Optimizing preoperative antibiotic use through improved penicillin allergy documentation.

DISCLAIMER: In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE: Penicillin allergy documentation in the electronic health record (EHR) lacks detail with regard to type of reaction, history of reaction, and other tolerated ß-lactams. Because of concern for penicillin allergy cross-reactivity with cefazolin, patients with a reported penicillin allergy are frequently prescribed suboptimal preoperative antibiotics, which have been associated with negative patient outcomes, including increased risk of surgical site infection. The purpose of this study was to increase preoperative use of cefazolin via improvement to the documentation of penicillin allergies in the EHR. METHODS: This single-center, quasi-experimental quality improvement study compared patients with a self-reported penicillin allergy admitted for select elective surgeries before and after implementation of a penicillin allergy questionnaire. The primary outcome was receipt of cefazolin for surgical prophylaxis. Secondary outcomes were the proportion of patients with detailed penicillin allergy documentation, the proportion of patients with surgical site infections occurring within 30 days of surgery, and the proportion of patients who received the full antibiotic dose before the first surgical incision. RESULTS: A total of 100 patients were included in the preintervention group, while 85 patients were included in the postintervention group. Cefazolin use was higher in the postintervention group (13.0% vs 41.2%; P < 0.001). The postintervention group also had a larger proportion of patients with detailed allergy documentation (2.0% vs 50.6%; P < 0.001) and who received the full preoperative antibiotic dose before the first incision (25.0% vs 48.2%; P = 0.001). There was no statistical difference between the groups in the incidence of surgical site infection at 30 days after surgery (3.0% vs 1.2%; P = 0.63). CONCLUSION: Preoperative cefazolin use was higher in patients with a reported penicillin allergy after implementation of a penicillin allergy questionnaire and EHR documentation tool.

Perceived Access to Outpatient Care and Hospital Reutilization Following Acute Respiratory Illnesses.

OBJECTIVE: Efforts to decrease hospital revisits often focus on improving access to outpatient follow-up. Our objective was to assess the relationship between perceived access to timely office-based care and subsequent 30-day revisits following hospital discharge for 4 common respiratory illnesses. METHODS: This was a prospective cohort study of children 2 weeks to 16years admitted to 5 US children's hospitals for asthma, bronchiolitis, croup, or pneumonia between July 2014 and June 2016. Hospital and emergency department (ED) (in the case of croup) admission surveys administered to caregivers included the Consumer Assessments of Healthcare Providers and Systems Timely Access to Care. Access composite scores (range 0-100, with greater scores indicating better access) were linked with 30-day ED revisits and inpatient readmissions from the Pediatric Health Information System. The relationship between access to timely care and repeat utilization was assessed using multivariable logistic regression adjusting for demographics, hospitalization, and home/outpatient factors. RESULTS: Of the 2438 children enrolled, 2179 (89%) reported an office visit in the previous 6 months. Average access composite score was 52.0 (standard deviation, 36.3). In adjusted analyses, greater access scores were associated with greater odds of 30-day ED revisits (odds ratio [OR] = 1.07; 95% confidence interval [CI], 1.02-1.13)-particularly for croup (OR = 1.17; 95% CI, 1.02-1.36)-but not inpatient readmissions (OR = 1.02; 95% CI, 0.96-1.09). CONCLUSIONS: Perceived access to timely office-based care was associated with significantly greater odds of subsequent ED revisit. Focusing solely on enhancing timely access to care following discharge for common respiratory illnesses may be insufficient to prevent repeat utilization.

Automated Adherence Reminders for High Risk Children With Asthma: A Research Protocol.

BACKGROUND: The use of inhaled corticosteroid (ICS) medications has been shown to improve asthma control and reduce asthma-related morbidity and mortality. Two recent randomized trials demonstrated dramatic improvements in ICS adherence by monitoring adherence with electronic sensors and providing automated reminders to participants to take their ICS medications. Given their lower levels of adherence and higher levels of asthma-related emergency department (ED) visits, hospitalizations, and death, urban minority populations could potentially benefit greatly from these types of interventions. OBJECTIVE: The principal objective of this study will be to evaluate the feasibility, acceptability, and limited efficacy of a text message (short message service, SMS) reminder intervention to enhance ICS adherence in an urban minority population of children with asthma. We will also assess trajectories of ICS adherence in the 2 months following asthma hospitalization. METHODS: Participants will include 40 children aged 2-13 years, who are currently admitted to the Children's Hospital of Philadelphia (CHOP) for asthma, and their parent or legal guardian. Participants will be assigned to intervention and control arms using a 1:1 randomization scheme. The intervention arm will receive daily text message reminders for a 30-day intervention phase following hospitalization. This will be followed by a 30-day follow-up phase, in which all participants may choose whether or not to receive the text messages. Feasibility will be assessed by measuring (1) retention of the participants through the study phases and (2) perceived usefulness, acceptability, and preferences regarding the intervention components. Limited efficacy outcomes will include percent adherence to prescribed ICS regimen measured using Propeller Health sensors and change in parent-reported asthma control. We will perform an exploratory analysis to assess for discrete trajectories of adherence using group-based trajectory modeling (GBTM). RESULTS: Study enrollment began in December 2015 and the intervention and follow-up phases are ongoing. Results of the data analysis are expected to be available by December 2016. CONCLUSIONS: This study will add to the literature by providing foundational feasibility data on which elements of a mobile health text-message reminder intervention may need to be modified to suit the needs and constraints of high-risk urban minority populations. TRIAL REGISTRATION: Clinicaltrials.gov NCT02615743; https://www.clinicaltrials.gov/ct2/show/study/NCT02615743 (Archived with WebCite at http://www.webcitation.org/6ji59rAXN).

Developing a scoring rubric for resident research presentations: a pilot study.

BACKGROUND: A requirement for all Accreditation Council for Graduate Medical Education (ACGME) approved residencies is the provision of "an opportunity for residents to participate in research." To comply with this requirement, most training programs encourage their residents to conduct research and to report their results. Few guidelines exist, however, for assessing the efficacy of the presentations. The goal of this pilot study was to develop a valid, one-page scoring rubric to be used during oral resident research presentations. Such a scoring rubric will facilitate acceptable agreement among faculty raters. METHODS: Content validity was addressed by adhering to the Standards for Educational and Psychological Testing. A one-page, five-domain, behaviorally worded scoring rubric was developed. Inter-rater reliability was derived and three ACGME General Competencies were also addressed within the rubric. RESULTS: The initial scoring rubric was tested with 11 resident oral presentations. The inter-rater reliability was 0.56 using Cronbach's alpha. The rubric was modified and the scale restricted to a 3-point scale. It was then tested with 17 additional presentations, which were independently rated by two general surgery faculty members. Cronbach's Alpha increased to 0.61. CONCLUSIONS: An objective method to evaluate a resident's oral research presentation has been successfully piloted. This content valid rubric possesses good inter-rater reliability according to established guidelines. Clearly defined behaviors have been outlined within the rubric. Program directors will have psychometrically sound evidence for the ACGME. Future research will address generalizability and concurrent validity using other types of resident assessment data.