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Biomedical subjects

D C Classen

Publications and source records attributed to D C Classen.

At least 55 records · Page 3Linked to original sources
PubMed1992

Clinical trial of junction seals for the prevention of urinary catheter-associated bacteriuria.

BACKGROUND: Preconnected catheter systems with sealed junctions have been associated with reduced rates of bacteriuria and mortality. A clinical trial was undertaken to evaluate the effectiveness of a junction seal applied after catheter insertion for preventing bacteriuria and reducing mortality. METHODS: Patients undergoing transurethral catheterization at a community hospital were randomized within 24 hours of catheter insertion to receive either a tape seal applied to the catheter-drainage tubing junction or no tape seal. Catheter urine cultures and catheter care violations were monitored daily until catheter removal or patient discharge. RESULTS: Overall, 124 (13.7%) of 903 patients in the group receiving a junction seal acquired bacteriuria, compared with 125 (14.9%) of 837 patients in the control group (P = .52, odds ratio = 0.91, 95% confidence interval, 0.69 to 1.20). Multivariate analysis revealed that only female gender and lack of systemic antibiotic use independently correlated with the development of bacteriuria; neither junction treatment randomization nor disconnection of the junction was associated with bacteriuria. Survival curve analysis of patients stratified by gender and antibiotic use revealed no significant differences in the rate of bacteriuria between treatment groups. The overall mortality in the tape seal group was less than that in the control group (6.6% vs. 8.0%, respectively), but not to a statistically significant extent despite stratification by antibiotic use. CONCLUSIONS: The use of a tape seal applied to the catheter-drainage tubing junction within 24 hours of catheter insertion was not associated with significantly lower rates of bacteriuria and mortality in patients undergoing short-term catheterization.

Bacteriuria↗
PubMed1992

Intensive surveillance of midazolam use in hospitalized patients and the occurrence of cardiorespiratory arrest.

Midazolam, a benzodiazepine used extensively as a sedative and a hypnotic for patients undergoing inpatient and outpatient medical procedures, has been associated with several side effects, the most serious of which are cardiac and respiratory arrest. We studied the use of midazolam and its association with cardiac and respiratory arrest among hospital patients at our institution. From 1988 through 1990 we identified 5439 patients exposed to midazolam, representing 8% of all patients admitted; 3031 (55.7%) received midazolam while not on mechanical ventilation. In the majority of patients the drug was given as a one-time dose, and the total dose was less than or equal to 5 mg in more than 70%. Three patients (0.099%) experienced respiratory arrest. All three events occurred within 2 hours after the last dose of midazolam had been given. All patients were elderly and all survived. The rate of respiratory arrest appears low at our institution and was associated with high doses of midazolam, concurrent use of opiates, and use in elderly patients.

Aged↗
PubMed1991

Computerized surveillance of adverse drug events in hospital patients.

OBJECTIVE: To develop a new method to improve the detection and characterization of adverse drug events (ADEs) in hospital patients. DESIGN: Prospective study of all patients admitted to our hospital over an 18-month period. SETTING: LDS Hospital, Salt Lake City, Utah, a 520-bed tertiary care center affiliated with the University of Utah School of Medicine, Salt Lake City. PATIENTS: We developed a computerized ADE monitor, and computer programs were written using an integrated hospital information system to allow for multiple source detection of potential ADEs occurring in hospital patients. Signals of potential ADEs, both voluntary and automated, included sudden medication stop orders, antidote ordering, and certain abnormal laboratory values. Each day, a list of all potential ADEs from these sources was generated, and a pharmacist reviewed the medical records of all patients with possible ADEs for accuracy and causality. Verified ADEs were characterized as mild, moderate, or severe and as type A (dose-dependent or predictable) or type B (idiosyncratic or allergic) reactions, and causality was further measured using a standardized scoring method. OUTCOME MEASURE: The number and characterization of ADEs detected. RESULTS: Over 18 months, we monitored 36,653 hospitalized patients. There were 731 verified ADEs identified in 648 patients, 701 ADEs were characterized as moderate or severe, and 664 were classified as type A reactions. During this same period, only nine ADEs were identified using traditional detection methods. Physicians, pharmacists, and nurses voluntarily reported 92 of the 731 ADEs detected using this automated system. The other 631 ADEs were detected from automated signals, the most common of which were diphenhydramine hydrochloride and naloxone hydrochloride use, high serum drug levels, leukopenia, and the use of phytonadione and antidiarrheals. The most common symptoms and signs were pruritus, nausea and/or vomiting, rash, and confusion-lethargy. The most common drug classes involved were analgesics, anti-infectives, and cardiovascular agents. CONCLUSION: We believe that screening for ADEs with a computerized hospital information system offers a potential method for improving the detection and characterization of these events in hospital patients.

Adolescent↗
PubMed1991

The HELP system and its application to infection control.

The HELP system is a comprehensive hospital information system that is linked to an allied financial data base. The clinical data base integrates information from areas such as admitting, pharmacy, radiology, surgery, pathology, nursing, respiratory therapy, and the clinical laboratories, including microbiology. This allows for the creation of an electronic medical record that contains all the clinical and financial data for each patient. The HELP system combines both communication and advice features through the use of data- and time-driven algorithms. We have used the HELP system to automate the surveillance and analysis of hospital-acquired infections and to identify patients at high risk for nosocomial infection. The expert system features have also been used to suggest alternatives for patients receiving inappropriate antimicrobial therapy, to improve the timing of antibiotic prophylaxis in surgery, and to curtail unnecessarily prolonged prophylaxis. Automated hospital information systems such as HELP can facilitate the investigation of a broad range of infection control, quality improvement, and cost-containment issues.

Cross Infection↗
PubMed1991

Prevention of catheter-associated bacteriuria: clinical trial of methods to block three known pathways of infection.

The simultaneous use of methods to block all three known pathways of bacterial entry into the bladders of catheterized patients has been suggested because of the limited effectiveness of individual methods that block single pathways. We conducted a randomized controlled trial to assess the prevention of bacteriuria in patients, using a three-way system that included a hydrophilic polymer-coated and preconnected sealed catheter system, daily catheter care, and disinfection of the outflow tube of the drainage bag with povidone-iodine (i.e., methods to block bacterial entry at the urethral insertion site, at the catheter drainage tube junction, and at the outflow tube). Among treated patients, 14 (4.7%) of 300 acquired bacteriuria as compared with 15 (4.9%) of 306 who did not receive the protocol treatments. Only 3 of 29 episodes of bacteriuria occurred in patients whose meatal cultures did not contain gram-negative bacilli or enterococci; thus migration of bacteria in the periurethral mucous sheath appeared to be the most common pathway by which bacteria gained entry into the bladder in this study. Catheter care and disinfection of the drainage bag outflow tube as used in this study remain unproven methods of preventing catheter-associated bacteriuria. Preconnected catheters with junction seals were used in both treated and untreated patients and, on the basis of previous studies, appear to be effective in reducing junction disconnections and bacteriuria. Therefore we conclude that the use of several simultaneous measures to prevent catheter-associated urinary infections is no more effective than the use of preconnected catheters with junction seals alone and is clearly more expensive.

Bacteriuria↗
PubMed1991

Daily meatal care for prevention of catheter-associated bacteriuria: results using frequent applications of polyantibiotic cream.

OBJECTIVE: To determine the efficacy of meatal treatment with a polyantibiotic cream in the prevention of bacteriuria during transurethral bladder catheterization. DESIGN: Randomized controlled trial. SETTING: Community teaching hospital. PATIENTS: Adult patients who underwent closed urinary catheter drainage for short and intermediate durations (two to 30 days). INTERVENTION: Polyantibiotic cream containing polymyxin B sulfate, neomycin sulfate, and gramicidin was applied to the urethral meatus-catheter interface three times daily from the first day of catheterization until bacteriuria was found. The onset of bacteriuria was defined as the day the colonizing species first achieved a colony count of greater than or equal to 1000 colonies/ml. Patients randomized to the control group received routine meatal care with cleansing of the meatal surface during daily bathing. RESULTS: Among 2,923 patients who were randomly allocated to receive either the protocol meatal care or routine care, the evaluable study population consisted of 747 patients who were nonbacteriuric and who remained catheterized for more than two days. Overall, 26 (6.8%) of 383 patients given the polyantibiotic treatment acquired bacteriuria, as compared to 37 (10.1%) of 364 patients not given this treatment (p = .167). A Cox proportional hazards regression analysis showed that, among putative risk factors including lack of meatal care, only female gender, a meatal swab culture yielding gram-negative rods or enterococci, and lack of antibiotic use during catheterization were independently associated with the development of bacteriuria. CONCLUSIONS: The adverse effect of meatal care noted in earlier studies of a disinfectant ointment applied twice daily was not found in this study of an antimicrobial preparation in a cream vehicle applied three times daily. However, the results do not support meatal care as an efficacious method to prevent catheter-associated bacteriuria in all patients.

Aged↗
PubMed1991

Surveillance for quality assessment: IV. Surveillance using a hospital information system.

Hospital surveillance for infection control purposes is a well-accepted method of following nosocomial infections in U.S. hospitals. However, hospital surveillance is being increasingly performed for nosocomial events in noninfectious areas, such as quality assurance and other areas of outcomes research. For the continued development of hospital surveillance in all these areas, dramatic growth in the amount of information collected will occur. To accommodate this growth and to validate new approaches in these areas, large amounts of data collection will be necessary. Collection of these data will be quite difficult without the creation of clinical hospital data bases in which large amounts of information are collected as a routine part of patient care, not as an elaborate addition to patient care. Automated hospital information systems, such as the HELP system, can facilitate the conduct of ongoing hospital surveillance not only in infection control but also in a broad range of areas, such as quality improvement outcomes research and cost-containment areas.

Cross Infection↗
PubMed1991

Development of a computerized adverse drug event monitor.

Adverse events during drug therapy are receiving renewed attention. Some adverse drug events (ADEs) are identified only after the widespread clinical use of a drug. The Food and Drug Administration advocates post-marketing surveillance systems to provide early warnings of previously undetected ADEs. The identification of ADEs by U.S. hospitals is now required by the Joint Commission on Accreditation of Healthcare Organizations. We developed a series of computer programs and data files on the HELP System to help identify ADEs. The HELP System monitors laboratory test results, drug orders, and data entered through a computerized ADE reporting program. A nurse or pharmacist verifies computer alerts of possible ADEs. The computerized system identified 401 ADEs during the first year of use compared to 9 by voluntary reporting methods during the previous year (p less than 0.001). This paper describes the development and early use of the computerized ADE surveillance system.

Adverse Drug Reaction Reporting Systems↗
PubMed1990

Failure of cephalosporins to prevent Staphylococcus aureus surgical wound infections.

Approximately 35,000 Staphylococcus aureus surgical wound infections occur annually in the United States. To investigate why S aureus causes infection despite the perioperative administration of cephalosporins, we compared 35 methicillin-susceptible isolates recovered from deep wound infections that complicated cefazolin prophylaxis (18 of 1650 patients) and cefamandole prophylaxis (17 of 3702 patients) with 64 colonizing isolates from presurgical patients. Compared with both colonizing and cefamandole-associated isolates, S aureus isolates from cefazolin-associated infections were more resistant to cefazolin by specialized assays. Staphylococcus aureus isolates that produced the A and C variants of staphylococcal beta-lactamase were associated with infections following cefazolin and cefamandole prophylaxis, respectively. These isolates hydrolyze the respective cephalosporins rapidly, suggesting that staphylococcal survival after perioperative prophylaxis may be mediated by in vivo degradation of the prophylactically administered cephalosporin. These data indicate that some S aureus wound infections occur because of deficiencies in antimicrobial effectiveness that are not detectable by routine susceptibility tests. This finding has important implications for the therapy and prevention of S aureus infection.

Cefamandole↗
PubMed1990

Therapeutic antibiotic monitoring: surveillance using a computerized expert system.

STUDY OBJECTIVE: To develop and evaluate a computerized system to monitor therapeutic antibiotics in a hospital setting. MATERIAL AND METHODS: From November 1986 through October 1987, we prospectively monitored 1,632 hospitalized patients who had 2,157 microbiology specimens sent for culture and sensitivity testing. During the study period, computer algorithms were used to identify patients whose antibiotic therapy was inappropriate in relation to microbiology culture and sensitivity data. When inconsistencies occurred between antibiotic therapy and in vitro sensitivity data, computer algorithms generated therapeutic antibiotic monitor (TAM) alerts. A clinical pharmacist then notified the attending physician of the alert. RESULTS: Antibiotic therapy was identified by the computer as inappropriate in 696 instances (32%). After we eliminated false-positive alerts, 420 evaluable TAM alerts remained. Physicians responded to the TAM alerts by either changing or starting antimicrobial therapy in 125 cases (30%). Moreover, physicians were previously unaware of the relevant susceptibility test results in 49% of the alerts. CONCLUSION: Computer-assisted monitoring is an efficient and promising method to identify and correct errors in antimicrobial prescribing and to assure the appropriate use of therapeutic antibiotics.

Algorithms↗
PubMed1990

Streptococcus mitis sepsis in bone marrow transplant patients receiving oral antimicrobial prophylaxis.

PURPOSE: Streptococcal infection has increasingly become a problem in neutropenic patients. We report on an outbreak of Streptococcus mitis sepsis in six bone marrow transplant patients receiving oral antimicrobial prophylaxis. PATIENTS AND METHODS: We performed an epidemiologic study of all patients in our bone marrow transplant program from 1986 to 1988. The hospital and microbiology records for all patients were reviewed. All bone marrow patients were treated according to specified protocols, including an oral prophylactic antimicrobial regimen that was changed in late 1987 from vancomycin/polymyxin/tobramycin to norfloxacin. Identification, susceptibility testing, and whole cell protein analysis of streptococcal isolates were performed at the Reference and Antimicrobial Investigations Laboratories at the Centers for Disease Control. RESULTS: We detected six cases of S. mitis sepsis among 21 patients undergoing bone marrow transplantation. No other concurrent pathogen was isolated from any patient at the time of the S. mitis bacteremia. Bacteremia developed within 72 hours of transplant in five of six patients and was associated with severe mucositis in four patients. An environmental study failed to reveal any common source for the outbreak, and whole cell protein analysis of all six S. mitis isolates revealed each to be distinct. Of 12 patients receiving oral vancomycin/polymyxin/tobramycin, one developed S. mitis bacteremia, versus five of nine patients receiving norfloxacin (p less than 0.03). CONCLUSION: We believe S. mitis bacteremia is a potential complication of bone marrow transplantation and is associated with antimicrobial prophylaxis with norfloxacin, especially in the setting of mucositis.

Administration, Oral↗
PubMed1990

Reducing the duration of prophylactic antibiotic use through computer monitoring of surgical patients.

The use of antibiotic prophylaxis for unnecessarily prolonged periods after surgical procedures can contribute to increased health care costs and adverse drug reactions as well as the development of antibiotic-resistant infections. Hospitals are under economic pressures to develop methods to control the excessive use of these drugs. We expanded the capabilities of our hospital information system to monitor the duration of surgical antibiotic prophylaxis. For six months during one year we used the computer system to monitor antibiotics received by every surgical patient and to identify patients receiving antibiotic prophylaxis longer than was deemed necessary according to generally accepted guidelines. For six months in the following year we used the system to monitor and identify the same types of patients and clinical pharmacists placed antibiotic "stop orders" in the charts of the patients identified by the computer. Surgical patients received an average of 19 doses of antibiotics in the first year compared with 13 doses in the second year (p less than 0.001). The average cost of antibiotics received more than 48 hours after the operation was $42 less per patient in year 2 than in year 1, resulting in a potential cost savings of $44,562 in six months. The computer system was found to be an efficient tool for monitoring all antibiotics given to surgical patients and identifying patients receiving antibiotic prophylaxis longer than necessary. Clinical use of this system appears to have resulted in improved usage of antibiotic prophylaxis.

Anti-Bacterial Agents↗
PubMed1989

Improved perioperative antibiotic use and reduced surgical wound infections through use of computer decision analysis.

A prospective study was performed over a two-year period to determine whether computer-generated reminders of perioperative antibiotic use could improve prescribing habits and reduce postoperative wound infections. During the first year, baseline patterns of antibiotic use and postoperative infection rates were established. During the second year, computer-generated reminders regarding perioperative antibiotic use were placed in the patient's medical record prior to surgery and patterns of antibiotic use and postoperative wound infections monitored. Hospitalized patients undergoing non-emergency surgery from June to November 1985 (3,263 patients), and from June to November 1986 (3,568) were monitored with respect to indications for perioperative antibiotic use, timing of antibiotic use and postoperative infectious complications. Perioperative antibiotic use was considered advisable for 1,621 (50%) patients in the 1985 sample and for 1,830 (51%) patients in the 1986 sample. Among these patients, antibiotics were given within two hours before the surgical incision in 638 (40%) of the 1985 sample and 1,070 (58%) of the 1986 sample (p less than 0.001). Overall, postoperative wound infections were detected in 28 (1.8%) of 1,621 patients in 1985 compared with 16 (0.9%) of 1,830 such patients in 1986 (p less than 0.03). We conclude that computer-generated reminders of perioperative antibiotic use improved prescribing habits with a concurrent decline in postoperative wound infections.

Anti-Bacterial Agents↗
PubMed1988

Serious Pseudomonas infections associated with endoscopic retrograde cholangiopancreatography.

After observing a single case of Pseudomonas aeruginosa bacteremia following endoscopic retrograde cholangiopancreatography (ERCP), six other P. aeruginosa infections that were temporally related to ERCP were retrospectively found over one year (August 1985 through July 1986) at LDS Hospital. In all seven patients, infection developed within five days after an ERCP. Five patients had bacteremia and two had cholangitis. All five of the Pseudomonas isolates available for testing were serotype 010. Cultures from the ERCP endoscope and several other endoscopes also yielded P. aeruginosa serotype 10, as did environmental cultures from equipment used to clean endoscopes. Among 167 ERCPs performed during the outbreak period, no other patient acquired P. aeruginosa infection. Each of the patients in the outbreak received the first scheduled ERCP of the day. The mean duration between the cleaning of the ERCP endoscope and its subsequent use was significantly longer in cases than in matched controls, a factor that may have permitted contaminating organisms to achieve high inocula in the inadequately cleaned endoscope. Epidemic control measures included improved disinfection of endoscopes, ongoing surveillance, and appropriate antimicrobial prophylaxis. This experience suggests that exogenous infection with Pseudomonas is associated with ERCP, that protracted and insidious outbreaks may occur, and that the occurrence of even a single case of Pseudomonas infection after ERCP should stimulate an epidemiologic investigation.

Cholangiopancreatography, Endoscopic Retrograde↗
PubMed1988

A program to help interns cope with stresses in an internal medicine residency.

A program in personal and professional development for interns was developed six years ago for the residency program in internal medicine of the University of Connecticut Affiliated Hospitals to reduce maladaptive responses to the stresses of medical training. The principal goals of the program are to provide a supportive atmosphere in which interns can discuss common concerns, build mutual trust among themselves, promote deeper self-understanding and sensitivity, develop coping strategies, and examine difficult situations in training. Sessions are scheduled regularly throughout the year and take place outside the hospital; interns are excused from their service responsibilities for the duration of the meeting. Participants focus equally on issues of professional concern (for example, relationships with staff members, peers, and attending physicians or bureaucratic problems such as lack of ancillary help) and personal concern (for example, making necessary life-style adjustments and handling family crises). A variety of techniques are used in the program, but small-group discussions and individual tasks are particularly emphasized. Participants have generally reported satisfaction with the program and positive effects upon their behavior at work and at home.

Adaptation, Psychological↗
PubMed1987

Detection of antibody to murine cytomegalovirus by enzyme-linked immunosorbent and indirect immunofluorescence assays.

We have compared murine cytomegalovirus (MCMV) antibody determination by enzyme-linked immunosorbent assay (ELISA) and indirect immunofluorescence assay. A comparison of antibody detection with 146 serum samples at a 1:20 dilution showed 100% agreement (60 negatives and 86 positives) between the assays. There was close agreement of endpoint determinations of sera by both methods. After experimental MCMV infection, antibody to MCMV was detected by both assays as early as day 7, and high titers persisted as late as 6 months. In contrast to immunocompetent littermates, athymic nude mice did not develop antibody after infection. Mice lacking antibody detectable by ELISA were susceptible to lethal MCMV challenge. In a survey of animals from five commercial sources, MCMV antibody was not detected unless mice were experimentally infected. MCMV antibody determination by ELISA is a convenient method, comparable to the indirect immunofluorescence assay in sensitivity and specificity.

Animals↗
PubMedDate not supplied

Medical subspecialty training and interest in cost containment education.

To investigate academic physicians' interest in learning methods to reduce health care costs, we asked the faculty and housestaff of a university-based department of internal medicine to rate their interest in 30 potential topics for medical grand rounds, a traditional forum for continuing medical education. The 30 topics were equally divided among clinical, research and cost-containment categories. The 29 housestaff and the 41 subspecialty faculty members clearly favored clinical and research topics over cost-containment topics (p less than 0.001). On the other hand, the nine general internists considered the cost-containment topics as attractive as the clinical and research topics and ranked them higher than did both the subspecialists (p less than 0.001) and the house-staff (p less than 0.05). Efforts to alter costs in academic medical centers may be hampered by the relative disinterest in cost-containment education among house officers and subspecialists, who are responsible for most of the health care delivery in this setting.

Attitude of Health Personnel↗