Biomedical subjects
Publications and source records attributed to C Salemi.
In 1991, heat-and-moisture exchangers were introduced with biweekly ventilator circuit tubing changes, resulting in elimination of multiple pieces of respiratory equipment and reduced labor costs. The annual savings were $157,000, totalling $1.5 million since the onset of the program. There have been no increases in rates of ventilator-associated pneumonia.
The American Society of Anesthesiology (ASA) scoring was performed for the National Nosocomial Infection Surveillance (NNIS) System surgical-site-infection (SSI) risk indexing in 250 prosthetic-joint surgeries. There were ASA scoring discrepancies in 59% of 116 ASA-3 surgeries and 2 out of 10 ASA-3 SSI. The original ASA scoring led to an uncorrected SSI rate of 5.8 per 100 surgeries in the NNIS risk group 0; with corrected ASA scores, the rate was 4.5 per 100 surgeries.
BACKGROUND: For the years 1987 through 1992, a study was undertaken to analyze nosocomial infection mortality data and to stratify risk according to severity of underlying illness to compare with published data from the Centers for Disease Control and Prevention. METHODS: Nosocomial infections that contributed to or caused death were identified. In addition, during 1990 through 1992, severity of illness was determined as the subjective estimate of the risk of death or lack of risk of death during the current hospital admission before the onset of the nosocomial infection. These groups were named +SIC and -SIC, respectively. RESULTS: It was determined that the data from death certificates in cases of known nosocomial infection were not sufficient to determine whether nosocomial infection contributed to or caused death. There was a 24% increase in cases of nosocomial infection contributing to or causing death when a physician reviewed deaths in patients with nosocomial infections who did not have a diagnosis of nosocomial infection listed on the death certificate. The rates for nosocomial infections contributing to or causing death are as follows: nosocomial pneumonia, 20%; and bloodstream infections, 19%. In patients who died and had severity of illness determination, there was a statistically significant difference in the rates of nosocomial infections contributing to or causing death between -SIC and +SIC groups for both nosocomial pneumonia and bloodstream infections. The rates for bloodstream infections were as follows: -SIC, 5%; and +SIC, 21%. For nosocomial pneumonia, the rates were as follows: -SIC, 13%; and +SIC, 23%. CONCLUSION: In published reports from the Centers for Disease Control and Prevention, a rate of 13% is given for nosocomial pneumonia and bloodstream infections contributing to or causing death; however, there is no stratification for severity of illness in these reports. The presence of life-threatening illness before the onset of nosocomial pneumonia or bloodstream infection accounts for most deaths among our patients. For valid comparisons, mortality outcome data for nosocomial infections should be stratified for risk according to severity of underlying illness.
Explore the source record for details and available documents.
BACKGROUND: A subjective severity of illness classification was evaluated in a study of nosocomial pneumonia. This is a 5-category system based on the determination of the control of underlying illness and the risk of death during current hospital admission. METHODS: A case-control study was performed with 128 cases of nosocomial pneumonia and 252 control patients. An additional 60 case and 90 control patients were used to compare this classification with APACHE II scoring in intensive care unit patients. RESULTS: In univariate analysis, the severity illness classification was significantly associated with nosocomial pneumonia risk (p < 0.01). APACHE II adequately predicted mortality rate but was not statistically significantly associated with nosocomial pneumonia risk among intensive care unit patients. In logistic regression analysis, the severity of illness classification, surgery, age, nasogastric tube placement, and histamine blockers each showed significant independent association with nosocomial pneumonia. CONCLUSIONS: The role of the severity of illness classification for risk stratification in nosocomial pneumonia is valid. Its roles in the evaluation of surgical wound infection, nosocomial bacteremia, and quality of care remain to be determined in subsequent studies.
In 1989, our medical center used continuous quality improvement concepts in the creation of a Nosocomial Pneumonia Prevention Team whose aim was to significantly reduce nosocomial ventilator-associated pneumonia. The team included representatives from nursing, respiratory therapy, pulmonary medicine, internal medicine, anesthesiology, education and training, and infection control. Because the majority of mechanically ventilated patients were located in the intensive care unit, this unit became the focus of the prevention efforts. Team meetings were held regularly, with all representatives brainstorming barriers, possible interventions, methods of outcome measurement, and frequency of evaluation. Policies and procedures were reviewed, surveillance was increased, handwashing practices were surveyed, periodic feedback to staff was begun, and an educational program was developed and presented. During 1990, we observed a 57% reduction in ventilator-associated pneumonia from the baseline years, 1987 and 1988. Statistical comparison of proportions by z test indicated a p value less than 0.05. Fifteen cases of nosocomial ventilator-associated pneumonia were prevented and a cost saving of $105,000 was realized. Performance of traditional surveillance for outliers, coupled with literature-based thresholds, can lead to tolerance of inordinately high endemic rates. Infection control programs can significantly reduce endemic rates of nosocomial ventilator-associated pneumonia through continuous quality improvement methods and multidisciplinary interventions, with standard infection control procedures used for improvement.
Fluconazole was administered at doses of 50-400 mg/d to 18 patients (15 men, three women) with coccidioidal meningitis. After a mean duration of treatment of 9.8 months, 10 (67%) of 15 assessable patients had responded, one (7%) of 15 had partially responded, and four (27%) of 15 had not responded to therapy. Five (63%) of eight assessable patients receiving fluconazole as sole therapy responded or partially responded. Two patients discontinued fluconazole after initially responding to therapy, and both experienced relapse. The toxicity of fluconazole remains minimal at doses to 400 mg/d. The penetration of fluconazole into cerebrospinal fluid is substantial at all doses studied. Thus fluconazole continues to show promise even as sole therapy against coccidioidal meningitis. Not all patients respond, however, and relapse may be a problem with the currently studied doses and durations of therapy.
OBJECTIVE: The objective of this study was to evaluate a clinical decision process model for the appropriateness of vancomycin use, using modified Hospital Infection Control Practice Advisory Committee (HICPAC) guidelines. DESIGN: All nondialysis vancomycin use was reviewed using the retrospective chart review method. The HICPAC guidelines were modified to distinguish between documented and suspected infections and appropriateness of vancomycin use initially and after 3 days of therapy. Data were collected on both vancomycin-use orders and vancomycin-use days. SETTING: 446-bed health maintenance organization teaching hospital. RESULTS: 758 uses of vancomycin from 1993 through 1995 were evaluated using the modified HICPAC guidelines. Initial use was appropriate in 71% of the cases, with 26% used for documented infections and 74% for suspected infections. Of the 536 orders of initial appropriate use, 176 courses of treatment with vancomycin were discontinued appropriately within 3 days. Ongoing use evaluation after 3 days revealed appropriate use in 45%, inappropriate ongoing use in 25%, and empirical ongoing use in 30% of the cases. There were adequate clinical or laboratory data available in 70% of cases after 3 days to discontinue vancomycin or to reclassify from suspected to documented infections or indications. Vancomycin-use evaluation solely after 3 days would not have disclosed 537 initial inappropriate vancomycin-use days, which were 44% of the total inappropriate use days. CONCLUSIONS: Comprehensive evaluation of vancomycin use with HICPAC guidelines should include a modification to encompass initial and 3-day reevaluation, because most initial use is for suspected, and not documented, infections. HICPAC guidelines do not address the issues of differentiating suspected from documented infection indications or ongoing empirical use. The clinical decision process model is a framework for documentation and data collection for use evaluation and addresses issues not covered in HICPAC vancomycin guidelines. This model could be used by other medical centers for evaluation of vancomycin or other antibiotics.
Explore the source record for details and available documents.