Robert Wachter, MD, MHM, has been named Most Influential Physician Executive by Modern Healthcare. Dr. Wachter tops the list of 50 of the country’s most influential physician executives and leaders, which includes two other hospitalists in the top 20. Dr. Wachter is the chief of the division of hospital medicine at the University of California San Francisco Medical Center and professor and associate chair of the department of medicine.

Patrick Conway, MD, MSc, MHM, was recently named one of America’s 50 Most Influential Physician Executives and Leaders by Modern Healthcare. At number 11, he is one of three hospitalists to be included this year. Dr. Conway is a pediatric hospitalist and acting deputy principal administrator for innovation and quality at the Centers for Medicare and Medicaid Services (CMS), as well as chief medical officer for CMS.

Vivek Murthy, MD, MBA, has also been included on Modern Healthcare’s list of the nation’s 50 Most Influential Physician Executives and Leaders as one of three hospitalists. Dr. Murthy is ranked at number 16, which puts all three featured hospitalists in the top 20. Dr. Murthy, who was recently appointed U.S. Surgeon General, is a practicing hospitalist at Brigham and Women’s Hospital in Boston.

Ron Greeno, MD, MHM, has been named by IPC Healthcare Inc. to the new position of chief strategy officer. Dr. Greeno will lead strategic initiatives for the North Hollywood, Calif.-based organization, which employs nearly 2,000 clinicians in more than 400 hospitals and 1,700 post-acute care facilities. Dr. Greeno, who previously served as CMO of Cogent, is a founding member of SHM, a current board member, and longtime chair of the SHM Public Policy Committee. “As a pioneer in hospital medicine,” said IPC CEO Adam Singer, MD, in a statement, “Dr. Greeno’s breadth of experience is uniquely qualified and well positioned to support IPC’s efforts in leading and innovating across the acute and post-acute care continuum.”

Joshua Brickner, DO, is the 2015 Physician of the Year at Lake Regional Health System in Osage Beach, Mo. Dr. Brickner is an adult and pediatric hospitalist at Lake Regional Hospital, a 116-bed acute care facility. Dr Brickner is lauded by his colleagues and patients for his compassion, bedside manner, and dedication to his patients.

Andrew Dunn, MD, MPH, SFHM, has been named the 2015-2016 chair of the Board of Governors of the American College of Physicians (ACP). Dr. Dunn is a senior fellow of SHM and currently works for Mount Sinai Health System as chief of the division of hospital medicine. He also teaches medicine at the Mount Sinai School of Medicine.

Louis O’Boyle, DO, SFHM, recently earned a Certificate of Leadership in Hospital Medicine (CLHM) from the Society of Hospital Medicine. Dr. O’Boyle completed a series of courses and a research study, “A Multidisciplinary, Multi-interventional Approach to Reducing Readmissions in the Rural Setting,” to become the fourth U.S. doctor to receive the CLHM. Dr. O’Boyle is chief hospitalist at Wayne Memorial Hospital in Honesdale, Pa.

Van “Beaux” Slaughter, MD, is the 2015 Physician of the Year at FirstHealth Richmond Memorial Hospital in Rockingham, N.C. Dr. Slaughter serves as director of hospitalist regional services for the FirstHealth Physician Group, as well as chief of the medical staff of the three campuses of FirstHealth Moore Regional Hospital. Dr. Slaughter is lauded for his “great bedside manner” and his polite and collaborative attitude toward his colleagues.

Surinder Yadav, MD, SFHM, is the new vice president of hospital medicine for CEP America, based in Emeryville, Calif. Dr. Yadav comes to CEP America from TeamHealth, where he served as senior regional medical director for the West Coast region. After he completed his residency at Baystate Medical Center in Springfield, Mass., Dr. Yadav served as associate medical director of hospital medicine and healthcare quality. CEP America is a private, national medical staffing company founded in 1975.

 

Business Moves

Apollo Medical Holdings, Inc. (ApolloMed), a private physician staffing company based in Glendale, Calif., has partnered with the University of Southern California’s Keck School of Medicine to launch the USC Hospitalist Leadership Fellowship Program. The program will be a one-year training and educational program for internal medicine graduates to gain experience in the delivery of hospital medicine.

Hospitalists Now Inc. (HNI) based in Austin, Texas, recently merged with Cambridge Hospitalists of Rancho Mirage, Calif., an acute-care hospitalist staffing company. HNI is a private hospitalist staffing firm serving hospitals in Texas, Louisiana, Florida, Rhode Island, and California.

IPC Healthcare recently acquired Accountability Healthcare in Birmingham, Ala., a regional post-acute care practice. IPC is a national physician staffing company providing hospitalist and post-acute care services in over 400 hospitals and 1,700 post-acute facilities across the country.

Robert Wachter, MD, MHM, has been named Most Influential Physician Executive by Modern Healthcare. Dr. Wachter tops the list of 50 of the country’s most influential physician executives and leaders, which includes two other hospitalists in the top 20. Dr. Wachter is the chief of the division of hospital medicine at the University of California San Francisco Medical Center and professor and associate chair of the department of medicine.

Patrick Conway, MD, MSc, MHM, was recently named one of America’s 50 Most Influential Physician Executives and Leaders by Modern Healthcare. At number 11, he is one of three hospitalists to be included this year. Dr. Conway is a pediatric hospitalist and acting deputy principal administrator for innovation and quality at the Centers for Medicare and Medicaid Services (CMS), as well as chief medical officer for CMS.

Vivek Murthy, MD, MBA, has also been included on Modern Healthcare’s list of the nation’s 50 Most Influential Physician Executives and Leaders as one of three hospitalists. Dr. Murthy is ranked at number 16, which puts all three featured hospitalists in the top 20. Dr. Murthy, who was recently appointed U.S. Surgeon General, is a practicing hospitalist at Brigham and Women’s Hospital in Boston.

Ron Greeno, MD, MHM, has been named by IPC Healthcare Inc. to the new position of chief strategy officer. Dr. Greeno will lead strategic initiatives for the North Hollywood, Calif.-based organization, which employs nearly 2,000 clinicians in more than 400 hospitals and 1,700 post-acute care facilities. Dr. Greeno, who previously served as CMO of Cogent, is a founding member of SHM, a current board member, and longtime chair of the SHM Public Policy Committee. “As a pioneer in hospital medicine,” said IPC CEO Adam Singer, MD, in a statement, “Dr. Greeno’s breadth of experience is uniquely qualified and well positioned to support IPC’s efforts in leading and innovating across the acute and post-acute care continuum.”

Joshua Brickner, DO, is the 2015 Physician of the Year at Lake Regional Health System in Osage Beach, Mo. Dr. Brickner is an adult and pediatric hospitalist at Lake Regional Hospital, a 116-bed acute care facility. Dr Brickner is lauded by his colleagues and patients for his compassion, bedside manner, and dedication to his patients.

Andrew Dunn, MD, MPH, SFHM, has been named the 2015-2016 chair of the Board of Governors of the American College of Physicians (ACP). Dr. Dunn is a senior fellow of SHM and currently works for Mount Sinai Health System as chief of the division of hospital medicine. He also teaches medicine at the Mount Sinai School of Medicine.

Louis O’Boyle, DO, SFHM, recently earned a Certificate of Leadership in Hospital Medicine (CLHM) from the Society of Hospital Medicine. Dr. O’Boyle completed a series of courses and a research study, “A Multidisciplinary, Multi-interventional Approach to Reducing Readmissions in the Rural Setting,” to become the fourth U.S. doctor to receive the CLHM. Dr. O’Boyle is chief hospitalist at Wayne Memorial Hospital in Honesdale, Pa.

Van “Beaux” Slaughter, MD, is the 2015 Physician of the Year at FirstHealth Richmond Memorial Hospital in Rockingham, N.C. Dr. Slaughter serves as director of hospitalist regional services for the FirstHealth Physician Group, as well as chief of the medical staff of the three campuses of FirstHealth Moore Regional Hospital. Dr. Slaughter is lauded for his “great bedside manner” and his polite and collaborative attitude toward his colleagues.

Surinder Yadav, MD, SFHM, is the new vice president of hospital medicine for CEP America, based in Emeryville, Calif. Dr. Yadav comes to CEP America from TeamHealth, where he served as senior regional medical director for the West Coast region. After he completed his residency at Baystate Medical Center in Springfield, Mass., Dr. Yadav served as associate medical director of hospital medicine and healthcare quality. CEP America is a private, national medical staffing company founded in 1975.

 

Business Moves

Apollo Medical Holdings, Inc. (ApolloMed), a private physician staffing company based in Glendale, Calif., has partnered with the University of Southern California’s Keck School of Medicine to launch the USC Hospitalist Leadership Fellowship Program. The program will be a one-year training and educational program for internal medicine graduates to gain experience in the delivery of hospital medicine.

Hospitalists Now Inc. (HNI) based in Austin, Texas, recently merged with Cambridge Hospitalists of Rancho Mirage, Calif., an acute-care hospitalist staffing company. HNI is a private hospitalist staffing firm serving hospitals in Texas, Louisiana, Florida, Rhode Island, and California.

IPC Healthcare recently acquired Accountability Healthcare in Birmingham, Ala., a regional post-acute care practice. IPC is a national physician staffing company providing hospitalist and post-acute care services in over 400 hospitals and 1,700 post-acute facilities across the country.

Robert Wachter, MD, MHM, has been named Most Influential Physician Executive by Modern Healthcare. Dr. Wachter tops the list of 50 of the country’s most influential physician executives and leaders, which includes two other hospitalists in the top 20. Dr. Wachter is the chief of the division of hospital medicine at the University of California San Francisco Medical Center and professor and associate chair of the department of medicine.

Patrick Conway, MD, MSc, MHM, was recently named one of America’s 50 Most Influential Physician Executives and Leaders by Modern Healthcare. At number 11, he is one of three hospitalists to be included this year. Dr. Conway is a pediatric hospitalist and acting deputy principal administrator for innovation and quality at the Centers for Medicare and Medicaid Services (CMS), as well as chief medical officer for CMS.

Vivek Murthy, MD, MBA, has also been included on Modern Healthcare’s list of the nation’s 50 Most Influential Physician Executives and Leaders as one of three hospitalists. Dr. Murthy is ranked at number 16, which puts all three featured hospitalists in the top 20. Dr. Murthy, who was recently appointed U.S. Surgeon General, is a practicing hospitalist at Brigham and Women’s Hospital in Boston.

Ron Greeno, MD, MHM, has been named by IPC Healthcare Inc. to the new position of chief strategy officer. Dr. Greeno will lead strategic initiatives for the North Hollywood, Calif.-based organization, which employs nearly 2,000 clinicians in more than 400 hospitals and 1,700 post-acute care facilities. Dr. Greeno, who previously served as CMO of Cogent, is a founding member of SHM, a current board member, and longtime chair of the SHM Public Policy Committee. “As a pioneer in hospital medicine,” said IPC CEO Adam Singer, MD, in a statement, “Dr. Greeno’s breadth of experience is uniquely qualified and well positioned to support IPC’s efforts in leading and innovating across the acute and post-acute care continuum.”

Joshua Brickner, DO, is the 2015 Physician of the Year at Lake Regional Health System in Osage Beach, Mo. Dr. Brickner is an adult and pediatric hospitalist at Lake Regional Hospital, a 116-bed acute care facility. Dr Brickner is lauded by his colleagues and patients for his compassion, bedside manner, and dedication to his patients.

Andrew Dunn, MD, MPH, SFHM, has been named the 2015-2016 chair of the Board of Governors of the American College of Physicians (ACP). Dr. Dunn is a senior fellow of SHM and currently works for Mount Sinai Health System as chief of the division of hospital medicine. He also teaches medicine at the Mount Sinai School of Medicine.

Louis O’Boyle, DO, SFHM, recently earned a Certificate of Leadership in Hospital Medicine (CLHM) from the Society of Hospital Medicine. Dr. O’Boyle completed a series of courses and a research study, “A Multidisciplinary, Multi-interventional Approach to Reducing Readmissions in the Rural Setting,” to become the fourth U.S. doctor to receive the CLHM. Dr. O’Boyle is chief hospitalist at Wayne Memorial Hospital in Honesdale, Pa.

Van “Beaux” Slaughter, MD, is the 2015 Physician of the Year at FirstHealth Richmond Memorial Hospital in Rockingham, N.C. Dr. Slaughter serves as director of hospitalist regional services for the FirstHealth Physician Group, as well as chief of the medical staff of the three campuses of FirstHealth Moore Regional Hospital. Dr. Slaughter is lauded for his “great bedside manner” and his polite and collaborative attitude toward his colleagues.

Surinder Yadav, MD, SFHM, is the new vice president of hospital medicine for CEP America, based in Emeryville, Calif. Dr. Yadav comes to CEP America from TeamHealth, where he served as senior regional medical director for the West Coast region. After he completed his residency at Baystate Medical Center in Springfield, Mass., Dr. Yadav served as associate medical director of hospital medicine and healthcare quality. CEP America is a private, national medical staffing company founded in 1975.

 

Business Moves

Apollo Medical Holdings, Inc. (ApolloMed), a private physician staffing company based in Glendale, Calif., has partnered with the University of Southern California’s Keck School of Medicine to launch the USC Hospitalist Leadership Fellowship Program. The program will be a one-year training and educational program for internal medicine graduates to gain experience in the delivery of hospital medicine.

Hospitalists Now Inc. (HNI) based in Austin, Texas, recently merged with Cambridge Hospitalists of Rancho Mirage, Calif., an acute-care hospitalist staffing company. HNI is a private hospitalist staffing firm serving hospitals in Texas, Louisiana, Florida, Rhode Island, and California.

IPC Healthcare recently acquired Accountability Healthcare in Birmingham, Ala., a regional post-acute care practice. IPC is a national physician staffing company providing hospitalist and post-acute care services in over 400 hospitals and 1,700 post-acute facilities across the country.

Clinical question: Have the causative organisms in pediatric bacteremia changed over time concurrent with introduction of the pneumococcal conjugate vaccine?

Background: Previous research has shown introduction of polyvalent pneumococcal conjugate vaccine led to changes in the organisms causing meningitis and otitis media, and patterns of nasopharyngeal colonization. Pneumococcus, historically, was a common cause of bacteremia. The availability of pneumococcal conjugate vaccine may have changed the organisms causing bacteremia in children.

Study design: Retrospective chart review and time series.

Setting: Children presenting to the ED of Alder Hey Children’s Hospital in Liverpool, England, from 2001 to 2011.

Synopsis: Five hundred seventy-five episodes of bacteremia were found in 525 children. Infants most commonly had E. coli and Group B streptococcal infections; children over age five most commonly had S. aureus. The introduction of the pneumococcal conjugate vaccine decreased pneumococcal bacteremia by 49% over the study period. This decrease was accompanied by an increase in Gram-negative bacteremia. Susceptibility to empiric antibiotics (third-generation cephalosporins) dropped from 96% to 83%. Over the study period, more children presented with central venous lines, which was felt to be due to increasing outpatient use of total parenteral nutrition (TPN).

Bottom line: Vaccination against pneumococcus is changing the microbiology of pediatric bacteremia, with fewer vaccine-preventable Gram-positive infections and more Gram-negative infections. This increases the likelihood of resistance to third-generation cephalosporins as empiric antibiotic.

Citation: Irwin AD, Drew RJ, Marshall P, et al. Etiology of childhood bacteremia and timely antibiotics administration in the emergency department. Pediatrics. 2015;135(4): 635-642.

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Dr. Stubblefield is a pediatric hospitalist at Nemours/Alfred I. Dupont Hospital for Children in Wilmington, Del., and assistant professor of pediatrics at Thomas Jefferson Medical College in Philadelphia

Clinical question: Have the causative organisms in pediatric bacteremia changed over time concurrent with introduction of the pneumococcal conjugate vaccine?

Background: Previous research has shown introduction of polyvalent pneumococcal conjugate vaccine led to changes in the organisms causing meningitis and otitis media, and patterns of nasopharyngeal colonization. Pneumococcus, historically, was a common cause of bacteremia. The availability of pneumococcal conjugate vaccine may have changed the organisms causing bacteremia in children.

Study design: Retrospective chart review and time series.

Setting: Children presenting to the ED of Alder Hey Children’s Hospital in Liverpool, England, from 2001 to 2011.

Synopsis: Five hundred seventy-five episodes of bacteremia were found in 525 children. Infants most commonly had E. coli and Group B streptococcal infections; children over age five most commonly had S. aureus. The introduction of the pneumococcal conjugate vaccine decreased pneumococcal bacteremia by 49% over the study period. This decrease was accompanied by an increase in Gram-negative bacteremia. Susceptibility to empiric antibiotics (third-generation cephalosporins) dropped from 96% to 83%. Over the study period, more children presented with central venous lines, which was felt to be due to increasing outpatient use of total parenteral nutrition (TPN).

Bottom line: Vaccination against pneumococcus is changing the microbiology of pediatric bacteremia, with fewer vaccine-preventable Gram-positive infections and more Gram-negative infections. This increases the likelihood of resistance to third-generation cephalosporins as empiric antibiotic.

Citation: Irwin AD, Drew RJ, Marshall P, et al. Etiology of childhood bacteremia and timely antibiotics administration in the emergency department. Pediatrics. 2015;135(4): 635-642.

---

Dr. Stubblefield is a pediatric hospitalist at Nemours/Alfred I. Dupont Hospital for Children in Wilmington, Del., and assistant professor of pediatrics at Thomas Jefferson Medical College in Philadelphia

Clinical question: Have the causative organisms in pediatric bacteremia changed over time concurrent with introduction of the pneumococcal conjugate vaccine?

Background: Previous research has shown introduction of polyvalent pneumococcal conjugate vaccine led to changes in the organisms causing meningitis and otitis media, and patterns of nasopharyngeal colonization. Pneumococcus, historically, was a common cause of bacteremia. The availability of pneumococcal conjugate vaccine may have changed the organisms causing bacteremia in children.

Study design: Retrospective chart review and time series.

Setting: Children presenting to the ED of Alder Hey Children’s Hospital in Liverpool, England, from 2001 to 2011.

Synopsis: Five hundred seventy-five episodes of bacteremia were found in 525 children. Infants most commonly had E. coli and Group B streptococcal infections; children over age five most commonly had S. aureus. The introduction of the pneumococcal conjugate vaccine decreased pneumococcal bacteremia by 49% over the study period. This decrease was accompanied by an increase in Gram-negative bacteremia. Susceptibility to empiric antibiotics (third-generation cephalosporins) dropped from 96% to 83%. Over the study period, more children presented with central venous lines, which was felt to be due to increasing outpatient use of total parenteral nutrition (TPN).

Bottom line: Vaccination against pneumococcus is changing the microbiology of pediatric bacteremia, with fewer vaccine-preventable Gram-positive infections and more Gram-negative infections. This increases the likelihood of resistance to third-generation cephalosporins as empiric antibiotic.

Citation: Irwin AD, Drew RJ, Marshall P, et al. Etiology of childhood bacteremia and timely antibiotics administration in the emergency department. Pediatrics. 2015;135(4): 635-642.

---

Dr. Stubblefield is a pediatric hospitalist at Nemours/Alfred I. Dupont Hospital for Children in Wilmington, Del., and assistant professor of pediatrics at Thomas Jefferson Medical College in Philadelphia

EDITOR’S NOTE: This month’s KCQ first appeared in October 2010 and since that time has been one of our website’s most-read articles, generating nearly 35,000-plus page views. Enjoy it again this month!

Case

While placing a central line, you sustain a needlestick. You’ve washed the area thoroughly with soap and water, but you are concerned about contracting a bloodborne pathogen. What is the risk of contracting such a pathogen, and what can be done to reduce this risk?

Overview

Needlestick injuries are a common occupational hazard in the hospital setting. According to the International Health Care Worker Safety Center, approximately 295,000 hospital-based healthcare workers experience occupational percutaneous injuries annually. In 1991, Mangione and colleagues surveyed internal medicine house staff and found an annual incidence of 674 needlestick injuries per 1,000 participants.¹ Other retrospective data estimate this risk to be as high as 839 per 1,000 healthcare workers annually.² Evidence from the CDC in 2004 suggests that because these numbers represent only self-reported injuries, the annual incidence of such injuries is much higher than the current estimates suggest.^2,3,4

More than 20 bloodborne pathogens (see Table 1) might be transmitted from contaminated needles or sharps, including human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV). A quick and appropriate response to a needlestick injury can greatly decrease the risk of disease transmission following an occupational exposure to potentially infectious materials.

Review of the Data

After any needlestick injury, an affected healthcare worker should wash the area with soap and water immediately. There is no contraindication to using antiseptic solutions, but there is also no evidence to suggest that this reduces the rates of disease transmission.

Because decisions for post-exposure prophylaxis often need to be made within hours, a healthcare worker should seek care in the facility areas responsible for managing occupational exposures. Healthcare providers should be encouraged and supported in reporting all sharps-related injuries to such departments.

The source patient should be identified and evaluated for potentially transmissible diseases, including HIV, HBV, and HCV. If indicated, the source patient should then undergo appropriate serological testing, and any indicated antiviral prophylaxis should be initiated (see Table 2).

Risk of Seroconversion

For all bloodborne pathogens, a needlestick injury carries a greater risk for transmission than other occupational exposures (e.g. mucous membrane exposure). If a needlestick injury occurs in the setting of an infected patient source, the risk of disease transmission varies for HIV, HBV, and HCV (see Table 3). In general, risk for seroconversion is increased with a deep injury, an injury with a device visibly contaminated with the source patient’s blood, or an injury involving a needle placed in the source patient’s artery or vein.^3,5,6

Human immunodeficiency virus. Contracting HIV after needlestick injury is rare. From 1981 to 2006, the CDC documented only 57 cases of HIV/AIDS in healthcare workers following occupational exposure and identified an additional “possible” 140 cases post-exposure.5,6 Of the 57 documented cases, 48 sustained a percutaneous injury.

 

Following needlestick injury involving a known HIV-positive source, the one-year risk of seroconversion has been estimated to be 0.3%.5,6 In 1997, Cardo and colleagues identified four factors associated with increased risk for seroconversion after a needlestick/sharps injury from a known positive-HIV source:

• Deep injury;
• Injury with a device visibly contaminated with the source patient’s blood;
• A procedure involving a needle placed in the source patient’s artery or vein; and
• Exposure to a source patient who died of AIDS in the two months following the occupational exposure.⁵

Hepatitis B virus. Widespread immunization of healthcare workers has led to a dramatic decline in occupationally acquired HBV. The CDC estimated that in 1985, approximately 12,500 new HBV infections occurred in healthcare workers.³ This estimate plummeted to approximately 500 new occupationally acquired HBV infections in 1997.³

Despite this improvement, hospital-based healthcare personnel remain at risk for HBV transmission after a needlestick injury from a known positive patient source. Few studies have evaluated the occupational risk of HBV transmission after a needlestick injury. Buergler and colleagues reported that, following a needlestick injury involving a known HBV-positive source, the one-year risk of seroconversion was 0.76% to 7.35% for nonimmunized surgeons and 0.23% to 2.28% for nonimmunized anesthesiologists.⁷

In the absence of post-exposure prophylaxis (PEP), an exposed healthcare worker has a 6% to 30% risk of becoming infected with HBV.^3,8 The risk is greatest if the patient source is known to be hepatitis B e antigen-positive, a marker for greater disease infectivity. When given within one week of injury, PEP with multiple doses of hepatitis B immune globulin (HBIG) provides an estimated 75% protection from transmission.

Healthcare workers who have received the hepatitis B vaccine and developed immunity have virtually no risk for infection.^6,7

Hepatitis C virus. Prospective evaluation has demonstrated that the average risk of HCV transmission after percutaneous exposure to a known HCV-positive source ranges from 0% to 7%.³ The Italian Study Group on Occupational Risk of HIV and Other Bloodborne Infections evaluated HCV seroconversion within six months of a reported exposure with enzyme immunoassay and immunoblot assay. In this study, the authors found a seroconversion rate of 1.2%.⁹

Further, they suggested that HCV seroconversion only occurred from hollow-bore needles, because no seroconversions were noted in healthcare workers who sustained injuries with solid sharp objects.

Post-Exposure Management

The CDC does not recommend prophylaxis when source fluids make contact with intact skin; however, if a percutaneous occupational exposure has occurred, PEPs exist for HIV and HBV but not for HCV.^3,6 If a source patient’s HIV, HBV, and HCV statuses are unknown, occupational health personnel can interview the patient to evaluate his or her risks and initiate testing. Specific information about the time and nature of exposure should be documented.

When testing is indicated, it should be done following institutional and state-specific exposure control policies and informed consent guidelines. In all situations, the decision to begin antiviral PEP should be carefully considered, weighing the benefits of PEP versus the risks and toxicity of treatment.

Human immunodeficiency virus. If a source patient is known to be HIV-positive, has a positive rapid HIV test, or if HIV status cannot be quickly determined, PEP is indicated and should be started as quickly as possible.^3,8,10

 

The 2013 U.S. Public Health Service recommendations for PEP call for initiating three (or more) antiretroviral drugs for all occupational exposures. Current recommendations indicate that PEP should be continued for four weeks, with concurrent clinical and laboratory evaluation for drug toxicity.¹⁰

Although the combination of HBIG and the hepatitis vaccine B series has not been evaluated as PEP in the occupational setting, evidence in the perinatal setting suggests this regimen is more effective than HBIG alone.^3,6,8

Hepatitis C virus. No PEP exists for HCV, and current recommendations for post-exposure management focus on early identification and treatment of chronic disease. There are insufficient data for a treatment recommendation for patients with acute HCV infection with no evidence of disease; the appropriate dosing of such a regimen is unknown. Further, evidence suggests that treatment started early in the course of chronic infection could be just as effective and might eliminate the need to treat persons whose infection will spontaneously resolve.⁷

Back to the Case

Your needlestick occurred while using a hollow-bore needle to cannulate a source patient’s vein, placing you at higher risk for seroconversion. You immediately reported the exposure to the department of occupational health at your hospital. The source patient’s HIV, HBV, and HCV serological statuses were tested, and the patient was found to be HBV-positive. After appropriate counseling, you decide to receive HBIG prophylaxis to reduce your chances of becoming infected with HBV infection.

Bottom Line

Healthcare workers who suffer occupational needlestick injuries require immediate identification and attention to avoid transmission of such infectious diseases as HIV, HBV, and HCV. Source patients should undergo rapid serological testing to determine appropriate PEP.

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Dr. Zehnder is a hospitalist and assistant professor of medicine at the University of Colorado Denver in Aurora.

References

1. Mangione CM, Gerberding JL, Cummings SR. Occupational exposure to HIV: Frequency and rates of underreporting of percutaneous and mucocutaneous exposures by medical housestaff. Am J Med. 1991;90(1):85-90.
2. Lee JM, Botteman MF, Nicklasson L, Cobden D, Pashos CL. Needlestick injury in acute care nurses caring for patients with diabetes mellitus: a retrospective study. Curr Med Res Opin. 2005;21(5):741-747.
3. Centers for Disease Control and Prevention. Workbook for designing, implementing, and evaluating a sharps injury prevention program. CDC website. Accessed May 31, 2015.
4. Lee JM, Botteman MF, Xanthakos N, Nicklasson L. Needlestick injuries in the United States. Epidemiologic, economic, and quality of life issues. AAOHN J. 2005;53(3):117-133.
5. Cardo DM, Culver DH, Ciesielski CA, et al. A case-control study of HIV seroconversion in health care workers after percutaneous exposure. Centers for Disease Control and Prevention Needlestick Surveillance Group. N Engl J Med. 1997;337(21):1485-1490.
6. Centers for Disease Control and Prevention. Exposure to blood: What healthcare personnel need to know. CDC website. Accessed May 31, 2015.
7. Buergler JM, Kim R, Thisted RA, Cohn SJ, Lichtor JL, Roizen MF. Risk of human immunodeficiency virus in surgeons, anesthesiologists, and medical students. Anesth Analg. 1992;75(1):118-124.
8. Centers for Disease Control and Prevention. Updated U.S. Public Health Service guidelines for the management of occupational exposures to HBV, HCV, and HIV and recommendations for postexposure prophylaxis. CDC website. Accessed May 31, 2015.
9. Puro V, Petrosillo N, Ippolito G. Risk of hepatitis C seroconversion after occupational exposure in health care workers. Italian Study Group on Occupational Risk of HIV and Other Bloodborne Infections. Am J Infect Control. 1995;23(5):273-277.
10. Updated US Public Health Service Guidelines for the management of occupational exposures to Human Immunodeficiency Virus and Recommendations for Postexposure Prophylaxis. Accessed May 31, 2015.

EDITOR’S NOTE: This month’s KCQ first appeared in October 2010 and since that time has been one of our website’s most-read articles, generating nearly 35,000-plus page views. Enjoy it again this month!

Case

While placing a central line, you sustain a needlestick. You’ve washed the area thoroughly with soap and water, but you are concerned about contracting a bloodborne pathogen. What is the risk of contracting such a pathogen, and what can be done to reduce this risk?

Overview

Needlestick injuries are a common occupational hazard in the hospital setting. According to the International Health Care Worker Safety Center, approximately 295,000 hospital-based healthcare workers experience occupational percutaneous injuries annually. In 1991, Mangione and colleagues surveyed internal medicine house staff and found an annual incidence of 674 needlestick injuries per 1,000 participants.¹ Other retrospective data estimate this risk to be as high as 839 per 1,000 healthcare workers annually.² Evidence from the CDC in 2004 suggests that because these numbers represent only self-reported injuries, the annual incidence of such injuries is much higher than the current estimates suggest.^2,3,4

More than 20 bloodborne pathogens (see Table 1) might be transmitted from contaminated needles or sharps, including human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV). A quick and appropriate response to a needlestick injury can greatly decrease the risk of disease transmission following an occupational exposure to potentially infectious materials.

Review of the Data

After any needlestick injury, an affected healthcare worker should wash the area with soap and water immediately. There is no contraindication to using antiseptic solutions, but there is also no evidence to suggest that this reduces the rates of disease transmission.

Because decisions for post-exposure prophylaxis often need to be made within hours, a healthcare worker should seek care in the facility areas responsible for managing occupational exposures. Healthcare providers should be encouraged and supported in reporting all sharps-related injuries to such departments.

The source patient should be identified and evaluated for potentially transmissible diseases, including HIV, HBV, and HCV. If indicated, the source patient should then undergo appropriate serological testing, and any indicated antiviral prophylaxis should be initiated (see Table 2).

Risk of Seroconversion

For all bloodborne pathogens, a needlestick injury carries a greater risk for transmission than other occupational exposures (e.g. mucous membrane exposure). If a needlestick injury occurs in the setting of an infected patient source, the risk of disease transmission varies for HIV, HBV, and HCV (see Table 3). In general, risk for seroconversion is increased with a deep injury, an injury with a device visibly contaminated with the source patient’s blood, or an injury involving a needle placed in the source patient’s artery or vein.^3,5,6

Human immunodeficiency virus. Contracting HIV after needlestick injury is rare. From 1981 to 2006, the CDC documented only 57 cases of HIV/AIDS in healthcare workers following occupational exposure and identified an additional “possible” 140 cases post-exposure.5,6 Of the 57 documented cases, 48 sustained a percutaneous injury.

 

Following needlestick injury involving a known HIV-positive source, the one-year risk of seroconversion has been estimated to be 0.3%.5,6 In 1997, Cardo and colleagues identified four factors associated with increased risk for seroconversion after a needlestick/sharps injury from a known positive-HIV source:

• Deep injury;
• Injury with a device visibly contaminated with the source patient’s blood;
• A procedure involving a needle placed in the source patient’s artery or vein; and
• Exposure to a source patient who died of AIDS in the two months following the occupational exposure.⁵

Hepatitis B virus. Widespread immunization of healthcare workers has led to a dramatic decline in occupationally acquired HBV. The CDC estimated that in 1985, approximately 12,500 new HBV infections occurred in healthcare workers.³ This estimate plummeted to approximately 500 new occupationally acquired HBV infections in 1997.³

Despite this improvement, hospital-based healthcare personnel remain at risk for HBV transmission after a needlestick injury from a known positive patient source. Few studies have evaluated the occupational risk of HBV transmission after a needlestick injury. Buergler and colleagues reported that, following a needlestick injury involving a known HBV-positive source, the one-year risk of seroconversion was 0.76% to 7.35% for nonimmunized surgeons and 0.23% to 2.28% for nonimmunized anesthesiologists.⁷

In the absence of post-exposure prophylaxis (PEP), an exposed healthcare worker has a 6% to 30% risk of becoming infected with HBV.^3,8 The risk is greatest if the patient source is known to be hepatitis B e antigen-positive, a marker for greater disease infectivity. When given within one week of injury, PEP with multiple doses of hepatitis B immune globulin (HBIG) provides an estimated 75% protection from transmission.

Healthcare workers who have received the hepatitis B vaccine and developed immunity have virtually no risk for infection.^6,7

Hepatitis C virus. Prospective evaluation has demonstrated that the average risk of HCV transmission after percutaneous exposure to a known HCV-positive source ranges from 0% to 7%.³ The Italian Study Group on Occupational Risk of HIV and Other Bloodborne Infections evaluated HCV seroconversion within six months of a reported exposure with enzyme immunoassay and immunoblot assay. In this study, the authors found a seroconversion rate of 1.2%.⁹

Further, they suggested that HCV seroconversion only occurred from hollow-bore needles, because no seroconversions were noted in healthcare workers who sustained injuries with solid sharp objects.

Post-Exposure Management

The CDC does not recommend prophylaxis when source fluids make contact with intact skin; however, if a percutaneous occupational exposure has occurred, PEPs exist for HIV and HBV but not for HCV.^3,6 If a source patient’s HIV, HBV, and HCV statuses are unknown, occupational health personnel can interview the patient to evaluate his or her risks and initiate testing. Specific information about the time and nature of exposure should be documented.

When testing is indicated, it should be done following institutional and state-specific exposure control policies and informed consent guidelines. In all situations, the decision to begin antiviral PEP should be carefully considered, weighing the benefits of PEP versus the risks and toxicity of treatment.

Human immunodeficiency virus. If a source patient is known to be HIV-positive, has a positive rapid HIV test, or if HIV status cannot be quickly determined, PEP is indicated and should be started as quickly as possible.^3,8,10

 

The 2013 U.S. Public Health Service recommendations for PEP call for initiating three (or more) antiretroviral drugs for all occupational exposures. Current recommendations indicate that PEP should be continued for four weeks, with concurrent clinical and laboratory evaluation for drug toxicity.¹⁰

Although the combination of HBIG and the hepatitis vaccine B series has not been evaluated as PEP in the occupational setting, evidence in the perinatal setting suggests this regimen is more effective than HBIG alone.^3,6,8

Hepatitis C virus. No PEP exists for HCV, and current recommendations for post-exposure management focus on early identification and treatment of chronic disease. There are insufficient data for a treatment recommendation for patients with acute HCV infection with no evidence of disease; the appropriate dosing of such a regimen is unknown. Further, evidence suggests that treatment started early in the course of chronic infection could be just as effective and might eliminate the need to treat persons whose infection will spontaneously resolve.⁷

Back to the Case

Your needlestick occurred while using a hollow-bore needle to cannulate a source patient’s vein, placing you at higher risk for seroconversion. You immediately reported the exposure to the department of occupational health at your hospital. The source patient’s HIV, HBV, and HCV serological statuses were tested, and the patient was found to be HBV-positive. After appropriate counseling, you decide to receive HBIG prophylaxis to reduce your chances of becoming infected with HBV infection.

Bottom Line

Healthcare workers who suffer occupational needlestick injuries require immediate identification and attention to avoid transmission of such infectious diseases as HIV, HBV, and HCV. Source patients should undergo rapid serological testing to determine appropriate PEP.

---

Dr. Zehnder is a hospitalist and assistant professor of medicine at the University of Colorado Denver in Aurora.

References

1. Mangione CM, Gerberding JL, Cummings SR. Occupational exposure to HIV: Frequency and rates of underreporting of percutaneous and mucocutaneous exposures by medical housestaff. Am J Med. 1991;90(1):85-90.
2. Lee JM, Botteman MF, Nicklasson L, Cobden D, Pashos CL. Needlestick injury in acute care nurses caring for patients with diabetes mellitus: a retrospective study. Curr Med Res Opin. 2005;21(5):741-747.
3. Centers for Disease Control and Prevention. Workbook for designing, implementing, and evaluating a sharps injury prevention program. CDC website. Accessed May 31, 2015.
4. Lee JM, Botteman MF, Xanthakos N, Nicklasson L. Needlestick injuries in the United States. Epidemiologic, economic, and quality of life issues. AAOHN J. 2005;53(3):117-133.
5. Cardo DM, Culver DH, Ciesielski CA, et al. A case-control study of HIV seroconversion in health care workers after percutaneous exposure. Centers for Disease Control and Prevention Needlestick Surveillance Group. N Engl J Med. 1997;337(21):1485-1490.
6. Centers for Disease Control and Prevention. Exposure to blood: What healthcare personnel need to know. CDC website. Accessed May 31, 2015.
7. Buergler JM, Kim R, Thisted RA, Cohn SJ, Lichtor JL, Roizen MF. Risk of human immunodeficiency virus in surgeons, anesthesiologists, and medical students. Anesth Analg. 1992;75(1):118-124.
8. Centers for Disease Control and Prevention. Updated U.S. Public Health Service guidelines for the management of occupational exposures to HBV, HCV, and HIV and recommendations for postexposure prophylaxis. CDC website. Accessed May 31, 2015.
9. Puro V, Petrosillo N, Ippolito G. Risk of hepatitis C seroconversion after occupational exposure in health care workers. Italian Study Group on Occupational Risk of HIV and Other Bloodborne Infections. Am J Infect Control. 1995;23(5):273-277.
10. Updated US Public Health Service Guidelines for the management of occupational exposures to Human Immunodeficiency Virus and Recommendations for Postexposure Prophylaxis. Accessed May 31, 2015.

EDITOR’S NOTE: This month’s KCQ first appeared in October 2010 and since that time has been one of our website’s most-read articles, generating nearly 35,000-plus page views. Enjoy it again this month!

Case

While placing a central line, you sustain a needlestick. You’ve washed the area thoroughly with soap and water, but you are concerned about contracting a bloodborne pathogen. What is the risk of contracting such a pathogen, and what can be done to reduce this risk?

Overview

Needlestick injuries are a common occupational hazard in the hospital setting. According to the International Health Care Worker Safety Center, approximately 295,000 hospital-based healthcare workers experience occupational percutaneous injuries annually. In 1991, Mangione and colleagues surveyed internal medicine house staff and found an annual incidence of 674 needlestick injuries per 1,000 participants.¹ Other retrospective data estimate this risk to be as high as 839 per 1,000 healthcare workers annually.² Evidence from the CDC in 2004 suggests that because these numbers represent only self-reported injuries, the annual incidence of such injuries is much higher than the current estimates suggest.^2,3,4

More than 20 bloodborne pathogens (see Table 1) might be transmitted from contaminated needles or sharps, including human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV). A quick and appropriate response to a needlestick injury can greatly decrease the risk of disease transmission following an occupational exposure to potentially infectious materials.

Review of the Data

After any needlestick injury, an affected healthcare worker should wash the area with soap and water immediately. There is no contraindication to using antiseptic solutions, but there is also no evidence to suggest that this reduces the rates of disease transmission.

Because decisions for post-exposure prophylaxis often need to be made within hours, a healthcare worker should seek care in the facility areas responsible for managing occupational exposures. Healthcare providers should be encouraged and supported in reporting all sharps-related injuries to such departments.

The source patient should be identified and evaluated for potentially transmissible diseases, including HIV, HBV, and HCV. If indicated, the source patient should then undergo appropriate serological testing, and any indicated antiviral prophylaxis should be initiated (see Table 2).

Risk of Seroconversion

For all bloodborne pathogens, a needlestick injury carries a greater risk for transmission than other occupational exposures (e.g. mucous membrane exposure). If a needlestick injury occurs in the setting of an infected patient source, the risk of disease transmission varies for HIV, HBV, and HCV (see Table 3). In general, risk for seroconversion is increased with a deep injury, an injury with a device visibly contaminated with the source patient’s blood, or an injury involving a needle placed in the source patient’s artery or vein.^3,5,6

Human immunodeficiency virus. Contracting HIV after needlestick injury is rare. From 1981 to 2006, the CDC documented only 57 cases of HIV/AIDS in healthcare workers following occupational exposure and identified an additional “possible” 140 cases post-exposure.5,6 Of the 57 documented cases, 48 sustained a percutaneous injury.

 

Following needlestick injury involving a known HIV-positive source, the one-year risk of seroconversion has been estimated to be 0.3%.5,6 In 1997, Cardo and colleagues identified four factors associated with increased risk for seroconversion after a needlestick/sharps injury from a known positive-HIV source:

• Deep injury;
• Injury with a device visibly contaminated with the source patient’s blood;
• A procedure involving a needle placed in the source patient’s artery or vein; and
• Exposure to a source patient who died of AIDS in the two months following the occupational exposure.⁵

Hepatitis B virus. Widespread immunization of healthcare workers has led to a dramatic decline in occupationally acquired HBV. The CDC estimated that in 1985, approximately 12,500 new HBV infections occurred in healthcare workers.³ This estimate plummeted to approximately 500 new occupationally acquired HBV infections in 1997.³

Despite this improvement, hospital-based healthcare personnel remain at risk for HBV transmission after a needlestick injury from a known positive patient source. Few studies have evaluated the occupational risk of HBV transmission after a needlestick injury. Buergler and colleagues reported that, following a needlestick injury involving a known HBV-positive source, the one-year risk of seroconversion was 0.76% to 7.35% for nonimmunized surgeons and 0.23% to 2.28% for nonimmunized anesthesiologists.⁷

In the absence of post-exposure prophylaxis (PEP), an exposed healthcare worker has a 6% to 30% risk of becoming infected with HBV.^3,8 The risk is greatest if the patient source is known to be hepatitis B e antigen-positive, a marker for greater disease infectivity. When given within one week of injury, PEP with multiple doses of hepatitis B immune globulin (HBIG) provides an estimated 75% protection from transmission.

Healthcare workers who have received the hepatitis B vaccine and developed immunity have virtually no risk for infection.^6,7

Hepatitis C virus. Prospective evaluation has demonstrated that the average risk of HCV transmission after percutaneous exposure to a known HCV-positive source ranges from 0% to 7%.³ The Italian Study Group on Occupational Risk of HIV and Other Bloodborne Infections evaluated HCV seroconversion within six months of a reported exposure with enzyme immunoassay and immunoblot assay. In this study, the authors found a seroconversion rate of 1.2%.⁹

Further, they suggested that HCV seroconversion only occurred from hollow-bore needles, because no seroconversions were noted in healthcare workers who sustained injuries with solid sharp objects.

Post-Exposure Management

The CDC does not recommend prophylaxis when source fluids make contact with intact skin; however, if a percutaneous occupational exposure has occurred, PEPs exist for HIV and HBV but not for HCV.^3,6 If a source patient’s HIV, HBV, and HCV statuses are unknown, occupational health personnel can interview the patient to evaluate his or her risks and initiate testing. Specific information about the time and nature of exposure should be documented.

When testing is indicated, it should be done following institutional and state-specific exposure control policies and informed consent guidelines. In all situations, the decision to begin antiviral PEP should be carefully considered, weighing the benefits of PEP versus the risks and toxicity of treatment.

Human immunodeficiency virus. If a source patient is known to be HIV-positive, has a positive rapid HIV test, or if HIV status cannot be quickly determined, PEP is indicated and should be started as quickly as possible.^3,8,10

 

The 2013 U.S. Public Health Service recommendations for PEP call for initiating three (or more) antiretroviral drugs for all occupational exposures. Current recommendations indicate that PEP should be continued for four weeks, with concurrent clinical and laboratory evaluation for drug toxicity.¹⁰

Although the combination of HBIG and the hepatitis vaccine B series has not been evaluated as PEP in the occupational setting, evidence in the perinatal setting suggests this regimen is more effective than HBIG alone.^3,6,8

Hepatitis C virus. No PEP exists for HCV, and current recommendations for post-exposure management focus on early identification and treatment of chronic disease. There are insufficient data for a treatment recommendation for patients with acute HCV infection with no evidence of disease; the appropriate dosing of such a regimen is unknown. Further, evidence suggests that treatment started early in the course of chronic infection could be just as effective and might eliminate the need to treat persons whose infection will spontaneously resolve.⁷

Back to the Case

Your needlestick occurred while using a hollow-bore needle to cannulate a source patient’s vein, placing you at higher risk for seroconversion. You immediately reported the exposure to the department of occupational health at your hospital. The source patient’s HIV, HBV, and HCV serological statuses were tested, and the patient was found to be HBV-positive. After appropriate counseling, you decide to receive HBIG prophylaxis to reduce your chances of becoming infected with HBV infection.

Bottom Line

Healthcare workers who suffer occupational needlestick injuries require immediate identification and attention to avoid transmission of such infectious diseases as HIV, HBV, and HCV. Source patients should undergo rapid serological testing to determine appropriate PEP.

---

Dr. Zehnder is a hospitalist and assistant professor of medicine at the University of Colorado Denver in Aurora.

References

1. Mangione CM, Gerberding JL, Cummings SR. Occupational exposure to HIV: Frequency and rates of underreporting of percutaneous and mucocutaneous exposures by medical housestaff. Am J Med. 1991;90(1):85-90.
2. Lee JM, Botteman MF, Nicklasson L, Cobden D, Pashos CL. Needlestick injury in acute care nurses caring for patients with diabetes mellitus: a retrospective study. Curr Med Res Opin. 2005;21(5):741-747.
3. Centers for Disease Control and Prevention. Workbook for designing, implementing, and evaluating a sharps injury prevention program. CDC website. Accessed May 31, 2015.
4. Lee JM, Botteman MF, Xanthakos N, Nicklasson L. Needlestick injuries in the United States. Epidemiologic, economic, and quality of life issues. AAOHN J. 2005;53(3):117-133.
5. Cardo DM, Culver DH, Ciesielski CA, et al. A case-control study of HIV seroconversion in health care workers after percutaneous exposure. Centers for Disease Control and Prevention Needlestick Surveillance Group. N Engl J Med. 1997;337(21):1485-1490.
6. Centers for Disease Control and Prevention. Exposure to blood: What healthcare personnel need to know. CDC website. Accessed May 31, 2015.
7. Buergler JM, Kim R, Thisted RA, Cohn SJ, Lichtor JL, Roizen MF. Risk of human immunodeficiency virus in surgeons, anesthesiologists, and medical students. Anesth Analg. 1992;75(1):118-124.
8. Centers for Disease Control and Prevention. Updated U.S. Public Health Service guidelines for the management of occupational exposures to HBV, HCV, and HIV and recommendations for postexposure prophylaxis. CDC website. Accessed May 31, 2015.
9. Puro V, Petrosillo N, Ippolito G. Risk of hepatitis C seroconversion after occupational exposure in health care workers. Italian Study Group on Occupational Risk of HIV and Other Bloodborne Infections. Am J Infect Control. 1995;23(5):273-277.
10. Updated US Public Health Service Guidelines for the management of occupational exposures to Human Immunodeficiency Virus and Recommendations for Postexposure Prophylaxis. Accessed May 31, 2015.

Clinical question: What is the influence of patient complexities on providers’ decisions to prescribe antibiotics in three common hospital-based clinical vignettes?

Background: Antibiotic treatment decisions for medically complex patients are complicated, because the risk of undertreatment may be severe, while overtreatment may be associated with adverse effects and the emergence of resistant pathogens. It is believed that physicians are more likely than not to prescribe antibiotics for complex patients.

Study design: Hospital-based, physician survey.

Setting: Three urban academic medical centers in Los Angeles County, Calif.

Synopsis: Physicians were presented with three clinical vignettes, with variations by age, comorbidity, functional status, and follow-up, and asked to choose the best antibiotic regimen. Of the 874 invited physicians, 255 (29%) responded to the survey; 245 physicians were eligible for the study.

Study results showed 28% to 49% of physicians recommended antibiotics that were inconsistent with national guidelines. This percentage increased to 48% to 63% for medically complex patients, defined as those with older age, high medical comorbidity burden, poor functional status, or limited follow-up after hospital discharge (P<0.01). Resident physicians (n=183) were more likely than attending physicians (n=57) to have recommended antibiotics in the baseline vignettes (43% vs. 34%, P<0.05) and in all four vignettes with patient complexities.

Bottom line: Inappropriate antibiotic use was prevalent and occurred more often for patients with medical complexities.

Citation: Wooten D, Kahn K, Grein JD, Eells SJ, Miller LG. The association of patient complexities with antibiotic ordering. J Hosp Med. 2015;10:1-7.

Clinical question: What is the influence of patient complexities on providers’ decisions to prescribe antibiotics in three common hospital-based clinical vignettes?

Background: Antibiotic treatment decisions for medically complex patients are complicated, because the risk of undertreatment may be severe, while overtreatment may be associated with adverse effects and the emergence of resistant pathogens. It is believed that physicians are more likely than not to prescribe antibiotics for complex patients.

Study design: Hospital-based, physician survey.

Setting: Three urban academic medical centers in Los Angeles County, Calif.

Synopsis: Physicians were presented with three clinical vignettes, with variations by age, comorbidity, functional status, and follow-up, and asked to choose the best antibiotic regimen. Of the 874 invited physicians, 255 (29%) responded to the survey; 245 physicians were eligible for the study.

Study results showed 28% to 49% of physicians recommended antibiotics that were inconsistent with national guidelines. This percentage increased to 48% to 63% for medically complex patients, defined as those with older age, high medical comorbidity burden, poor functional status, or limited follow-up after hospital discharge (P<0.01). Resident physicians (n=183) were more likely than attending physicians (n=57) to have recommended antibiotics in the baseline vignettes (43% vs. 34%, P<0.05) and in all four vignettes with patient complexities.

Bottom line: Inappropriate antibiotic use was prevalent and occurred more often for patients with medical complexities.

Citation: Wooten D, Kahn K, Grein JD, Eells SJ, Miller LG. The association of patient complexities with antibiotic ordering. J Hosp Med. 2015;10:1-7.

Clinical question: What is the influence of patient complexities on providers’ decisions to prescribe antibiotics in three common hospital-based clinical vignettes?

Background: Antibiotic treatment decisions for medically complex patients are complicated, because the risk of undertreatment may be severe, while overtreatment may be associated with adverse effects and the emergence of resistant pathogens. It is believed that physicians are more likely than not to prescribe antibiotics for complex patients.

Study design: Hospital-based, physician survey.

Setting: Three urban academic medical centers in Los Angeles County, Calif.

Synopsis: Physicians were presented with three clinical vignettes, with variations by age, comorbidity, functional status, and follow-up, and asked to choose the best antibiotic regimen. Of the 874 invited physicians, 255 (29%) responded to the survey; 245 physicians were eligible for the study.

Study results showed 28% to 49% of physicians recommended antibiotics that were inconsistent with national guidelines. This percentage increased to 48% to 63% for medically complex patients, defined as those with older age, high medical comorbidity burden, poor functional status, or limited follow-up after hospital discharge (P<0.01). Resident physicians (n=183) were more likely than attending physicians (n=57) to have recommended antibiotics in the baseline vignettes (43% vs. 34%, P<0.05) and in all four vignettes with patient complexities.

Bottom line: Inappropriate antibiotic use was prevalent and occurred more often for patients with medical complexities.

Citation: Wooten D, Kahn K, Grein JD, Eells SJ, Miller LG. The association of patient complexities with antibiotic ordering. J Hosp Med. 2015;10:1-7.

Clinical question: Which parameters predict emergency CAP, defined as the requirement for mechanical ventilation (MV), vasopressor support (VS), or death within three to seven days?

Background: Major causes of short-term mortality in CAP include respiratory failure, septic shock, and decompensated co-morbidity. Studies have demonstrated that immediate interventions can have a substantial impact on outcomes; improving prognosis will require early recognition of CAP as a medical emergency.

Study design: Retrospective evaluation of prospective cohort study.

Setting: Hospitalized patients recruited from the multicenter, German Competence Network for the study of CAP (CAPNETZ).

Synopsis: Investigators included 3,427 patients; those who required immediate mechanical ventilation or presented in septic shock had significantly lower mortality rates than those who presented without immediate need for MV or VS. Using multivariate Cox regression, independent predictors for the development of emergency CAP within 72 hours were determined. The study also evaluated the ATS/IDA 2007 nine minor criteria for severe pneumonia in predicting emergency CAP.

Bottom line: Emergency CAP is rare but carries important prognostic considerations. Identifying those patients at risk for clinical deterioration could help in early identification and management of this subgroup of patients. Altered mental status and vital signs (hypotension, tachypnea, tachycardia, hypothermia), acute organ dysfunction, home O2, and multilobar infiltrates have been found to be independent predictors of emergency CAP. Regular evaluation of these parameters, coupled with established scores such as the ATS/IDSA 2007 minor criteria, should help guide management.

Citation: Kolditz, M, Ewig S, Klapdor B, et al. Community-acquired pneumonia as medical emergency: predictors of early deterioration. Thorax. 2015;70(6):551-558. doi:10.1136/thoraxjnl-2014-206744.

Clinical question: Which parameters predict emergency CAP, defined as the requirement for mechanical ventilation (MV), vasopressor support (VS), or death within three to seven days?

Background: Major causes of short-term mortality in CAP include respiratory failure, septic shock, and decompensated co-morbidity. Studies have demonstrated that immediate interventions can have a substantial impact on outcomes; improving prognosis will require early recognition of CAP as a medical emergency.

Study design: Retrospective evaluation of prospective cohort study.

Setting: Hospitalized patients recruited from the multicenter, German Competence Network for the study of CAP (CAPNETZ).

Synopsis: Investigators included 3,427 patients; those who required immediate mechanical ventilation or presented in septic shock had significantly lower mortality rates than those who presented without immediate need for MV or VS. Using multivariate Cox regression, independent predictors for the development of emergency CAP within 72 hours were determined. The study also evaluated the ATS/IDA 2007 nine minor criteria for severe pneumonia in predicting emergency CAP.

Bottom line: Emergency CAP is rare but carries important prognostic considerations. Identifying those patients at risk for clinical deterioration could help in early identification and management of this subgroup of patients. Altered mental status and vital signs (hypotension, tachypnea, tachycardia, hypothermia), acute organ dysfunction, home O2, and multilobar infiltrates have been found to be independent predictors of emergency CAP. Regular evaluation of these parameters, coupled with established scores such as the ATS/IDSA 2007 minor criteria, should help guide management.

Citation: Kolditz, M, Ewig S, Klapdor B, et al. Community-acquired pneumonia as medical emergency: predictors of early deterioration. Thorax. 2015;70(6):551-558. doi:10.1136/thoraxjnl-2014-206744.

Clinical question: Which parameters predict emergency CAP, defined as the requirement for mechanical ventilation (MV), vasopressor support (VS), or death within three to seven days?

Background: Major causes of short-term mortality in CAP include respiratory failure, septic shock, and decompensated co-morbidity. Studies have demonstrated that immediate interventions can have a substantial impact on outcomes; improving prognosis will require early recognition of CAP as a medical emergency.

Study design: Retrospective evaluation of prospective cohort study.

Setting: Hospitalized patients recruited from the multicenter, German Competence Network for the study of CAP (CAPNETZ).

Synopsis: Investigators included 3,427 patients; those who required immediate mechanical ventilation or presented in septic shock had significantly lower mortality rates than those who presented without immediate need for MV or VS. Using multivariate Cox regression, independent predictors for the development of emergency CAP within 72 hours were determined. The study also evaluated the ATS/IDA 2007 nine minor criteria for severe pneumonia in predicting emergency CAP.

Bottom line: Emergency CAP is rare but carries important prognostic considerations. Identifying those patients at risk for clinical deterioration could help in early identification and management of this subgroup of patients. Altered mental status and vital signs (hypotension, tachypnea, tachycardia, hypothermia), acute organ dysfunction, home O2, and multilobar infiltrates have been found to be independent predictors of emergency CAP. Regular evaluation of these parameters, coupled with established scores such as the ATS/IDSA 2007 minor criteria, should help guide management.

Citation: Kolditz, M, Ewig S, Klapdor B, et al. Community-acquired pneumonia as medical emergency: predictors of early deterioration. Thorax. 2015;70(6):551-558. doi:10.1136/thoraxjnl-2014-206744.

Clinical question: How effective are multicomponent, nonpharmacological interventions at reducing delirium and preventing poor outcomes?

Background: Delirium is an acute disorder with significant morbidity and mortality. Systemic reviews and clinical guidelines recommend targeted, multicomponent, nonpharmacologic strategies for prevention. The Hospital Elder Life Program (HELP) uses an interdisciplinary team to implement nonpharmacologic interventions, such as reorientation, early mobilization, therapeutic activities, hydration, nutrition, sleep strategies, and hearing and vision adaptation. Trials of nonpharmacological strategies to prevent this disorder have been limited to small-scale studies.

Study design: Systemic literature review and meta-analysis.

Synopsis: Fourteen studies involving 12 unique interventions were identified and results were pooled for meta-analysis, with primary outcomes being incidence and falls. Secondary outcomes were length of stay, institutionalization, and change in functional or cognitive status. Eleven studies were found to have demonstrated significant reductions in delirium incidence (odds ratio [OR], 0.47; 95% CI, 0.38-0.58), with four trials reducing delirium incidence by 44% (OR, 0.56; 95%CI, 0.42-0.76). Four studies demonstrated a significant decrease in the rate of falls (OR, 0.38; 95% CI, 0.25-0.60), with two studies reducing falls by 64% (OR, 0.36; 95% CI, 0.22-0.61). Institutionalization and length of stay did not demonstrate statistical significance between the two groups.

Bottom line: Multicomponent, nonpharmacological delirium prevention interventions were found to be effective in decreasing the occurrence of both delirium and falls during hospitalization in older persons.

Citation: Hshieh TT, Yue J, Oh E, et al. Effectiveness of multicomponent nonpharmacological delirium interventions. JAMA. 2015;175(4):512-520.

Clinical question: How effective are multicomponent, nonpharmacological interventions at reducing delirium and preventing poor outcomes?

Background: Delirium is an acute disorder with significant morbidity and mortality. Systemic reviews and clinical guidelines recommend targeted, multicomponent, nonpharmacologic strategies for prevention. The Hospital Elder Life Program (HELP) uses an interdisciplinary team to implement nonpharmacologic interventions, such as reorientation, early mobilization, therapeutic activities, hydration, nutrition, sleep strategies, and hearing and vision adaptation. Trials of nonpharmacological strategies to prevent this disorder have been limited to small-scale studies.

Study design: Systemic literature review and meta-analysis.

Synopsis: Fourteen studies involving 12 unique interventions were identified and results were pooled for meta-analysis, with primary outcomes being incidence and falls. Secondary outcomes were length of stay, institutionalization, and change in functional or cognitive status. Eleven studies were found to have demonstrated significant reductions in delirium incidence (odds ratio [OR], 0.47; 95% CI, 0.38-0.58), with four trials reducing delirium incidence by 44% (OR, 0.56; 95%CI, 0.42-0.76). Four studies demonstrated a significant decrease in the rate of falls (OR, 0.38; 95% CI, 0.25-0.60), with two studies reducing falls by 64% (OR, 0.36; 95% CI, 0.22-0.61). Institutionalization and length of stay did not demonstrate statistical significance between the two groups.

Bottom line: Multicomponent, nonpharmacological delirium prevention interventions were found to be effective in decreasing the occurrence of both delirium and falls during hospitalization in older persons.

Citation: Hshieh TT, Yue J, Oh E, et al. Effectiveness of multicomponent nonpharmacological delirium interventions. JAMA. 2015;175(4):512-520.

Clinical question: How effective are multicomponent, nonpharmacological interventions at reducing delirium and preventing poor outcomes?

Background: Delirium is an acute disorder with significant morbidity and mortality. Systemic reviews and clinical guidelines recommend targeted, multicomponent, nonpharmacologic strategies for prevention. The Hospital Elder Life Program (HELP) uses an interdisciplinary team to implement nonpharmacologic interventions, such as reorientation, early mobilization, therapeutic activities, hydration, nutrition, sleep strategies, and hearing and vision adaptation. Trials of nonpharmacological strategies to prevent this disorder have been limited to small-scale studies.

Study design: Systemic literature review and meta-analysis.

Synopsis: Fourteen studies involving 12 unique interventions were identified and results were pooled for meta-analysis, with primary outcomes being incidence and falls. Secondary outcomes were length of stay, institutionalization, and change in functional or cognitive status. Eleven studies were found to have demonstrated significant reductions in delirium incidence (odds ratio [OR], 0.47; 95% CI, 0.38-0.58), with four trials reducing delirium incidence by 44% (OR, 0.56; 95%CI, 0.42-0.76). Four studies demonstrated a significant decrease in the rate of falls (OR, 0.38; 95% CI, 0.25-0.60), with two studies reducing falls by 64% (OR, 0.36; 95% CI, 0.22-0.61). Institutionalization and length of stay did not demonstrate statistical significance between the two groups.

Bottom line: Multicomponent, nonpharmacological delirium prevention interventions were found to be effective in decreasing the occurrence of both delirium and falls during hospitalization in older persons.

Citation: Hshieh TT, Yue J, Oh E, et al. Effectiveness of multicomponent nonpharmacological delirium interventions. JAMA. 2015;175(4):512-520.

Clinical question: Does EGDT for sepsis reduce mortality at 90 days compared with standard therapy?

Background: EGDT is recommended in international guidelines for the resuscitation of patients presenting with early septic shock; however, adoption has been limited, and uncertainty about its effectiveness remains.

Study design: Pragmatic, multicenter, randomized controlled trial (RCT) with intention to treat analysis.

Setting: Fifty-six National Health Service EDs in the United Kingdom.

Synopsis: ProMISe trial enrolled 1,251 patients with severe sepsis or septic shock and patients were randomized to usual-care group (as determined by the treating clinicians) or algorithm-driven EGDT, which included continuous central venous oxygen saturation (ScvO2) using the original EGDT protocol. The primary outcome of all-cause mortality at 90 days was not significantly different between the two groups: 29.5% in EGDT and 29.2% in the usual-care group (P=0.9). This translated into a relative risk of 1.01% (95% CI 0.85-1.20) in the EGDT group. There were no meaningful differences in secondary outcomes.

Both groups in this study were actually well matched for most interventions. The main difference was in the use of continuous ScvO2 measurement and central venous pressure to guide management. Perhaps we should not completely dismiss the term EGDT. Most of our “usual care” consists of early intervention and goal-directed therapy.

Bottom line: In patients identified early with septic shock, the use of EGDT vs. “usual” care did not result in a statistical difference in 90-day mortality.

Citation: Mouncey PR, Osborn TM, Power GS, et al. Trial of early, goal-directed resuscitation for septic shock. N Engl J Med. 2015;372:1301-1311.

Clinical question: Does EGDT for sepsis reduce mortality at 90 days compared with standard therapy?

Background: EGDT is recommended in international guidelines for the resuscitation of patients presenting with early septic shock; however, adoption has been limited, and uncertainty about its effectiveness remains.

Study design: Pragmatic, multicenter, randomized controlled trial (RCT) with intention to treat analysis.

Setting: Fifty-six National Health Service EDs in the United Kingdom.

Synopsis: ProMISe trial enrolled 1,251 patients with severe sepsis or septic shock and patients were randomized to usual-care group (as determined by the treating clinicians) or algorithm-driven EGDT, which included continuous central venous oxygen saturation (ScvO2) using the original EGDT protocol. The primary outcome of all-cause mortality at 90 days was not significantly different between the two groups: 29.5% in EGDT and 29.2% in the usual-care group (P=0.9). This translated into a relative risk of 1.01% (95% CI 0.85-1.20) in the EGDT group. There were no meaningful differences in secondary outcomes.

Both groups in this study were actually well matched for most interventions. The main difference was in the use of continuous ScvO2 measurement and central venous pressure to guide management. Perhaps we should not completely dismiss the term EGDT. Most of our “usual care” consists of early intervention and goal-directed therapy.

Bottom line: In patients identified early with septic shock, the use of EGDT vs. “usual” care did not result in a statistical difference in 90-day mortality.

Citation: Mouncey PR, Osborn TM, Power GS, et al. Trial of early, goal-directed resuscitation for septic shock. N Engl J Med. 2015;372:1301-1311.

Clinical question: Does EGDT for sepsis reduce mortality at 90 days compared with standard therapy?

Background: EGDT is recommended in international guidelines for the resuscitation of patients presenting with early septic shock; however, adoption has been limited, and uncertainty about its effectiveness remains.

Study design: Pragmatic, multicenter, randomized controlled trial (RCT) with intention to treat analysis.

Setting: Fifty-six National Health Service EDs in the United Kingdom.

Synopsis: ProMISe trial enrolled 1,251 patients with severe sepsis or septic shock and patients were randomized to usual-care group (as determined by the treating clinicians) or algorithm-driven EGDT, which included continuous central venous oxygen saturation (ScvO2) using the original EGDT protocol. The primary outcome of all-cause mortality at 90 days was not significantly different between the two groups: 29.5% in EGDT and 29.2% in the usual-care group (P=0.9). This translated into a relative risk of 1.01% (95% CI 0.85-1.20) in the EGDT group. There were no meaningful differences in secondary outcomes.

Both groups in this study were actually well matched for most interventions. The main difference was in the use of continuous ScvO2 measurement and central venous pressure to guide management. Perhaps we should not completely dismiss the term EGDT. Most of our “usual care” consists of early intervention and goal-directed therapy.

Bottom line: In patients identified early with septic shock, the use of EGDT vs. “usual” care did not result in a statistical difference in 90-day mortality.

Citation: Mouncey PR, Osborn TM, Power GS, et al. Trial of early, goal-directed resuscitation for septic shock. N Engl J Med. 2015;372:1301-1311.

Clinical question: Among patients presenting to the ED with sepsis, who will progress to septic shock within 48 hours of arrival?

Background: This study describes patient characteristics present within four hours of ED arrival associated with developing septic shock between four and 48 hours after arrival.

Study design: Retrospective chart review.

Setting: ED patients hospitalized at two large academic institutions.

Synopsis: A total of 18,100 patients were admitted from the ED, of which 3,960 patients had two or more systemic inflammatory response syndrome criteria, and 1,316 patients had sepsis within four hours of arrival. One hundred eleven patients with sepsis (8.4%) progressed to septic shock between four to 48 hours of ED arrival.

Characteristics associated with the progression included female gender (odds ratio, 1.59; 95% CI, 1.02-2.47), nonpersistent hypotension (odds ratio, 6.24; 95% CI, 3.58-10.86), bandemia at least 10% (odds ratio, 2.60; 95% CI, 1.50-4.51), lactate of at least 4.0 mmol/L (odds ratio, 5.30; 95% CI, 2.59-10.84), and past medical history of coronary artery disease (odds ratio, 2.01; 95% 1.26-3.44).

Bottom line: Although everyone presenting with sepsis should be treated aggressively, special consideration should be given to patients who are “high risk” to develop septic shock, using the predictors delineated above.

Citation: Capp R, Horton CL, Takhar SS, et al. Predictors of patients who present to the emergency department with sepsis and progress to septic shock between 4 and 48 hours of emergency department arrival. Crit Care Med. 2015;43(5):983-988.

Clinical question: Among patients presenting to the ED with sepsis, who will progress to septic shock within 48 hours of arrival?

Background: This study describes patient characteristics present within four hours of ED arrival associated with developing septic shock between four and 48 hours after arrival.

Study design: Retrospective chart review.

Setting: ED patients hospitalized at two large academic institutions.

Synopsis: A total of 18,100 patients were admitted from the ED, of which 3,960 patients had two or more systemic inflammatory response syndrome criteria, and 1,316 patients had sepsis within four hours of arrival. One hundred eleven patients with sepsis (8.4%) progressed to septic shock between four to 48 hours of ED arrival.

Characteristics associated with the progression included female gender (odds ratio, 1.59; 95% CI, 1.02-2.47), nonpersistent hypotension (odds ratio, 6.24; 95% CI, 3.58-10.86), bandemia at least 10% (odds ratio, 2.60; 95% CI, 1.50-4.51), lactate of at least 4.0 mmol/L (odds ratio, 5.30; 95% CI, 2.59-10.84), and past medical history of coronary artery disease (odds ratio, 2.01; 95% 1.26-3.44).

Bottom line: Although everyone presenting with sepsis should be treated aggressively, special consideration should be given to patients who are “high risk” to develop septic shock, using the predictors delineated above.

Citation: Capp R, Horton CL, Takhar SS, et al. Predictors of patients who present to the emergency department with sepsis and progress to septic shock between 4 and 48 hours of emergency department arrival. Crit Care Med. 2015;43(5):983-988.

Clinical question: Among patients presenting to the ED with sepsis, who will progress to septic shock within 48 hours of arrival?

Background: This study describes patient characteristics present within four hours of ED arrival associated with developing septic shock between four and 48 hours after arrival.

Study design: Retrospective chart review.

Setting: ED patients hospitalized at two large academic institutions.

Synopsis: A total of 18,100 patients were admitted from the ED, of which 3,960 patients had two or more systemic inflammatory response syndrome criteria, and 1,316 patients had sepsis within four hours of arrival. One hundred eleven patients with sepsis (8.4%) progressed to septic shock between four to 48 hours of ED arrival.

Characteristics associated with the progression included female gender (odds ratio, 1.59; 95% CI, 1.02-2.47), nonpersistent hypotension (odds ratio, 6.24; 95% CI, 3.58-10.86), bandemia at least 10% (odds ratio, 2.60; 95% CI, 1.50-4.51), lactate of at least 4.0 mmol/L (odds ratio, 5.30; 95% CI, 2.59-10.84), and past medical history of coronary artery disease (odds ratio, 2.01; 95% 1.26-3.44).

Bottom line: Although everyone presenting with sepsis should be treated aggressively, special consideration should be given to patients who are “high risk” to develop septic shock, using the predictors delineated above.

Citation: Capp R, Horton CL, Takhar SS, et al. Predictors of patients who present to the emergency department with sepsis and progress to septic shock between 4 and 48 hours of emergency department arrival. Crit Care Med. 2015;43(5):983-988.

Clinical question: Does developing individualized care plans in the inpatient setting reduce unnecessary ED visits, hospital readmissions, and hospital costs for frequent users of hospital services?

Background: High utilizers of healthcare services are recognized as medically and psychosocially complex and are at risk for adverse outcomes. Although they make up a small fraction of the patient population (1%), they have high rates of ED visits and hospital admissions and account for 21% of national healthcare spending and hospital costs.

Study design: QI intervention with retrospective pre-/post-intervention analysis.

Setting: Inpatient, tertiary academic medical center.

Synopsis: A multidisciplinary team integrated individualized care plans for 24 high utilizer patients into the EHR from August 1, 2012, to August 31, 2013. These plans summarized medical, psychiatric, and social histories, hospital utilization patterns, and management strategies, including connecting individuals to appropriate services. Outcomes were measured six and 12 months after implementation.

Hospital admissions decreased by 56% (P<0.001) and 50.5% (P>0.003); 30-day readmission decreased by 66% (P<0.001) and 51.5% (P<0.002); ED costs, ED visits, and inpatient length of stay did not change significantly. Inpatient variable direct costs were reduced by 47.7% and 35.8% (P=0.052) at six- and 12-month analysis, respectively.

Bottom line: Individualized care plans developed by a multidisciplinary team and integrated into the EHR at the time of hospitalization can reduce hospital admissions, 30-day readmissions, and hospital costs for high-utilizing patients.

Citation: Mercer T, Bae J, Kipnes J, Velazquez M, Thomas S, Setji N. The highest utilizers of care: individualized care plans to coordinate care, improve healthcare service utilization, and reduce costs at an academic tertiary care center [published online ahead of print April 9, 2015]. J Hosp Med. doi 10.1002/jhm.2351

Clinical question: Does developing individualized care plans in the inpatient setting reduce unnecessary ED visits, hospital readmissions, and hospital costs for frequent users of hospital services?

Background: High utilizers of healthcare services are recognized as medically and psychosocially complex and are at risk for adverse outcomes. Although they make up a small fraction of the patient population (1%), they have high rates of ED visits and hospital admissions and account for 21% of national healthcare spending and hospital costs.

Study design: QI intervention with retrospective pre-/post-intervention analysis.

Setting: Inpatient, tertiary academic medical center.

Synopsis: A multidisciplinary team integrated individualized care plans for 24 high utilizer patients into the EHR from August 1, 2012, to August 31, 2013. These plans summarized medical, psychiatric, and social histories, hospital utilization patterns, and management strategies, including connecting individuals to appropriate services. Outcomes were measured six and 12 months after implementation.

Hospital admissions decreased by 56% (P<0.001) and 50.5% (P>0.003); 30-day readmission decreased by 66% (P<0.001) and 51.5% (P<0.002); ED costs, ED visits, and inpatient length of stay did not change significantly. Inpatient variable direct costs were reduced by 47.7% and 35.8% (P=0.052) at six- and 12-month analysis, respectively.

Bottom line: Individualized care plans developed by a multidisciplinary team and integrated into the EHR at the time of hospitalization can reduce hospital admissions, 30-day readmissions, and hospital costs for high-utilizing patients.

Citation: Mercer T, Bae J, Kipnes J, Velazquez M, Thomas S, Setji N. The highest utilizers of care: individualized care plans to coordinate care, improve healthcare service utilization, and reduce costs at an academic tertiary care center [published online ahead of print April 9, 2015]. J Hosp Med. doi 10.1002/jhm.2351

Clinical question: Does developing individualized care plans in the inpatient setting reduce unnecessary ED visits, hospital readmissions, and hospital costs for frequent users of hospital services?

Background: High utilizers of healthcare services are recognized as medically and psychosocially complex and are at risk for adverse outcomes. Although they make up a small fraction of the patient population (1%), they have high rates of ED visits and hospital admissions and account for 21% of national healthcare spending and hospital costs.

Study design: QI intervention with retrospective pre-/post-intervention analysis.

Setting: Inpatient, tertiary academic medical center.

Synopsis: A multidisciplinary team integrated individualized care plans for 24 high utilizer patients into the EHR from August 1, 2012, to August 31, 2013. These plans summarized medical, psychiatric, and social histories, hospital utilization patterns, and management strategies, including connecting individuals to appropriate services. Outcomes were measured six and 12 months after implementation.

Hospital admissions decreased by 56% (P<0.001) and 50.5% (P>0.003); 30-day readmission decreased by 66% (P<0.001) and 51.5% (P<0.002); ED costs, ED visits, and inpatient length of stay did not change significantly. Inpatient variable direct costs were reduced by 47.7% and 35.8% (P=0.052) at six- and 12-month analysis, respectively.

Bottom line: Individualized care plans developed by a multidisciplinary team and integrated into the EHR at the time of hospitalization can reduce hospital admissions, 30-day readmissions, and hospital costs for high-utilizing patients.

Citation: Mercer T, Bae J, Kipnes J, Velazquez M, Thomas S, Setji N. The highest utilizers of care: individualized care plans to coordinate care, improve healthcare service utilization, and reduce costs at an academic tertiary care center [published online ahead of print April 9, 2015]. J Hosp Med. doi 10.1002/jhm.2351

Clinical question: Did revision of guidelines recommending computerized tomography (CT) scan before lumbar puncture (LP) reduce delayed treatment of acute bacterial meningitis (ABM)?

Background: Guidelines were introduced in Sweden in 2004 identifying patients at risk for LP-induced brain herniation. They were revised in 2009 to exclude moderate to severe mental status impairment and new seizures as contraindications to LP. This study evaluates the effects of the revision.

Study design: Retrospective.

Setting: Inpatient; two to six months post-discharge.

Synopsis: Data from the Swedish Quality Registry for Community-Acquired Acute Bacterial Meningitis from 2005 to 2009 (394 patients) was compared to data from 2010 to 2012 (318 patients). Mortality and neurological deficits were analyzed, as were effects of LP-CT sequence on time to treatment and outcome.

Treatment was started 1.18 hours earlier (95%CI, .46-1.90 hours, P<0.01) in 2010-2012. After adjusting for confounding factors, there was a nonsignificant reduction in mortality. Treatment delay was significantly associated with increased mortality of 12.6% per hour (95% CI, 3.4%-14.4%; P<0.01). There was significant reduction of neurological sequelae during 2010-2012.

CT performed before LP was associated with a treatment delay of 1.6 hours. In patients with impaired mental status in whom LP was done before CT, mortality was similar and the risk of neurological sequelae was lower.

The study is limited by its retrospective design, nonspecific criteria for diagnosing ABM, and frequent use of meropenem between 2010-2012.

Bottom line: The 2009 revision of Swedish guidelines resulted in earlier treatment of ABM, lower mortality, and fewer unfavorable results, suggesting further revision of international guidelines.

Citation: Glimåker M, Johansson B, Grindborg Ö, Bottai M, Lindquist L, Sjölin J. Adult bacterial meningitis: earlier treatment and improved outcome following guideline revision promoting prompt lumbar puncture. Clin Infect Dis. 2015;60(8):1162-1169.

Clinical question: Did revision of guidelines recommending computerized tomography (CT) scan before lumbar puncture (LP) reduce delayed treatment of acute bacterial meningitis (ABM)?

Background: Guidelines were introduced in Sweden in 2004 identifying patients at risk for LP-induced brain herniation. They were revised in 2009 to exclude moderate to severe mental status impairment and new seizures as contraindications to LP. This study evaluates the effects of the revision.

Study design: Retrospective.

Setting: Inpatient; two to six months post-discharge.

Synopsis: Data from the Swedish Quality Registry for Community-Acquired Acute Bacterial Meningitis from 2005 to 2009 (394 patients) was compared to data from 2010 to 2012 (318 patients). Mortality and neurological deficits were analyzed, as were effects of LP-CT sequence on time to treatment and outcome.

Treatment was started 1.18 hours earlier (95%CI, .46-1.90 hours, P<0.01) in 2010-2012. After adjusting for confounding factors, there was a nonsignificant reduction in mortality. Treatment delay was significantly associated with increased mortality of 12.6% per hour (95% CI, 3.4%-14.4%; P<0.01). There was significant reduction of neurological sequelae during 2010-2012.

CT performed before LP was associated with a treatment delay of 1.6 hours. In patients with impaired mental status in whom LP was done before CT, mortality was similar and the risk of neurological sequelae was lower.

The study is limited by its retrospective design, nonspecific criteria for diagnosing ABM, and frequent use of meropenem between 2010-2012.

Bottom line: The 2009 revision of Swedish guidelines resulted in earlier treatment of ABM, lower mortality, and fewer unfavorable results, suggesting further revision of international guidelines.

Citation: Glimåker M, Johansson B, Grindborg Ö, Bottai M, Lindquist L, Sjölin J. Adult bacterial meningitis: earlier treatment and improved outcome following guideline revision promoting prompt lumbar puncture. Clin Infect Dis. 2015;60(8):1162-1169.

Clinical question: Did revision of guidelines recommending computerized tomography (CT) scan before lumbar puncture (LP) reduce delayed treatment of acute bacterial meningitis (ABM)?

Background: Guidelines were introduced in Sweden in 2004 identifying patients at risk for LP-induced brain herniation. They were revised in 2009 to exclude moderate to severe mental status impairment and new seizures as contraindications to LP. This study evaluates the effects of the revision.

Study design: Retrospective.

Setting: Inpatient; two to six months post-discharge.

Synopsis: Data from the Swedish Quality Registry for Community-Acquired Acute Bacterial Meningitis from 2005 to 2009 (394 patients) was compared to data from 2010 to 2012 (318 patients). Mortality and neurological deficits were analyzed, as were effects of LP-CT sequence on time to treatment and outcome.

Treatment was started 1.18 hours earlier (95%CI, .46-1.90 hours, P<0.01) in 2010-2012. After adjusting for confounding factors, there was a nonsignificant reduction in mortality. Treatment delay was significantly associated with increased mortality of 12.6% per hour (95% CI, 3.4%-14.4%; P<0.01). There was significant reduction of neurological sequelae during 2010-2012.

CT performed before LP was associated with a treatment delay of 1.6 hours. In patients with impaired mental status in whom LP was done before CT, mortality was similar and the risk of neurological sequelae was lower.

The study is limited by its retrospective design, nonspecific criteria for diagnosing ABM, and frequent use of meropenem between 2010-2012.

Bottom line: The 2009 revision of Swedish guidelines resulted in earlier treatment of ABM, lower mortality, and fewer unfavorable results, suggesting further revision of international guidelines.

Citation: Glimåker M, Johansson B, Grindborg Ö, Bottai M, Lindquist L, Sjölin J. Adult bacterial meningitis: earlier treatment and improved outcome following guideline revision promoting prompt lumbar puncture. Clin Infect Dis. 2015;60(8):1162-1169.