Antibiotic use for presumed neonatally acquired infections far exceeds that for central line-associated blood stream infections: an exploratory critique.

OBJECTIVE: To assess antibiotic use as a complementary neonatal intensive care unit (NICU) infection measure to the central line-associated blood stream infection (CLABSI) rate. STUDY DESIGN: Patient days (PDs), line days, antibiotic (AB) use, CLABSI and other proven infections were analyzed in consecutive admissions to two NICUs over 3 and 6 months, respectively, from 1 January 2008 until discharge. An antibiotic course (AC) consisted of one or more uninterrupted antibiotic days (AD), classified as perinatal or neonatal, if started ≤3 d or ≥4 d post birth and as rule-out sepsis or presumed infection (PI) if treated ≤4 d or ≥5d, respectively. Events were expressed per 1000 PD and aggregated by conventional treatment categories and by clinical perception of infection certainty: possible, presumed or proven. RESULT: The cohort included 754 patients, 18,345 PD, 6637 line days, 718 AC and 4553 AD. Of total antibiotic use, neonatal use constituted 39.2% of ACs, and 29.0% of ADs, When analyzed per 1000 PD, antibiotic use to treat PIs vs CLABSIs, was either 14 fold (CI 6.6-30) higher for ACs (5.40 vs 0.38/1000 PD, P<0.0001) or 8.8 fold (CI 7.1-11) higher for ADs (48.3 vs 5.5/1000 PD, P<0.0001). CONCLUSION: CLABSI rates, present a lower limit of NICU-acquired infections, whereas antibiotic-use measures, about 10-fold higher, may estimate an upper limit of that burden. Antibiotic-use metrics should be evaluated further for their ability to broaden NICU infection assessment and to guide prevention and antibiotic stewardship efforts.

A statewide quality improvement collaborative to reduce neonatal central line-associated blood stream infections.

OBJECTIVE: The objective of this study was to reduce central line-associated blood stream infections (CLABSIs) among 13 collaborating regional neonatal intensive care units by 25%. We tested the hypothesis that change could be attributed to the quality improvement collaborative by testing for 'special cause' variation. STUDY DESIGN: Our prevention project included five features: (1) leadership commitment, (2) potentially best practices, (3) collaborative processes, (4) audit and feedback tools and (5) quality improvement techniques. Baseline (1 January 2006 to 30 August 2006) data were compared with the intervention (1 September 2006 to 30 June 2007) and post-intervention (1 July 2007 to 30 December 2007) periods and analyzed using statistical process control (SPC) methods. RESULT: We detected special cause variation, suggesting that the collaborative was associated with reduced infection rates, from 4.32 to 3.22 per 1000 line days (a 25% decrease) when comparing the baseline with the follow-up period. CONCLUSION: The collaborative's process was associated with fewer infections. SPC suggested that systematic changes occurred. The remaining challenges include sustaining or even further reducing the infection rate.

Prevention of Group B Streptococcus early-onset disease: a toolkit by the California Perinatal Quality Care Collaborative.

The California Perinatal Quality Care Collaborative (CPQCC) was organized in 1996 in an effort to improve perinatal outcomes in California. CPQCC has a robust infrastructure of quality improvement resources and expertise and uses a database of demographic and outcome data from neonatal intensive care units in California. In 2004, CPQCC developed a toolkit to provide an evidence-based framework and supporting documents for hospitals to use in systematically addressing persistent early-onset disease (EOD) because of Group B Streptococcus (GBS) in their centers. The CPQCC toolkit was based on the 2002 Centers for Disease Control guideline, 'Prevention of Perinatal Group B Streptococcal Disease.' This article presents an updated version of the CPQCC toolkit reflecting several population studies published since the 2002 guideline. Current epidemiological trends in incidence of EOD with GBS, changes in antibiotic sensitivity and the potential value of newer strategies are discussed.

The Kaiser Permanente prenatal smoking-cessation trial: when more isn't better, what is enough?

INTRODUCTION: The effectiveness of low-cost smoking interventions targeted to pregnant women has been demonstrated, although few gains in absolute cessation rates have been reported in the past decade. Under conditions of typical clinical practice, this study examined whether outcomes achieved with brief counseling from prenatal care providers and a self-help booklet could be improved by adding more resource-intensive cognitive-behavioral programs. DESIGN: Randomized Clinical Trial. SETTING: A large-group-model managed care organization. PARTICIPANTS: 390 English-speaking women 18 years of age or older who self-reported to be active smokers at their initial prenatal appointment. INTERVENTION: Participants were randomized to one of three groups: (1) a self-help booklet tailored to smoking patterns, stage of change, and lifestyle of pregnant smokers; (2) the booklet plus access to a computerized telephone cessation program based on interactive voice response technology; or (3) the booklet plus proactive telephone counseling from nurse educators using motivational interviewing techniques and strategies. No attempt was made to change smoking-related usual care advice from prenatal providers. MAIN OUTCOME MEASURE: Biochemically confirmed abstinence measured by level of cotinine in urine samples obtained during a routine prenatal visit at approximately the 34th week of pregnancy. RESULTS: Twenty percent of participants were confirmed as abstinent with no significant differences found between intervention groups. Multivariate baseline predictors of cessation included number of cigarettes smoked per day, confidence in ability to quit, exposure to passive smoke, and educational level. No differential intervention effects were found within strata of these predictors or by baseline stage of readiness to change. Cessation rates among heavier smokers were strikingly low in all intervention groups. CONCLUSION: Neither a computerized telephone cessation program nor systematic provision of motivational counseling improved cessation rates over a tailored self-help booklet delivered within the context of brief advice from prenatal providers. Innovative strategies need to be developed to increase the effectiveness of existing prenatal smoking interventions. Special attention should be paid to the needs of heavier smokers.

Ocular quinine toxicity treated with hyperbaric oxygen.

Ocular quinine toxicity typically involves a partial or total and often permanent loss of vision. Apart from gastric lavage and oral administration of activated charcoal, current treatment modalities are of doubtful efficacy. Two patients with quinine amaurosis were treated with hyperbaric oxygen (HBO2) in an effort to increase oxygen delivery to the retina. Visual outcomes in these patients were evaluated. Two patients had bilateral no light perception vision and dilated, nonreactive pupils within hours of ingesting 13-15 g of quinine in addition to other drugs. Following initial oral charcoal administration, HBO2 therapy was used. Within 17 h after quinine ingestion, both patients underwent HBO2 therapy at 2.4 atm abs with 100% O2 for 90 min. Both patients had return of visual acuity to 20/20 in both eyes less than 24 h after treatment. Follow-up visual fields revealed constriction and paracentral scotomas bilaterally. We conclude that HBO2 may represent an additional or alternative, and perhaps safer, method of treatment for ocular quinine toxicity.

One health maintenance organization's experience: obstetric costs depend more on staffing patterns than on mode of delivery.

The objective of this study was to examine whether the mode of obstetric delivery is related to resource costs, case mix, maternal length of stay, or neonatal morbidity. Patients (27,289) who delivered babies at nine hospitals within one health maintenance organization in 1989 were the source of data. Case-mix adjustment and outcome measures (maternal length of stay and neonatal morbidity) were computed from discharge abstract indicators, whereas cost data (direct professional hours) came from departmental financial reports. Costs and outcomes were adjusted by regression analysis for differences in case mix and then compared by correlation analysis. Neither adjusted nor unadjusted cesarean-section rates and obstetric cost per case were significantly correlated over the range of observed cesarean-section rates. Aggregate cesarean-section rates and outcome indicators were also statistically unrelated. Cesarean-section rate variation across hospitals was unrelated to the observed variation in obstetric costs, which were closely related to variations in staffing and less closely to differences in patient case mix and scale.

Perinatal services in the era of managed care: a Kaiser Permanente physician's perspective.

Evolving market forces are reshaping current patient, parent, provider, insurer, and hospital relationships. The traditional individualistic focus for accountability and responsibility is being supplemented by population-wide responsibilities and accountabilities. These changes, often lumped together as "managed care", are being implemented with evolving ideas on how best to manage an organize collaborative activity. In this article it is reasoned that perinatal services will improve as objective outcome measures guide the development, evolution, and operation of competing managed care networks. The article illustrates how a managed perinatal care network works with experiences drawn from the perinatal service programs of Kaiser Permanente's Southern California Region.

Using health care outcomes to improve patient care in the NICU.

The authors describe their use of outcomes research in improving the care of infants in a ten-hospital network of neonatal intensive care units. Improvements in the processes of care for infants born with very low birth weights, and those suffering from chronic lung disease and nosocomial infections, are among the issues discussed.

Cost-effectiveness and data envelopment analysis.

Data Envelopment Analysis (DEA) identifies price and technical inefficiencies among decision-making units. With controls for differences in case-mix and standardized outcomes, DEA's "best practice" frontier can be interpreted as a "cost-effectiveness" frontier. This study illustrates the key concepts, identifies the decisions required to use the technique for medical care decision making, and presents an application to a system of nine hospitals that offer obstetric services.

Why pay extra for cesarean-section deliveries?

Third-party insurers typically pay at least 50% more for cesarean sections than for vaginal deliveries, suggesting that a reduced national cesarean-section rate could save payers more than $1 billion annually. This paper discusses the payment implications of a cost-effectiveness study, based on the experience within one health maintenance organization, in which cesarean-section rates were unrelated either to direct costs or to perinatal outcomes. Given these results, insurers should consider paying a flat fee for obstetric services unless differing risk levels or risk-adjusted outcomes justify different amounts.

Computerized algorithms and pediatricians' management of common problems in a community clinic.

In 1987, a microcomputer clinical algorithm (CA) system for constructing and using CAs for patient care was designed and implemented for six common primary care pediatrics problems. Six community clinic pediatricians agreed to use the system for several months. Length of patient's visit, completeness of data collection, antibiotic use, and appropriateness of clinical plan were measured before the computers were introduced (without CAs) and after the computers were introduced (both with and without CAs). All performance measures improved after the introduction of CAs. However, CA implementation had to be discontinued after five weeks because the CAs were too tedious for the physicians to follow during routine care. The authors conclude that CAs cannot be successfully sustained with physicians for common problems, even though their design and use can significantly improve the process of care.

Cost-effectiveness and obstetric services.

This study employs two risk-adjustment strategies to model the cost-effectiveness of obstetric services for eight hospitals in an urban health maintenance organization. Costs are adjusted by an index based on the expected length of a mother's stay, derived from a two stage regression analysis. Logistic regression of the probability of a cesarean-section on a set of clinical indicators constitutes the first stage. The second stage, an ordinary least squares regression, accounts for 30% of the variation in the logarithm of hours of stay but generates unbiased estimates for various subsets of cases. Adjusted costs per delivery range from roughly 22% below to 31% above the mean. Perinatal mortality rates--adjusted for differences in birthweight, sex, plurality, and race--serve as the outcome indicators. Risk-adjusted costs and risk-adjusted mortality rates are positively correlated with one another (r = .69, P = .06); in particular, the lowest cost hospital generated excellent outcomes. Adjusted cesarean-section rates, however, are not correlated with either adjusted costs (r = -.03, P = .95) or adjusted perinatal mortality rates (r = -.13, P = .75). These results suggest that cost management should focus on staff levels and mix more than on practice patterns and that care management should focus on practice patterns in relation to their influences on outcomes.

Rheumatology algorithms for primary care physicians.

Primary care physicians were trained on three rheumatology topics to assess the effectiveness of an educational strategy for continuing medical education. Algorithm training was shown to be at least as effective as that based on standard prose monographs. Both training groups improved their knowledge of patient management skills but there were no statistically significant differences between groups in the amount learned. When algorithms were used to design text materials, the designed texts required less study time than did the annotated clinical algorithms alone. That difference was significant for the shoulder pain materials (P less than 0.05) but not for the osteoporosis materials. The ratio of knowledge gained to study time was significantly higher for the algorithm group on the low back pain topic (P less than 0.05) but not for the other topics. Taped interview problems tests were studied as a method for assessing patient management skills related to problem-specific indicator conditions and were found to produce interrater reliability greater than 0.80 on five of the six tests.

Construction of clinical algorithms for educational programs.

Clinical algorithms have been used successfully in a variety of health care settings to assist health care professionals in the diagnosis and management of medical problems. In addition to their clinical applications, algorithms also serve as an instructional resource by themselves and when used in conjunction with other educational methodologies. A recommended algorithm development process is described for cancer educators who wish to take advantage of the unique contribution clinical algorithms can offer for their educational programs. Algorithm design conventions are reviewed and specific writing suggestions are offered for the guidance of educators who want to design their own clinical algorithms. Objections to clinical algorithms can often be attributed to a misunderstanding of their proper role, which is to facilitate, not dictate, the decision process and guide the application of management logic. Clinical algorithms are a valuable instructional resource that can be used in a wide range of educational settings from self-instruction units to the design of lecture presentations.

Effective thrombolytic therapy of aortic thrombosis in the small premature infant.

Aortic thrombosis in the very-low-birthweight premature infant has remained both a diagnostic and a therapeutic dilemma. Nine small infants were evaluated for symptoms of extremity and/or visceral ischemia. All were found to have aortoiliac thrombosis most likely related to indwelling umbilical artery catheters. Diagnostic and therapeutic options were evaluated. An angiogram obtained through the catheter was found to be the most effective diagnostic technique. Local infusion of intra-arterial streptokinase (50 U/kg/h) directly into the clot for 36 hours resulted in resolution of ischemic symptoms. No complications were encountered with the use of this protocol.

Increasing frequency of penicillin-resistant pneumococci: epidemiological aspects and case-control study.

At the Hadassah University Hospital, Mt. Scopus, Jerusalem, the frequency of patients with relatively penicillin-resistant pneumococci (RPRP) isolates has increased from 0.9 to 10.8% during the years 1979-82. Infants and children were particularly involved. Significantly more RPRP isolates were found in those less than 14 years old than in those who were older (P less than 0.005). The determination of susceptibility or relative resistance to penicillin was based on the disk sensitivity method, which remained unchanged throughout the study period. The minimal inhibitory concentration (MIC) to penicillin G was also determined for 20 RPRP isolates and was found to be in the range of relative resistance to penicillin (0.25 to 0.50 micrograms/ml) in all 20 isolates. A case-control study of 16 index patients examined antibiotic usage during the 60 days preceding pneumococcal isolation. Total antibiotic usage was high in both groups (18.8 vs. 8.8 days, P = 0.2); beta-lactam antibiotic usage was significantly higher in the RPRP group than in the control group (13.3 vs. 4.2 days, 0.01 less than P less than 0.02). General prescribing practices, even in nonisolated areas where there is no need for public health programs to dispense prophylactic antibiotics, may produce sufficiently high antibiotic exposures to aid the emergence of RPRP strains.