Purpose To streamline workflow of the culture review process in the emergency department (ED), a transition from a nurse-driven to a pharmacist-initiated process was implemented. Methods This was a single-center retrospective study conducted at an adult urban level 1 trauma academic medical center. The pharmacist-initiated culture review process was compared to the previous nurse-initiated process. The primary objective was time from final culture result to patient contact by an advanced practice provider. Secondary objectives included incidence of treatment failure and hospital admission within 30 days of ED visit. Results A total of 283 patients met inclusion criteria: 144 patients in the pre-intervention group and 139 patients in the postintervention group. Patients were contacted a median time of 15.7 hours (95% confidence interval [CI], 9.88-18.83) earlier for definitive urinary tract infection antibiotic therapy and 46.7 hours (95% CI, 33.34-61.62) earlier for definitive sexually transmitted infection therapy in the pharmacist-initiated workflow compared to the nurse-initiated workflow (P < 0.001). Treatment failure occurred in 0.01% of patients in the postintervention group and 6.3% in the pre-intervention group (P = 0.01). Hospital admission within 30 days of the ED visit occurred in 0% of patients in the postintervention group and 4.2% in the pre-intervention group (P = 0.03). Conclusion Pharmacist-initiated culture review in the ED at an academic medical center reduced time from final culture to patient contact for optimal antibiotic therapy and decreased hospital admission and treatment failure rates. A change in the culture review workflow involving pharmacists appears to have a positive impact on clinical outcomes.
Study Objectives: Point-of-care ultrasound (POCUS) is integral to the care of patients in the emergency department. Unfortunately, ultrasound probes can act as fomites for pathogen transmission from patient to patient despite various cleaning methods and barrier precautions. It is pertinent to understand what factors contribute to this and how we can best reduce this risk. The objective of this study was to detect growth of methicillin-sensitive Staphylococcus aureus (MSSA) from POCUS probes after scanning an inoculated pork model with several types of conduction media to investigate the difference in pathogen transmission.Methods: A portion of store-bought pork shoulder was disinfected with chlorhexidine and allowed to dry. One mL of a cultured sample of abscessconcentration MSSA was used to inoculate the specimen. A linear transducer was cleansed with a sterilizing cloth and the end of the probe was then covered with a Tegaderm (3M, Maplewood, MN). One of three conduction media was applied to the pork shoulder: sterile saline, chlorhexidine, or sterile gel. The probe was then used to perform a soft tissue scan of the pork shoulder for one minute. After this, the probe was swabbed and cultured to detect transmission of MSSA. This was done four times for each of the three media types.Results: None of the four saline or four chlorhexidine probe swabs grew MSSA when cultured. Three of the four sterile gel probe swabs grew MSSA.Conclusions: These results suggest that sterile ultrasound gel may be more likely to transmit skin pathogens to the probe during POCUS in a simulated environment. However, larger studies and further exploration into this topic are necessary to draw clinical conclusions.
operator was blinded to our study outcomes. Data from these forms and patient demographic data was systematically collected by trained abstractors who were blinded to our study objectives. Data was separately checked for accuracy by the investigators. Hypoxemia was defined as oxygen saturation < 90%. The primary outcome was mortality evaluated by multivariable logistic regression adjusting for the following potential confounders: pre-RSI hypoxemia, hypoxemia during RSI, Injury Severity Score (ISS), Glasgow Coma Scale (GCS), neuromuscular blocking agent (NMBA) for paralysis, and type of injury. Statistical significance was determined by a P value of < 0.05.Results: 245 patients were included in our analysis. One patient was excluded for indata. The investigators found no other errors in the data collection. There were 40 deaths among the included patients. 186 (76%) did not have hypoxemia during RSI, and 59 (24%) had documented hypoxemia during RSI. The two groups were similar with regard to mean pre-RSI oxygen saturation (97% versus 96%), frequency of pre-RSI hypoxemia (6% versus 7%), median ISS (27 versus 27), mean GCS (10 versus 10), the presence of head or facial trauma (45% versus 41%), blunt versus penetrating injury (14% versus 20%), mean systolic blood pressure (133 mmHg versus 132 mmHg), mean heart rate per minute (99 versus 93), mean respiratory rate per minute (21 versus 22), operator level training, or mortality (15% versus 20%). There was no multicollinearity detected. Our 4variable (ISS, pre-RSI hypoxemia, hypoxemia during RSI, and GCS) logistic regression model was aided by the use of ISS as a scale variable (P ¼ <0.001). Pre-RSI hypoxemia was not significantly associated with mortality in the model. Hypoxemia during RSI had an adjusted OR (aOR) of 2.6 (95% CI: 1.0 -6.4; P ¼ .044), and GCS < 8 had an aOR of 4.2 (95% CI: 1.8 -10.0; P ¼ 0.001) for mortality. The addition of type of injury, choice of NMBA, and operator level of training to the model did not change the statistical significance (P ¼ < 0.05) of hypoxemia during intubation and GCS < 8 or the insignificance (P ¼ > 0.05) of pre-RSI hypoxemia to predict mortality.Conclusions: Hypoxemia during RSI, but not pre-RSI hypoxemia, and low GCS in trauma patients undergoing RSI in the ED are predictors of mortality. This study is the first to report that transient hypoxemia during RSI of trauma patients is associated with in-hospital mortality. Our results support the avoidance of hypoxemia during RSI in trauma patients regardless of the oxygen saturation prior to intubation.
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