Advocate Trinity Hospital

OBJECTIVE: We report our results using Onyx HD-500 (Micro Therapeutics, Inc., Irvine, CA) in the endovascular treatment of wide-neck intracranial aneurysms, which have a high rate of incomplete occlusion and recanalization with platinum coils. METHODS: Sixty-nine patients with 84 aneurysms were treated. Most of the aneurysms were located in the anterior circulation (80 of 84 aneurysms), were unruptured (74 of 84 aneurysms), and were incidental. Ten presented with subarachnoid hemorrhage, and 15 were symptomatic. All aneurysms had wide necks (neck >4 mm and/or dome-to-neck ratio <1.5). Fifty aneurysms were small (<12 mm), 30 were large (12 to <25 mm) and 4 were giant. Angiographic follow-up was available for 65 of the 84 aneurysms at 6 months, for 31 of the 84 aneurysms at 18 months, and for 5 of the 84 aneurysms at 36 months. RESULTS: Complete aneurysm occlusion was seen in 65.5% of aneurysms on immediate control, in 84.6% at 6 months, and in 90.3% at 18 months. The rates of complete occlusion were 74%, 95.1%, and 95.2% for small aneurysms and 53.3%, 70%, and 80% for large aneurysms at the same follow-up periods. Progression from incomplete to complete occlusion was seen in 68.2% of all aneurysms, with a higher percentage in small aneurysms (90.9%). Aneurysm recanalization was observed in 3 patients (4.6%), with retreatment in 2 patients (3.3%). Procedural mortality was 2.9%. Overall morbidity was 7.2%. CONCLUSION: Onyx embolization of intracranial wide-neck aneurysms is safe and effective. Morbidity and mortality rates are similar to those of other current endovascular techniques. Larger samples and longer follow-up periods are necessary.

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

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.

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 &amp;lt; .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.

At least 18 million people in the United States have asthma. Despite the publication of national guidelines, the delivery of care has not substantially changed. This article describes a program at Chicago city sites to improve the delivery of care to adults and children with asthma. Using consistent comprehensive patient education materials, innovative provider education, and a variety of continuous quality improvement interventions including creation of a designated practitioner, this project enhances partnership between patients and health care providers.

OBJECTIVE: This study describes routine HIV screening implementation and outcomes in three hospitals in Chicago, Illinois. METHODS: Retrospective data from three hospitals were examined, and routine testing procedures, testing volume, reactive test results, and linkage-to-care outcomes were documented. RESULTS: From January 2012 through March 2014, 40,788 HIV tests were administered at the three hospitals: 18,603 (46%) in the emergency department (ED), 7,546 (19%) in the inpatient departments, and 14,639 (36%) in outpatient clinics. The screened patients varied from 1% to 22% of the total eligible patient population across hospitals. A total of 297 patients tested positive for HIV for a seropositivity rate of 0.7%; 129 (43%) were newly diagnosed and 168 (57%) were previously diagnosed, with 64% of those previously diagnosed out of care at the time of screening. The inpatient areas had the highest seropositivity rate (0.6%). The percentage of newly diagnosed patients overall who were linked to care was 77%. Of newly diagnosed patients, 51% had ≥ 1 missed opportunity for testing (with a mean of 3.8 visits since 2006), and 30% of patients with missed opportunities were late testers (baseline CD4+ counts <200 cells per cubic millimeter). CONCLUSION: Routine screening is an essential tool for identifying new infections and patients with known infection who are out of care. Hospitals need to provide HIV screening in inpatient and outpatient settings--not just EDs--to decrease missed opportunities. Routine screening success will be driven by how notification and testing are incorporated into the normal medical flow, the level of leadership buy-in, the ability to conduct quality assurance, and local testing laws.

OBJECTIVE: Experimental work suggests a neuroprotective role for magnesium sulfate in aneurysmal subarachnoid hemorrhage. We retrospectively review the incidence of clinically relevant vasospasm in patients treated or not with continuous magnesium infusion after onset of subarachnoid hemorrhage. METHODS: All patient records in Albany Medical Center with the diagnosis of SAH between January 1999 and June 2004 were reviewed. Patients who presented to the emergency department within 72 hours of onset were entered in the study. Patients were defined as in clinical vasospasm if there was an acute neurological change in association with abnormal trancranial Doppler (TCD), CT angiogram (CTA) or digital subtraction angiography (DSA). RESULTS: A total of 85 patients were selected. Magnesium sulfate was infused in 43 patients. When compared with patients who did not receive MgSO(4), there was a statistically significant lower incidence of clinical and radiological vasospasm in those who had the continuous infusion of magnesium sulfate (p<0.01). There was no statistically significant difference between patients who were coiled or clipped. CONCLUSION: Continuous magnesium sulfate infusion for the management of clinically significant cerebral vasospasm is safe and reduces the incidence of clinically significant cerebral vasospasm. Large, multicenter, controlled studies should be performed in order to determine the true effectiveness of the treatment in a controlled setting.

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.

OBJECTIVES: The backbone of neuroendovascular surgery was developed in the decades of the 1960s, 1970s and 1980s. Catheter, balloon and coil technologies were further added to the armamentarium of endovascular treatment of cerebral arterial aneurysms and vasospasm. MATERIAL AND METHODS: Development of detachable coils in the early 1990s was a major breakthrough in the management of intracranial arterial aneurysms. We reviewed available literature and evidence and summarized historical landmarks in the development of neuroendovascular surgery for intracranial arterial aneurysms. CONCLUSION: Current management of intracranial aneurysms is a merge between derived knowledge of early generational concepts and current technology.

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.

There is no question that reengineering impacts organizational culture. In the case of a community-based hospital, it becomes more than just changing the culture--a new culture must emerge. However, cultural change does not have to be negative. The empowerment of reengineering causes employees to think beyond their jobs and to begin seeing their roles in the organization. At first, reengineering appeared to be in direct conflict with CQI principles and the organization's culture. However, culture, no matter how positive or strong, cannot threaten organizational survival. Survival demands the emergence of a new culture. The grassroots nature of CQI and reengineering can create an opportunity to improve labor relations, develop more effective work processes, and assure long-term viability in a rapidly consolidating industry.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are frequently used to manage mild to moderate pain. While limited use is appropriate for many patients, there are safety concerns with use in certain patient populations or with long-term use of these agents. Topical NSAIDs may provide analgesic benefits while decreasing the overall risks of adverse effects. This article will review safety information for both oral and topical NSAIDs.

OBJECTIVES: Anatomical concepts derived by surgical management of intracranial aneurysms provided a pathway to the current integration and practice of aneurysm treatment. These important early developments, such as the surgical microscope in the late 1960s, the development of new surgical techniques and catheters and the evolution of imaging technology, have all provided a fundamental sequence to current clinical practice. MATERIAL AND METHODS: The 1960s can be recognized as the dawn of the current era of aneurysm management. It was during this time period that the quest for novel methods of treatment that carried less risk and severity to the patients was being considered with comparable results. CONCLUSION: The current management of intracranial aneurysms is a merge between derived knowledge of early generational concepts and current technology. A clear and conclusive understanding of these current achievements is, however, still in their infancy.

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: Acute agitation is a common presentation in the emergency department (ED) and is of high concern due to safety risks for patients and the healthcare team. As a result, it is crucial to efficiently relieve agitation in these patients. Numerous studies conducted in the pre-hospital setting and the ED have found ketamine to be an effective agent with quicker onset of action than benzodiazepines or antipsychotics for initial control of acute agitation. Ketamine dosing in these studies ranged from 2-5 mg/kg IM (intramuscular). To date, there is no study comparing low-dose (LD), ~2 mg/kg, versus standard dose (SD), 4-5 mg/kg, ketamine IM for acute agitation.The purpose of this study was to assess the effectiveness and safety of ketamine IM < 2.5 mg/kg versus > 2.5 mg/kg for severe agitation. Methods: This was a single-center, retrospective, two-arm cohort. Adult patients that received ketamine IM for acute agitation in the ED were included in this study. Patients were excluded if they received another sedative within 30 minutes of ketamine administration. The primary outcome was resolution of agitation at 15 minutes after ketamine administration. Resolution of agitation was defined as documentation from a healthcare provider, lack of additional sedative agent within 30 minutes from ketamine administration, or ability to complete necessary procedures. The secondary outcomes included use of agitation rescue medications within 30 minutes, adverse events, and time to medical clearance. Results: Of the 82 patients with an IM ketamine order that were evaluated, 68 met the study criteria. The LD cohort included 52 patients while 16 patients received SD ketamine. Mean age, sex, baseline psychiatric/substance abuse history were similar between groups. Successful sedation was similar between groups, LD 88.5% compared to SD 93.8%, (p=0.998). Rescue sedation was required in 16% of LD patients in the low-dose group and 6.3% of SD patients (p=0.32). Respiratory intervention was required in 13.5% in LD arm and 31.4% in SD (p=0.89). Conclusions: LD and SD IM ketamine resulted in similar rates of successful sedation in acutely agitated patients in the ED.

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.

Failure to successfully cross a total occlusion is one of the major causes for unsuccessful percutaneous revascularization. In the United States, there are several different technologies, but not every hospital has every technology. There are other ways to treat these patients without expensive technologies and that is with the skills and persistence. An ideal endovascular tool should be cost effective, efficient, and safe and should maintain good outcomes.There are many endovascular tools, one can use for improving outcomes during endovascular revascularization. Wires and catheters are comparatively the cheapest tools of this treatment modality. Newer technology includes crossing devices, drug coated balloons, and drug eluting stents.

2006 marked the 40th year of publication for The Annals. Throughout its history, The Annals has provided important contributions to the development of clinical pharmacy. In 2007, we are continuing to publish articles reflecting on the history of clinical pharmacy through the eyes of practitioners, including those pioneering clinical pharmacy, as well as those who have more recently entered the profession and a well-established specialty. In addition, we are also presenting articles and editorials from the early history of The Annals that have given direction and shape to the practice of clinical pharmacy (see page 121).

Failure to successfully cross a total occlusion is one of the major causes for unsuccessful percutaneous revascularization. In the United States, there are several different technologies, but not every hospital has every technology. There are other ways to treat these patients without expensive technologies and that is with the skills and persistence. An ideal endovascular tool should be cost effective, efficient, and safe and should maintain good outcomes. There are many endovascular tools, one can use for improving outcomes during endovascular revascularization. Wires and catheters are comparatively the cheapest tools of this treatment modality. Newer technology includes crossing devices, drug coated balloons, and drug eluting stents.

Abstract Background The Clinical and Laboratory Standards Institute (CLSI) lowered the minimum inhibitory concentration (MIC) breakpoints of various β-lactam antimicrobials eliminating the need for confirmatory testing of extended-spectrum β-lactamase (ESBL) organisms. Our institution adopted the new CLSI breakpoints in June 2015. This multi-site study assessed the impact of laboratory cessation of ESBL reporting on the MIC distribution of commonly used antimicrobials and clinical outcomes. Methods This retrospective study included adult inpatients with positive blood cultures for Escherichia coli, Klebsiella pneumoniae, K. oxytoca, or Proteus mirabilis from June 2012 to June 2018. Patients were included in the pre-implementation group if they had an ESBL-positive blood culture from June 2012 to May 2015 and in the post-implementation group if they had a ceftriaxone-resistant organism from June 2015 to June 2018. Patients who died or transitioned to hospice within 48 hours of blood culture identification or before final susceptibilities were excluded. The primary outcome was MIC distribution of ceftriaxone, ceftazidime, cefepime, piperacillin/tazobactam, fluoroquinolones, and carbapenems. Secondary outcomes were antimicrobial prescribing patterns, 30-day all-cause mortality, 30-day re-infection rate, and time to microbiological clearance. Results A total of 249 patients were included (n = 40, pre-implementation; n = 209, post-implementation). Pitt Bacteremia Scores were significantly higher in the pre-implementation group (3.59 ± 2.85 vs. 2.21 ± 2.06; P = 0.0004). The median MIC distribution for each antimicrobial stayed within one dilution throughout the study timeframe. Carbapenem use decreased in the post-implementation group [n = 35 (87%) vs. n = 131 (63%)]. No significant differences were noted for other secondary outcomes: 30-day all-cause mortality (15% vs. 10%; P = 0.40), 30-day re-infection rate (2.5% vs. 4.3%; P = 1), and time to microbiological clearance (2.28 ± 1.2 vs. 2.41 ± 1.76 days; P = 0.72). Conclusion Adoption of lowered CLSI breakpoints did not impact MIC distribution of select antimicrobials for Enterobacteriaceae; however, it has affected antimicrobial prescribing patterns. Disclosures All authors: No reported disclosures.