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Lexington, KY, United States

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.

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.

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.

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.

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.

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