Lexington, KY, United States
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Ferraris V.A.,Lexington Veterans Affairs Medical Center | Ferraris V.A.,University of Kentucky | Davenport D.L.,University of Kentucky | Saha S.P.,University of Kentucky | And 2 more authors.
Archives of Surgery | Year: 2012

Objective: To examine outcomes in patients who receive small amounts of intraoperative blood transfusion. Design: Longitudinal, uncontrolled observational study evaluating results of intraoperative transfusion in patients entered into the American College of Surgeons National Surgical Quality Improvement Program database. We made propensity-matched comparisons between patients who received and did not receive intraoperative transfusion to minimize confounding when estimating the effect of intraoperative transfusion on postoperative outcomes. Setting: We queried the American College of Surgeons National Surgical Quality Improvement Program database for patients undergoing operations between January 1, 2005, and December 31, 2009. Patients: A large sample of surgical patients from 173 hospitals throughout the United States. Main Outcome Measures: Operative mortality and serious perioperative morbidity (≥1 of 20 complications). Results: After exclusions, 941 496 operations were analyzed in patients from 173 hospitals. Most patients (893 205 patients [94.9%]) did not receive intraoperative transfusions. Patients who received intraoperative infusion of 1 unit of packed red blood cells (15 186 patients [1.6%]) had higher unadjusted rates of mortality and more serious morbidity. These rates further increased with intraoperative transfusion of more than 1 unit of packed red blood cells in a dose-dependent manner. After propensity matching to adjust for multiple preoperative risks, transfusion of a single unit of packed red blood cells increased the multivariate risk of mortality, wound problems, pulmonary complications, postoperative renal dysfunction, systemic sepsis, composite morbidity, and postoperative length of stay compared with propensity-matched patients who did not receive intraoperative transfusion. Conclusions: There is a dose-dependent adverse effect of intraoperative blood transfusion. It is likely that a small, possibly discretionary amount of intraoperative transfusion leads to increased mortality, morbidity, and resource use, suggesting that caution should be used with intraoperative transfusions for mildly hypovolemic or anemic patients. ©2012 American Medical Association. All rights reserved.


Ferraris V.A.,University of Kentucky | Ferraris V.A.,Lexington Veterans Affairs Medical Center | Davenport D.L.,University of Kentucky | Saha S.P.,University of Kentucky | And 3 more authors.
Annals of Thoracic Surgery | Year: 2011

Background: Massive intraoperative transfusion is associated with increased morbidity and mortality in patients undergoing noncardiac thoracic operations. We examined whether this association carries over to patients who receive only 1 to 2 units of packed red blood cells (PRBCs) during their operation. Methods: We queried the American College of Surgeon's National Surgical Quality Improvement Project database for patients undergoing noncardiac, nonvascular thoracic operations during a 5-year period. Patient 30-day morbidity (1 or more of 20 complications) and mortality were evaluated. We used propensity-score matching to minimize confounding when estimating the effect of transfusion on postoperative morbidity. Results: We analyzed 8728 nonvascular thoracic operations in patients from 173 hospitals. Of these, 7875 (90.2%) did not receive intraoperative transfusions. The 579 patients (6.6%) who received 1 to 2 units of intraoperative PRBCs had higher unadjusted rates of wound problems, pulmonary complications, sepsis/shock, composite morbidity, mortality, and length of stay than those who did not receive transfusions. These rates further increased with postoperative transfusion of more than 2 units of intraoperative PRBC. After propensity adjustment, transfusion of 1 or 2 units of PRBCs increased the multivariate risk of composite morbidity, pulmonary complications, systemic sepsis, wound complications, and the postoperative length of stay compared with those who did not receive transfusions. Conclusions: In patients undergoing noncardiac thoracic operations, there is a dose-dependent adverse effect of intraoperative blood transfusion on outcomes, with even seemingly small amounts of blood (1 or 2 units of PRBCs) increasing morbidity and resource utilization. Clinicians should be cautious with intraoperative transfusions of 1 or 2 units of PRBC for mildly hypovolemic or anemic patients. © 2011 The Society of Thoracic Surgeons.


Chen H.J.,Lexington Veterans Affairs Medical Center | Steinke D.T.,University of Kentucky | Karounos D.G.,University of Kentucky | Lane M.T.,Lexington Veterans Affairs Medical Center | Matson A.W.,Lexington Veterans Affairs Medical Center
Annals of Pharmacotherapy | Year: 2010

BACKGROUND: Hyperglycemia is an important marker for clinical outcomes and mortality in hospitalized patients. New national standards have been established emphasizing the importance of improving inpatient glycemic control in individuals with diabetes or new-onset hyperglycemia. Implementation of these new standards is complex and requires a multidisciplinary team approach. A basal-bolus insulin regimen approach has been shown to improve inpatient glycemic control. Few studies have been published regarding basal-bolus insulin protocol outcomes in the non-intensive care unit (ICU) setting. OBJECTIVE: To evaluate the efficacy of a basal-bolus insulin protocol on inpatient glycemic control in a non-ICU setting, as measured by mean blood glucose and number of hypoglycemic episodes per patient admission. METHODS: A retrospective, observational, single-center study was conducted to compare blood glucose control pre- (October 2006-March 2007) and postprotocol (November 2007-January 2008) implementation. Inclusion criteria consisted of patient admission to a medical or surgical ward for at least 72 hours, with a diagnosis of diabetes, or presentation with 2 blood glucose readings greater than 180 mg/dL. Patients admitted to the ICU or those not admitted to a medical or surgical ward were excluded. RESULTS: Following protocol implementation, the mean ± SD blood glucose level increased from 174 ± 88 mg/dL to 188 ± 95 mg/dL (p < 0.001) and the hypoglycemic incidents significantly decreased, from 1.11 to 0.51 events per patient admission (p < 0.0025). CONCLUSIONS: In this pilot study, implementation of a basal-bolus insulin protocol significantly reduced hypoglycemic events; however, mean blood glucose values increased. These results suggest that a basal-bolus insulin protocol can reduce hypoglycemia; however, factors such as protocol compliance, barriers in overcoming the use of the traditional sliding scale insulin regimens, staff education, and change of work-flow habits can influence the overall efficacy and impact of a basal-bolus insulin protocol on inpatient glycemic control.


Evans M.E.,Lexington Veterans Affairs Medical Center | Evans M.E.,University of Kentucky | Kralovic S.M.,Cincinnati Veterans Affairs Medical Center | Kralovic S.M.,University of Cincinnati | And 6 more authors.
American Journal of Infection Control | Year: 2014

The Veterans Affairs methicillin-resistant Staphylococcus aureus (MRSA) Prevention Initiative was implemented in its 133 long-term care facilities in January 2009. Between July 2009 and December 2012, there were ∼12.9 million resident-days in these facilities nationwide. During this period, the mean quarterly MRSA admission prevalence increased from 23.3% to 28.7% (P <.0001, Poisson regression for trend), but the overall rate of MRSA health care-associated infections decreased by 36%, from 0.25 to 0.16/1,000 resident-days (P <.0001, Poisson regression for trend). © 2014 by the Association for Professionals in Infection Control and Epidemiology, Inc.


Ferraris V.A.,University of Kentucky | Ferraris V.A.,Lexington Veterans Affairs Medical Center | Bolanos M.,University of Kentucky | Martin J.T.,University of Kentucky | And 2 more authors.
JAMA Surgery | Year: 2014

IMPORTANCE: A minority of patients who experience postoperative complications die (failure to rescue). Understanding the preoperative factors that lead to failure to rescue helps surgeons predict and avoid operative mortality. OBJECTIVE: To provide a mechanism for identifying a high-risk group of patients with postoperative complications who are at a substantially increased risk for failure to rescue. DESIGN, SETTING, AND PATIENTS: Observational study evaluating failure to rescue in patients entered into the American College of Surgeons National Surgical Quality Improvement Program database. The large sample of surgical patients included in this study underwent a wide range of operations during a 5-year period in more than 200 acute care hospitals. We examined and identified patients at high risk for failure to rescue using propensity stratification. We also developed a risk-scoring system that allowed preoperative identification of patients at the highest risk for failure to rescue. MAIN OUTCOMES AND MEASURES: Risk-scoring system that predicts failure to rescue. RESULTS: Of the 1 956 002 database patients, there were 207 236 patients who developed serious postoperative complications. Deaths occurred in 21 731 patients with serious complications (10.5%failure to rescue). Stratification of patients into quintiles, according to their propensity for developing serious complications, found that 90% of operative deaths occurred in the highest-risk quintile, usually within a week of developing the initial complication. A risk-scoring system for failure to rescue, based on regression-derived variable odds ratios, predicted patients in the highest-risk quintile with good predictive accuracy. Only 31.8%of failure-to-rescue patients had a single postoperative complication. Perioperative deaths increased exponentially as the number of complications per patient increased. Patients with complications who had surgical residents involved in their care had reduced rates of failure to rescue compared with patients without resident involvement. CONCLUSIONS AND RELEVANCE: Twenty percent of high-risk patients account for 90% of failure to rescue (Pareto principle). More than two-thirds of patients with failure to rescue have multiple complications. On average, a few days elapse before death following a complication. A risk-scoring system based on preoperative variables predicts patients in the highest-risk category of failure to rescue with good accuracy. In high-risk patients who develop complications, our results suggest that early intervention, preferably in a high-level intensive care facility with a surgical training program, offers the best chance to reduce failure-to-rescue rates. Copyright 2014 American Medical Association. All rights reserved


Evans M.E.,Veterans Health Administration | Evans M.E.,Lexington Veterans Affairs Medical Center | Evans M.E.,University of Kentucky | Simbartl L.A.,National Infectious Diseases Service | And 6 more authors.
Infection Control and Hospital Epidemiology | Year: 2014

Objective. An initiative was implemented in July 2012 to decrease Clostridium difficile infections (CDIs) in Veterans Affairs (VA) acute care medical centers nationwide. This is a report of national baseline CDI data collected from the 21 months before implementation of the initiative. Methods. Personnel at each of 132 data-reporting sites entered monthly retrospective CDI case data from October 2010 through June 2012 into a central database using case definitions similar to those of the National Healthcare Safety Network multidrug-resistant organism/CDI module. Results. There were 958,387 hospital admissions, 5,286,841 patient-days, and 9,642 CDI cases reported during the 21-month analysis period. The pooled CDI admission prevalence rate (including recurrent cases) was 0.66 cases per 100 admissions. The nonduplicate/nonrecurrent community-onset not-healthcare-facility-associated (CO-notHCFA) case rate was 0.35 cases per 100 admissions, and the community-onset healthcare facility-associated (CO-HCFA) case rate was 0.14 cases per 100 admissions. Hospital-onset healthcare facility-associated (HO-HCFA), clinically confirmed HO-HCFA (CC-HO-HCFA), and CO-HCFA rates were 9.32, 8.40, and 2.56 cases per 10,000 patient-days, respectively. There were significant decreases in admission prevalence (P =.0006, Poisson regression), HO-HCFA (P =.003), and CC-HO-HCFA (P =.004) rates after adjusting for type of diagnostic test. CO-HCFA and CO-notHCFA rates per 100 admissions also trended downward (P =.07 and.10, respectively). Conclusions. VA acute care medical facility CDI rates were higher than those reported in other healthcare systems, but unlike rates in other venues, they were decreasing or trending downward. Despite these downward trends, there is still a substantial burden of CDI in the system supporting the need for efforts to decrease rates further. © 2014 by The Society for Healthcare Epidemiology of America. All rights reserved.


Ferraris V.A.,University of Kentucky | Ferraris V.A.,Lexington Veterans Affairs Medical Center | Hochstetler M.,University of Kentucky | Martin J.T.,University of Kentucky | And 2 more authors.
Surgery (United States) | Year: 2015

Introduction Every experienced surgeon has a patient whose life was saved by a blood transfusion (the "good"). In contrast, an overwhelming amount of evidence suggests that perioperative blood transfusion can be associated with adverse surgical outcomes (the "bad"). We wondered what patient characteristics, if any, can explain this clinical dichotomy with certain patients benefiting from transfusion, whereas others are harmed by this intervention. Methods We queried the American College of Surgeons National Surgical Quality Improvement Project database containing patient information entered between 2010 and 2012 to identify differences in mortality and morbidity among patients receiving blood transfusion within 72 hours of their operative procedure compared with those who did not receive any blood. We calculated the relative risk of developing a serious complication or of operative mortality in propensity-stratified patients with equivalent predicted risk of developing a serious complication or operative mortality. Results There were 470,407 patients in the study group. Of these, 32,953 patients (7.0%) received at least a single blood transfusion within 72 hours of operation. The percent of transfused patients who died or developed serious morbidity was 11.3% and 55.4% compared with 1.3% and 6.1% in nontransfused patients (both P <.001). Operative mortality, rates of failure to rescue, and serious postoperative complications are increased in patients who receive a postoperative transfusion, both in unadjusted comparisons and in propensity-matched comparisons. Dividing patients into regression-stratified deciles with equal numbers of deaths in each group found that patients at the greatest risk for development of death or serious complications had nonsignificant risk of harm from blood transfusion, whereas patients in the least risk deciles had between an 8- and 12-fold increased risk of major adverse events associated with transfusion. Conclusion We found that high-risk patients do not have a significant risk from blood transfusion, but low-risk patients have between an 8- and 10-fold excess risk of adverse outcomes when they receive a blood transfusion. We speculate that careful preoperative assessment of transfusion risk and intervention based on this assessment could minimize operative morbidity and mortality, especially because the patients at least risk are more likely to undergo elective operations and provide time for therapeutic interventions to improve transfusion risk profiles. © 2015 Elsevier Inc. All rights reserved.


Bardach S.H.,Lexington Veterans Affairs Medical Center | Schoenberg N.E.,University of Kentucky
Patient Education and Counseling | Year: 2014

Objective: Despite numerous benefits of consuming a healthy diet and receiving regular physical activity, engagement in these behaviors is suboptimal. Since primary care visits are influential in promoting healthy behaviors, we sought to describe whether and how diet and physical activity are discussed during older adults' primary care visits. Methods: 115 adults aged 65 and older consented to have their routine primary care visits recorded. Audio-recorded visits were transcribed and diet and physical activity content was coded and analyzed. Results: Diet and physical activity were discussed in the majority of visits. When these discussions occurred, they lasted an average of a minute and a half. Encouragement and broad discussion of benefits of improved diet and physical activity levels were the common type of exchange. Discussions rarely involved patient behavioral self-assessments, patient questions, or providers' recommendations. Conclusions: The majority of patient visits include discussion of diet and physical activity, but these discussions are often brief and rarely include recommendations. Practice implications: Providers may want to consider ways to expand their lifestyle behavior discussions to increase patient involvement and provide more detailed, actionable recommendations for behavior change. Additionally, given time constraints, a wider array of approaches to lifestyle counseling may be necessary. © 2014.


Walsh K.A.,University of Kentucky | Walsh K.A.,Lexington Veterans Affairs Medical Center | Lewis D.A.,University of Kentucky | Lewis D.A.,South Pointe Hospital | And 5 more authors.
Annals of Pharmacotherapy | Year: 2013

BACKGROUND: Pharmacologic prophylaxis for venous thromboembolism (VTE) in patients with chronic liver disease (CLD) presents a unique challenge because of coagulopathies associated with the disease. When evaluating whether these patients require VTE prophylaxis upon hospitalization, it would be advantageous if risk factors for the development of VTE in this population were known. OBJECTIVE: To evaluate risk factors associated with the development of VTE in patients with CLD. METHODS: A retrospective case-control study was conducted. Patients admitted to the University of Kentucky Chandler Hospital from October 2006 to July 2010 with a diagnosis of CLD and VTE were matched in a 1:3 fashion with CLD patients without VTE. The primary objective was to determine whether there were significant differences in laboratory values between the 2 groups. RESULTS: During this time, 27 patients with CLD (1.0%) were diagnosed with VTE. These patients had significantly lower median aspartate aminotransferase (AST) (47 vs 70 U/L, p = 0.04), alanine transaminase (ALT) (24.5 vs 36 U/L, p = 0.02), albumin (2.1 vs 2.4 g/dL, p = 0.02) and hematocrit (Hct) (28.3% vs 32%, p = 0.03) values compared to the control patients. Patients with albumin lower than 1.9 g/dL had a 5.1 times greater risk of VTE compared to patients with albumin of 2.8 g/dL and higher (OR 5.14, 95% CI 1.05-25.2). CONCLUSIONS: Patients with CLD who developed VTE had significantly lower AST, ALT, albumin, and Hct compared to those of control patients. Studies are necessary to further examine the significance of this finding. © 1967-2013 Harvey Whitney Books Co. All rights reserved.


Downs J.,University of North Carolina at Chapel Hill | Wolfe T.,Lexington Veterans Affairs Medical Center | Walker H.,University of North Carolina at Chapel Hill
Journal of Spinal Cord Medicine | Year: 2014

Context: Case of an adult patient with paraplegia managing neurogenic bladder with intermittent catheterization who was not performing a standard bowel program for management of neurogenic bowel.Findings: Patient presented with increasing spasticity, fecal incontinence, and abdominal pain and ultimately was hospitalized for management. Imaging revealed massive fecal impaction, resulting in ureteral obstruction and hydronephrosis. Despite repeated aggressive bowel regimens, serial abdominal X-rays showed continued large stool burden. Ultimately surgical intervention was required to evacuate the colon and subsequently the hydronephrosis resolved.Conclusion/Clinical relevance: This case illustrates the importance of proper management of neurogenic bowel, as significant medical complications, such as hydronephrosis can occur with poorly managed neurogenic bowel. © The Academy of Spinal Cord Injury Professionals, Inc. 2014.

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