maze Long Delay Recall. Overall, children with hypertension had worse performance, with effect sizes ranging from small to large. And again, when the investigators looked only at those children with low maternal education, the effect size between the groups increased. The impact seemed strongest on the RAVLT Recognition Test, in which the effect size increased from small to large.

The baseline findings were unadjusted for any other factors that might influence cognition, Dr. Lande noted. However, they do speak to the need for physicians who treat these children to be aware of the potential for learning problems, especially among children with lower socioeconomic status.

"These results are preliminary findings, which will be further elucidated as the study enrollment goes forward," he said. "We don’t know their clinical significance yet. Until they become more clear, though, clinicians should be aware of the possibility of increased learning problems in their patients with hypertension."

Dr. Lande said he had no financial disclosures

[email protected]

WASHINGTON – Children with hypertension performed worse on tests of attention, and verbal and visual recall, according to some early findings of an ongoing study.

A low socioeconomic status seemed to amplify those problems, putting some children at an even higher risk, Dr. Marc Lande said at the annual meeting of the Pediatric Academic Societies.

"These baseline data don’t tell us why these differences occur," he said in an interview. "It is possible that the hypertension itself is causing a problem since we know that the brain is a target organ of hypertension. However, it is also possible that children with cognitive problems are more prone to develop hypertension."

He and his colleagues shared some baseline data from their prospective, multicenter study of neurocognition in children with primary hypertension. The study will eventually enroll 75 children with newly diagnosed primary hypertension and 75 matched normotensive controls. At baseline, both groups will have the same neurocognitive tests. During the following year, the hypertensive children will be treated with lifestyle management and angiotensin-converting enzyme inhibitors, if needed. After a year, all of the children will repeat the same neurocognitive tests.

So far, the cohort includes 37 children with hypertension and 24 controls. Their mean age is 15 years; about half of each group has mothers with less than a high school education – a measure used to indicate lower socioeconomic status. Obesity is present in 70% of the hypertensive group and 58% of the normotensive group. There are no significant differences in IQ, said Dr. Lande, a pediatric nephrologist at University of Rochester (N.Y.) Medical Center.

All of the children had 24-hour ambulatory blood pressure monitoring at baseline. The mean 24-hour systolic blood pressure load was 50% in the hypertensive group and 7% in the normotensive group. The mean 24-hour diastolic load was 22% in the hypertensive group and 5% in the normotensive group – despite the fact that almost 60% of these children were obese.

Dr. Lande presented his baseline data, showing that children in the hypertensive group were already experiencing some neurocognitive differences, compared with the control group.

On the baseline neurocognitive tests, children with hypertension scored worse than the controls on the Rey Auditory Verbal Learning Test (RAVLT) and the Conners’ Continuous Performance Test II (CPT II), although scores on the Spatial Span Forward (SSF) test were not markedly different.

When the comparison was limited to those children with less-educated mothers, the CPT II and SSF performance differences were amplified. The RAVLT performance was largely unaffected.

Findings were similar on three tests of executive function - the CPT II Commissions, Digit Span Backward, and Parent BRIEF Global Executive Composite – with hypertensive children performing worse on all three. When the analysis was limited to children of lower socioeconomic status, the difference was amplified, increasing from a small to moderate or moderate to large effect size.

There were four tests of memory: the RAVLT Short and Long Delay tests, the RAVLT List A Recognition test, and the CogState Maze Long Delay Recall. Overall, children with hypertension had worse performance, with effect sizes ranging from small to large. And again, when the investigators looked only at those children with low maternal education, the effect size between the groups increased. The impact seemed strongest on the RAVLT Recognition Test, in which the effect size increased from small to large.

The baseline findings were unadjusted for any other factors that might influence cognition, Dr. Lande noted. However, they do speak to the need for physicians who treat these children to be aware of the potential for learning problems, especially among children with lower socioeconomic status.

"These results are preliminary findings, which will be further elucidated as the study enrollment goes forward," he said. "We don’t know their clinical significance yet. Until they become more clear, though, clinicians should be aware of the possibility of increased learning problems in their patients with hypertension."

Dr. Lande said he had no financial disclosures

[email protected]

Half of patients admitted to U.S. hospitals for nonsurgical reasons were given opioids during their stay, according to a large national database review.

The medications were also given in relatively high doses – a mean of 70 mg oral morphine equivalents daily overall, but 100 mg or higher in about a quarter of patients, Dr. Shoshana Herzig said at the annual meeting of the Society of Hospital Medicine.

"Given the prevalence of high-dose exposure, the known risks of these drugs, and the older age of many recipients, opportunities exist to make opioid use safer in patients," said Dr. Herzig of Beth Israel Deaconess Medical Center, Boston.

Courtesy BIDMC

Dr. Herzig used data extracted from a large, national hospital database. The database contains administrative information from 600 U.S. hospitals, and reflects about 25% of the nation’s annual hospital discharges.

For this analysis, she selected 1.14 million nonsurgical admissions that occurred among 286 hospitals from July 2009 to June 2010. Opioid exposure was defined as at least one charge for an opioid medication during the admission or on the day of discharge. The database does not provide information about discharge prescriptions, nor does it describe in detail the pain complaint associated with the charge.

The patients’ median age was 64 years; 46% were male. Morphine was the most commonly prescribed (20%), followed by hydrocodone (14%), and hydromorphone (13%). Patients received the drugs parenterally (66%), orally (65%), or both.

Overall, opioids were used in 51% of admissions, including 45% of patients aged 65 years and older. Many patients (43%) received two or more different opioids. More than half of those who took the drugs during their stay (52%) also had them on the day of discharge.

The observed rate of opioid use varied considerably among the hospitals, ranging from 5% in the lowest-prescribing hospital to 72% in the highest-prescribing hospital, with a mean of 51%.

Dr. Herzig found regional differences as well, with the highest use in Western states (55% of all admissions), followed by Southern states (53% of admissions), the Midwest (50%), and the Northeast (39%).

A multivariate analysis that controlled for patient demographics, comorbidities, and hospital characteristics found a number of significant associations with opioid use.

Compared with whites and Hispanics, black patients were less likely to receive the drugs (odds ratio, 0.93). Patients with musculoskeletal injuries were most likely to receive opioids (OR, 2.0), as were patients with cancer (OR, 1.2). Psychiatric and alcohol admissions were significantly less likely to get opioids (OR, 0.37 and 0.46, respectively), but there was no significant relationship with an admission for substance abuse.

Some typically painful procedures significantly predicted opioid use, including cardiovascular procedures (OR, 1.8), gastrointestinal procedures (OR, 1.7), and mechanical ventilation (OR, 1.4).

The analysis didn’t allow any conclusions to be drawn about causality, Dr. Herzig said, but the findings call for more research. "Increased attention should be paid to the role that inpatient opioid prescribing plays in the increased rates of chronic opioid use and overdose-related deaths in the United States."

Dr. Herzig had no financial declarations.

[email protected]

Half of patients admitted to U.S. hospitals for nonsurgical reasons were given opioids during their stay, according to a large national database review.

The medications were also given in relatively high doses – a mean of 70 mg oral morphine equivalents daily overall, but 100 mg or higher in about a quarter of patients, Dr. Shoshana Herzig said at the annual meeting of the Society of Hospital Medicine.

"Given the prevalence of high-dose exposure, the known risks of these drugs, and the older age of many recipients, opportunities exist to make opioid use safer in patients," said Dr. Herzig of Beth Israel Deaconess Medical Center, Boston.

Courtesy BIDMC

Dr. Herzig used data extracted from a large, national hospital database. The database contains administrative information from 600 U.S. hospitals, and reflects about 25% of the nation’s annual hospital discharges.

For this analysis, she selected 1.14 million nonsurgical admissions that occurred among 286 hospitals from July 2009 to June 2010. Opioid exposure was defined as at least one charge for an opioid medication during the admission or on the day of discharge. The database does not provide information about discharge prescriptions, nor does it describe in detail the pain complaint associated with the charge.

The patients’ median age was 64 years; 46% were male. Morphine was the most commonly prescribed (20%), followed by hydrocodone (14%), and hydromorphone (13%). Patients received the drugs parenterally (66%), orally (65%), or both.

Overall, opioids were used in 51% of admissions, including 45% of patients aged 65 years and older. Many patients (43%) received two or more different opioids. More than half of those who took the drugs during their stay (52%) also had them on the day of discharge.

The observed rate of opioid use varied considerably among the hospitals, ranging from 5% in the lowest-prescribing hospital to 72% in the highest-prescribing hospital, with a mean of 51%.

Dr. Herzig found regional differences as well, with the highest use in Western states (55% of all admissions), followed by Southern states (53% of admissions), the Midwest (50%), and the Northeast (39%).

A multivariate analysis that controlled for patient demographics, comorbidities, and hospital characteristics found a number of significant associations with opioid use.

Compared with whites and Hispanics, black patients were less likely to receive the drugs (odds ratio, 0.93). Patients with musculoskeletal injuries were most likely to receive opioids (OR, 2.0), as were patients with cancer (OR, 1.2). Psychiatric and alcohol admissions were significantly less likely to get opioids (OR, 0.37 and 0.46, respectively), but there was no significant relationship with an admission for substance abuse.

Some typically painful procedures significantly predicted opioid use, including cardiovascular procedures (OR, 1.8), gastrointestinal procedures (OR, 1.7), and mechanical ventilation (OR, 1.4).

The analysis didn’t allow any conclusions to be drawn about causality, Dr. Herzig said, but the findings call for more research. "Increased attention should be paid to the role that inpatient opioid prescribing plays in the increased rates of chronic opioid use and overdose-related deaths in the United States."

Dr. Herzig had no financial declarations.

[email protected]

Half of patients admitted to U.S. hospitals for nonsurgical reasons were given opioids during their stay, according to a large national database review.

The medications were also given in relatively high doses – a mean of 70 mg oral morphine equivalents daily overall, but 100 mg or higher in about a quarter of patients, Dr. Shoshana Herzig said at the annual meeting of the Society of Hospital Medicine.

"Given the prevalence of high-dose exposure, the known risks of these drugs, and the older age of many recipients, opportunities exist to make opioid use safer in patients," said Dr. Herzig of Beth Israel Deaconess Medical Center, Boston.

Courtesy BIDMC

Dr. Herzig used data extracted from a large, national hospital database. The database contains administrative information from 600 U.S. hospitals, and reflects about 25% of the nation’s annual hospital discharges.

For this analysis, she selected 1.14 million nonsurgical admissions that occurred among 286 hospitals from July 2009 to June 2010. Opioid exposure was defined as at least one charge for an opioid medication during the admission or on the day of discharge. The database does not provide information about discharge prescriptions, nor does it describe in detail the pain complaint associated with the charge.

The patients’ median age was 64 years; 46% were male. Morphine was the most commonly prescribed (20%), followed by hydrocodone (14%), and hydromorphone (13%). Patients received the drugs parenterally (66%), orally (65%), or both.

Overall, opioids were used in 51% of admissions, including 45% of patients aged 65 years and older. Many patients (43%) received two or more different opioids. More than half of those who took the drugs during their stay (52%) also had them on the day of discharge.

The observed rate of opioid use varied considerably among the hospitals, ranging from 5% in the lowest-prescribing hospital to 72% in the highest-prescribing hospital, with a mean of 51%.

Dr. Herzig found regional differences as well, with the highest use in Western states (55% of all admissions), followed by Southern states (53% of admissions), the Midwest (50%), and the Northeast (39%).

A multivariate analysis that controlled for patient demographics, comorbidities, and hospital characteristics found a number of significant associations with opioid use.

Compared with whites and Hispanics, black patients were less likely to receive the drugs (odds ratio, 0.93). Patients with musculoskeletal injuries were most likely to receive opioids (OR, 2.0), as were patients with cancer (OR, 1.2). Psychiatric and alcohol admissions were significantly less likely to get opioids (OR, 0.37 and 0.46, respectively), but there was no significant relationship with an admission for substance abuse.

Some typically painful procedures significantly predicted opioid use, including cardiovascular procedures (OR, 1.8), gastrointestinal procedures (OR, 1.7), and mechanical ventilation (OR, 1.4).

The analysis didn’t allow any conclusions to be drawn about causality, Dr. Herzig said, but the findings call for more research. "Increased attention should be paid to the role that inpatient opioid prescribing plays in the increased rates of chronic opioid use and overdose-related deaths in the United States."

Dr. Herzig had no financial declarations.

[email protected]

NATIONAL HARBOR, MD. – A project aimed at improving the transition of care from hospitals to outpatient facilities significantly reduced 30-day readmission rates in a group of Illinois hospitals.

Hospitals that adopted the Project BOOST protocol also improved several quality measures of their discharge process, Dr. Jing Li said at the annual meeting of the Society of Hospital Medicine.

Project BOOST (Better Outcomes by Optimizing Safe Transitions) is a patient-centered, multicomponent intervention designed to enhance the hospital discharge transition. Integration of BOOST tools into the discharge process at a hospital is facilitated by physician-mentored implementation that provides expertise in care transitions, quality improvement, and outside support for internal change.

In 2011, a statewide survey determined that Illinois hospitals fell into the bottom quartile for 30-day readmission rates of Medicare beneficiaries when compared with other U.S. hospitals. In response to that report, BlueCross BlueShield of Illinois, the Illinois Hospital Association, and Northwestern University, Chicago, entered into the Project BOOST program to enhance care for patients at hospitals all across the state, said Dr. Li, director of Project BOOST at the university.

The pilot cohort in Illinois consisted of 14 hospitals, all of which received mentored implementation with coaching, monthly teleconferences, and regular data collection. Dr. Li presented results for six of these, because the other eight lacked adequate means of data collection during that first wave.

Of the six hospitals, five were community, nonteaching facilities; the other was also a community hospital, but it had a teaching component. Four of the facilities were urban, one suburban, and one rural. The mean bed size was 343, but that ranged from 255 to 501.

The midyear implementation survey showed 79% of BOOST teams implemented comprehensive patient readmission risk assessment; 57% implemented the discharge checklist; 79% started to use teach-back for patient and family education; 79% established mechanisms to ensure information was available to subacute providers at the time of discharge; and all hospitals conducted follow-up phone calls to more than 60% of their discharged patients.

The six hospitals for which BOOST and comparison unit data were available experienced a 25% relative reduction in 30-day readmission rates (from 16% to 12%), with a significant downward trend over time. Over the same period, the 30-day readmission rate in comparison units remained flat.

The program is now being implemented in 22 more facilities across the state, Dr. Li said.

The project is being funded by BlueCross BlueShield of Illinois. Dr. Li had no financial disclosures.

[email protected]

NATIONAL HARBOR, MD. – A project aimed at improving the transition of care from hospitals to outpatient facilities significantly reduced 30-day readmission rates in a group of Illinois hospitals.

Hospitals that adopted the Project BOOST protocol also improved several quality measures of their discharge process, Dr. Jing Li said at the annual meeting of the Society of Hospital Medicine.

Project BOOST (Better Outcomes by Optimizing Safe Transitions) is a patient-centered, multicomponent intervention designed to enhance the hospital discharge transition. Integration of BOOST tools into the discharge process at a hospital is facilitated by physician-mentored implementation that provides expertise in care transitions, quality improvement, and outside support for internal change.

In 2011, a statewide survey determined that Illinois hospitals fell into the bottom quartile for 30-day readmission rates of Medicare beneficiaries when compared with other U.S. hospitals. In response to that report, BlueCross BlueShield of Illinois, the Illinois Hospital Association, and Northwestern University, Chicago, entered into the Project BOOST program to enhance care for patients at hospitals all across the state, said Dr. Li, director of Project BOOST at the university.

The pilot cohort in Illinois consisted of 14 hospitals, all of which received mentored implementation with coaching, monthly teleconferences, and regular data collection. Dr. Li presented results for six of these, because the other eight lacked adequate means of data collection during that first wave.

Of the six hospitals, five were community, nonteaching facilities; the other was also a community hospital, but it had a teaching component. Four of the facilities were urban, one suburban, and one rural. The mean bed size was 343, but that ranged from 255 to 501.

The midyear implementation survey showed 79% of BOOST teams implemented comprehensive patient readmission risk assessment; 57% implemented the discharge checklist; 79% started to use teach-back for patient and family education; 79% established mechanisms to ensure information was available to subacute providers at the time of discharge; and all hospitals conducted follow-up phone calls to more than 60% of their discharged patients.

The six hospitals for which BOOST and comparison unit data were available experienced a 25% relative reduction in 30-day readmission rates (from 16% to 12%), with a significant downward trend over time. Over the same period, the 30-day readmission rate in comparison units remained flat.

The program is now being implemented in 22 more facilities across the state, Dr. Li said.

The project is being funded by BlueCross BlueShield of Illinois. Dr. Li had no financial disclosures.

[email protected]

NATIONAL HARBOR, MD. – A project aimed at improving the transition of care from hospitals to outpatient facilities significantly reduced 30-day readmission rates in a group of Illinois hospitals.

Hospitals that adopted the Project BOOST protocol also improved several quality measures of their discharge process, Dr. Jing Li said at the annual meeting of the Society of Hospital Medicine.

Project BOOST (Better Outcomes by Optimizing Safe Transitions) is a patient-centered, multicomponent intervention designed to enhance the hospital discharge transition. Integration of BOOST tools into the discharge process at a hospital is facilitated by physician-mentored implementation that provides expertise in care transitions, quality improvement, and outside support for internal change.

In 2011, a statewide survey determined that Illinois hospitals fell into the bottom quartile for 30-day readmission rates of Medicare beneficiaries when compared with other U.S. hospitals. In response to that report, BlueCross BlueShield of Illinois, the Illinois Hospital Association, and Northwestern University, Chicago, entered into the Project BOOST program to enhance care for patients at hospitals all across the state, said Dr. Li, director of Project BOOST at the university.

The pilot cohort in Illinois consisted of 14 hospitals, all of which received mentored implementation with coaching, monthly teleconferences, and regular data collection. Dr. Li presented results for six of these, because the other eight lacked adequate means of data collection during that first wave.

Of the six hospitals, five were community, nonteaching facilities; the other was also a community hospital, but it had a teaching component. Four of the facilities were urban, one suburban, and one rural. The mean bed size was 343, but that ranged from 255 to 501.

The midyear implementation survey showed 79% of BOOST teams implemented comprehensive patient readmission risk assessment; 57% implemented the discharge checklist; 79% started to use teach-back for patient and family education; 79% established mechanisms to ensure information was available to subacute providers at the time of discharge; and all hospitals conducted follow-up phone calls to more than 60% of their discharged patients.

The six hospitals for which BOOST and comparison unit data were available experienced a 25% relative reduction in 30-day readmission rates (from 16% to 12%), with a significant downward trend over time. Over the same period, the 30-day readmission rate in comparison units remained flat.

The program is now being implemented in 22 more facilities across the state, Dr. Li said.

The project is being funded by BlueCross BlueShield of Illinois. Dr. Li had no financial disclosures.

[email protected]

NATIONAL HARBOR, MD. – A hospital-wide rapid response protocol decreased the time to antibiotic administration and improved sepsis bundle compliance by creating a team approach to sepsis management.

Creating "Code Sepsis" involved every member of the clinical care team, from nursing assistants to attending physicians, Dr. Catherine Jones said at the annual meeting of the Society of Hospital Medicine. The pilot project has been so successful that it’s being implemented in other units of Wake Forest Baptist Medical Center, Winston-Salem, N.C.

"We’ve started a modified version of it in our surgical intensive care units and, in April, our emergency department rolled out this exact same process. Our goal is to roll it out throughout the organization, including our comprehensive cancer center, because it’s not unusual for patients to show up in clinic with severe sepsis," said Dr. Jones, a patient safety and hospital quality expert at the group.

The incidence of sepsis has been on an upward trajectory since 2000, she said, because of a variety of factors. An aging population and the more frequent use of invasive procedures, chemotherapy, and immunosuppressive drugs probably all contribute to the problem. Patients who develop sepsis are eight times more likely to die during a hospital admission.

The good news is that the international "Surviving Sepsis" campaign, which advocated a resuscitation bundle approach designed for early intervention, does seem to be making a difference in outcomes since it was inaugurated in 2002.

The key element seems to be the earlier timing of antibiotic delivery, with an estimate of one patient saved for every seven bundles implemented, Dr. Jones said.

"The problem is that, on the floor, early recognition of sepsis is difficult. It’s a spectrum of illness from infection to sepsis, severe sepsis, and septic shock, and none of these stages have simple, definable signs, symptoms, lab values, or imaging findings. Many other conditions mimic sepsis and present with the same criteria and organ failure as severe sepsis."

Several years ago, the facility began looking at its overall mortality figures, with a goal of reducing mortality by 15%. Since sepsis is an important driver of mortality, it became a target for intervention. A working group composed of interns, nurses, nursing assistants, pharmacists, and respiratory therapists met for 2 days to create an action plan – and Code Sepsis was born. The name was chosen for two reasons, Dr. Jones said: It connotes both a sense of urgency, and the understanding that there is a set protocol to follow.

The rapid response team is the protocol’s backbone. Consisting of two critical care nurses and a first-call provider, the team goes into action any time a patient meets the criteria for possible sepsis. The nurses activate Code Sepsis by calling emergency communications; they quickly the get blood work done and sent to the lab, and administer any initial treatments. The first call provider evaluates the patient and gives appropriate orders. Respiratory therapists obtain blood gases and manage any airway issues, and a pharmacist expedites the preparation and delivery of antibiotics. An ICU triage nurse locates a bed if the patient needs a transfer to a higher care unit.

The goal is to get broad-spectrum antibiotics flowing within an hour of the code being called. Fluid resuscitation is administered if there’s an elevated lactate level or a mean arterial pressure of less than 65 mmHg.

To make things even smoother, every nursing unit has prepackaged Code Sepsis equipment bundles complete with intravenous supplies and everything necessary to draw blood and send it off for rapid analysis.

The program, launched in March 2012, is now associated with a number of improved treatment parameters, Dr. Jones said. By September 2012, rapid response for potentially unstable patients rose from 30% to 70%. By last March, there were also significant increases in 100% bundle compliance. Antibiotics are now almost always administered in 1 hour or less of a Code Sepsis initiation. The risk-adjusted mortality index has fallen from a high of about 1.8 before the protocol to less than 1.25 – also a significant improvement.

The road to these improvements wasn’t always smooth, Dr. Jones said. The Code Sepsis model required some fine-tuning along the way. And the very valid concern of antibiotic overuse was not an easy obstacle to surmount.

"That was a big barrier. There is a lot of concern in our organization about the early use of antibiotics. To appropriately deliver those within 1 hour requires a leap of faith and the understanding that you may end up giving antibiotics to some who don’t need them, in order to make sure you give them within 1 hour to every patient who does."

Dr. Jones reported having no financial disclosures.

NATIONAL HARBOR, MD. – A hospital-wide rapid response protocol decreased the time to antibiotic administration and improved sepsis bundle compliance by creating a team approach to sepsis management.

Creating "Code Sepsis" involved every member of the clinical care team, from nursing assistants to attending physicians, Dr. Catherine Jones said at the annual meeting of the Society of Hospital Medicine. The pilot project has been so successful that it’s being implemented in other units of Wake Forest Baptist Medical Center, Winston-Salem, N.C.

"We’ve started a modified version of it in our surgical intensive care units and, in April, our emergency department rolled out this exact same process. Our goal is to roll it out throughout the organization, including our comprehensive cancer center, because it’s not unusual for patients to show up in clinic with severe sepsis," said Dr. Jones, a patient safety and hospital quality expert at the group.

The incidence of sepsis has been on an upward trajectory since 2000, she said, because of a variety of factors. An aging population and the more frequent use of invasive procedures, chemotherapy, and immunosuppressive drugs probably all contribute to the problem. Patients who develop sepsis are eight times more likely to die during a hospital admission.

The good news is that the international "Surviving Sepsis" campaign, which advocated a resuscitation bundle approach designed for early intervention, does seem to be making a difference in outcomes since it was inaugurated in 2002.

The key element seems to be the earlier timing of antibiotic delivery, with an estimate of one patient saved for every seven bundles implemented, Dr. Jones said.

"The problem is that, on the floor, early recognition of sepsis is difficult. It’s a spectrum of illness from infection to sepsis, severe sepsis, and septic shock, and none of these stages have simple, definable signs, symptoms, lab values, or imaging findings. Many other conditions mimic sepsis and present with the same criteria and organ failure as severe sepsis."

Several years ago, the facility began looking at its overall mortality figures, with a goal of reducing mortality by 15%. Since sepsis is an important driver of mortality, it became a target for intervention. A working group composed of interns, nurses, nursing assistants, pharmacists, and respiratory therapists met for 2 days to create an action plan – and Code Sepsis was born. The name was chosen for two reasons, Dr. Jones said: It connotes both a sense of urgency, and the understanding that there is a set protocol to follow.

The rapid response team is the protocol’s backbone. Consisting of two critical care nurses and a first-call provider, the team goes into action any time a patient meets the criteria for possible sepsis. The nurses activate Code Sepsis by calling emergency communications; they quickly the get blood work done and sent to the lab, and administer any initial treatments. The first call provider evaluates the patient and gives appropriate orders. Respiratory therapists obtain blood gases and manage any airway issues, and a pharmacist expedites the preparation and delivery of antibiotics. An ICU triage nurse locates a bed if the patient needs a transfer to a higher care unit.

The goal is to get broad-spectrum antibiotics flowing within an hour of the code being called. Fluid resuscitation is administered if there’s an elevated lactate level or a mean arterial pressure of less than 65 mmHg.

To make things even smoother, every nursing unit has prepackaged Code Sepsis equipment bundles complete with intravenous supplies and everything necessary to draw blood and send it off for rapid analysis.

The program, launched in March 2012, is now associated with a number of improved treatment parameters, Dr. Jones said. By September 2012, rapid response for potentially unstable patients rose from 30% to 70%. By last March, there were also significant increases in 100% bundle compliance. Antibiotics are now almost always administered in 1 hour or less of a Code Sepsis initiation. The risk-adjusted mortality index has fallen from a high of about 1.8 before the protocol to less than 1.25 – also a significant improvement.

The road to these improvements wasn’t always smooth, Dr. Jones said. The Code Sepsis model required some fine-tuning along the way. And the very valid concern of antibiotic overuse was not an easy obstacle to surmount.

"That was a big barrier. There is a lot of concern in our organization about the early use of antibiotics. To appropriately deliver those within 1 hour requires a leap of faith and the understanding that you may end up giving antibiotics to some who don’t need them, in order to make sure you give them within 1 hour to every patient who does."

Dr. Jones reported having no financial disclosures.

NATIONAL HARBOR, MD. – A hospital-wide rapid response protocol decreased the time to antibiotic administration and improved sepsis bundle compliance by creating a team approach to sepsis management.

Creating "Code Sepsis" involved every member of the clinical care team, from nursing assistants to attending physicians, Dr. Catherine Jones said at the annual meeting of the Society of Hospital Medicine. The pilot project has been so successful that it’s being implemented in other units of Wake Forest Baptist Medical Center, Winston-Salem, N.C.

"We’ve started a modified version of it in our surgical intensive care units and, in April, our emergency department rolled out this exact same process. Our goal is to roll it out throughout the organization, including our comprehensive cancer center, because it’s not unusual for patients to show up in clinic with severe sepsis," said Dr. Jones, a patient safety and hospital quality expert at the group.

The incidence of sepsis has been on an upward trajectory since 2000, she said, because of a variety of factors. An aging population and the more frequent use of invasive procedures, chemotherapy, and immunosuppressive drugs probably all contribute to the problem. Patients who develop sepsis are eight times more likely to die during a hospital admission.

The good news is that the international "Surviving Sepsis" campaign, which advocated a resuscitation bundle approach designed for early intervention, does seem to be making a difference in outcomes since it was inaugurated in 2002.

The key element seems to be the earlier timing of antibiotic delivery, with an estimate of one patient saved for every seven bundles implemented, Dr. Jones said.

"The problem is that, on the floor, early recognition of sepsis is difficult. It’s a spectrum of illness from infection to sepsis, severe sepsis, and septic shock, and none of these stages have simple, definable signs, symptoms, lab values, or imaging findings. Many other conditions mimic sepsis and present with the same criteria and organ failure as severe sepsis."

Several years ago, the facility began looking at its overall mortality figures, with a goal of reducing mortality by 15%. Since sepsis is an important driver of mortality, it became a target for intervention. A working group composed of interns, nurses, nursing assistants, pharmacists, and respiratory therapists met for 2 days to create an action plan – and Code Sepsis was born. The name was chosen for two reasons, Dr. Jones said: It connotes both a sense of urgency, and the understanding that there is a set protocol to follow.

The rapid response team is the protocol’s backbone. Consisting of two critical care nurses and a first-call provider, the team goes into action any time a patient meets the criteria for possible sepsis. The nurses activate Code Sepsis by calling emergency communications; they quickly the get blood work done and sent to the lab, and administer any initial treatments. The first call provider evaluates the patient and gives appropriate orders. Respiratory therapists obtain blood gases and manage any airway issues, and a pharmacist expedites the preparation and delivery of antibiotics. An ICU triage nurse locates a bed if the patient needs a transfer to a higher care unit.

The goal is to get broad-spectrum antibiotics flowing within an hour of the code being called. Fluid resuscitation is administered if there’s an elevated lactate level or a mean arterial pressure of less than 65 mmHg.

To make things even smoother, every nursing unit has prepackaged Code Sepsis equipment bundles complete with intravenous supplies and everything necessary to draw blood and send it off for rapid analysis.

The program, launched in March 2012, is now associated with a number of improved treatment parameters, Dr. Jones said. By September 2012, rapid response for potentially unstable patients rose from 30% to 70%. By last March, there were also significant increases in 100% bundle compliance. Antibiotics are now almost always administered in 1 hour or less of a Code Sepsis initiation. The risk-adjusted mortality index has fallen from a high of about 1.8 before the protocol to less than 1.25 – also a significant improvement.

The road to these improvements wasn’t always smooth, Dr. Jones said. The Code Sepsis model required some fine-tuning along the way. And the very valid concern of antibiotic overuse was not an easy obstacle to surmount.

"That was a big barrier. There is a lot of concern in our organization about the early use of antibiotics. To appropriately deliver those within 1 hour requires a leap of faith and the understanding that you may end up giving antibiotics to some who don’t need them, in order to make sure you give them within 1 hour to every patient who does."

Dr. Jones reported having no financial disclosures.

NATIONAL HARBOR, MD. – Angiotensin receptor blockade on the morning of a major orthopedic surgery was associated with a tripling in the risk of acute kidney injury – a link probably driven by the drugs’ association with perioperative hypotension, a retrospective analysis has found.

"Our study does support the idea of withholding beta-blockers on the morning of these major procedures," Dr. Eileen Hennrikus reported at the annual meeting of the Society of Hospital Medicine.

Extant literature has confirmed a link between beta-blockers and hypotension in connection with cardiovascular surgery, but not orthopedic surgery. Dr. Hennrikus, of the Milton S. Hershey Medical Center, Hershey, Penn., examined the link in patients undergoing elective spine fusions, total hip or total knee replacement – procedures typically associated with greater blood loss than cardiovascular surgeries.

She used retrospective data from 922 patients who had undergone any of the three surgeries during 2010. Induction hypotension was defined as a systolic blood pressure of 80 mm Hg for at least 10 minutes within a half hour of anesthesia induction. Intraoperative hypotension was defined as a systolic blood pressure of 80 mm Hg for at least 10 minutes during maintenance anesthesia. The measure of acute kidney injury was an increase in serum creative of at least 0.3 mg/dL, or a 50% increase over preoperative levels.

Of the entire cohort, 37% (343) patients received their prescribed angiotensin receptor blocker or angiotensin converting enzyme inhibitor on the morning of their surgery. The incidence of induction hypotension was significantly greater in those patients in patients who took the medication than in those who did not (12% vs. 6.7%; OR 1.93). Acute kidney injury was also significantly more common among those who had the medications, however (8% vs. 2%; OR 5.4). Intraoperative hypotension was not significantly different between the groups.

Dr. Hennrikus conducted a multivariate analysis to further tease out the relationship between the medications and acute kidney injury. The regression controlled for age, medical comorbidities (diabetes, coronary artery disease, hypertension, and congestive heart failure), body mass index, medications (diuretics, beta-blockers, calcium channel blockers, general anesthesia-induction agents, and vasopressors), and blood loss.

After adjustment for all of those factors, angiotensin blockade conferred a threefold increase in the risk of acute kidney injury (OR 2.97). Although in the primary analysis, intraoperative hypotension had not been significantly associated with the drugs, it more than doubled the risk of kidney injury the risk (OR 2.6) in the multivariate analysis.

The model also revealed something of a surprise, Dr. Hennrikus said: Body mass index was an independent risk factor for acute kidney injury. For every 5 kg/m² increase in BMI, the risk increased by 29% (OR 1.29).

Acute kidney injury exerted its own influence over hospital length of stay and mortality. The length of stay was significantly longer in patients who had kidney injury (6. days vs. 3 days). Two-year mortality was also significantly higher (6% vs. 2%).

Neither Dr. Hennrikus nor her coinvestigators reported having any financial conflicts.

[email protected]

NATIONAL HARBOR, MD. – Angiotensin receptor blockade on the morning of a major orthopedic surgery was associated with a tripling in the risk of acute kidney injury – a link probably driven by the drugs’ association with perioperative hypotension, a retrospective analysis has found.

"Our study does support the idea of withholding beta-blockers on the morning of these major procedures," Dr. Eileen Hennrikus reported at the annual meeting of the Society of Hospital Medicine.

Extant literature has confirmed a link between beta-blockers and hypotension in connection with cardiovascular surgery, but not orthopedic surgery. Dr. Hennrikus, of the Milton S. Hershey Medical Center, Hershey, Penn., examined the link in patients undergoing elective spine fusions, total hip or total knee replacement – procedures typically associated with greater blood loss than cardiovascular surgeries.

She used retrospective data from 922 patients who had undergone any of the three surgeries during 2010. Induction hypotension was defined as a systolic blood pressure of 80 mm Hg for at least 10 minutes within a half hour of anesthesia induction. Intraoperative hypotension was defined as a systolic blood pressure of 80 mm Hg for at least 10 minutes during maintenance anesthesia. The measure of acute kidney injury was an increase in serum creative of at least 0.3 mg/dL, or a 50% increase over preoperative levels.

Of the entire cohort, 37% (343) patients received their prescribed angiotensin receptor blocker or angiotensin converting enzyme inhibitor on the morning of their surgery. The incidence of induction hypotension was significantly greater in those patients in patients who took the medication than in those who did not (12% vs. 6.7%; OR 1.93). Acute kidney injury was also significantly more common among those who had the medications, however (8% vs. 2%; OR 5.4). Intraoperative hypotension was not significantly different between the groups.

Dr. Hennrikus conducted a multivariate analysis to further tease out the relationship between the medications and acute kidney injury. The regression controlled for age, medical comorbidities (diabetes, coronary artery disease, hypertension, and congestive heart failure), body mass index, medications (diuretics, beta-blockers, calcium channel blockers, general anesthesia-induction agents, and vasopressors), and blood loss.

After adjustment for all of those factors, angiotensin blockade conferred a threefold increase in the risk of acute kidney injury (OR 2.97). Although in the primary analysis, intraoperative hypotension had not been significantly associated with the drugs, it more than doubled the risk of kidney injury the risk (OR 2.6) in the multivariate analysis.

The model also revealed something of a surprise, Dr. Hennrikus said: Body mass index was an independent risk factor for acute kidney injury. For every 5 kg/m² increase in BMI, the risk increased by 29% (OR 1.29).

Acute kidney injury exerted its own influence over hospital length of stay and mortality. The length of stay was significantly longer in patients who had kidney injury (6. days vs. 3 days). Two-year mortality was also significantly higher (6% vs. 2%).

Neither Dr. Hennrikus nor her coinvestigators reported having any financial conflicts.

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NATIONAL HARBOR, MD. – Angiotensin receptor blockade on the morning of a major orthopedic surgery was associated with a tripling in the risk of acute kidney injury – a link probably driven by the drugs’ association with perioperative hypotension, a retrospective analysis has found.

"Our study does support the idea of withholding beta-blockers on the morning of these major procedures," Dr. Eileen Hennrikus reported at the annual meeting of the Society of Hospital Medicine.

Extant literature has confirmed a link between beta-blockers and hypotension in connection with cardiovascular surgery, but not orthopedic surgery. Dr. Hennrikus, of the Milton S. Hershey Medical Center, Hershey, Penn., examined the link in patients undergoing elective spine fusions, total hip or total knee replacement – procedures typically associated with greater blood loss than cardiovascular surgeries.

She used retrospective data from 922 patients who had undergone any of the three surgeries during 2010. Induction hypotension was defined as a systolic blood pressure of 80 mm Hg for at least 10 minutes within a half hour of anesthesia induction. Intraoperative hypotension was defined as a systolic blood pressure of 80 mm Hg for at least 10 minutes during maintenance anesthesia. The measure of acute kidney injury was an increase in serum creative of at least 0.3 mg/dL, or a 50% increase over preoperative levels.

Of the entire cohort, 37% (343) patients received their prescribed angiotensin receptor blocker or angiotensin converting enzyme inhibitor on the morning of their surgery. The incidence of induction hypotension was significantly greater in those patients in patients who took the medication than in those who did not (12% vs. 6.7%; OR 1.93). Acute kidney injury was also significantly more common among those who had the medications, however (8% vs. 2%; OR 5.4). Intraoperative hypotension was not significantly different between the groups.

Dr. Hennrikus conducted a multivariate analysis to further tease out the relationship between the medications and acute kidney injury. The regression controlled for age, medical comorbidities (diabetes, coronary artery disease, hypertension, and congestive heart failure), body mass index, medications (diuretics, beta-blockers, calcium channel blockers, general anesthesia-induction agents, and vasopressors), and blood loss.

After adjustment for all of those factors, angiotensin blockade conferred a threefold increase in the risk of acute kidney injury (OR 2.97). Although in the primary analysis, intraoperative hypotension had not been significantly associated with the drugs, it more than doubled the risk of kidney injury the risk (OR 2.6) in the multivariate analysis.

The model also revealed something of a surprise, Dr. Hennrikus said: Body mass index was an independent risk factor for acute kidney injury. For every 5 kg/m² increase in BMI, the risk increased by 29% (OR 1.29).

Acute kidney injury exerted its own influence over hospital length of stay and mortality. The length of stay was significantly longer in patients who had kidney injury (6. days vs. 3 days). Two-year mortality was also significantly higher (6% vs. 2%).

Neither Dr. Hennrikus nor her coinvestigators reported having any financial conflicts.

[email protected]