Impact of a national antimicrobial stewardship mentoring program: Insights and lessons learned.

PURPOSE: The impact of an interprofessional mentoring program to advance antimicrobial stewardship programs (ASPs) in selected U.S. hospitals and lessons learned are described. SUMMARY: A seven-step mentoring process with self-assessment, telephone calls, continuing education, a one-day onsite visit, action plan, and outcome data collection and analysis was provided to ASP teams at nine hospitals. Six hospitals completed the program. A significant improvement in the timeliness and appropriateness of i.v. antibiotic therapy (defined as a hang time within one hour after prescriber order entry and broad-spectrum coverage for gram-negative pathogens administered first when combination therapy was used) was observed in patients with sepsis over the 12-month period after implementation of the mentoring program. As a result of requiring hospital administration's participation in the mentoring program, increased funding became available at three hospitals for the microbiology laboratory to provide new rapid diagnostic tests and for pharmacist and physician time to devote to ASP activities. The collaboration and engagement of ASP team members, inclusion of hospital administrators and pharmacy directors in the onsite mentoring visits, and an experienced mentor team with an infectious diseases (ID) physician and ID pharmacist contributed to ASP success. Challenges included insufficient time to collect outcome metrics due to competing hospital priorities and loss of momentum over time. CONCLUSION: A mentoring program for antimicrobial stewardship provided the perspective that comes from experience. Engagement of hospital administration was a key factor for both developing and sustaining a stewardship program.

Critical Illness in Patients With Asplenia.

The critically ill, asplenic patient presents a variety of management challenges. Historically, the focus of the care of the asplenic population has been the prevention and management of infection, including the often-fatal overwhelming postsplenectomy infection with encapsulated organisms such as Streptococcus pneumoniae. Recently, however, there has been increasing recognition of the spleen's function in areas outside of immunity because the asplenic state has been identified as a risk factor for such vascular complications as thrombosis and pulmonary hypertension resulting from dysregulated inflammation and coagulation. Because of the relatively small size of this population and the relative infrequency with which critical illness occurs in it, there are few controlled trials that can serve as a basis for therapeutic maneuvers; thus, optimal management requires an astute clinician with an understanding of the pathogenetic mechanisms underlying the reported consequences of splenectomy. The purpose of this review is to explore the pathophysiology of the asplenic state-impairment in adaptive immunity, loss of blood filtration, endothelial dysfunction, and dysregulated coagulation-and how it leads to infection, thrombosis, and pulmonary hypertension as well as to discuss the implications of these conditions on the management of the critically ill, splenectomized patient.

TEACHING VALUES IN MEDICINE VIA AWARENESS CREATED THROUGH ART.

The design of a new medical education building sought through art to create awareness of important values in physicians. An antique silk embroidery depicting Aesculapius crowning a man charged to protect the medical profession from quackery is placed at the beginning of the space leading into the simulation laboratories to highlight the importance of competency. A charcoal drawing by an important regional artist conveys the message that trust can arise from vulnerability, with optimal mentoring being the outcome. A round table with an authentic French Art Deco lantern and a commissioned table designed as an interpretation of the lantern create the sense of importance that fosters critical thinking and professionalism. An outdoor terrace was designed to challenge residents and medical students to become in touch with their capacity for humanism in medicine. Included among the various elements to nurture this core value are an outdoor classroom, conversation gardens, open spaces under plane trees (which are within the family of trees under which Hippocrates taught), and a reflection cove (reminiscent of those sought by poets who travelled to Ravello, Italy, in an attempt to find the meaning of life). The major focal point on the terrace is a commissioned Dale Chihuly sculpture of red reeds intended to encourage art as a form of healing and as a source of humanism.

Inferior vena caval filters: key considerations.

Surgical interruption of the inferior vena cava (IVC) as a means to prevent pulmonary embolism and its consequences has been entertained since the end of the 19th century. Initial methods were crude, however, but their deficiencies led to the development of newer techniques. Despite increasing indications and use of permanent IVC filters there remains controversy regarding their efficacy and complications. The purpose of this article is to review the pertinent literature and, it is hoped, aid in the development of a rational approach to the use of IVC filters. The evolving data regarding the retrievable filters are also discussed.