Impact of antibiotic choices made in the emergency department on appropriateness of antibiotic treatment of urinary tract infections in hospitalized patients.

BACKGROUND: Overuse of antibiotics to treat urinary tract infections (UTIs) is common in hospitalized patients and may begin in the emergency department (ED). METHODS: For a 4-week period we reviewed medical records of all patients admitted to the hospital who initiated treatment for a UTI in the ED. RESULTS: According to study criteria, initiation of antibiotics was inappropriate for 55 of 94 patients (59% [95% confidence interval {CI}, 48%-69%]), and continuation after admission was inappropriate for 54 of 80 patients (68% [95% CI, 57%-78%]). CONCLUSION: Failure to reevaluate the need for antibiotics initiated in the ED to treat UTIs may lead to overuse of antibiotics in hospitalized patients.

Graying of the HIV epidemic: a challenge for inpatient medicine providers.

Since the advent of anti-retroviral therapy, patients with HIV are living longer, and in the year 2015, over half of those infected with the virus will be older than age 50. Moreover, as the general aging population continues to grow, more elderly individuals will become newly infected with HIV. Older patients with HIV contribute to high numbers of initial and rehospitalizations, have longer lengths of hospital day stays, and are at increased risk of death compared to younger patients with HIV and those without HIV. Age-related comorbidities can be exaggerated in HIV-positive patients on and off therapy. Furthermore, signs and symptoms of HIV and AIDS may mimic features seen in the normal aging process of older adults. Internists caring for patients in inpatient settings will be expected to care for and diagnose increasing numbers of older patients with HIV. This will be critical for improving quality of patient care, reducing morbidity and mortality, and managing newly diagnosed patients earlier in the disease course while reducing spread of the virus. Internists should be central leaders in the development of targeted and non-targeted HIV screening efforts in inpatient general medicine wards.

The effect of computerized provider order entry on medical students' ability to write orders.

BACKGROUND: Computerized provider order entry (CPOE) is being implemented at increasing numbers of U.S. hospitals, yet the effects of CPOE on medical student education are largely unstudied. PURPOSE: The objective is to investigate the effects of CPOE on medical students' ability to write orders for patients. METHODS: One hundred forty-three medical students who began their Basic Medicine clerkship between March 2003 and April 2004 were asked to write mock admission orders for a patient with pneumonia after the 1st month of their clerkship. Students had spent the month at 1 of 3 hospitals: 1 using CPOE, 1 paper orders, and 1 that began using CPOE midway through this study. Admission orders were scored for the presence of specific orders and features. RESULTS: One hundred twenty students attempted to write admission orders. Students who trained at hospitals using CPOE and those who trained at hospitals using paper orders included expected basic, lifesaving, and higher level orders at similar rates. No significant differences in order clarity or inclusion of unnecessary orders were found for the 2 groups. No significant differences were found when controlling for school year and 4 modifiable rotation features. CONCLUSIONS: When admission order completeness and quality for medical students who trained at hospitals using CPOE were compared to those who trained using handwritten orders, no important differences were found.

Improving utilization of antimicrobial drugs among physician assistants in the ED.

OBJECTIVE: This study examines the effectiveness of an educational intervention that used audit and feedback to influence physician assistant (PA) antimicrobial utilization in an emergency department (ED). METHODS: Twelve ED PAs participated in this pre- and postintervention study. Their prescribing patterns were retrospectively reviewed and classified as appropriate, effective but inappropriate, or inappropriate using a previously developed methodology. A hospitalist physician conducted a 1-hour academic detailing intervention session with each PA that reviewed inappropriate prescribing practices and provided feedback for improvement based on current guidelines. After the meetings, the prescribing patterns of the providers were followed prospectively and comparisons were made between the proportions of antimicrobials prescribed appropriately and inappropriately before and after the intervention. RESULTS: The percentage of appropriate prescriptions increased from 64% (95% CI, 58-72) to 81% (95% CI, 75-86), whereas the proportion of inappropriate prescriptions decreased from 36% (95% CI, 31-43) to 19% (95% CI, 14-23) across the study periods (both P < .001). CONCLUSION: PA antimicrobial utilization was responsive to an academic detailing initiative that relied heavily on audit and feedback of past performance. Targeting PAs in quality improvement initiatives may be a highly effective way to influence change in health care utilization.

The good news about CPOE and medical student ordering ability.

When the quality of orders written by medical students was compared for those who trained at hospitals using computerized provider order entry (CPOE) to those who trained using handwritten orders, no significant differences were found.