Interpersonal Violence and Social Determinants of Health.

Social determinants of health (SDOH) influence patient outcomes and risk assessment. This study focuses on interpersonal violence, trauma outcomes, and SDOH. We hypothesized patients with lower SDOH experience worse trauma outcomes and present from higher-risk communities. Demographics, SDOH, and outcomes for patients admitted to surgical trauma suffering interpersonal violence were collected and analyzed. Home addresses were plotted, identifying areas of need compared with Area Deprivation Index (ADI). Only 18.8% of patients had documented SDOH, yielding small sample size. Analysis revealed no statistically significant associations (P < .05) between SDOH and trauma outcomes, including ICU length of stay and stress concern (P = .0804). Heat mapping revealed several hot spots across our catchment area, correlating with higher-ranked ADIs and increased deprivation. This study demonstrated SDOH can bring value in determining patient risk, emphasizing resource dedication to documenting these factors. Home addresses in conjunction with ADIs can ascertain areas for resource allocation within communities.

The relationship between required physician letters of recommendation and decreasing diversity in osteopathic medical school admissions.

CONTEXT: Some racial and ethnic groups are underrepresented in the medical field because they face unique barriers to admission to medical school. One admission requirement that can present a barrier for applicants is the physician letter of recommendation (PLOR). Undergraduate students report confusion with the application process and lack of mentorship to be two of their biggest challenges to becoming a doctor. It is especially challenging to those who already have limited access to practicing physicians. Therefore, we hypothesized that in the presence of a PLOR requirement, the diversity of students who apply and matriculate into medical school will be decreased. OBJECTIVES: This study aims to determine if a relationship exists between a PLOR requirement for the medical school application and the proportion of underrepresented in medicine (URM) students applying and matriculating to that school. METHODS: A retrospective study was conducted utilizing data published by the American Association of Colleges of Osteopathic Medicine Application Services (AACOMAS) on the race and ethnicity of applicants and matriculants to osteopathic medical schools during the years 2009-2019. In total, 35 osteopathic schools with 44 campuses were included in the study. Schools were grouped based on whether they required a PLOR. For each group of schools, descriptive statistics were performed for the following variables: number of total applicants, class size, application rate per ethnicity, matriculation rate per ethnicity, number of applicants per ethnicity, number of matriculants per ethnicity, and percentage of student body per ethnicity. The Wilcoxon rank-sum test was utilized to detect differences between the two groups. Statistical significance was assessed at the α=0.05 level. RESULTS: Schools that required a PLOR showed decreases in the number of applicants across all races and ethnicities. Black students showed the greatest difference between groups and were the only ethnicity to show significant reductions across all outcomes in the presence of a PLOR requirement. On average, schools that required a PLOR have 37.3% (185 vs. 295; p<0.0001) fewer Black applicants and 51.2% (4 vs. 8.2; p<0.0001) fewer Black matriculants. CONCLUSIONS: This study strongly suggests a relationship between requiring a PLOR's and decreasing racial and ethnic diversity in medical school matriculants, specifically the Black applicants. Based on this result, it is recommended that the requirement of a PLOR be discontinued for osteopathic medical schools.

Multi-modal Pain Control Protocol Decreases Narcotic Consumption in an Inpatient Trauma Population.

INTRODUCTION: Opioid use after surgery or trauma has been implicated as a contributing factor to opioid dependence. The Acute Care Surgery (ACS) service at our community-based trauma center instituted an opioid-minimizing, multi-modal pain control (MMPC) protocol. The classes of pain medication included a non-opioid analgesic, a non-steroidal anti-inflammatory drug, a gabapentinoid, a skeletal muscle relaxant, and a topical anesthetic. We hypothesize that the MMPC will result in lower opioid consumption compared with the prior STP as evidenced by lower morphine milligram equivalents (MME) per day. METHODS: All adult patients (≥18 years) admitted to the ACS service from Jan 2014 to Dec 2015 and Jan 2018 to Dec 2019 were screened for inclusion. The standard pain control group (STP) and MMPC groups were defined by the year of admission. The primary outcome is opioid use per day, calculated in MME received. Secondary outcomes of the study include daily pain scores, incidence of opioid-related complications, death, ventilator days, intensive care unit length of stay, and hospital length of stay (HLOS) days. RESULTS: Multi-modal pain control protocol group was older and less injured than STP group. Daily opioid utilization was significantly less in the MMPC group (22.5 MMEs/d vs 60MMEs/d in the STP group, P < .0001). Additionally, daily pain scores were not different between groups. Secondary outcomes did not vary between the two groups. CONCLUSION: This study shows that implementation of a MMPC protocol resulted in lower opioid consumption in injured patients. Pain was equivalently controlled during the MMPC protocol period as demonstrated by similar pain scores.

Safety and Outcome of Intracranial Pressure Monitor Placement Performed by Trauma Critical Care Surgeons.

INTRODUCTION: The Brain Trauma Foundation advises intracranial pressure monitor placement (ICPM) following traumatic brain injury (TBI) with a Glasgow Coma Scale (GCS) score ≤8 and an abnormal head computed tomographic scan (CT) finding. Prior studies demonstrated that ICPMs could be placed by non-neurosurgeons. We hypothesized that ICPM placement by trauma critical care surgeons (TCCS) would increase appropriate utilization (AU), decrease time to placement (TTP), and have equivalent complications to those placed by neurosurgeons. METHODS: We retrospectively reviewed medical records of adult trauma patients admitted with a TBI in a historical control group (HCG) and practice change group (PCG). Demographics, Injury Severity Score (ISS), outcomes, ICPM placement by provider type, and time to placement were identified. Complications and appropriate utilization were recorded. RESULTS: 70 patients in the HCG and 84 patients in the PCG met criteria for inclusion. Demographics, arrival GCS, ICU GCS, ISS, and admission APACHE II scores were not statistically significant. AU was 7/70 for HCG vs 19/84 in the PCG (P = .04036). Median TTP was 6.5 hours for HCG vs 5.25 for PCG (P = .9308). Interquartile range showed the data clustered around an earlier placement time, 2.3-14.0 hours, in the PCG. Complications between the 2 groups were not statistically significant, 0/7 for HCG vs 5/19 for PCG (P = .2782). DISCUSSION: This study confirms that ICPMs can be safely placed by TCCS. Our results demonstrate that placement of ICPMs by TCCS improves AU and possibly improves TTP.

An assessment of the distance between the phrenic nerve and major intrathoracic structures.

BACKGROUND: There is a lack of consensus in the literature regarding phrenic nerve proximity to thoracic structures at the level of the diaphragm. This study was undertaken to provide thoracic surgeons data on phrenic nerve location in order to reduce iatrogenic injury during invasive surgery. METHODS: Bilateral thoracic dissection was performed on 43 embalmed human cadavers (25 males; 18 females) and data was obtained from 33 left and 40 right phrenic nerves. The site of phrenic nerve penetration into the diaphragm was identified. Calipers were used to measure the distance from each phrenic nerve to the: inferior vena cava (IVC), descending aorta, esophagus, lateral thoracic wall and anterior thoracic wall. RESULTS: Mean thoracic diameter of male cadavers was significantly greater than that of female cadavers (P value <0.0001). There was no statistically significant difference between the distances from each phrenic nerve to visceral structures between males and females, except regarding the distance from the right phrenic nerve to the anterior thoracic wall where males exhibited significantly greater distances (P value =0.0234). CONCLUSIONS: This study provides important data on phrenic nerve proximity to intrathoracic structures in an effort to help reduce iatrogenic injury during procedures within the thoracic cavity. Although males had a significantly larger thoracic diameter than females, the only statistically significant difference showed that the right phrenic nerve is deeper in the thoracic cavity in males. As this nerve passes closer to visceral structures it may be more susceptible to damage from pathology in surrounding vessels. This may explain the increased incidence of right phrenic nerve damage due to aortic aneurysm in males reported in the literature.

Blood Glucose Control in Noncritically Ill Patients Is Associated With a Decreased Length of Stay, Readmission Rate, and Hospital Mortality.

PURPOSE: Multiple studies have shown that hyperglycemia correlates with mortality and morbidity in critically ill patients. This has not been demonstrated in noncritically hospitalized patients. The primary objective of this study was to determine whether glycemic control shortens the length of stay (LOS). Secondary objectives included assessing readmissions, in-hospital mortality, and rates of hypoglycemia. METHODS: A retrospective review of hospitalized patients admitted between 2008 and 2012 with fingerstick blood sugar (FSBS) was performed. Patients were divided into two groups: "controlled" FSBS (≥80% of FSBS were <180 mg/dL) and "uncontrolled" FSBS (<80% of FSBS were <180 mg/dL). The average LOS (ALOS) in days, in-hospital mortality, readmission rates, and rates of hypoglycemia was compared. RESULTS: A total of 32,851 patient records were reviewed. ALOS for patients with controlled and uncontrolled FSBS was 5.86 and 6.17 days, respectively (p < .0001). Readmission within 30 days and hospital mortality were significantly lower in patients with controlled FSBS (p = .0000, .00001), whereas rates of hypoglycemia were significantly higher in the uncontrolled group (p = .00000). CONCLUSIONS: Glycemic control was associated with decreased LOS, hospital mortality, and 30-day readmission rate in noncritically ill patients regardless of the presence or absence of diabetes.

Opportunities missed: improving the rate of contraceptive counseling or provision when prescribing reproductive-aged women potentially teratogenic medications in a family medicine resident clinic.

BACKGROUND: Studies show poor documentation of contraceptive counseling when prescribing women teratogenic medications, suggesting a missed opportunity for contraceptive education. STUDY DESIGN: A retrospective chart review of selected Food and Drug Administration class D and X medications evaluated the office visit initiating this medication for documentation of either contraceptive counseling or provision. Following an educational intervention, another retrospective review was conducted to determine if the rate of counseling improved. RESULTS: The initial rate of documented counseling was 46% and improved to 80% following the educational intervention (p=.0002), an improvement in both overall rate and that seen in the previous year. CONCLUSIONS: This study is the first to document contraceptive counseling rates when providing teratogenic medications in a training setting. It illustrates a need for increased attentiveness in primary care training practices to the risks of teratogenic medications and the need for comprehensive contraceptive counseling. Simple interventions may improve this rate and decrease missed opportunities.

Using the electronic medical record to improve asthma severity documentation and treatment among family medicine residents.

BACKGROUND AND OBJECTIVES: Use of electronic medical records (EMRs) is being advocated to improve quality of care. The objectives of this study were (1) to determine the effect of EMR template use on family medicine residents' documentation of the severity classification of asthma and (2) to determine if documentation leads to appropriate treatment. METHODS: We reviewed the charts of patients with asthma seen by residents in the Center for Family Medicine (CFM) between July 1, 2007, and December 31, 2007. Data gathered from each chart included disease severity classification, medication regimen, and use of the asthma template. In July 2008, efforts at increasing residents' knowledge of asthma severity classification and documentation via EMR were made. A post-intervention chart review was performed on patients with asthma seen by the residents between July 1, 2008, and December 31, 2008. RESULTS: Documentation of asthma severity increased significantly from 24% in the pre- to 44% in the post-intervention phase. Use of the EMR template significantly increased the rate of inhaled corticosteroid prescriptions, from 36.7% to 71.1%. CONCLUSIONS: Use of an asthma template within the EMR improves documentation of asthma severity and appropriate treatment.

Patient falls: acute care nurses' experiences.

AIM: To describe the findings from a qualitative study exploring acute care nurses' experiences with patient falls. BACKGROUND: Patient falls continue to be a problem in acute care settings for nurses at the point of care. Despite the growing body of knowledge related to risk factors and interventions for fall prevention, minimal attention has been given to nurses' perspectives of patient falls. DESIGN: A qualitative descriptive design was used. METHOD: Focus group discussions were conducted with nurses working on a cross-section of inpatient acute care settings. Audio-taped sessions were transcribed and analysed thematically. RESULTS: Nurses described their experience of falls as 'knowing the patient as safe', an ongoing affirmation that the patient was free from harm. In this focused, narrowly defined and highly specific knowing, nurses employed the key strategies of assessment, monitoring and communicating. Variable conditions influenced whether these strategies were effective in giving nurses the knowledge they needed to keep the patient safe. When strategies failed to provide nurses with knowledge of their patients as safe and patients fell, this created considerable stress for nurses and prompted them to use a range of coping strategies. CONCLUSION: Knowing the patient as safe has the potential to resolve the tension between patient safety and independence. The critical, often taken for granted, activities used by nurses in this knowing must be expanded to include the meaning falls have for patients and attend to factors beyond nurses control such as environmental redesign and staffing. RELEVANCE TO CLINICAL PRACTICE: Nurses play an important role in fall prevention through knowing the patient as safe but must be supported through the use of a multi-faceted approach extending from the individual nurse to the institutional level.

Monitoring and feedback of hand hygiene compliance and the impact on facility-acquired methicillin-resistant Staphylococcus aureus.

In 2006, we began monitoring hand hygiene compliance by direct observation. In 2006, with no changes in the methicillin-resistant Staphylococcus aureus (MRSA) control program, a 38% reduction of facility-acquired rates for this organism was realized. These results indicate that focused monitoring of hand hygiene can reduce facility-acquired rates of MRSA.

Rapid response teams: do they make a difference?

Hundreds of lives are now being saved in hospitals across the country with the use of rapid response teams. These teams are composed of clinicians who bring critical care expertise to the patient bedside. The purpose of these teams is to assess and stabilize the patient, assist with communication among the interdisciplinary care providers, educate and support the staff caring for the patient, and assist with transfer of the patient if necessary. Research has shown that, with successful implementation of a rapid response team, the percent of codes and mortality rates decrease. The purpose of this study was to evaluate the effectiveness of implementing a rapid response team at 1 medical center. The results from the study demonstrated a decrease in the percent of codes outside the critical care units. However, it did not show a decrease in overall mortality rates for the patients. Data review will continue as we strive to improve our overall mortality rates while maintaining a decrease in the amount of codes.

Managing the storm: an emergency department capacity strategy.

This article assesses the extent to which a team using quality improvement methods could improve the timeliness of the flow of admitted patients through the emergency department in one hospital. Using a structured approach, a multidisciplinary team redesigned the processes for admitting patients from the emergency department to the inpatient unit. Indicators of capacity limitations in the inpatient environment were also identified as triggers for a tiered institutional response to capacity constraints. Three time intervals in the admission process were identified for measuring performance, with comparisons to the same months of the previous year to determine significance. Significant reductions in the median minutes for a majority of the time intervals studied were achieved during the 6-month study period. The data from the study suggest that improvements in patient progression through an emergency department can be achieved with quality improvement methods. Success factors for this and other improvement strategies are discussed.

Spartanburg Fall Risk Assessment Tool: a simple three-step process.

The purpose of this study was to develop a valid, reliable, and user-friendly fall risk assessment tool that is a sensitive predictor for falls in the acute care population. Fall risk factors were determined from extensive review of evidence-based studies available from a PubMed search. Previous falls, medications, and gait were found to be the top three risk factors for predicting a true risk for falls in multiple health care settings. The Spartanburg Fall Risk Assessment Tool (SFRAT) is unique from other fall risk assessment tools in combining intrinsic, patient-related factors, with a direct measure of the patient's functional status. Interrater reliability of the SFRAT using Cohen's kappa was .9008, which reflects almost perfect agreement. The predictability analysis found the SFRAT to be 100% sensitive for falls (27/27) with no false negatives. Specificity was 28% (48/172) with 124 false positives. These false positives may actually reflect patients who were at true risk for fall but were prevented from falling due to effective interventions instituted by the staff providing their care. The SFRAT fall risk assessment is a simple, reliable tool easily incorporated by nurses into their direct care routine.

Impact of implementing a method of feedback and accountability related to contact precautions compliance.

BACKGROUND: In January 2002, Infection control professionals for Spartanburg Regional Healthcare System held a planning retreat focused on patient safety. The main challenge discussed was the control of antibiotic-resistant organisms. Rounds on the patient care units had revealed compliance issues with the current isolation procedures. The team developed a process improvement project coined the Effective Processes in Infection Control Project (EPIC). With a broad challenge of antibiotic resistance, the focus was narrowed to isolation precautions for methicillin-resistant Staphylococcus aureus (MRSA). METHODS: The initial stage of the EPIC project was education, followed by routine unit rounds to monitor compliance. A tool was developed to provide immediate feedback for the nursing units. Summary reports were generated for clinical directors as a method of accountability for unit leadership. Rates for facility-acquired MRSA were monitored and compared with MRSA days at risk. RESULTS: Over a 1-year period of increased accountability, the facility-acquired rate of MRSA decreased by 30%, even though the days at risk increased. The decrease was maintained during year 2. CONCLUSIONS: The results of this project point to the importance of accountability with isolation precautions in the effort to combat the spread of MRSA in the hospital setting.