Incidence of type 1 diabetes in Germany is not higher than predicted.
Explore the source record for details and available documents.
Adolescent↗
Biomedical subjects
D C Classen
Publications and source records attributed to D C Classen.
Implementing antibiotic practice guidelines through computer-assisted decision support: clinical and financial outcomes.
OBJECTIVE: To determine the clinical and financial outcomes of antibiotic practice guidelines implemented through computer-assisted decision support. DESIGN: Descriptive epidemiologic study and financial analysis. SETTING: 520-bed community teaching hospital in Salt Lake City, Utah. PATIENTS: All 162 196 patients discharged from LDS Hospital between 1 January 1988 and 31 December 1994. INTERVENTION: An antibiotic management program that used local clinician-derived consensus guidelines embedded in computer-assisted decision support programs. Prescribing guidelines were developed for inpatient prophylactic, empiric, and therapeutic uses of antibiotics. MEASUREMENTS: Measures of antibiotic use included timing of preoperative antibiotic administration and duration of postoperative antibiotic use. Clinical outcomes included rates of adverse drug events, patterns of antimicrobial resistance, mortality, and length of hospital stay. Financial and use outcomes were expressed as yearly expenditures for antibiotics and defined daily doses per 100 occupied bed-days. RESULTS: During the 7-year study period, 63 759 hospitalized patients (39.3%) received antibiotics. The proportion of the hospitalized patients who received antibiotics increased each year, from 31.8% in 1988 to 53.1% in 1994. Use of broad-spectrum antibiotics increased from 24% of all antibiotic use in 1988 to 47% in 1994. The annual Medicare case-mix index increased from 1.7481 in 1988 to 2.0520 in 1993. Total acquisition costs of antibiotics (adjusted for inflation) decreased from 24.8% ($987,547) of the pharmacy drug expenditure budget in 1988 to 12.9% ($612,500) in 1994. Antibiotic costs per treated patient (adjusted for inflation) decreased from $122.66 per patient in 1988 to $51.90 per patient in 1994. Analysis using a standardized method (defined daily doses) to compare antibiotic use showed that antibiotic use decreased by 22.8% overall. Measures of antibiotic use and clinical outcomes improved during the study period. The percentage of patients having surgery who received appropriately timed preoperative antibiotics increased from 40% in 1988 to 99.1% in 1994. The average number of antibiotic doses administered for surgical prophylaxis was reduced from 19 doses in the base year to 5.3 doses in 1994. Antibiotic-associated adverse drug events decreased by 30%. During the study, antimicrobial resistance patterns were stable, and length of stay remained the same. Mortality rates decreased from 3.65% in 1988 to 2.65% in 1994 (P < 0.001). CONCLUSIONS: Computer-assisted decision support programs that use local clinician-derived practice guidelines can improve antibiotic use, reduce associated costs, and stabilize the emergence of antibiotic-resistant pathogens.
Anti-Bacterial Agents↗
A large randomized clinical trial of a silver-impregnated urinary catheter: lack of efficacy and staphylococcal superinfection.
PURPOSE: The antibacterial activity of silver-containing compounds has recently been employed in constructing medical devices, such as vascular and urinary catheters, that may be effective in blocking infection. The present study was designed to evaluate the efficacy of a silver oxide-coated urinary catheter. PATIENTS AND METHODS: A total of 1,309 hospitalized patients who required placement of an indwelling urinary catheter for 24 hours or longer were randomly assigned to receive either a silicone catheter coated externally with 5% silver oxide or a standard silicone elastomer-coated latex catheter. Daily catheter-urine specimens were collected aseptically and catheter-care violations were monitored daily for the duration of the catheterization. RESULTS: Bacteriuria developed in 85 of 745 patients (11.4%) in the silver-coated catheter group and in 73 of 564 patients (12.9%) in the control group (P = 0.45). In women who did not receive antibiotics, the rates were 29.3% and 30.4%, respectively (P = 0.98). In men who did not receive antibiotics, the rate of bacteriuria was significantly higher with the silver-coated catheter (29.4% compared to 8.3%, respectively, P = 0.02). Staphylococcal species were isolated more often from the silver-coated catheter group than from the control group (25% versus 8% of all isolates, respectively, P = 0.002). CONCLUSIONS: This study, the largest ever reported evaluating any silver-impregnated device, has not only failed to demonstrate the efficacy of silver in prevention of catheter-associated bacteriuria, as suggested in prior studies, but it has also shown a significantly increased incidence of bacteriuria in male patients and a significantly increased occurrence of staphylococcal bacteriuria. These results suggest the need for caution and for similar large-scale trials before silver-containing compounds are widely used for preventing device-associated infections, both in vascular and urinary catheters.
Bacteriuria↗
The computer-based patient record: the role of the hospital epidemiologist.
Despite advances in computers and software for data analysis, hospital epidemiologists still must use manual methods for data collection. To automate infection control surveillance fully, healthcare institutions need computerized medical records; however, very few institutions currently have such a system. Healthcare institutions appreciate the need for automation, but frequently do not see a clear path to the desired outcome. In this article, we outline the important issues that hospital epidemiologists must understand if they wish to help their institutions to computerize their medical records.
Hospital Information Systems↗
Candidal brain abscess associated with vascular invasion: a devastating complication of vascular catheter-related candidemia.
We describe a patient who developed Candida albicans brain abscess associated with prominent vascular invasion following an episode of central venous catheter-related fungemia. The increasing population of immunosuppressed patients and the frequent use of broad-spectrum antimicrobials, corticosteroids, chemotherapeutics, organ transplantation, and prolonged supportive measures are responsible for an increasing incidence of candidal infections. Brain abscess is a rare complication of candidemia but may be expected to become more common as venous catheter-related fungemia is encountered more frequently.
Amphotericin B↗
Rheumatic pneumonia: reappearance of a previously recognized complication of acute rheumatic fever.
The clinical diagnosis of acute rheumatic fever (ARF) may be challenging; however, a constellation of signs including new valvular insufficiency, cardiomegaly, and heart failure should readily prompt consideration of the diagnosis of rheumatic carditis. In addition, pulmonary findings are compatible with ARF, as associated pulmonary involvement may represent rheumatic pneumonia. We report the case of a young man with ARF and rheumatic pneumonia, a previously described but rare complication of ARF.
Adult↗
A decision support tool for antibiotic therapy.
We developed a decision support tool to assist physicians anticipating the need for antibiotic therapy. The initial screen alerts physicians of pertinent patient information, provides direct access to other essential medical information, and stimulates clinical judgment by suggesting an antibiotic regimen. The decision support tool also suggests the dose and interval for any ordered antibiotics selected by the physicians. During a 7-month pilot study, all antibiotics for patients admitted to the Shock/Trauma/Respiratory Intensive Care Unit (STRICU) were ordered using the decision support tool. Clinical data from the study period and a 12-month control period (the previous year) were collected and compared. The decision support tool was used to order antibiotics 588 times during the study period and the suggested antibiotics were used 218 (37%) times. The computer suggested dosages were used over 90% of the time. The mean cost of antibiotics was $87.00 (p < 0.04) less per patient during the study period as compared to the control period. Prospective assessment revealed only 3 antibiotic adverse drug events (ADEs) (0.9%) among 336 study patients as compared to 15 ADEs (2.4%) among 626 control patients (p = 0.164).
Anti-Bacterial Agents↗
Improving empiric antibiotic selection using computer decision support.
BACKGROUND: Physicians frequently need to start antibiotic therapy before the results of bacterial cultures and antibiotic susceptibility tests are available. We developed and evaluated a computerized antibiotic consultant to assist physicians in the selection of appropriate empiric antibiotics. METHODS: We used a two-stage random-selection study to compare antibiotics suggested by the antibiotic consultant with 482 associated antibiotic susceptibility results and the concurrent antibiotics ordered by physicians. The antibiotics ordered by randomized physicians were then compared between crossover periods of antibiotic consultant use. RESULTS: The antibiotic consultant suggested an antibiotic regimen to which all isolated pathogens were shown to be susceptible for 453 (94%) of 482 culture results, while physicians ordered an antibiotic regimen to which all isolated pathogens were susceptible for 369 culture results (77%) (P < .001). The physicians who prescribed antibiotics to which all pathogens were susceptible did so a mean of 21 hours after the culture specimens were collected. Physicians ordered appropriate antibiotics within 12 hours of the culture collection significantly more often when they had use of the antibiotic consultant than during the period before use (P < .035). Moreover, 88% of the physicians stated they would recommend the program to other physicians, 85% said the program improved their antibiotic selection, and 81% said they felt use of the program improved patient care. CONCLUSIONS: Information from computer-based medical records can be used to help improve physicians' selection of empiric antibiotics for infections.
Anti-Bacterial Agents↗
Information management in infectious diseases: survival of the fittest.
Like all physicians, infectious disease practitioners are concerned and uncertain about their future role as the United States undergoes a major reform of its health care system. Managed care has become the dominant type of health care provided to most patients in the United States, and specialists are increasingly threatened as patient referrals decrease, reimbursements decline, and health care organizations preferentially recruit primary care physicians over specialists. These changes may represent a potential shift in responsibilities and duties for many infectious disease practitioners. The primary role of the infectious disease physician has traditionally been consultative, although many practitioners have organized programs in infection control, hospital epidemiology, and antibiotic management. These programs have become more important as managed care organizations understand the implications of their potential cost savings. The value of these programs will also be significantly enhanced by the ongoing revolution in medical information management that is being driven by computerization. This paper outlines the enlarging role of computerized information management in clinical patient care and its impact on infectious disease practitioners who are increasingly involved in infection control, hospital epidemiology, and antibiotic management programs, as well as in the development of computerized clinical information systems.
Communicable Diseases↗
Preventing adverse drug events in hospitalized patients.
OBJECTIVE: To use computerized adverse drug event (ADE) surveillance to help identify methods to reduce the number of ADEs in hospitalized patients. DESIGN: Prospective study of 79,719 hospitalized patients during a 44-month period. SETTING: LDS Hospital, a 520-bed tertiary care center affiliated with the University of Utah School of Medicine, Salt Lake City. INTERVENTION: Sequential study periods of at least one year each were compared. In the first period, data were collected but not reported to physicians, pharmacists, or nurses. In the subsequent study periods, three interventions (computerized alerts of drug allergies, standardized antibiotic administration rates, and timely physician notification of all ADEs) were made to reduce the number of type B (allergic or idiosyncratic reactions) and severe ADEs. RESULTS: In the first study period, we identified 56 type B ADEs during 120,213 patient days. During two subsequent study periods that included alerts to physicians of known drug allergies and standardized antibiotic administration rates, 8 type B events were identified during 113,237 patient days and 18 during 107,868 patient days, respectively (p < 0.002). Early notification of physicians of all confirmed ADEs regardless of severity was associated with a significant reduction of ADEs classified as severe from 41 during 113,859 patient days in the first study period to 12 during 103,071 patient days and 15 during 108,320 patient days in two subsequent study periods, respectively (p < 0.001). CONCLUSIONS: Prospective surveillance of computer-based medical records for known drug allergies and appropriate drug administration rates can reduce the number of type B ADEs. Early ADE detection and notification of physicians permit drug and dosage changes that reduce the progression of mild and moderate ADEs to more severe conditions.
Adverse Drug Reaction Reporting Systems↗
Prospective surveillance of imipenem/cilastatin use and associated seizures using a hospital information system.
OBJECTIVE: To develop computerized methods to monitor and recommend dosage changes for patients treated with excessive dosages of imipenem/cilastatin (I/C) and to determine the incidence of I/C-associated seizures in our patient population. DESIGN: Prospective observational and interventional study of all patients admitted to LDS Hospital and treated with I/C from May 1, 1987, through June 30, 1991. SETTING: LDS Hospital, Salt Lake City, UT, a 520-bed, tertiary care center associated with the University of Utah School of Medicine. PATIENTS: Using a hospital information system we developed computerized algorithms to identify and monitor patients receiving I/C. These algorithms screened the computer-stored medical records of all inpatient admissions for I/C prescription orders. Computer-decision support algorithms estimated the renal function of each I/C-treated patient and provided suggestions when dosages were determined to be excessive. Additional computer-generated alerts identified patients who were receiving anticonvulsants concomitantly with I/C or whose therapy reflected dosage changes in the previous 24 hours. A list of all I/C-treated patients with alerts was reviewed daily by a clinical pharmacist and prescribing physicians were contacted if the computer-generated suggestions were clinically relevant. MAIN OUTCOME MEASURE: The number and characterization of I/C-associated seizures. RESULTS: From May 1, 1987, through June 30, 1991, we prospectively monitored 107,600 patients of whom 1951 were treated with I/C. The following risk factors for I/C-associated seizures were observed in the I/C-treated population: CNS disease (6 percent), seizure disorders (0.6 percent), and abnormal renal function (70 percent). The observational and interventional methods employed in this study resulted in 79 percent of the patients receiving I/C dosages appropriate for their corresponding renal function. During the 50-month study period, we detected four seizures (0.20 percent) in the I/C-treated patients. All 4 patients were receiving I/C dosages that were excessive with respect to their renal function. CONCLUSIONS: Our rate of seizure (0.2 percent) was lower than the 1-2 percent rate reported in the literature despite the fact that more than 70 percent of the patients who received I/C had risk factors for seizure. We believe that appropriate dosing of I/C results in a low rate of associated seizures. Computer-assisted monitoring of I/C dosages in relation to renal function resulted in a reduced incidence of seizures.
Adolescent↗
Using a hospital information system to assess the effects of adverse drug events.
The most common adverse events experienced by hospitalized patients are drug related. While numerous studies have described the incidence and types of adverse drug events (ADEs), the actual effect of these events on patient outcomes have only been estimated. The studies that have described the effects of ADEs on patient outcomes have not stratified patients by severity of illness and hospital costs were estimated based on a percent of hospital charges. We designed a study to utilize the resources of our hospital information system to assess the attributable effects of ADEs on hospital length of stay and cost of hospitalization. This approach emphasized the difference between study patients and their matched control patients rather than overall differences between patients with and without ADEs. In addition, we used nursing acuity data to help adjust severity of illness within DRG groups and actual hospital costs were used instead of estimated costs. This study found that while the average length of stay for patients with ADEs was 8.19 days compared to 4.36 days for matched control patients, the attributable difference due to the ADEs was 1.94 days. Similar methods found that patients with ADEs had an average cost of hospitalization of $10,584 compared to $5,350 for those without and the attributable difference due to ADEs was $1,939. This indicates that the 569 ADEs at our hospital during 1992 resulted in an additional 1,104 extra patient days at a cost of $1,103,291.
Adverse Drug Reaction Reporting Systems↗
The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection.
BACKGROUND: Randomized, controlled trials have shown that prophylactic antibiotics are effective in preventing surgical-wound infections. However, it is uncertain how the timing of antibiotic administration affects the risk of surgical-wound infection in actual clinical practice. METHODS: We prospectively monitored the timing of antibiotic prophylaxis and studied the occurrence of surgical-wound infections in 2847 patients undergoing elective clean or "clean-contaminated" surgical procedures at a large community hospital. The administration of antibiotics 2 to 24 hours before the surgical incision was defined as early; that during the 2 hours before the incision, as preoperative; that during the 3 hours after the incision, as perioperative; and that more than 3 but less than 24 hours after the incision, as postoperative. RESULTS: Of the 1708 patients who received the prophylactic antibiotics preoperatively, 10 (0.6 percent) subsequently had surgical-wound infections. Of the 282 patients who received the antibiotics perioperatively, 4 (1.4 percent) had such infections (P = 0.12; relative risk as compared with the preoperatively treated group, 2.4; 95 percent confidence interval, 0.9 to 7.9). Of 488 patients who received the antibiotics postoperatively, 16 (3.3 percent) had wound infections (P less than 0.0001; relative risk, 5.8; 95 percent confidence interval, 2.6 to 12.3). Finally, of 369 patients who had antibiotics administered early, 14 (3.8 percent) had wound infections (P less than 0.0001; relative risk, 6.7; 95 percent confidence interval, 2.9 to 14.7). Stepwise logistic-regression analysis confirmed that the administration of antibiotics in the preoperative period was associated with the lowest risk of surgical-wound infection. CONCLUSIONS: We conclude that in surgical practice there is considerable variation in the timing of prophylactic administration of antibiotics and that administration in the two hours before surgery reduces the risk of wound infection.
Adult↗
Computerized identification of patients at high risk for hospital-acquired infection.
Surveillance for hospital-acquired infections is required in U.S. hospitals, and statistical methods have been used to predict the risk of infection. We used the HELP (Health Evaluation through Logical Processing) Hospital Information System at LDS Hospital to develop computerized methods to identify and verify hospital-acquired infections. The criteria for hospital-acquired infection are standardized and based on the guidelines of the Study of the Efficacy of Nosocomial Infection Control and the Centers for Disease Control. The computer algorithms are automatically activated when key items of information, such as microbiology results, are reported. Computer surveillance identified more hospital-acquired infections than did traditional methods and has replaced manual surveillance in our 520-bed hospital. Data on verified hospital-acquired infections are electronically transferred to a microcomputer to facilitate outbreak investigation and the generation of reports on infection rates. Recently, we used the HELP system to employ statistical methods to automatically identify high-risk patients. Patient data from more than 6000 patients were used to develop a high-risk equation. Stepwise logistic regression identified 10 risk factors for nosocomial infection. The HELP system now uses this logistic-regression equation to monitor and determine the risk status for all hospitalized patients each day. The computer notifies infection control practitioners each morning of patients who are newly classified as being at high risk. Of 605 hospital-acquired infections during a 6-month period, 472 (78%) occurred in high-risk patients, and 380 (63%) were predicted before the onset of infection. Computerized regression equations to identify patients at risk of having hospital-acquired infections can help focus prevention efforts.
Cross Infection↗
Randomized trial of meatal care with silver sulfadiazine cream for the prevention of catheter-associated bacteriuria.
A randomized, controlled, prospective clinical trial involving 696 hospitalized patients was undertaken to determine the effectiveness of 1% silver sulfadiazine cream applied twice daily to the urethral meatus in preventing transurethral catheter-associated bacteriuria. The overall incidence of bacteriuria was 11.4% (38/332) in the treated group and 13.2% (48/364) in the untreated group (P = .56; odds ratio, 0.85; 95% confidence interval, 0.53-1.37). Cox proportional hazards analysis identified female sex, lack of antibiotic use, and a positive initial meatal culture (but not treatment randomization or lack of urinemeter use) as independent variables associated with an increased risk of bacteriuria. Survival curve analysis of subgroups stratified by sex and antibiotic use failed to detect an effect of silver sulfadiazine on the rate of bacteriuria. Meatal care with silver sulfadiazine cream did not prevent the development of catheter-associated bacteriuria in short-term catheterized patients.
Administration, Topical↗
Description of a computerized adverse drug event monitor using a hospital information system.
To improve the detection and characterization of adverse drug events (ADEs) in hospitalized patients, a computerized adverse drug event monitor was developed. Computer programs were written to allow for voluntary as well as automated detection of adverse drug events using the HELP hospital information system, a large integrated hospital database containing computerized patient medical records and a knowledge base allowing for automated medical decisions. Programs were created to allow simple computer entry of potential adverse drug events by physicians, pharmacists, and nurses. Automated detection of potential adverse drug events relied on signals such as sudden medication stop orders, "antidote" orders, and selected abnormal laboratory values. Each day a list of all potential adverse drug events from these sources was generated and a pharmacist reviewed the medical records and interviewed healthcare personnel associated with patients identified as having potential adverse drug events. This process allowed for characterization of the event, causality assessment, and follow-up of the resulting clinical course by the pharmacist. The permanent storage of these results in the computerized patient medical record permits their future retrieval to prevent adverse drug events during subsequent hospital care. The authors conclude that fully integrated hospital systems will permit the further development and evaluation of computer-assisted methods for the detection of adverse drug events in hospitalized patients.
Adverse Drug Reaction Reporting Systems↗
Prevention of adverse drug events through computerized surveillance.
Adverse drug events (ADEs) are a serious health problem and are the leading adverse event experienced by hospitalized patients. Numerous hospitals have used different methods to improve the reporting of ADEs but few have undertaken studies aimed at the prevention of ADEs. We found that computerized ADE surveillance identified significantly more ADEs than our previous voluntary reporting method. Moreover, the computerized ADE surveillance system created a database of ADEs which allowed us to analyze the ADEs and design methods for prevention. We found that computer alerts of previously known drug allergies generated when drugs were ordered significantly reduced the number of type B ADEs, 56 vs 8 (p < 0.001). In addition, we found that the timely surveillance of ADEs combined with physician notification reduced the number of severe ADEs, 41 vs 12 (p < 0.001). Initial analysis of the ADE database has shown that on average patients with type B ADEs are hospitalized longer (17 vs 14 days) and have larger hospitalization costs ($30,617 vs $23,256) than patients with type A ADEs. Patients with severe ADEs also are hospitalized longer (20 vs 13 days) and have larger hospitalization costs ($38,007 vs $22,474) than patients with moderate ADEs. This indicates that the prevention and early treatment of ADEs can reduce the length of hospitalization and result in a considerable cost savings to the hospital.
Clinical Pharmacy Information Systems↗