Effectiveness of a simple intervention for prevention of catheter-associated urinary tract infections on a medical hospital unit.

BACKGROUND: Urinary tract infections (UTI) are one of the most common hospital-acquired infections with 80% as a result of urinary catheterisation. AIM/OBJECTIVE: This study examined the impact of a simple intervention consisting of a daily chart reminder in patients with indwelling urinary catheters (IUC) on the duration of catheter use and the incidence of catheter-associated UTIs (CAUTIs). METHODS: The trial used a prospective pretest-post-test design with a control group over a six-month period conducted on two medical units of a community teaching hospital. We included all patients admitted to two medical units between 1 June and 30 November 2016 who had an IUC inserted at the study site. During the intervention phase, a sticker was placed in the charts of patients with urinary catheters reminding physicians to assess for catheter removal if not clinically necessary. RESULTS: A total of 195 patients participated in this study (112 control unit, 83 intervention unit). There was a decrease in the duration of IUC use on the intervention unit from 11.7 days to 7.5 days (P = 0.0028). There was a decrease in repeated catheterisation from 11.1% to 2.1% (P = 0.0882), and CAUTIs from 17.5% to 4.6% (P = 0.0552) but this did not reach statistical significance. DISCUSSION: The implementation of a daily IUC reminder sticker in patient charts was associated with a significant reduction in the mean duration of indwelling catheter use with a trend towards a reduction in the frequency of repeated urinary catheterisation and rate of CAUTIs.

Patient outcomes in teaching versus nonteaching general internal medicine services: a systematic review and meta-analysis.

PURPOSE: Patient care quality appears to be similar when delivered by trainee and attending physicians. The authors conducted a systematic review and meta-analysis to examine whether outcomes differ for general internal medicine (GIM) patients admitted to teaching versus nonteaching services. METHOD: The authors searched Medline, EMBASE, and Cochrane Library databases in May 2012 to identify peer-reviewed, English-language studies with contemporaneous controls comparing inpatient mortality, 30-day readmission rate, and/or length of stay (LOS) for inpatients admitted to teaching or nonteaching GIM services. RESULTS: The 15 included studies (1 randomized controlled trial, 14 observational) included 108,570 patients admitted to U.S. hospitals during 1987-2011. Inpatient mortality did not differ between teaching and nonteaching services (13 studies, 108,015 patients; 2.5% versus 2.8%; OR, 1.07; 95% CI, 0.87-1.32; I = 82%); results were consistent in risk-adjusted studies (adjusted OR, 0.91; 95% CI, 0.76-1.08) and higher-quality studies (OR, 0.94; 95% CI, 0.73-1.21). There were no differences in 30-day readmission rates (11 studies, 106,021 patients; 15.1% versus 13.1%; OR, 1.05; 95% CI, 0.93-1.18). Patients on teaching services appeared to have longer LOS (11 studies, 82,352 patients; unadjusted mean difference, 0.40 days; 95% CI, 0.04-0.77 days), but there was substantial heterogeneity (I = 95%). Differences disappeared in risk-adjusted studies (mean difference: -0.09 days; 95% CI, -0.24 to 0.06 days) and in higher-quality studies (mean difference: -0.05 days; 95% CI, -0.37 to 0.28 days). CONCLUSIONS: There was no convincing evidence that outcomes differed substantively for patients admitted to teaching or nonteaching GIM services.

Postdischarge outcomes in heart failure are better for teaching hospitals and weekday discharges.

BACKGROUND: It is unclear whether teaching status or day of discharge influences outcomes after a heart failure hospitalization. METHODS AND RESULTS: We evaluated adults discharged after a heart failure hospitalization between 1999 and 2009 in Alberta, Canada. The primary outcome was death or nonelective readmission 30 days postdischarge. Of 12 216 patients discharged from teaching hospitals and 12 157 patients from nonteaching hospitals, 20 524 (84%) discharges occurred on weekdays. Although they had greater comorbidity and used more healthcare resources before their heart failure hospitalization, patients discharged from teaching hospitals exhibited shorter lengths of stay (adjusted ratio, 0.83; 95% confidence interval [CI], 0.80-0.86) and significantly lower rates of death or readmission in the 30 days after discharge than those discharged from nonteaching hospitals (17.4% versus 22.1%; adjusted hazard ratio [aHR], 0.83; 95% CI, 0.77-0.89). Patients discharged on weekdays were older and had greater comorbidity, yet exhibited significantly lower rates of death or readmission at 30 days than those discharged on weekends (19.5% versus 21.1%; aHR, 0.87; 95% CI, 0.80-0.94). Compared with weekend discharge from a nonteaching hospital, 30-day death/readmission rates were lower for weekday discharge from a nonteaching hospital (aHR, 0.85; 95% CI, 0.77-0.94), weekend discharge from a teaching hospital (aHR, 0.80; 95% CI, 0.69-0.92), and weekday discharge from a teaching hospital (aHR, 0.71, 95% CI, 0.63-0.79). CONCLUSIONS: Patients discharged from teaching hospitals or on weekdays exhibited better outcomes despite having higher risk profiles. Future studies should focus on distinguishing which discharge processes differ between teaching and nonteaching hospitals and between weekdays and weekends to define those that optimize patient outcomes.

Predicting the risk of unplanned readmission or death within 30 days of discharge after a heart failure hospitalization.

BACKGROUND: The accuracy of current models to predict the risk of unplanned readmission or death after a heart failure (HF) hospitalization is uncertain. METHODS: We linked four administrative databases in Alberta to identify all adults discharged alive after a HF hospitalization between April 1999 and 2009. We randomly selected one episode of care per patient and evaluated the accuracy of five administrative data-based models (4 already published, 1 new) for predicting risk of death or unplanned readmission within 30 days of discharge. RESULTS: Over 10 years, 59652 adults (mean age 76, 50% women) were discharged after a HF hospitalization. Within 30 days of discharge, 11199 (19%) died or had an unplanned readmission. All 5 administrative data models exhibited moderate discrimination for this outcome (c-statistic between 0.57 and 0.61). Neither Centers for Medicare and Medicaid Services (CMS)-endorsed model exhibited substantial improvements over the Charlson score for prediction of 30-day post-discharge death or unplanned readmission. However, a new model incorporating length of index hospital stay, age, Charlson score, and number of emergency room visits in the prior 6 months (the LaCE index) exhibited a 20.5% net reclassification improvement (95% CI, 18.4%-22.5%) over the Charlson score and a 19.1% improvement (95% CI, 17.1%-21.2%) over the CMS readmission model. CONCLUSIONS: None of the administrative database models are sufficiently accurate to be used to identify which HF patients require extra resources at discharge. Models which incorporate length of stay such as the LaCE appear superior to current CMS-endorsed models for risk adjusting the outcome of "death or readmission within 30 days of discharge".

Preoperative thienopyridine use and outcomes after surgery: a systematic review.

BACKGROUND: Although studies have demonstrated excess risk of ischemic events if aspirin is withheld preoperatively, it is unclear whether preoperative thienopyridine use influences postoperative outcomes. METHODS: We conducted a systematic review of 37 studies (31 cardiac and 6 noncardiac surgery, 3 randomized, 34 observational) comparing postoperative outcomes in patients who were versus were not exposed to thienopyridine in the 5 days before surgery. RESULTS: Exposure to thienopyridine in the 5 days preceding surgery (compared with no exposure) was not associated with any reduction in postoperative myocardial infarction (23 studies, 12,872 patients, 3.4% vs 3.0%, odds ratio [OR] 0.98; 95% confidence interval [CI], 0.72-1.34), but was associated with increased risks of stroke (16 studies, 10,265 patients, 1.9% vs 1.4%, OR 1.54; 95% CI, 1.08-2.20), reoperation for bleeding (32 studies, 19,423 patients, 4.3% vs 1.8%, OR 2.62; 95% CI, 1.96-3.49), and all-cause mortality (28 studies, 22,990 patients, 3.7% vs 2.6%, OR 1.38; 95% CI, 1.13-1.69). Results were identical when analyses were restricted to long-term users of thienopyridines who continued versus held the medication in the 5 days before surgery. Although all associations were similar in direction for the subset of patients undergoing noncardiac surgery, 97% of the outcome data in this meta-analysis came from cardiac surgery trials. CONCLUSIONS: These data support withholding thienopyridines 5 days before cardiac surgery; there was insufficient evidence to make definitive recommendations for elective noncardiac surgery although the direction and magnitude of associations were similar.

Frailty markers predicting emergency department visits in a community-dwelling sample of vulnerable seniors in Montreal.

Frailty puts individuals at increased risk for poor health outcomes. Elderly individuals use a disproportionate amount of emergency department (ED) resources. To investigate the relationship between frailty markers and the effect on ED use by community-dwelling seniors, we conducted a secondary analysis of a 22-month prospective randomized control trial in Montreal, Canada, using the Service Intégrés pour les Personnes Âgées en Perte d'Autonomie (SIPA) database. We assessed a sample of 565 individuals using five frailty markers: physical activity, strength, cognition, energy, and mobility. Univariate and multivariable logistic regression was performed to assess for potential relationship between frailty markers and ED visits. The findings revealed that 70 per cent of the participants had at least three frailty markers. No relationship was found between frailty markers and ED visits. These results suggest that in severely functionally disabled, community-dwelling elderly, the presence of frailty markers does not appear to predict ED visits.

Rapid insertion of GLUT2 into the rat jejunal brush-border membrane promoted by glucagon-like peptide 2.

A possible role for GLUT2 transiently expressed in the rat jejunal brush-border membrane (BBM) under the influence of glucagon-like peptide 2 (GLP-2) was investigated using in vivo perfusion of the intestinal lumen as well as isolation of membrane proteins and immunohistochemistry. A 1 h vascular infusion of GLP-2 in vivo doubled the rate of fructose absorption and this increase could be blocked by luminal phloretin. Immunohistochemistry of frozen sections of rat jejunum showed the expression of GLUT2 in both the basolateral and BBMs of mature enterocytes. Perfusion of the intestinal lumen with 50 mM D-glucose or vascular infusion of 800 pM GLP-2 for 1 h increased the expression of GLUT2 in the BBM. Quantification of these changes using Western blotting of biotinylated surface-exposed protein showed a doubling of the expression of GLUT2 in the BBM, but the effects of glucose and GLP-2 were not additive. These results indicate that vascular GLP-2 can promote the insertion of GLUT2 into the rat jejunal BBM providing a low-affinity/high-capacity route of entry for dietary hexoses.