Faculty Bibliography

During an 18-month period in a burn center (January 1995 through June 1996), 109 single-patient MRSA isolates were identified and 102 isolates (94%) were available for DNA fingerprinting. Ninety-nine isolates (97%) carried the mecA polymorph I and Tn554 type E. Pulsed-field electrophoresis (PFGE) identified 8 patterns, of which 60 isolates were of pattern F2. The I:E:F clonal type and a stable drug multidrug resistant phenotype (sensitivity only to trimethoprim/sulfamethoxazole and vancomycin) indicated that these isolates were closely related to the Iberian clone of MRSA, which is widely spread in Europe. The initial source of I:E:F isolates was sputum 49%, blood 23%, wound 16%, urine 7%, and intravascular catheter tip 5%. Fifty-four percent of patients had smoke inhalation injury, and 51/53 required intubation or tracheostomy. Forty-three isolates were considered invasive (positive blood culture). The overall mortality was 30%. Despite infection control measures, the I:E:F clone continued to be recovered from patients during the 18 months of study. This outbreak is the first known report of the Iberian MRSA clone in the United States

The value and necessity of performing right heart catheterizations for coronary artery disease have been increasingly questioned. Preliminary analyses of the procedure among Medicare and Medicaid patients in New York State revealed significant inter-hospital variations in the frequencies with which such catheterizations were performed. These data suggested that right heart catheterizations (RHC) were being performed routinely. Medicare and Medicaid claims data for bilateral catheterizations were analyzed before and after an educational intervention program involving the state's 53 catheterization laboratories. The educational intervention was multifaceted and consisted of disseminating suggested guidelines established with the assistance of the New York State Chapter of the American College of Cardiology, the Committee on Cardiovascular Disease of the Medical Society of the State of New York, and the Cardiac Advisory Council of the New York State Department of Health. Posteducational intervention assessments were made over a 4-year period. The baseline data for 1992 demonstrated that 10 (18.4%) laboratories had performed RHC routinely (70-100%) on Medicare and Medicaid patients undergoing catheterization. In contrast, 34 (64.2%) laboratories performed RHC in less than 20% of their Medicare cases, whereas 39 (73.5%) did so among Medicaid cases. Eighteen (34%) laboratories performed RHC in less than 10% of Medicare cases. These data indicated that there was significant inter-hospital variation in the frequency with which RHC was performed. Beginning in 1993, ongoing educational meetings and conferences were held with all laboratories, but especially with the 10 that were at the high end of the RHC performance level. As a result of this ongoing intervention, the rate of RHC among Medicare patients fell from 89/100,000 in 1992 to 65/100,000 beneficiaries in 1996. From another perspective, the percentage of catheterized Medicare patients undergoing RHC fell from 30.5% in 1992 to 17.4% in 1996. The decline among the 10 laboratories was even more dramatic; the percentage of catheterized Medicare patients undergoing RHC fell from 89.1% in 1992 to 31.6% in 1996. The parallel drop for Medicaid patients over the same time period was from 92.8 to 32.7%. The results of the study indicate that many previously performed RHC in patients with coronary artery disease were routine and not medically indicated. The dramatic decreases in RHC documented in this study over a 4-year period demonstrate the success of quality improvement efforts jointly undertaken by providers and a peer review organization