HCA healthcare journal of medicine最新文献

{"title":"Implementation of Clinical Pharmacy Surveillance Technology and a Pharmacy Practice Model Re-Design Across a Multi-State Health System.","authors":"Elizabeth H Wiggins,&nbsp;Joan Kramer,&nbsp;L Hayley Burgess,&nbsp;Carley Warren","doi":"10.36518/2689-0216.1391","DOIUrl":"https://doi.org/10.36518/2689-0216.1391","url":null,"abstract":"<p><strong>Background: </strong>Outcomes-directed pharmacy models are necessary to further comprehensive, patient-centric clinical care. This report describes the implementation of clinical surveillance technology and the development of clinical pharmacy metrics to measure outcomes that support return on investment. The overall goal of clinical surveillance technology implementation in this quality improvement project was to extend the pharmacists' reach and to improve patient safety and clinical outcomes with greater operational efficiencies.</p><p><strong>Methods: </strong>In 2013, a clinical pharmacy surveillance tool was piloted and expanded over the next 2 years to 154 hospitals across the health system. Over the next 6 years, the number of hospitals utilizing the technology, the number of drug therapy modifications, the time to pharmacist intervention, clinical pharmacy metric results, and return on investment were tracked.</p><p><strong>Results: </strong>From 2015 to 2021, the number of hospitals with clinical surveillance technology implemented grew to 177 hospitals. During this same time, the number of frontline clinical pharmacist drug therapy modifications more than doubled, and the time for pharmacists to respond to alerts decreased from 13.9 to 2.6 hours. Since 2015, the percentage of patients on vancomycin de-escalated by 3 days of therapy has increased by 12% and the percentage of patients with a UTI treated with fluoroquinolone decreased by 25%. Hard and soft dollar savings resulted in an annual return on investment of 1:12.9.</p><p><strong>Conclusion: </strong>After implementing the redesigned pharmacy services model, pharmacists were more efficient and patient outcomes improved.</p>","PeriodicalId":73198,"journal":{"name":"HCA healthcare journal of medicine","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10324869/pdf/26890216_vol4_iss2_111.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"10167671","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Ambivalence at 10 000 Feet.","authors":"Marc Perlman","doi":"10.36518/2689-0216.1526","DOIUrl":"https://doi.org/10.36518/2689-0216.1526","url":null,"abstract":"<p><p>Description The transition from medical neophyte to seasoned physician is a gradual process spanning the course of many years. However, there are various milestones throughout the experience that capture increases in decision-making capacity and responsibility, such as the switch from pre-clinical to clinical medical education. Medical students in their clinical years are endowed with an abundance of knowledge from their pre-clinical years and are just beginning to synthesize and apply that information to patient care. \"Ambivalence at 10 000 Feet\" captures a reflection of a third-year medical student on the theoretical decision to provide emergency medical care in the absence of other trained medical personnel.</p>","PeriodicalId":73198,"journal":{"name":"HCA healthcare journal of medicine","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10332376/pdf/26890216_vol4_iss3_257.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9804816","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Complications of Cardiopulmonary Bypass From an Anesthesia Perspective: A Clinical Review.","authors":"Alex Roberts,&nbsp;Elizabeth C Duncan,&nbsp;Paul Hargrave,&nbsp;David Redding Kingery,&nbsp;Josh Barnes,&nbsp;Derek L Horstemeyer,&nbsp;Russell F Stahl","doi":"10.36518/2689-0216.1525","DOIUrl":"https://doi.org/10.36518/2689-0216.1525","url":null,"abstract":"<p><p>Description Cardiopulmonary bypass (CPB) is frequently used for open heart surgery and other procedures that utilize temporary substitution or support of heart and lung function. While it is widely accepted as the predominant method to carry out these procedures, it is not without possible complications. CPB can be seen as the ultimate \"team sport\" as it includes and is dependent on contributions from multiple professionals including anesthesiologists, cardiothoracic surgeons, and perfusion technicians. In this clinical review paper, we examine possible complications of CPB, primarily from the perspective of the anesthesiologist, and how to troubleshoot them if they arise, which often requires the involvement of other essential team members.</p>","PeriodicalId":73198,"journal":{"name":"HCA healthcare journal of medicine","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10327958/pdf/26890216_01042023_13.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9808346","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The Legal Limits of Parental Autonomy: Do Parents Have the Right to Refuse Intramuscular Vitamin K for Their Newborn?","authors":"Shannon M Isennock","doi":"10.36518/2689-0216.1289","DOIUrl":"https://doi.org/10.36518/2689-0216.1289","url":null,"abstract":"<p><p>Description The American Academy of Pediatrics recommends that all newborns receive an intra-muscular (IM) dose of vitamin K within 6 hours of delivery for the prevention of vitamin K deficiency bleeding (VKDB). There has been an increase in the number of parents who have refused the IM vitamin K dose for their infant based on its possible link to leukemia, preservatives that may lead to adverse reactions, and wanting to avoid pain for the infant. When newborns do not receive IM vitamin K, the most serious feared potential complication is intracranial hemorrhage with potential neurologic sequela including seizures, developmental delay, and death. Recent studies support the contention that parents are making the choice to refuse IM vitamin K without sufficient knowledge of the potential consequences. Parental decisions typically align with the best interest of the child; however, when parental decisions veer from the child's best interest, the limit of parental autonomy is tested. The precedent set by previous cases in which parental autonomy was challenged suggests parents should not be able to refuse IM vitamin K because the therapy has nearly no burden and forgoing this therapy has the potential for substantial harm. It has been argued that as long as the degree of intrusion is modest (a single IM injection) and the benefit substantial (prevention of possible death), states are granted the power to mandate the use of such an intervention. Mandated IM vitamin K for all newborns, regardless of parental approval, would rescind some parental autonomy but improve overall beneficence, nonmaleficence, and justice in the care of newborns.</p>","PeriodicalId":73198,"journal":{"name":"HCA healthcare journal of medicine","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10327957/pdf/26890216_01042023_05.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9808351","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Rapid Hepatomegaly From Ruxolitinib Discontinuation Syndrome.","authors":"Ryan Jansen van Rensburg,&nbsp;Shayna Hale,&nbsp;Anna Calara,&nbsp;Kulveer Dabb,&nbsp;Uday Dandamudi,&nbsp;Parth Desai","doi":"10.36518/2689-0216.1518","DOIUrl":"https://doi.org/10.36518/2689-0216.1518","url":null,"abstract":"<p><strong>Introduction: </strong>Ruxolitinib (RUX) is a Food and Drug Administration-approved Janus Kinase (JAK) inhibitor shown to be effective in improving hypercatabolic symptoms and splenomegaly in patients with myelofibrosis (MF). RUX therapy provides symptomatic benefits for MF patients but is often discontinued for various reasons including worsening cytopenias. Ruxolitinib Discontinuation Syndrome (RDS) involves an acute cytokine-storm rebound phenomenon that can manifest as an acute relapse of symptoms, worsening splenomegaly, respiratory distress, systemic inflammatory response syndrome, or disseminated intravascular coagulopathy.</p><p><strong>Case presentation: </strong>We present the case of a patient with JAK2-positive post-polycythemia vera MF, whose RUX therapy was discontinued due to an active gastrointestinal (GI) bleed and worsening cytopenias. The patient had recently started azacitidine and was on the drug combination prior to hospitalization. The patient developed what appears to be the first case of acute onset accelerated massive hepatomegaly, a previously undescribed clinical manifestation of RDS.</p><p><strong>Conclusion: </strong>Although rare, medical professionals should maintain a high suspicion of RDS in hospitalized patients following the discontinuation of RUX.</p>","PeriodicalId":73198,"journal":{"name":"HCA healthcare journal of medicine","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10324862/pdf/26890216_vol4_iss2_199.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9865188","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Reducing Unnecessary Acid Suppression Use in Hospitalized Patients: A Description of Targeted Strategies Implemented Across a Large Health System.","authors":"Elizabeth H Wiggins,&nbsp;L Hayley Burgess,&nbsp;Joan Kramer","doi":"10.36518/2689-0216.1471","DOIUrl":"https://doi.org/10.36518/2689-0216.1471","url":null,"abstract":"<p><strong>Background: </strong>Ensuring the appropriate use of proton pump inhibitors (PPIs) and histamine type 2-receptor antagonists (H2RAs) is an important hospital patient safety and quality initiative because therapy may be inappropriately continued during transitions of care. In this article, we aim to describe the impact of targeted quality improvement strategies to reduce unnecessary acid suppression use in hospitalized patients across a large health system.</p><p><strong>Methods: </strong>Beginning January 1, 2018, focused quality improvement strategies to prevent unnecessary initiation and continuation of proton pump inhibitors (PPIs) and histamine type 2-receptor antagonists (H2RAs) were implemented throughout a large health system. Targeted strategies were initially tested as part of the PPI deprescribing Institute for Healthcare Improvement (IHI) International Innovators Network initiative and were expanded to include H2RAs for hospitalized patients. Strategies to decrease PPIs and H2RAs during hospitalization included standardization of stress ulcer prophylaxis care pathways, evidence-based order set modifications, technology-driven support, and clinical pharmacy metric performance to goal. PPI/H2RA days of therapy (DOT) per 1000 patient days were measured from the first quarter (1Q) of 2017 to the fourth quarter (4Q) of 2021 to determine if implemented strategies resulted in improvement.</p><p><strong>Results: </strong>After quality improvement strategies were implemented, the number of PPI/H2RA DOT was reduced by 7.9 days per 1000 patient days each quarter over 4 years. The average PPI/H2RA DOT per 1000 patient days decreased from 592 (1Q 2017) to 439 (4Q 2021). In the fourth quarter of 2018, 45 hospitals (28%) achieved a 10% reduction in combined PPI/H2RA DOT per 1000 patient days, and 121 hospitals (97%) attained the goal of greater than 25% of eligible patients deprescribed PPI/H2RA for ICU patients in the fourth quarter of 2019. In the fourth quarter of 2020, 97 hospitals (87%) met the metric of 40% or more of eligible patients deprescribed from PPI/H2RA in or after an ICU stay, and 85 hospitals (87%) reached 50% or more of eligible patients deprescribed PPI/H2RA in or after an ICU stay in 4Q2021.</p><p><strong>Conclusion: </strong>Targeted quality improvement strategies decreased unnecessary PPI and H2RA use for a large health system over 4 years. Continually evaluating measured results along with establishing a new clinical pharmacy metric goal each year to encourage further improvement contributed to deprescribing success.</p>","PeriodicalId":73198,"journal":{"name":"HCA healthcare journal of medicine","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10324858/pdf/26890216_vol4_iss2_125.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9799594","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Demonstration of the Managing for Daily Improvement Quality Improvement Methodology in an Alcohol Withdrawal Protocol Audit.","authors":"Alex Stephens,&nbsp;Diana Hoot,&nbsp;Amy Cain","doi":"10.36518/2689-0216.1617","DOIUrl":"https://doi.org/10.36518/2689-0216.1617","url":null,"abstract":"<p><strong>Background: </strong>The Clinical Institute Withdrawal Assessment for Alcohol, Revised (CIWA-Ar) is an assessment tool designed to standardize care and minimize the risk of complications in patients experiencing alcohol withdrawal. After discovering an increase in medication errors and late assessments under this protocol, pharmacists at a 218-bed community hospital performed an audit of protocol compliance using a performance improvement methodology known as Managing for Daily Improvement (MDI).</p><p><strong>Methods: </strong>A daily audit of CIWA-Ar protocol compliance was performed across all hospital units, followed by discussions with frontline nurses regarding barriers to compliance. The daily audit included assessments of appropriate monitoring frequency, medication administration, and medication coverage. Nurses caring for CIWA-Ar patients were interviewed to identify perceived barriers to protocol compliance. The MDI methodology provided a framework and tools to visualize audit results. The visual management tools used in the methodology include daily tracking of 1 or more discrete process measures, daily identification of barriers to perfect process performance at the patient and process level, and collaborative action plan tracking to resolve barriers.</p><p><strong>Results: </strong>Forty-one audits were collected for 21 unique patients over 8 days. After conversations with multiple nurses across different units, the most commonly reported barrier to compliance was a lack of communication at shift handoff. The results of this audit were discussed with nurse educators, patient safety and quality leaders, and frontline nurses. Process improvement opportunities identified from this data included improved widespread nursing education, development of protocol auto-discontinuation criteria based on scores, and determination of downtime processes for the protocol.</p><p><strong>Conclusion: </strong>The MDI quality tool successfully assisted in identifying end-user barriers to and focused areas of improvement of compliance with a nurse-driven CIWA-Ar protocol. This tool is elegant in its simplicity and ease of use. It can be customized to cover any timeframe or monitoring frequency while providing visualization of progress over time.</p>","PeriodicalId":73198,"journal":{"name":"HCA healthcare journal of medicine","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10324878/pdf/26890216_vol4_iss2_187.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"10167242","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Accidental Extravasation of Mitomycin C into the Subcutaneous Tissue.","authors":"Johnathon Chung,&nbsp;Brooke Walterscheid,&nbsp;Jose Lopez-Vera,&nbsp;Hytham Rashid,&nbsp;Mike K Liang","doi":"10.36518/2689-0216.1451","DOIUrl":"https://doi.org/10.36518/2689-0216.1451","url":null,"abstract":"<p><strong>Introduction: </strong>Mitomycin C (MMC) is a common chemotherapeutic agent used to treat a variety of solid tumors. Cutaneous adverse events are rare, but MMC is a known vesicant reported to cause tissue necrosis and sloughing, erythema, and ulceration if incorrectly infused into the subcutaneous tissue. Definitive treatment of extravasation injuries due to MMC depends on the severity of the cutaneous manifestation, which includes stopping the infusion, removing the catheter, or possible debridement.</p><p><strong>Case presentation: </strong>We present the case of a 70-year-old female with extensive soft-tissue injury secondary to extravasation of MMC that required hospital admission and surgical intervention to remove the implantable venous access device.</p><p><strong>Conclusion: </strong>Extravasation injuries caused by vesicant drugs, such as MMC, often present as local skin irritation and inflammation. MMC extravasation may present a wide range of skin and soft tissue manifestations, ranging from erythema to ulcerations to necrosis. This rare but potentially detrimental complication of chemotherapy infusions should be recognized in cancer patients.</p>","PeriodicalId":73198,"journal":{"name":"HCA healthcare journal of medicine","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10324860/pdf/26890216_vol4_iss2_205.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9810444","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"My Heart.","authors":"Mina Bhatnagar","doi":"10.36518/2689-0216.1479","DOIUrl":"https://doi.org/10.36518/2689-0216.1479","url":null,"abstract":"<p><p>Description A poem expressing a daughter's love for her father through their shared passions for cardiology and medicine.</p>","PeriodicalId":73198,"journal":{"name":"HCA healthcare journal of medicine","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10327950/pdf/26890216_01042023_69.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9814137","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Clinical Impact of Oral Step-Down Therapy for Gram-Negative Bacteremia: A Retrospective Study.","authors":"Nhi Nguyen,&nbsp;Ashitha Jayachandran,&nbsp;Minhhang Mui,&nbsp;Kelsey Olson","doi":"10.36518/2689-0216.1399","DOIUrl":"https://doi.org/10.36518/2689-0216.1399","url":null,"abstract":"<p><strong>Background: </strong>In recent years, there has been a growing body of evidence that supports oral step-down therapy for the treatment of gram-negative bacteremia. The purpose of this study was to compare outcomes for hospitalized patients who received intravenous-only (IV-only) therapy versus oral step-down therapy with low, moderate, and highly bioavailable antimicrobials for the treatment of gram-negative bacteremia.</p><p><strong>Methods: </strong>In this retrospective, single-center, observational study, we examined data from adult patients hospitalized with gram-negative bacteremia in a 1-year period. Data analysis was performed using information collected from electronic medical records and a clinical surveillance system.</p><p><strong>Results: </strong>A total of 199 patients were included in this study. Patients in the IV-only group had higher Charlson comorbidity index scores at baseline and higher rates of intensive care unit admission while bacteremic (<i>P</i> = .0096 and .0026, respectively). The primary outcome of 30-day all-cause mortality was significantly lower in the oral step-down group (<i>P</i> < .0001). Secondary outcomes of 30-day bacteremia recurrence, line-associated complications, and hospital length of stay were similar between groups. The total duration of antibiotic therapy was one day longer for oral step-down patients (<i>P</i> = .0015) and the estimated cost of antibiotic therapy was significantly lower in this group (<i>P</i> < .00001).</p><p><strong>Conclusion: </strong>In this retrospective study, oral step-down therapy was not associated with increased 30- day all-cause mortality. Oral step-down therapy was also more cost-effective than IV-only therapy, while both groups had similar bacteremia recurrence within 30 days.</p>","PeriodicalId":73198,"journal":{"name":"HCA healthcare journal of medicine","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10324867/pdf/26890216_vol4_iss2_119.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"10185932","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}