Advocate South Suburban Hospital

Contrast-induced nephropathy is the third most common cause of hospital-acquired renal failure, after decreased renal perfusion and nephrotoxic medications. Identification of patients at risk and implementation of preventive strategies can decrease the incidence of this nephropathy. Prevention strategies focus on counteracting vasoconstriction, enhancing blood flow through the nephron, and providing protection against injury by oxygen free radicals. Knowledge of the adverse effects associated with infusion of contrast media, identification of patients at risk for contrast-induced nephropathy, and application of evidence-based prevention strategies allow nurses to assist in the prevention of contrast-induced nephropathy.

C andida auris is an emerging, multidrug-resistant, healthcare-associated fungal pathogen that was first reported in Japan in 2009 and has now been isolated on 6 continents (1-9). C. auris has been identified as the causative pathogen in various invasive fungal infections, including bloodstream infections (2,4), and is associated with outbreaks across healthcare settings (6,10). Risk factors for C. auris infection are similar to other Candida infections including prolonged hospitalization, abdominal surgery, diabetes mellitus, intensive care unit (ICU) admission, use of central venous and urinary catheters, immunocompromising conditions, chronic kidney disease, and exposure to broad-spectrum antibiotic and antifungal agents (10-13). Investigations in the Chicago, Illinois, USA, area have found a high prevalence of C. auris colonization at ventilator-capable skilled nursing facilities (14) and have shown higher rates of C. auris colonization among patients who are mechanically ventilated, have a gastrostomy tube, or have a urinary catheter (15). Reported mortality rates attributable to invasive C. auris infection range from 30% to 59% globally (13,16) and from 22% to 57% in the United States

An avulsion fracture on the dorsolateral aspect of the calcaneus at the origin of the extensor digitorum brevis muscle was identified after inversion injuries of the ankle. The avulsion occurred in 10% of emergency room patients with clinically suspected ankle fractures. The routine dorsoplantar view of the foot and/or the routine anteroposterior view of the ankle demonstrated the fracture. The fracture is most often confused with the os peroneum, or with the fracture of the anterior process of the calcaneus. Treatment is conservative with elevation, supportive bandage, and early activity.

Background: The objective of this study was to demonstrate the feasibility and associations with short‐term outcomes of a medical nutrition therapy (MNT) intervention in patients with systemic scleroderma (SSc). Materials and Methods: Eighteen patients with SSc, gastrointestinal (GI) involvement, and unintentional weight loss were consented and recruited for a 6‐week MNT intervention, in addition to their usual medical management. MNT emphasized increased calorie and protein intake, modified textures, and lifestyle modifications. Symptoms, anthropometrics, diet (24‐hour recall), and body composition (dual‐energy x‐ray absorptiometry) were assessed pre‐ and postintervention. Sarcopenia was defined as appendicular lean height (ALH) for women <5.45 kg/m 2 and for men <7.26 kg/m 2 . Descriptive, parametric, and nonparametric statistics were conducted. Results: Participants (n = 18) were predominantly white (78%), female (89%), malnourished (83%), and 51.3 ± 11.0 years of age with a body mass index of 22.6 ± 6.7 kg/m 2 . Significant decreases in nutrition symptom scores (12.8 vs 7.6, P < .05) and improvements in ALH (5.6 ± 0.8 vs 5.8 ± 0.8 kg/m 2 , respectively; P = .05) occurred pre‐ vs postintervention, respectively (n = 14). Sarcopenia was observed in 54% of participants at baseline and 39% at follow‐up ( P = .02). Caloric intake (1400 vs 1577 kcal/d, P = .12) and macronutrient distribution (ie, % fat, protein, carbohydrate) did not change significantly pre‐ vs postintervention, respectively. Conclusions: Individually tailored MNT can improve symptom burden and potentially ALH in patients with SSc involving the GI tract. This study underscores the clinical potential of multidisciplinary patient management and the need for larger nutrition intervention trials of longer duration in these patients.

Fluoroquinolones (FQs) are often preferred as oral step-down therapy for bloodstream infections (BSIs) due to favorable pharmacokinetic parameters; however, they are also associated with serious adverse events. The objective of this study was to compare clinical outcomes for patients who received an oral FQ versus an oral beta-lactam (BL) as step-down therapy for uncomplicated streptococcal BSIs. This multicenter, retrospective cohort study analyzed adult patients who completed therapy with an oral FQ or BL with at least one blood culture positive for a Streptococcus species from 1 January 2014 to 30 June 2019.

In Brief The assessment of pain experienced by the patient requiring mechanical ventilation can be a challenge for critical care nurses. This study was conducted to assess the reliability and validity of two pain behavior assessment tools. Patients who met the inclusion criteria were enrolled from 13 critical care units and one long-term acute care unit within eight hospitals. A total of 200 patients were assessed over an 8-week period. The findings suggest that both tools have adequate reliability and validity. Use of a pain behavior tool is one strategy to improve assessment of pain experienced by the mechanically ventilated adult patient who is unable to provide a self-report. This article presents the results of a study conducted to assess the reliability and validity of two pain behavior assessment tools for the intubated adult patient.

BACKGROUND: Anecdotal evidence suggests that high-dose intravenous immunoglobulin (IVIG) is useful in the management of human immunodeficiency virus (HIV)-associated thrombocytopenia. STUDY DESIGN AND METHODS: To rigorously evaluate this therapy, a crossover study was designed to compare IVIG, given at 1 g per kg per day for 2 consecutive days each week for 4 weeks, with intravenous saline placebo administered according to the same schedule. Subjects were randomly assigned to receive either IVIG or saline during the first 4 weeks; if IVIG was given, there was a 4-week period of no therapy before beginning placebo administration. Criteria for eligibility were platelet count of less than 50,000 per microL (50 x 10(9)/L), elevated platelet-associated IgG levels, increased megakaryocytes in the bone marrow, and positive HIV antibody test. Twelve patients (11 men, 1 woman) were studied. Seven patients completed the full protocol. Four dropped out: after 2, 5 (2 patients), and 8 weeks that included at least 2 weeks of IVIG. RESULTS: All patients sustained an increase in platelet count in response to IVIG, with increments ranging from 15,000 to 358,000 per microL (15 to 350 x 10(9)/L) (mean, 180,000/microL [180 x 10(9)/L]; median, 174,000/microL [174 x 10(9)/L]). No patient had an increase after placebo infusions. There were no adverse effects of treatment, and weekly chemical analyses showed no new abnormalities except for mild elevations in the serum protein. The duration of responses ranged from 2 to 10 weeks. No patient demonstrated refractoriness to IVIG. CONCLUSION: IVIG consistently raises platelet counts in patients with HIV-associated thrombocytopenia.

This investigation explored the factor structure, reliability, and validity of the Devereux Elementary School Behavior Rating Scale, employing a large (n = 648) sample of children. Factor analysis suggested that the Devereux scale can be described by four factors, which were named Disruptive-Oppositional, Poor Comprehension-Disattention, Cooperative-Initiating, and Performance Anxiety. All four factors showed high internal consistency, and three of the four were stable over a 17-mo. period. Correlations of the four factors with academic achievement, IQ, socioeconomic status, and peer ratings of social competence are presented. All four factors showed significant relations with these variables, with Poor Comprehension-Disattention the strongest of all. Multiple regression analysis indicated that the Poor Comprehension-Disattention factor accounted for significant variance in academic achievement even after IQ was taken into account. Large differences between classroom means on the factor scores suggested that Devereux ratings for individual students may need to be interpreted cautiously.

Abstract Background The purpose of this study was to evaluate the impact of infectious diseases consultation (IDC) and a real-time antimicrobial stewardship (AMS) review on the management of Staphylococcus aureus bacteremia (SAB). Methods This retrospective study included adult inpatients with SAB from January 2016 to December 2018 at 7 hospitals. Outcomes were compared between 3 time periods: before mandatory IDC and AMS review (period 1), after mandatory IDC and before AMS review (period 2), and after mandatory IDC and AMS review (period 3). The primary outcome was bundle adherence, defined as appropriate intravenous antimicrobial therapy, appropriate duration of therapy, appropriate surveillance cultures, echocardiography, and removal of indwelling intravenous catheters, if applicable. Secondary end points included individual bundle components, source control, length of stay (LOS), 30-day bacteremia-related readmission, and in-hospital all-cause mortality. Results A total of 579 patients met inclusion criteria for analysis. Complete bundle adherence was 65% in period 1 (n = 241/371), 54% in period 2 (n = 47/87), and 76% in period 3 (n = 92/121). Relative to period 3, bundle adherence was significantly lower in period 1 (odds ratio [OR], 0.58; 95% confidence interval [CI], 0.37–0.93; P = .02) and period 2 (OR, 0.37; 95% CI, 0.20–0.67; P = .0009). No difference in bundle adherence was noted between periods 1 and 2. Significant differences were seen in obtaining echocardiography (91% vs 83% vs 100%; P < .001), source control (34% vs 45% vs 45%; P = .04), and hospital LOS (10.5 vs 8.9 vs 12.0 days; P = .01). No differences were noted for readmission or mortality. Conclusions The addition of AMS pharmacist review to mandatory IDC was associated with significantly improved quality care bundle adherence.

The end of the formal unit orientation program is a stressful time of adjustment for nurses hired into critical care without previous critical care experience. Although most units offer reassurance that experienced colleagues will provide the needed guidance, consistent support may not be available for many reasons. Development of a structured postorientation program designed to provide support and ongoing feedback to bedside nurses who have completed orientation is one strategy to assist nurses through this period of adjustment. The experience and expertise of the tele-intensive care unit nurse are excellent resources that can be called on to provide the needed support.

An integrated healthcare delivery system requires a consistent patient care delivery model. The authors describe the process used to define common elements of the patient care model. These elements include the roles of chief nurse executives, first-line managers, staff registered nurses, and unlicensed assistive personnel. In addition, the philosophy of nursing and support functions (staff education and nursing dashboard for quality measurement) in place across the system are discussed.

Increased mortality has been identified as the sepsis cascade progresses from sepsis to severe sepsis to septic shock. Estimates reflect sepsis death rates ranging from 10% to 20%, severe sepsis death rates of 20% to 50%, and septic shock fatality rates of 40% to 80%. The high rates of morbidity, mortality, and Medicare costs prompted the Centers for Medicare and Medicaid Services to implement bundled care and public reporting of the Early Management Bundle, Severe Sepsis/Septic Shock (SEP-1) quality measure in 2015. Sepsis care bundles were identified to be beneficial since the 1990s as the bundle facilitates efficient, effective, and timely delivery of care to support quality improvement. The SEP-1 measure can be challenging and requires the nurse's active participation. Nurses need increased knowledge of the sepsis cascade and treatments as defined in the SEP-1 quality measure. Increased knowledge and application of bundle elements are lifesaving and can influence postdischarge outcomes. This article discusses the nurse's role in meeting the specific elements of each bundle and strategies to improve bundle compliance.

Purpose: To obtain consensus on the key areas of burden associated with existing devices and to understand the requirements for a comprehensive next-generation diagnostic device to be able to solve current challenges and provide more accurate prediction of intraocular lens (IOL) power and presbyopia correction IOL success. Patients and Methods: Thirteen expert refractive cataract surgeons including three steering committee (SC) members constituted the voting panel. Three rounds of voting included a Round 1 structured electronic questionnaire, Round 2 virtual face-to-face meeting, and Round 3 electronic questionnaire to obtain consensus on topics related to current limitations and future solutions for preoperative cataract-refractive diagnostic devices. Results: Forty statements reached consensus including current limitations (n = 17) and potential solutions (n = 23) associated with preoperative diagnostic devices. Consistent with existing evidence, the panel reported unmet needs in measurement accuracy and validation, IOL power prediction, workflow, training, and surgical planning. A device that facilitates more accurate corneal measurement, effective IOL power prediction formulas for atypical eyes, simplified staff training, and improved decision-making process for surgeons regarding IOL selection is expected to help alleviate current burdens. Conclusion: Using a modified Delphi process, consensus was achieved on key unmet needs of existing preoperative diagnostic devices and requirements for a comprehensive next-generation device to provide better objective and subjective outcomes for surgeons, technicians, and patients.

PURPOSE: The aim of this study was to explore the common characteristics of patients diagnosed with upper-extremity venous thromboembolism (UEVTE) during hospitalization. DESIGN: This was a retrospective chart review. SETTING: This study was performed at a Midwest multisite hospital of 5 acute-care hospitals and 2051 beds. SAMPLE: The sample was composed of 777 hospitalized adult patients who had a positive upper-extremity venous Doppler from July 2008 to July 2009. RESULTS: Patients were adults with a mean age of 66.6 (SD, 17.0) years and mean hospital stay of 15.7 (SD, 12.4) days. When assessing the arm clots, 398 patients (51.2%) had a right arm clot, 317 patients (40.8%) had a left arm clot, and 62 patients (8.0%) had clots in both arms. Patients were primarily admitted with medical conditions, and more than one-half were overweight or obese (59.2%). Nearly 50% of patients were at the highest venous thromboembolism (VTE) risk upon admission (n = 362), were tobacco users (n = 379), and had surgeries or invasive procedures performed prior to upper-extremity venous Doppler (n = 395). In 58.6% of the patients, chemoprophylaxis through intravenous anticoagulation therapy was administered during the first 3 days of admission. In patients with an intravenous catheter in an arm, UEVTE was likely to occur in the same arm (right and left arm, P < .001). IMPLICATIONS: Nurses caring for patients with characteristics commonly found in cases of UEVTE should regularly monitor the arms of their patients and communicate findings in shift reports to heighten awareness of UEVTE risk. In addition, patients with medical diagnoses that prevent use of early anticoagulation for VTE prophylaxis such as gastrointestinal bleed, hematologic disorders, trauma, and hemorrhagic strokes should be frequently assessed for UEVTE. Learning the characteristics of patients who had UEVTE during their hospitalization and the role of early and late anticoagulation in the development of UEVTE would advance nurse assessment and lead to novel interventions and future research.

INTRODUCTION: Pain after laparoscopic cholecystectomy is reportedly complex and multifaceted, and has been cited as the most frequent reason for prolonged convalescence. The use of opioid therapy, a common pain management strategy, can be limited by potentially severe adverse events. In this report, I describe the use of liposome bupivacaine, administered via transversus abdominis plane (TAP) infiltration, in a patient undergoing emergency laparoscopic cholecystectomy. CASE: The patient underwent an emergency laparoscopic cholecystectomy complicated by an unexpected correction of partially detached mesh implanted during prior ventral hernia repair. The patient was discharged to the post-anesthesia care unit, but reported a pain score of 8 (11-point scale; 10 = worst possible pain). Fentanyl rescue therapy failed to alleviate the pain. Liposome bupivacaine was administered via bilateral TAP infiltration as postsurgical rescue pain medication, part of a multimodal analgesic regimen. RESULTS: The patient tolerated the TAP infiltration well and subsequently reported a pain score of 2 and a pain satisfaction score of 10 (11-point scale; 10 = completely satisfied). No additional analgesics were required. The patient was discharged on postoperative day 1, resumed normal activities in <24 hours, and remained satisfied with the pain management for 5 days. DISCUSSION: TAP infiltration of liposome bupivacaine was associated with improvement in postsurgical pain control, eliminated the need for additional opioids, and reduced the length of hospital stay from the usual 3 days to <24 hours. CONCLUSIONS: Liposome bupivacaine administered via TAP infiltration shows potential as part of a multimodal analgesic regimen in laparoscopic cholecystectomy.

Abstract Background Infectious diseases consult (IDC) and antimicrobial stewardship (AMS) intervention independently demonstrate improved management of Staphylococcus aureus bacteremia (SAB). However, data supporting utilizing both strategies is limited. The objective of the current study is to assess evidence-based bundle adherence for SAB in the presence and absence of mandatory IDC and AMS pharmacist review in a multi-site health system. Methods This retrospective study included adult inpatients with SAB from January 2016 to December 2018 at seven hospitals. Outcomes were compared between three groups: pre-mandatory IDC and AMS review (group 1), post-mandatory IDC and pre-AMS review (group 2), and post-mandatory IDC and AMS review (group 3). The primary outcome was bundle adherence defined as: appropriate intravenous antimicrobial therapy, appropriate duration of therapy, 24–48-hour surveillance cultures until documented clearance, echocardiography, and removal of indwelling intravenous catheters, if applicable. Secondary endpoints included individual bundle components, source control, length of stay (LOS), 30-day bacteremia-related readmission, and in-hospital all-cause mortality. Results A total of 579 patients met the final inclusion criteria for analysis. Complete bundle adherence was achieved in 65% of patients for group 1 (n = 371), 54% for group 2 (n = 87), and 76% for group 3 (n = 121). Adherence to bundle elements was significantly higher in group 3 when compared with group 1 (odds ratio [OR] 0.58, 95% confidence interval [CI] 0.37–0.93), and group 2 (OR 0.37, 95% CI 0.20 – 0.67). No difference in bundle adherence was noted between groups 1 and 2. When comparing groups 1, 2 and 3, significant differences were seen in obtaining echocardiography (91% vs. 83% vs. 100%; P = 0.0378), and hospital LOS (10.5 vs. 8.85 vs. 12.0 days; P = 0.0149), respectively. Increased hospital LOS in group 3 may be due to nonsignificant higher rates of complicated bacteremia compared with groups 2 and 1 (32% vs. 44% vs. 43%, P = 0.09), respectively. No differences were noted for readmission or mortality. Conclusion The addition of AMS pharmacist review to mandatory IDC significantly improved quality care bundle adherence. Disclosures All authors: No reported disclosures.

Presented is a statistical approach for examining multiple years of travel time data to determine if any trends can be quantified reliably by using only 4 years of observed data. Empirical data for 80 routes covering more than 4025 km were collected in the summers of 1994, 1995, 1996, and 1997 and compiled into a database for public release in the fall of 1997. From this database, seven routes were selected then sampled over all 4 years. These seven routes are primary arterials of regional significance in northeastern Illinois. A multiple regression analysis was performed on the seven arterials to determine if there was a statistically significant difference in the observed mean route travel times over the 4-year period. The regression analysis indicated that only one of seven routes experienced a statistically significant change in directional route travel time between 1994 and 1997. Because only one of seven routes was significantly different, the analyst may merge multiple years of data for an individual route into a single data set to build a more robust database. Also, quantifiable change in travel time may be difficult to perceive year by year. This has significant implications for the design of a sampling strategy that needs to measure performance on approximately 28 980 directional route km of roadways. It would be better to sample fewer routes more intensely on a regular interval than to sample many routes lightly every year.

Abstract Double-hit and double-expressor phenotypes in lymphomas are characterized by activation of the expression of the MYC and BCL2 genes through diverse mechanisms including chromosomal translocations and amplifications. Herein, we report a high-grade B-cell lymphoma in a patient with evidence for a chromothripsis event (via chromosomal microarray methodology) at chromosome 8, resulting in a focal copy number gain of the MYC locus, not detected by conventional fluorescence in situ hybridization for MYC despite strong MYC expression by immunohistochemical analysis. Chromosome analysis from the biopsy was not successful because of an extensive tissue necrosis. Chromothripsis is suggested as another mechanism for the activation of MYC in non-Hodgkin lymphoma, resulting in aggressive disease course, and this case underscores the need for chromosomal microarray testing in select cases to identify aggressive biology.

273 Background: Vascular involvement is a key determinant of resectability and treatment sequencing in pancreatic cancer (PC). Current staging requires multidetector CT (MDCT) and endoscopic ultrasonography (EUS), but there are still occasions when vascular involvement cannot be fully assessed. Current NCCN guidelines recommend using magnetic resonance imaging (MRI) for clarifying these ambiguities. The primary aim of our study is to access the accuracy of CT, MRI, and EUS in staging resectabilty of PC. The secondary aim is to assess internal consistency in the evaluation of vascular involvement among different staging modalities. Methods: We retrospectively reviewed 40 medical records of patients who were treated at LUMC for PC from 2006 to present. We evaluated 8 MDCT scans and 8 MRI scans in addition to their EUS reports. Seven board certified radiologists analyzed the 16 imaging studies using a standardized template. Unweighted Kappa statistic and observed agreement analysis was calculated to assess inter-observer agreement on vessel involvement between the imaging studies compared to the EUS reports. We sought to examine degree of concordance for involvement of the superior mesenteric artery (SMA), superior mesenteric vein (SMV), and main portal vein (MPV) with the pancreatic tumor. Results: Low Kappa and observed agreement in respect to vascular involvement between MDCT and EUS was found for SMV (K = 0.33, 62.5%), SMA (K = -0.2, 62.5%), and MPV (K = 0.38, 75%), indicating low concordance. Low Kappa and observed agreement in respect to vascular involvement between MRI and EUS was found for SMV (K = 0.09, 37.5%), SMA (K = 0.14, 62.5%), and MPV (K = 0.47, 75%). Low Kappa and observed agreement in respect to vascular involvement between MRI and MDCT in comparison to EUS was found for SMV (K = 0.11, 50%), SMA (K = 0.20, 75%), and MPV (K = 0.14, 62.5%). Conclusions: Concordance was shown within each imaging modality when analyzed by radiologists. Due to high discordance across different staging modalities, however, MRI and CT scans complement each other in determining degree of vascular involvement. We believe both imaging modalities should be used in staging borderline resectable PC.

Pat Juarez is system-wide clinical education specialist in critical care and clinical nurse specialist in the ICU of Advocate South Suburban Hospital, Hazel Crest, IL. Contact author: [email protected].