Use of a telehealth follow-up system to facilitate treatment and discharge of emergency department patients with severe cellulitis
INTRODUCTION/BACKGROUND:Novel long-acting lipoglycopeptide antibiotics allow for the treatment and discharge of selected emergency department (ED) patients with cellulitis who require intravenous antibiotics. Telehealth systems have shown success in remote management of dermatologic conditions; we implemented a telehealth follow-up program for patients diagnosed with cellulitis in the ED, treated with single-dose dalbavancin, and discharged. METHODS:This was a prospective, multi-center observational study. Patients were included based on clinical criteria and ability to complete follow-up using a smartphone and enroll in an online care portal. We examined the rate of successful telehealth follow-up at 24- and 72-hour intervals from discharge. We also examined the ED return rate within 14Â days, reviewed any visits to determine cause of return, and for admission. RESULTS:55 patients were enrolled. 54/55 patients completed at least one telehealth follow up encounter (98.2%). 13 patients (23.6%) had a return ED visit within 14Â days; no patients required admission for worsening cellulitis. Patient engagement in the telehealth program decreased over time; there was an approximately 11% decrease in engagement between the 24 and 72-hour follow-up call, and a 15% decrease in engagement between the 24 and 72-hour image upload. Patients over 65 had a lower rate of image upload (31%) than younger patients (80.6%). DISCUSSION/CONCLUSIONS:A telehealth follow-up system for discharged emergency department patients with cellulitis demonstrated high rates of engagement. In these patients who -may have otherwise required admission for intravenous antibiotics, telehealth-facilitated outpatient management resulted in a low ED return rate and no inpatient admissions for cellulitis.
Dalbavancin Use in the Emergency Department Setting
BACKGROUND:Although dalbavancin's (DBV's) long half-life and one-time dosing strategy confer ideal administration in the ambulatory setting, the optimal role of DBV in the management of acute bacterial skin and skin structure infections (ABSSSIs) remains to be elucidated. OBJECTIVES/OBJECTIVE:The primary objective of this study was to compare treatment outcomes of ABSSSI between patients who received DBV in the emergency department (ED) as part of standard care versus patients who received DBV as part of a telehealth program. METHODS:This was a retrospective cohort study evaluating patients who received DBV at 3 urban EDs. The primary end point was the incidence of ABSSSI recurrence. Secondary outcomes included need for hospital admission and ED length of stay (LOS; in hours). RESULTS:A total of 65 ABSSSI treatment courses were included; 42 were included in the telehealth criteria (TC) cohort and 23 in the initial criteria (IC) cohort. There were 14% (6/42) infection recurrences in the TC cohort and 22% (5/23) in the IC cohort, with median time to recurrence being 4 and 14 days, respectively. Median ED LOS was significantly shorter in the TC (5 vs 25 hours, P < 0.05). Numerically fewer individuals in the TC cohort required inpatient admission (0 vs n = 2, 9%). Conclusion and Relevance: Our results suggest that patients may be safely administered DBV in an ED setting, with telehealth follow-up. Providing structured patient selection criteria is an effective method of assisting ED providers in selecting appropriate DBV candidates to limit potential recurrences and readmissions.
Bending the cost curve: time series analysis of a value transformation programme at an academic medical centre
BACKGROUND:Reducing costs while increasing or maintaining quality is crucial to delivering high value care. OBJECTIVE:To assess the impact of a hospital value-based management programme on cost and quality. DESIGN/METHODS:Time series analysis of non-psychiatric, non-rehabilitation, non-newborn patients discharged between 1 September 2011 and 31 December 2017 from a US urban, academic medical centre. INTERVENTION/METHODS:NYU Langone Health instituted an institution-wide programme in April 2014 to increase value of healthcare, defined as health outcomes achieved per dollar spent. Key features included joint clinical and operational leadership; granular and transparent cost accounting; dedicated project support staff; information technology support; and a departmental shared savings programme. MEASUREMENTS/METHODS:Change in variable direct costs; secondary outcomes included changes in length of stay, readmission and in-hospital mortality. RESULTS:The programme chartered 74 projects targeting opportunities in supply chain management (eg, surgical trays), operational efficiency (eg, discharge optimisation), care of outlier patients (eg, those at end of life) and resource utilisation (eg, blood management). The study cohort included 160â€‰434 hospitalisations. Adjusted variable costs decreased 7.7% over the study period. Admissions with medical diagnosis related groups (DRG) declined an average 0.20% per month relative to baseline. Admissions with surgical DRGs had an early increase in costs of 2.7% followed by 0.37% decrease in costs per month. Mean expense per hospitalisation improved from 13% above median for teaching hospitals to 2% above median. Length of stay decreased by 0.25% per month relative to prior trends (95%â€‰CI -0.34 to 0.17): approximately half a day by the end of the study period. There were no significant changes in 30-day same-hospital readmission or in-hospital mortality. Estimated institutional savings after intervention costs were approximately $53.9â€‰million. LIMITATIONS/CONCLUSIONS:Observational analysis. CONCLUSION/CONCLUSIONS:A systematic programme to increase healthcare value by lowering the cost of care without compromising quality is achievable and sustainable over several years.
Fidaxomicin Therapy in Critically Ill Patients with Clostridium difficile Infection
Fidaxomicin was given to treat proven Clostridium difficile infection (CDI) in 20 patients receiving care in critical care units (CCUs) and compared with 30 patients on general medical floors. At baseline, CCU patients had more initial CDI episodes, severe and complicated disease, and concurrent broad-spectrum antibiotic coverage. On multivariate analysis, response of fidaxomicin therapy among critically ill patients was comparable to that among patients in the general medical wards.
Developing the advanced practice recruitment strategy at an academic medical center: The APRN pipeline
The Institute of Medicine's (IOM) recommendation to remove barriers to practice and enable advanced practice registered nurses (APRNs) and registered nurses (RNs) to practice to the full extent of their education and training. 1 expanded the use of advanced practice nurses in the country. The more restrictive Accreditation Council for Graduate Medical Education (ACGME) and Residency Review Committee (RRC) requirements on residency training and work hours increased the hiring of APRNs to fill the void created by a reduction in GME trainees.2 Finally, the Affordable Care Act created additional demand for more providers to meet the needs of the newly insured population, particularly in primary care.3
Preventing surgical site infections: a randomized, open-label trial of nasal mupirocin ointment and nasal povidone-iodine solution
BACKGROUND: Treatment of Staphylococcus aureus colonization before surgery reduces risk of surgical site infection (SSI). The regimen of nasal mupirocin ointment and topical chlorhexidine gluconate is effective, but cost and patient compliance may be a barrier. Nasal povidone-iodine solution may provide an alternative to mupirocin. METHODS: We conducted an investigator-initiated, open-label, randomized trial comparing SSI after arthroplasty or spine fusion in patients receiving topical chlorhexidine wipes in combination with either twice daily application of nasal mupirocin ointment during the 5 days before surgery or 2 applications of povidone-iodine solution into each nostril within 2 hours of surgical incision. The primary study end point was deep SSI within the 3 months after surgery. RESULTS: In the modified intent-to-treat analysis, a deep SSI developed after 14 of 855 surgical procedures in the mupirocin group and 6 of 842 surgical procedures in the povidone-iodine group (P = .1); S. aureus deep SSI developed after 5 surgical procedures in the mupirocin group and 1 surgical procedure in the povidone-iodine group (P = .2). In the per protocol analysis, S. aureus deep SSI developed in 5 of 763 surgical procedures in the mupirocin group and 0 of 776 surgical procedures in the povidone-iodine group (P = .03). CONCLUSIONS: Nasal povidone-iodine may be considered as an alternative to mupirocin in a multifaceted approach to reduce SSI. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01313182.
Diagnostic feasibility of procalcitonin in recipients of liver, kidney and hematopoietic stem cell transplantation [Meeting Abstract]
Objectives: Accurate diagnosis of infections in transplant recipients remains a daunting task. To address the diagnoses dilemma, we assessed feasibility of procalcitonin (PCT), a recently approved biomarker in patients at a major University Medical Center in New York. Methods: All data was retrieved retrospectively after approval from Institutional Review Board. Transplant recipients were compared with general medicine patients, and patients with hematologic neoplasia and those being cared for in medical and surgical intensive care units between April 2012 and February 2013. Chi-square and Mann Whitney U test were used for statistical analysis. PCT (ng/ml) and other values are given as median [range]. Results: Among 342 patients studied, transplant recipients (n=26) were younger (60 vs. 69 years; p<0.01), had fewer cardiovascular diseases (19.2% vs. 44.3%; P<0.05), whereas diabetes was more common compared with other patients (53.8% vs. 21.8%; P<0.05). APACHE II scores was not different in either group (15 vs. 17; p=0.06). Similarly, there were no differences for corticosteroid use, chemotherapy and surgeries (P>0.05). PCT values were higher in transplant recipients with bacteremia, Gram-negative infections, and pneumonia (Table 1). There were no significant differences in PCT values among recipients of SOT vs. HSCT (1.62 [0.05-197] vs. 0.28 [0.05-13.1], respectively; P=0.3) during early (<1 month) or later transplant period (1.9 [0.05-13.10] vs. 1.15 [0.015-197], respectively; P=0.8). Conclusions: PCT appears as a promising diagnostic tool for transplant recipients with bacteremia, Gram-negative infections and pneumonia. Further validation studies are underway. TABLE 1. Comparison of PCT in transplant and other patients. (Table Presented)
Fidaxomicin versus Conventional Antimicrobial Therapy in 59 Recipients of Solid Organ and Hematopoietic Stem Cell Transplantation with Clostridium difficile-Associated Diarrhea
The feasibility of fidaxomicin versus vancomycin and metronidazole (conventional therapy) was assessed in 59 transplant recipients with 61 episodes of Clostridium difficile-associated diarrhea (CDAD). Overall clinical cure was achieved in 86% of episodes, and in 7% of episodes, infection recurred. Fidaxomicin was well tolerated. Clinical cures were not significantly different compared with conventional therapy (67% versus 89%, respectively; P = 0.06). Univariate analysis of predictors for lack of clinical cure included continued use of broad-spectrum systemic antibiotics (P = 0.026) and prior diagnosis of CDAD (95% confidence interval, 1.113 to 19.569; odds ratio, 4.667; P = 0.041). New-onset vancomycin-resistant Enterococcus (VRE) colonization was not noted after fidaxomicin therapy alone. However, this occurred in 10 of 28 patients (36%) following conventional therapy, and 2 of 3 patients with subsequent bacteremia died.
Enterococcal Colonization and Disease in Solid-Organ Versus Hematologic Malignancy and Hematopoietic Stem Cell Transplantation Units (2000-2011) [Meeting Abstract]
Management of infections in patients with gynecologic malignancy