Implementation of the Cardiac Arrest Sonographic Assessment (CASA) protocol for patients with cardiac arrest is associated with shorter CPR pulse checks.

OBJECTIVE: We aim to evaluate whether implementation of the "Cardiac Arrest Sonographic Assessment" (CASA) protocol reduces the duration of interruptions in CPR during resuscitation of cardiac arrest (CA) compared to the pre-intervention period. METHODS: This was a quasi-experimental pre and post intervention study completed over 19 months in an urban Emergency Department. CA resuscitations were filmed and analyzed with respect to pulse check duration and use of point-of-care ultrasound (POCUS). After one year, an intervention was implemented: ED residents and faculty were taught the CASA protocol and instructed on how to implement it within CA resuscitation. The primary outcome was the difference in CPR pulse check duration between the pre and post intervention period. Videos from pre and post intervention CA resuscitations were coded by two reviewers. RESULTS: Data was collected prospectively for 267 sequential cardiac arrests. 38 pre-intervention and 45 post-intervention resuscitations were videoed and included in analysis. Both groups had a median of 3 pulse checks and 2 POCUS exams performed per code. CPR pulse checks involving POCUS exams were 4.0 s (95%CI 1.7-6.3) shorter in the post-intervention group than in the pre-intervention group. CPR pause durations were 3.1 s (95%CI 0.7-5.6) shorter when the ultrasound probe was placed on the chest before stopping CPR compared to placement after stopping CPR, and 3.1 s (95%CI 0.6-5.6) shorter when an ED ultrasound fellowship trained faculty was present compared to non-ultrasound fellowship faculty. The proportion of pulse checks with ultrasound use increased from 64% before the intervention to 80% after the intervention. CONCLUSION: In this pre and post-intervention study, the implementation of a structured algorithm for ultrasound use during cardiac arrest significantly reduced the duration of CPR interruptions when ultrasound was performed.

Point-of-care ultrasound use in patients with cardiac arrest is associated prolonged cardiopulmonary resuscitation pauses: A prospective cohort study.

OBJECTIVE: We aim to evaluate if point-of-care ultrasound use in cardiac arrest is associated with CPR pause duration. METHODS: This is a prospective cohort study of patients with cardiac arrest (CA) presenting to an urban emergency department from July 2016 to January 2017. We collected video recordings of patients with CA in designated code rooms with video recording equipment. The CAs recordings were reviewed and coded by two abstractors. The primary outcome was the difference CPR pause duration when POCUS was and was not performed. RESULTS: A total of 110 CPR pauses were evaluated during this study. The median CPR pause with POCUS performed lasted 17s (IQR 13 - 22.5) versus 11s (IQR 7 - 16) without POCUS. In addition, multiple regression analysis demonstrated that POCUS was associated with longer pauses (6.4s, 95%CI 2.1- 10.8); ultrasound fellowship trained faculty trended towards shorter CPR pauses (-4.1s, 95%CI -8.8-0.6) compared to non-ultrasound fellowship trained faculty; and when the same provider led the resuscitation and performed the POCUS, pause durations were 6.1s (95%CI 0.4 -11.8) longer than when another provider performed the POCUS. CONCLUSION: In this prospective cohort trial of 24 patients with CA, POCUS during CPR pauses was associated with longer interruptions in CPR.

Including catheter-associated urinary tract infections in the 2008 CMS payment policy: a qualitative analysis.

The study presented in this article addresses the impact of the 2008 nonpayment policy of the Centers for Medicare and Medicaid Services (CMS) on catheter-associated urinary tract infections (CAUTIs) from the perspective of infection preventionists. With rich qualitative data, it sheds light on the day-to-day impact of this recent health policy on CAUTI prevention.

Aging population and future burden of pneumococcal pneumonia in the United States.

Pneumococcal pneumonia is concentrated among the elderly. Using a decision analytic model, we projected the future incidence of pneumococcal pneumonia and associated healthcare utilization and costs accounting for an aging US population. Between 2004 and 2040, as the population increases by 38%, pneumococcal pneumonia hospitalizations will increase by 96% (from 401 000 to 790 000), because population growth is fastest in older age groups experiencing the highest rates of pneumococcal disease. Absent intervention, the total cost of pneumococcal pneumonia will increase by $2.5 billion annually, and the demand for healthcare services for pneumococcal pneumonia, especially inpatient capacity, will double in coming decades.

Pneumococcal carriage and antibiotic resistance in young children before 13-valent conjugate vaccine.

BACKGROUND: We sought to measure trends in Streptococcus pneumoniae carriage and antibiotic resistance in young children in Massachusetts communities after widespread adoption of heptavalent 7-valent pneumococcal conjugate vaccine (PCV7) and before the introduction of the 13-valent PCV (PCV13). METHODS: We conducted a cross-sectional study including collection of questionnaire data and nasopharyngeal specimens among children aged <7 years in primary care practices from 8 Massachusetts communities during the winter season of 2008-2009 and compared with similar studies performed in 2001, 2003-2004, and 2006-2007. Antimicrobial susceptibility testing and serotyping were performed on pneumococcal isolates, and risk factors for colonization in recent seasons (2006-2007 and 2008-2009) were evaluated. RESULTS: We collected nasopharyngeal specimens from 1011 children, 290 (29%) of whom were colonized with pneumococcus. Non-PCV7 serotypes accounted for 98% of pneumococcal isolates, most commonly 19A (14%), 6C (11%), and 15B/C (11%). In 2008-2009, newly targeted PCV13 serotypes accounted for 20% of carriage isolates and 41% of penicillin-nonsusceptible S. pneumoniae. In multivariate models, younger age, child care, young siblings, and upper respiratory illness remained predictors of pneumococcal carriage, despite near-complete serotype replacement. Only young age and child care were significantly associated with penicillin-nonsusceptible S. pneumoniae carriage. CONCLUSIONS: Serotype replacement post-PCV7 is essentially complete and has been sustained in young children, with the relatively virulent 19A being the most common serotype. Predictors of carriage remained similar despite serotype replacement. PCV13 may reduce 19A and decrease antibiotic-resistant strains, but monitoring for new serotype replacement is warranted.

The Medicare policy of payment adjustment for health care-associated infections: perspectives on potential unintended consequences.

In 2008, the Centers for Medicare & Medicaid Services introduced a new policy to adjust payment to hospitals for health care-associated infections (HAIs) not present on admission. Interviews with 36 hospital infection preventionists across the United States explored the perspectives of these key stakeholders on the potential unintended consequences of the current policy. Responses were analyzed using an iterative coding process where themes were developed from the data. Participants' descriptions of unintended impacts of the policy centered around three themes. Results suggest the policy has focused more attention on targeted HAIs and has affected hospital staff; relatively fewer systems changes have ensued. Some consequences of the policy, such as infection preventionists having less time to devote to HAIs other than those in the policy or having less time to implement prevention activities, may have undesirable effects on HAI rates if hospitals do not recognize and react to potential time and resource gaps.

Making the CMS payment policy for healthcare-associated infections work: organizational factors that matter.

Healthcare-associated infections (HAIs) are among the most common adverse events in hospitals, and the morbidity and mortality associated with them are significant. In 2008, the Centers for Medicare and Medicaid Services (CMS) implemented a new financial policy that no longer provides payment to hospitals for services related to certain infections not present on admission and deemed preventable. At present, little is known about how this policy is being implemented in hospital settings. One key goal of the policy is for it to serve as a quality improvement driver within hospitals, providing the rationale and motivation for hospitals to engage in greater infection-related surveillance and prevention activities. This article examines the role organizational factors, such as leadership and culture, play in the effectiveness of the CMS policy as a quality improvement (QI) driver within hospital settings. Between late 2009 and early 2010, interviews were conducted with 36 infection preventionists working at a national sample of 36 hospitals. We found preliminary evidence that hospital executive behavior, a proactive infection control (IC) culture, and clinical staff engagement played a favorable role in enhancing the recognition, acceptance, and significance of the CMS policy as a QI driver within hospitals. We also found several other contextual factors that may impede the degree to which the above factors facilitate links between the CMS policy and hospital QI activities.

Healthcare utilization and cost of pneumococcal disease in the United States.

BACKGROUND: Streptococcus pneumoniae continues to cause a variety of common clinical syndromes, despite vaccination programs for both adults and children. The total U.S. burden of pneumococcal disease is unknown. METHODS: We constructed a decision tree-based model to estimate U.S. healthcare utilization and costs of pneumococcal disease in 2004. Data were obtained from the 2004-2005 National (Hospital) Ambulatory Medical Care Surveys (outpatient visits, antibiotics) and the National Hospital Discharge Survey (hospitalization rates), and CDC surveillance data. Other assumptions regarding the incidence of each syndrome due to pneumococcus, expected health outcomes, and healthcare utilization were derived from literature and expert opinion. Healthcare and time costs used 2007 dollars. RESULTS: We estimate that, in 2004, pneumococcal disease caused 4.0 million illness episodes, 22,000 deaths, 445,000 hospitalizations, 774,000 emergency department visits, 5.0 million outpatient visits, and 4.1 million outpatient antibiotic prescriptions. Direct medical costs totaled $3.5 billion. Pneumonia (866,000 cases) accounted for 22% of all cases and 72% of pneumococcal costs. In contrast, acute otitis media and sinusitis (1.5 million cases each) comprised 75% of cases but only 16% of direct medical costs. Patients ≥ 65 years old, accounted for most serious cases and the majority of direct medical costs ($1.8 billion in healthcare costs annually). In this age group, pneumonia caused 242,000 hospitalizations, 1.4 million hospital days, 194,000 emergency department visits, 374,000 outpatient visits, and 16,000 deaths. However, if work loss and productivity are considered, the cost of pneumococcal disease among younger working adults (18-<50) nearly equaled those ≥ 65. CONCLUSIONS: Pneumococcal disease remains a substantial cause of morbidity and mortality even in the era of routine pediatric and adult vaccination. Continued efforts are warranted to reduce serious pneumococcal disease, especially adult pneumonia.