Donna Prentice

Purpose: This study evaluated clinician adherence to the American College of Physicians Best Practice Advice for diagnosis of pulmonary embolism. Design: A prospective, single-center, descriptive design was utilized. Methods: A heterogeneous sample of 111 hemodynamically stable adult inpatients with a computed tomography pulmonary angiogram ordered was consented. Electronic medical records were reviewed for demographic and clinical variables to determine adherence. The 6 individual best practice statements and the overall adherence were evaluated by taking the sum of “yes” answers divided by the sample size. Results: Overall adherence was 0%. Partial adherence was observed with clinician-recorded clinical decisions rules and obtaining d-dimer (3.6% [4/111] and 10.2% [9/88], respectively) of low/intermediate probability scorers. Age adjustment of d-dimer was not recorded. Computed tomography pulmonary angiogram was the first diagnostic test in 89.7% (79/88) in low/intermediate probability patients. Conclusion: In hemodynamically stable, hospitalized adults, adherence to best practice guidelines for diagnosis of pulmonary embolism was minimal. Clinical utility of the guidelines in hospitalized adults needs further evaluation. Systems problems (eg, lack of standardized orders, age-adjusted d-dimer values, information technology support) likely contributed to poor guideline adherence.

A non-randomized single center prospective, descriptive, correlational design was used to determine what end-tidal carbon dioxide (EtCO₂) level provided the best sensitivity, specificity, and negative predictive value to exclude pulmonary embolism (PE) diagnosis in hemodynamically stable hospitalized adults ( n = 111). The financial impact and harm avoidance of adding EtCO₂ to the PE diagnostic process also were examined. PE diagnosis was determined by computed tomography pulmonary angiography (CTPA). PE prevalence was 18.9%. Mean±SD EtCO₂ was lower for PE positive than negative participants (28 ± 7.8 to 33 ± 8.1 mmHg respectively 95% CI: 1.22–8.96; P = .01). For PE exclusion, an EtCO₂ cutoff ≥42 mmHg yielded 100% sensitivity, 12.2% specificity, and 100% negative predictive value. For every six inpatients assessed with EtCO₂, one could be saved from unnecessary CTPA. Eliminating unnecessary CTPA removes the potential harm associated with radiation and intravenous contrast exposure. Additionally, an EtCO₂ cutoff ≥42 mmHg could eliminate ~$88,000/year in healthcare waste at this institution.

Objectives: To generate system insights on patient and provider levers and strategies that must be activated to improve hospital-based smoking cessation treatment. Design: Mixed methods study including a series of in-depth group model building sessions, which informed the design of an online survey completed by healthcare providers and a structured interview protocol administered at the bedside to patients who smoke. Setting: Large, tertiary care hospital in the Midwestern United States. Participants: Group model building : 28 healthcare providers and 22 previously-hospitalised patients; Online survey : 308 healthcare providers; Bedside interviews : 205 hospitalised patients. Primary and secondary outcome measures: Hypothesis-generating, participatory qualitative methods informed the examination of the following quantitative outcomes: patient interest versus provider perception of patient interest in smoking cessation and treatment; patient-reported receipt versus provider-reported offering of inpatient smoking cessation interventions; and priority ratings of importance and feasibility of strategies to improve treatment. Results: System insights included patients frequently leaving the floor to smoke, which created major workflow disruption. Leverage points included interventions to reduce withdrawal symptoms, and action ideas included nurse-driven protocols for timely administration of nicotine replacement therapy. Quantitative data corroborated system insights; for instance, 80% of providers reported that patients frequently leave the floor to smoke, leading to safety risks, missed assessments and inefficient use of staff time. Patients reported significantly lower rates of receiving any smoking cessation interventions, compared with provider reports (mean difference=17.4%–33.7%, p<0.001). Although 92% of providers cited patient interest as a key barrier, only 4% of patients indicated no interest in quitting or reducing smoking. Conclusions: Engaging hospital providers and patients in participatory approaches to develop an implementation strategy revealed discrepant perceptions of patient interest and frequency of hospital-based treatment for smoking. These findings spurred adoption of standardised point-of-care treatment for cigarette smoking, which remains highly prevalent yet undertreated among hospitalised patients.

Objective: Intensive care unit patients are at risk for catheter-associated urinary tract infection. Earlier removal of catheters may be possible with accurate measurement of bladder volume. The purpose was to compare measured bladder volumes with bedside ultrasound, bladder scanner, and urine volume. Design: Prospective correlational descriptive study. Setting: Surgical/trauma intensive care unit and medical intensive care unit. Patients: Renal dialysis patients with less than 100 ml of urine in 24 h prior to urinary catheter removal and patients with suspected catheter obstruction. Measurements and main results: A physician trained in ultrasound and an advanced practice registered nurse trained in bladder scanning measured bladder volume; each blinded to the other’s measurement. Device used first (ultrasound or bladder scanner) alternated daily. The intensive care unit team determined need for intermittent catheterization or treatment for suspected obstruction. Fifty-one measurements from 13 patients were obtained with results reported in milliliters. Ultrasound measurements were a mean volume of 72.1 ± 127 (range: 1.7–666) and the bladder scanner measurements were 117 ± 131 (0–529). On six occasions in five dialysis patients, urine volume measurement was available. The mean difference in ultrasound–urine volume mean difference was 0.5 ± 37.8 (range: −68 to 38.2) and the bladder scanner–urine volume was 132 ± 167 (−72 to 397). Two patients with suspected catheter obstructions had ultrasound, bladder scanner, urine volume measurements, respectively: (1) 539, 51, >300 (began voiding before catheter replaced); (2) 666, 68, 1000 with catheter replacement. Conditions leading to greatest differences were obesity, indwelling catheter and ascites. Conclusions: These results demonstrate the inaccuracy of the bladder scanner. Ultrasound measurements appear more accurate. To remove urinary catheters in patients with minimal to low urine output, serial ultrasound measurements can be used to monitor bladder volumes and return of renal function.

Background: Methicillin-resistant Staphylococcus aureus (MRSA) is a virulent organism causing substantial morbidity and mortality in intensive care units. Chlorhexidine gluconate, a topical antiseptic solution, is effective against a wide spectrum of gram-positive and gram-negative bacteria, including MRSA. Objectives To examine the impact of a bathing protocol using chlorhexidine gluconate and bath basin management on MRSA acquisition in 5 adult intensive care units and to examine the cost differences between chlorhexidine bathing by using the bath-basin method versus using prepackaged chlorhexidine-impregnated washcloths.Methods: The protocol used a 4-oz bottle of 4% chlorhexidine gluconate soap in a bath basin of warm water. Patients in 3 intensive care units underwent active surveillance for MRSA acquisition; patients in 2 other units were monitored for a new positive culture for MRSA at any site 48 hours after admission.Results: Before the protocol, 132 patients acquired MRSA in 34333 patient days (rate ratio, 3.84). Afterwards, 109 patients acquired MRSA in 41376 patient days (rate ratio, 2.63). The rate ratio difference is 1.46 (95% CI, 1.12–1.90; P = .003). The chlorhexidine soap and bath basin method cost $3.18 as compared with $5.52 for chlorhexidine-impregnated wipes (74% higher).Conclusions: The chlorhexidine bathing protocol is easy to implement, cost-effective, and led to decreased unit-acquired MRSA rates in a variety of adult intensive care units.

To compare heparin (3 mL, 10 units/mL) and 0.9% sodium chloride (NaCl, 10 mL) flush solutions with respect to central venous catheter lumen patency. Single-center, randomized, open label trial. Medical intensive care unit and Surgical/Burn/Trauma intensive care unit at Barnes-Jewish Hospital, St. Louis, MO. Three hundred forty-one patients with multilumen central venous catheters. Patients with at least one lumen with a minimum of two flushes were included in the analysis. Patients were randomly assigned within 12 hrs of central venous catheter insertion to receive either heparin or 0.9% sodium chloride flush. The primary outcome was lumen nonpatency. Secondary outcomes included the rates of loss of blood return, inability to infuse or flush through the lumen (flush failure), heparin-induced thrombocytopenia, and catheter-related blood stream infection. Assessment for patency was performed every 8 hrs in lumens without continuous infusions for the duration of catheter placement or discharge from intensive care unit. Three hundred twenty-six central venous catheters were studied yielding 709 lumens for analysis. The nonpatency rate was 3.8% in the heparin group (n = 314) and 6.3% in the 0.9% sodium chloride group (n = 395) (relative risk 1.66, 95% confidence interval 0.86–3.22, p = .136). The Kaplan-Meier analysis for time to first patency loss was not significantly different (log rank = 0.093) between groups. The rates of loss of blood return and flush failure were similar between the heparin and 0.9% sodium chloride groups. Pressure-injectable central venous catheters had significantly greater rates of nonpatency (10.6% vs. 4.3%, p = .001) and loss of blood return (37.0% vs. 18.8%, p <.001) compared to nonpressure-injectable catheters. The frequencies of heparin-induced thrombocytopenia and catheter-related blood stream infection were similar between groups. 0.9% sodium chloride and heparin flushing solutions have similar rates of lumen nonpatency. Given potential safety concerns with the use of heparin, 0.9% sodium chloride may be the preferred flushing solution for short-term use central venous catheter maintenance.