Faculty Bibliography

Dialysis patients are often iron deficient due to a multiple factors. Ferric pyrophosphate citrate is a complex iron salt that can be given via dialysate allowing maintenance of hemoglobin (Hgb) concentration and iron balance while reducing the need for IV iron. The purpose of this study is to perform a cost evaluation of FPC and the effect it has on lowering the dose/use of ESAs and IV iron therapy. This study reviewed the same 100 hemodialysis patient's charts before and after the use of FPC. The data points that were collected and analyzed are as follows: hemoglobin, ferritin levels, average weekly ESA dosing, and IV iron replacement therapy dose. Out of 100 patients, there was no statistical difference in the average hemoglobin, ferritin, and iron saturation levels observed in the patients before and after FPC use. The average weekly dose of darbepoetin alfa per patient was 52.74 μg before the FPC group compared to 39.27 μg in the post FPC group (P < .0001). The total dose of ferric gluconate per patient was 3290.01 mg in the before FPC group and 585.60 mg in the post FPC group (P < .0001). The average total iron sucrose dose per patient in the before FPC group was 3097.92 mg versus 1216.67 mg in the post FPC group (P < .1563). When comparing FPC's cost and implementation into both of our outpatient dialysis centers, this yielded a net savings of $296 751.49.

INTRODUCTION/BACKGROUND:Stop the Bleed (STB) is a national training program aiming to decrease the mortality associated with life-threatening bleeding due to injury. The purpose of this study was to evaluate the efficacy and confidence level of security personnel placing a tourniquet (TQ) compared to civilians. METHODS:Pre and post questionnaires were shared with security personnel (Group 1) and civilians (Group 2). Both groups were assessed to determine comfort level with TQ placement. Time and success rate for placement was recorded pre- and post-STB training. A generalized linear mixed model or generalized estimating equations was used to compare pre and post measurements. RESULTS:There were 234 subjects enrolled. There was a statistically significant improvement between the pre- and post-training responses in both groups with respect to comfort level in placing a TQ. Participants also demonstrated increased familiarity with the anatomy and bleeding control after STB training. A higher successful TQ placement was obtained in both groups after STB training (Pre-training: Group 1 [17.4%], Group 2 [12.8%]; Post-training: Group 1 [94.8%], Group 2 [92.3%]). Both groups demonstrated improved time to TA placement with a longer mean time improvement achieved in Group 1. Although the time to TQ placement pre-and post-training was statistically significant, we found that the post-training times between Groups 1 and 2 were similar (P = .983). CONCLUSIONS:Participants improved their confidence level with the use of hemorrhage control techniques and dramatically increased the rate and time to successful placement of a TQ. While civilians had the greatest increase in comfort level, the security personnel group saw the most significant reduction in the time to successful TQ placement. These findings highlight the critical role of STB in educating and empowering both civilians and security personnel in bleeding control techniques.

OBJECTIVE:Aggression from patients and families on health care providers (HCP) is common yet understudied. We measured its prevalence and impact on HCPs in inpatient and outpatient settings. METHODS:Four thousand six hundred seven HCPs employed by a community teaching hospital received an anonymous survey with results analyzed. RESULTS:Of 1609 HCPs (35%) completing the survey, 88% of inpatient staff reported experiencing different types of aggression compared to 82% in outpatient setting. Almost half did not report it to their supervisor. Younger staff were more likely to report abuse. Negative impacts on productivity and patient care were reported. A third of all responders' indicated negative effects on mental health. CONCLUSIONS:Despite negative impacts on staff wellbeing and productivity, patient/family aggression toward HCPs is highly prevalent and underreported. Our healthcare system needs measures to address staff security and wellness.

BACKGROUND:We hypothesized that the outcomes of trauma patients with a body mass index (BMI) equal to or greater than 30 compared to patients with BMI less than 30 would not differ at a level 1 trauma center that is also a Metabolic and Bariatric Surgery Center of Excellence in the Metabolic and Bariatric Surgery Accreditation Quality Improvement Program (MBSAQIP). STUDY DESIGN/METHODS:Patients equal to and greater than 18 years old treated between 1/1/2018 and 12/31/2020 were included. Demographics, BMI, comorbidities, and outcomes (hospital-LOS, ICU-LOS, blood products used, and mortality) were compared between 2 groups: obese (BMI ≥30) vs non-obese (BMI <30). RESULTS:< .0001). When adjusted for age, sex, DM, dementia, ISS, and ICU admission, there was no statistically significant difference in hospital-LOS (4.30 [95% CI: 4.10, 4.52] vs 4.48 [95% CI: 4.18, 4.79]) or mortality. No statistical differences were seen between the 2 groups in blood product use. CONCLUSIONS:Obesity did not correlate with poorer outcomes at an ACS-verified level 1 Trauma Center and Bariatric Surgery Center of Excellence. Further studies are needed to determine whether outcomes vary at hospitals without both designations.

BACKGROUND:Cesarean rates have been used as obstetrical quality indicators. However, these approaches do not take into consideration the accompanying maternal and neonatal morbidity. A challenge in the field of obstetrics has been to establish a valid outcomes quality measure that encompasses pre-existing high-risk maternal factors, as well as associated maternal and neonatal morbidity that is universally acceptable to all stakeholders including patients, health care providers, payers, and governmental agencies. OBJECTIVES/OBJECTIVE:The objectives of this study were to: (i) establish a new single metric for obstetric quality improvement among nulliparous with term, singleton, vertex (NTSV) patients, which integrates cesarean rates adjusted for pre-existing high risk maternal factors with the associated maternal and neonatal morbidity; this single metric has been termed obstetric safety and quality index (OSQI); and (ii) determine if obstetrician quality ranking by this new metric is different as compared to the rating based on individual crude and/or risk-adjusted cesarean rates. STUDY DESIGN/METHODS:This is a cross-sectional study that identified all NTSV patients delivered by 12 randomly chosen obstetricians in a single institution. A review of all records was performed including maternal high-risk factors, maternal and neonatal outcomes. Maternal and neonatal charts were reviewed to determine crude and adjusted cesarean rates by obstetrician, and to quantify maternal and neonatal complications. We estimated the obstetrician-specific crude cesarean rates, as well as rates adjusted for obstetrician-specific maternal and neonatal complications from logistic regression models. From this model, we derived the OSQI index for each obstetrician. The final ranking based on the OSQI was compared to the initial ranking by crude cesarean rates. Maternal and neonatal morbidities were analyzed as ≥1 and as well as ≥2 maternal and/or neonatal complications. RESULTS:These 12 obstetricians delivered a total of 535 women; thus, 1070 (535 maternal and 535 neonatal) charts were reviewed to determine crude and adjusted cesarean rates by obstetrician, and to quantify maternal and neonatal complications. The ranking of crude cesarean delivery rates was not correlated (rho=0.05, 95% confidence interval -0.54, 0.60) to the final ranking based on the OSQI index. Eight of 12 obstetricians shifted their rank quartiles following adjustments for high-risk maternal conditions and maternal and neonatal outcomes. There was a strong correlation between the ranking based on ≥1 vs. ranking based on ≥2 CMM/CNM (rho=0.63, 95% confidence interval 0.08, 0.88). CONCLUSIONS:Ranking based on crude cesarean rates varies significantly after considering high-risk maternal conditions and the associated maternal and neonatal outcomes. Therefore, the OSQI is a single metric which may potentially help to identify ways to improve upon clinician practice standards within an institution. Use of this novel quality measure may help to change initiatives geared towards patient safety balancing cesarean rates with maternal and neonatal mortality. This metric could potentially be also used to compare obstetric quality not only among individual obstetricians but also among hospitals which practice obstetrics.

BACKGROUND:Evidence-based feeding practices are often variable among neonatal providers due to lack of knowledge and neonatal intensive care unit (NICU) feeding culture norms. PURPOSE/OBJECTIVE:To evaluate changes in NICU nurses' knowledge, perceptions, feeding practices and culture following education about, and implementation of, an evidence-based Infant-Driven Feeding (IDF) protocol. METHODS:A pre-/postprospective comparative design was used to survey 120 registered nurses employed in a level 3 NICU about feeding practices, knowledge, and culture prior to IDF education and 1 to 2 months after IDF implementation. RESULTS:The preeducation survey yielded 59 respondents; of these, 30 responded to the same survey after IDF implementation. Postimplementation responses were significant for fewer nurses making decisions to begin oral feedings (P = .035), greater use of gestational age to increase frequency of oral feeding attempts (P = .03), less reliance on weight loss to decrease oral feeding attempts (P = .018), an increase in use of combination interventions to prepare infants for oral feeding (P = .001), and greater willingness to allow a rest period or stop the feeding if an infant falls asleep after completing 70% of the feeding (P = .03). IMPLICATIONS FOR PRACTICE AND RESEARCH/UNASSIGNED:Trends in several survey categories following the education program and implementation of IDF support the use of evidence-based practices (EBPs) such as IDF. Future research focused on nurses' perceptions of how education influences integration of specific EBPs into practice is needed. Evaluating EBP mentorship combined with education about EBPs can provide insights on how best to integrate EBPs into practice.

BACKGROUND:Asthma, a common childhood condition, often presents with chronic cough. While evaluating for chronic cough, many specialists obtain a baseline chest radiograph (CR) to assess for other causes. Usually read as 'normal', sometimes CRs will reveal evidence of airway inflammation in the form of subtle findings, such as 'increased interstitial markings' or 'peribronchial thickening'. There is sparse literature in the outpatient setting correlating findings on baseline CRs with adverse outcomes such as systemic steroid use, emergency department (ED) visit or hospitalisation. METHODS:This was a retrospective study of patients seen at our institution's Pediatric Pulmonology outpatient clinic. We reviewed the charts of all new patients aged 0-18 years who presented between January 2015 and December 2017. Patients were included if they were diagnosed with asthma, had a CR after the initial visit and were followed up at least twice. Adverse outcomes include systemic steroid use, ED visit or hospitalisation. RESULTS:130 subjects were included. 89 subjects had clear CRs and 41 subjects had CRs with airway inflammation. Overall events were higher in the airway inflammation group (22.5% vs 46.3%, respectively, p<0.0058). There were no significant differences between in terms of oral corticosteroid use or hospitalisations. There was a significant difference between the two groups in terms of ED visits (2.2% vs 14.6%, respectively, p=0.0121). CONCLUSION/CONCLUSIONS:This study shows a positive correlation between airway inflammation findings on baseline CR and subsequent ED visits in patients with asthma.