Interventions using electronic medical records improve follow up of infants born to hepatitis C virus infected mothers.

BACKGROUND: The American Academy of Pediatrics recommends hepatitis C virus (HCV) antibody testing for all HCV- exposed infants at age ≥ 18 months. However, many of these infants are not appropriately tested. In 2006, the pediatric infectious disease service (PIDS) at our institution implemented interventions using electronic medical records (EMR) to improve appropriate HCV testing for HCV-exposed infants. METHODS: Two-part study: During the first period (January 1, 1993, to December 31, 2005), medical records of all infants born to mothers with HCV were retrospectively reviewed for patient's demographics and infant's HCV testing. PIDS interventions included contacting the primary care physician through EMR requesting HCV testing for children without proper testing. During the second period (January 1, 2006, to December 31, 2011), interventions using EMR were implemented prospectively, including PIDS consultations during birth hospitalization for all HCV-exposed infants, addition of HCV exposure to the EMR problem list and communication with PCPs via the EMR to assure appropriate HCV testing. RESULTS: About 67,112 infants were born during the study period; 280 had maternal HCV infection and 193 continued to receive medical care at our institution. PIDS interventions using EMR resulted in a significant improvement of appropriate HCV testing among HCV-exposed infants from 8% (10/121) to 50% (36/72); P <0.0001. It also resulted in the identification of 5 new HCV-infected children; 3 of them were born before 2006 and previously undiagnosed. CONCLUSIONS: Interventions using EMR improved the identification and appropriate HCV follow up of infants born to HCV-infected mothers.

Risk factors and outcomes associated with surgical site infections after craniotomy or craniectomy.

OBJECT: Many studies that have evaluated surgical site infections (SSIs) after craniotomy or craniectomy (CRANI) did not use robust methods to assess risk factors for SSIs or outcomes associated with SSIs. The authors conducted the current study to identify risk factors for SSIs after CRANI procedures and to evaluate outcomes attributed to SSIs. METHODS: The authors performed a nested case-control study of patients undergoing CRANI procedures between 2006 and 2010 at the University of Iowa Hospitals and Clinics. They identified 104 patients with SSIs and selected 312 controls. They collected data from medical records and used multivariate analyses to identify risk factors and outcomes associated with SSIs. RESULTS: Thirty-two percent of SSIs were caused by Staphylococcus aureus, 88% were deep incisional or organ space infections, and 70% were identified after discharge. Preoperative length of stay (LOS) ≥ 1 day was the only significant patient-related factor in the preoperative model (OR 2.1 [95% CI 1.2-3.4]) and in the overall model (OR 1.9 [95% CI 1.1-3.3]). Procedure-related risk factors that were significant in the overall model included Gliadel wafer use (OR 6.7 [95% CI 2.5-18.2]) and postoperative CSF leak (OR 3.5 [95% CI 1.4-8.5]). The preoperative SSI risk index, including body mass index, previous brain operation, chemotherapy on admission, preoperative LOS, procedure reason, and preoperative glucose level, had better predictive efficacy (c-statistic = 0.664) than the National Healthcare Safety Network risk index (c-statistic = 0.547; p = 0.004). Surgical site infections were associated with increased LOS during the initial hospitalizations (average increase of 50%) or readmissions (average increase of 100%) and with an increased risk of readmissions (OR 7.7 [95% CI 4.0-14.9]), reoperations (OR 36 [95% CI 14.9-87]), and death (OR 3.4 [95% CI 1.5-7.4]). CONCLUSIONS: Surgeons were able to prospectively assess a patient's risk of SSI based on preoperative risk factors and they could modify some processes of care to lower the risk of SSI. Surgical site infections substantially worsened patients' outcomes. Preventing SSIs after CRANI could improve patient outcomes and decrease health care utilization.

Hospital costs associated with smoking in veterans undergoing general surgery.

BACKGROUND: Approximately 30% of patients undergoing elective general surgery smoke cigarettes. The association between smoking status and hospital costs in general surgery patients is unknown. The objectives of this study were to compare total inpatient costs in current smokers, former smokers, and never smokers undergoing general surgical procedures in Veterans Affairs (VA) hospitals; and to determine whether the relationship between smoking and cost is mediated by postoperative complications. STUDY DESIGN: Patients undergoing general surgery during the period of October 1, 2005 to September 30, 2006 were identified in the VA Surgical Quality Improvement Program (VASQIP) data set. Inpatient costs were extracted from the VA Decision Support System (DSS). Relative surgical costs (incurred during index hospitalization and within 30 days of operation) for current and former smokers relative to never smokers, and possible mediators of the association between smoking status and cost were estimated using generalized linear regression models. Models were adjusted for preoperative and operative variables, accounting for clustering of costs at the hospital level. RESULTS: Of the 14,853 general surgical patients, 34% were current smokers, 39% were former smokers, and 27% were never smokers. After controlling for patient covariates, current smokers had significantly higher costs compared with never smokers: relative cost was 1.04 (95% Cl 1.00 to 1.07; p = 0.04); relative costs for former smokers did not differ significantly from those of never smokers: 1.02 (95% Cl 0.99 to 1.06; p = 0.14). The relationship between smoking and hospital costs for current smokers was partially mediated by postoperative respiratory complications. CONCLUSIONS: These findings complement emerging evidence recommending effective smoking cessation programs in general surgical patients and provide an estimate of the potential savings that could be accrued during the preoperative period.