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Donald A Goldmann

Publications and source records attributed to Donald A Goldmann.

36 records · Page 2Linked to original sources
PubMed2004

The asthma kiosk: a patient-centered technology for collaborative decision support in the emergency department.

The authors report on the development and evaluation of a novel patient-centered technology that promotes capture of critical information necessary to drive guideline-based care for pediatric asthma. The design of this application, the asthma kiosk, addresses five critical issues for patient-centered technology that promotes guideline-based care: (1) a front-end mechanism for patient-driven data capture, (2) neutrality regarding patients' medical expertise and technical backgrounds, (3) granular capture of medication data directly from the patient, (4) formal algorithms linking patient-level semantics and asthma guidelines, and (5) output to both patients and clinical providers regarding best practice. The formative evaluation of the asthma kiosk demonstrates its ability to capture patient-specific data during real-time care in the emergency department (ED) with a mean completion time of 11 minutes. The asthma kiosk successfully links parents' data to guideline recommendations and identifies data critical to health improvements for asthmatic children that otherwise remains undocumented during ED-based care.

Algorithms↗
PubMed2004

Quantifying uncertainty: physicians' estimates of infection in critically ill neonates and children.

To determine the diagnostic accuracy of physicians' prior probability estimates of serious infection in critically ill neonates and children, we conducted a prospective cohort study in 2 intensive care units. Using available clinical, laboratory, and radiographic information, 27 physicians provided 2567 probability estimates for 347 patients (follow-up rate, 92%). The median probability estimate of infection increased from 0% (i.e., no antibiotic treatment or diagnostic work-up for sepsis), to 2% on the day preceding initiation of antibiotic therapy, to 20% at initiation of antibiotic treatment (P<.001). At initiation of treatment, predictions discriminated well between episodes subsequently classified as proven infection and episodes ultimately judged unlikely to be infection (area under the curve, 0.88). Physicians also showed a good ability to predict blood culture-positive sepsis (area under the curve, 0.77). Treatment and testing thresholds were derived from the provided predictions and treatment rates. Physicians' prognoses regarding the presence of serious infection were remarkably precise. Studies investigating the value of new tests for diagnosis of sepsis should establish that they add incremental value to physicians' judgment.

Child↗
PubMed2004

The teicoplanin-associated locus regulator (TcaR) and the intercellular adhesin locus regulator (IcaR) are transcriptional inhibitors of the ica locus in Staphylococcus aureus.

Infections involving Staphylococcus aureus are often more severe and difficult to treat when the organism assumes a biofilm mode of growth. The polysaccharide poly-N-acetylglucosamine (PNAG), also known as polysaccharide intercellular adhesin, is synthesized by the products of the intercellular adhesin (ica) locus and plays a key role in biofilm formation. Numerous conditions and exogenous factors influence ica transcription and PNAG synthesis, but the regulatory factors and pathways through which these environmental stimuli act have been only partially characterized. We developed a DNA affinity chromatography system to purify potential regulatory proteins that bind to the ica promoter region. Using this technique, we isolated four proteins, including the staphylococcal gene regulator SarA, a MarR family transcriptional regulator of the teicoplanin-associated locus TcaR, DNA-binding protein II, and topoisomerase IV, that bound to the ica promoter. Site-directed deletion mutagenesis of tcaR indicated that TcaR was a negative regulator of ica transcription, but deletion of tcaR alone did not induce any changes in PNAG production or in adherence to polystyrene. We also investigated the role of IcaR, encoded within the ica locus but divergently transcribed from the biosynthetic genes. As has been shown previously in Staphylococcus epidermidis, we found that IcaR was also a negative regulator of ica transcription in S. aureus. We also demonstrate that mutation of icaR augmented PNAG production and adherence to polystyrene. Transcription of the ica locus, PNAG production, and adherence to polystyrene were further increased in a tcaR icaR double mutant. In summary, TcaR appeared to be a weak negative regulator of transcription of the ica locus, whereas IcaR was a strong negative regulator, and in their absence PNAG production and biofilm formation were enhanced.

Acetylglucosamine↗
PubMed2003

Administrative databases provide inaccurate data for surveillance of long-term central venous catheter-associated infections.

BACKGROUND: Efficient methods are needed to monitor infections associated with long-term central venous catheters (CVCs) in both inpatient and outpatient settings. Automated medical records and claims data have been used for surveillance of these infections without evaluation of their accuracy or validity. OBJECTIVE: To determine the feasibility of using electronic records to identify CVC placement and design a system for identifying CVC-associated infections. DESIGN AND SETTING: Retrospective cohort study at an HMO and two teaching hospitals in Boston, one adult (hospital A) and one pediatric (hospital B), between January 1991 and December 1997. Tunneled catheters, totally implanted catheters, and hemodialysis catheters were examined. Claims databases of both the HMO and the hospitals were searched for 10 CPT codes, 2 ICD-9 codes, and internal charge codes indicating CVC insertion. Lists were compared with each other and with medical records for correlation and accuracy. PATIENTS: All members of the HMO who had a CVC inserted at one of the two hospitals during the study period. RESULTS: There was wide variation in the CVC insertions identified in each database. Although ICD-9 codes at each hospital and CPT/ICD-9 combinations at the HMO found similar total numbers of CVCs, there was little overlap between the individuals identified (62% for hospital A with HMO and 4% for hospital B). CONCLUSION: Claims data from different sources do not identify the same CVC insertion procedures. Current administrative databases are not ready to be used for electronic surveillance of CVC-associated complications without extensive modification and validation.

Boston↗
PubMed2003

Notifying emergency department patients of negative test results: pitfalls of passive communication.

OBJECTIVE: Many emergency departments that perform a high volume of group A Streptococcus throat cultures inform patients or parents that unless they are notified of a positive result they can assume that their throat culture result is negative. Thus, positive throat culture results are communicated actively and negative results are communicated passively. We sought to determine the effectiveness and safety of such a system. METHODS: Prospective cohort study of 301 consecutive patients who had group A Streptococcus throat cultures obtained between March 28, 2000, and May 10, 2000, in the emergency department of an urban, academic, tertiary-care children's hospital. Outcomes were determined by telephone surveys of patients or their parents or guardians. The primary outcome was whether respondents had accurate knowledge of the throat culture result. Secondary outcomes included receipt of appropriate treatment instructions, need for another telephone call to the emergency department or primary-care provider to clarify the result or treatment instructions, satisfaction with the communication process, and preference to receive both positive and negative results or just positive results. RESULTS: Fifty-three percent of respondents did not have accurate knowledge of the throat culture result, 5% received inappropriate treatment instructions, 13% sought further clarification, 29% were dissatisfied with the communication process, and 85% preferred to receive both positive and negative results. Parents of patients with positive results were more likely to have accurate knowledge of the result (odds ratio 6.9, 95% confidence interval 1.4-65.7) and to be satisfied with the communication process. CONCLUSIONS: Passive communication of negative throat culture results to patients seen in the emergency department can be unreliable. Active communication of both positive and negative results may improve patient knowledge and satisfaction and ensure appropriate therapy, but in the absence of automated notification systems, would be resource intensive.

Adolescent↗
PubMed2003

Misconceptions about colds and predictors of health service utilization.

OBJECTIVE: Colds accounted for 1.6 million emergency department (ED) visits and 25 million ambulatory visits by children and adults in 1998. Although most colds are caused by viruses and do not require medical intervention, many families seek health care for the treatment of colds. Parental misconceptions about the cause and appropriate treatment of colds may contribute to unnecessary health service utilization. The objective of this study was to determine predictors of reported ED use and ambulatory care use for colds among families with young children. METHODS: This study was an observational, prospective cohort study to determine attack rates for respiratory illnesses within families that have at least 1 child who is 6 months to 5 years of age and enrolled in out-of-home child care. Families were randomly selected from 5 pediatric practices in Massachusetts and were considered eligible when the child was enrolled in child care with at least 5 other children for >or=10 hours per week. Enrolled families were asked to complete a survey that assessed knowledge about colds, antibiotic indications, and frequency of health service utilization. Predictors of self-reported use of health care services were assessed in multivariate logistic regression models. RESULTS: Of the 261 families enrolled in the study, 197 families (75%) returned completed surveys. Although 93% of parents understood that viruses caused colds, 66% of parents also believed that colds were caused by bacteria. Fifty-three percent believed that antibiotics were needed to treat colds. Parents reported that they would visit the ED (23%) or their doctor's office (60%) when their child had a cold. Predictors of ED use on multivariate analysis included Medicaid insurance (odds ratio [OR]: 17.6 [2.2-139.3]), history of wheezing (OR: 18.3 [4.4-75.8]), and belief that antibiotics treat colds (OR: 4.2 [1.4-12.9]). Predictors of ambulatory care use included parent younger than 30 years (OR: 10.0 [1.6-64.3]), history of wheezing (OR: 5.6 [1.1-29.7]), and belief that antibiotics treat colds (OR: 3.8 [1.7-8.5]). CONCLUSIONS: Misconceptions about the appropriate treatment of colds are predictive of increased health service utilization. Targeted educational interventions for families may reduce inappropriate antibiotic-seeking behavior and unnecessary health service utilization for colds.

Adult↗
PubMed2003

Prioritizing strategies for preventing medication errors and adverse drug events in pediatric inpatients.

OBJECTIVES: Medication errors in pediatric inpatients occur at similar rates as in adults but have 3 times the potential to cause harm. Error prevention strategies in this setting remain largely untested. The objective of this study was to classify the major types of medication errors in pediatric inpatients and to determine which strategies might most effectively prevent them. METHODS: A prospective cohort study was conducted of 1020 patients who were admitted to 2 academic medical centers during a 6-week period in April and May 1999. Medication errors were characterized by subtype. Physician raters evaluated error prevention strategies and identified those that might be most effective in preventing errors. RESULTS: Of 10 778 medication orders reviewed, 616 contained errors. Of these, 120 (19.5%) were classified as potentially harmful, including 115 potential adverse drug events (18.7%) and 5 preventable adverse drug events (0.8%). Most errors occurred at the ordering stage (74%) and involved errors in dosing (28%), route (18%), or frequency (9%). Three interventions might have prevented most potentially harmful errors: 1) computerized physician order entry with clinical decision support systems (76%); 2) ward-based clinical pharmacists (81%); and 3) improved communication among physicians, nurses, and pharmacists (86%). Interrater reliability of error prevention strategy assignment was good (agreement: 0.92; kappa: 0.82). CONCLUSIONS: Of the assessed interventions, computerized physician order entry with clinical decision support systems; ward-based clinical pharmacists; and improved communication among physicians, nurses, and pharmacists had the greatest potential to reduce medication errors in pediatric inpatients. Development, implementation, and assessment of such interventions in the pediatric inpatient setting are needed.

Adult↗
PubMed2003

Evaluation and development of potentially better practices to prevent neonatal nosocomial bacteremia.

OBJECTIVE: Six neonatal intensive care units (NICUs) that are members of the Vermont Oxford National Evidence-Based Quality Improvement Collaborative for Neonatology collaborated to reduce infection rates. There were 7 centers in the original focus group, but 1 center left the collaborative after 1 year. The objective of this study was to develop strategies to decrease nosocomial infection rates in NICUs. METHODS: The process included a comprehensive literature review, internal practice analyses, benchmark studies, and development of practical experience through rapid-cycle changes, subsequent analysis, and feedback. This process led to 3 summary statements on potentially better practices in handwashing, approach to nosocomial sepsis evaluations, and central venous catheter management. RESULTS: These statements provide a basis for an evidence-based approach to lowering neonatal intensive care unit nosocomial infection rates. CONCLUSIONS: The 2-year process also led to changes in the culture and habits of the institutions involved, which should in turn have long-term effects on other aspects of quality improvement.

Bacteremia↗
PubMed2002

Effect of a pediatric hospitalist system on housestaff education and experience.

OBJECTIVE: To determine the effect of a pediatric hospitalist system on housestaff education and experience. SETTING: Free-standing academic children's hospital. Hospitalists were introduced in June 24, 1998, to supervise teaching and care on the general pediatric wards. METHODS: On 2 surveys, housestaff rated their skills, knowledge, and experiences on the wards (experiences survey), and the quality of teaching and supervision by attending physicians (attending survey). Responses before and after the introduction of the hospitalist system were compared using Wilcoxon nonparametric tests. RESULTS: Seventy-six (70%) of the 109 interns and 54 (62%) of the 87 senior residents responded to the experiences survey. Following introduction of the hospitalist system, the interns' mean overall rating of the general pediatrics wards rose from 4.1 to 4.7 on a 5-point Likert scale (P =.01). Their ratings of comparison rotations did not change significantly. Interns' satisfaction with the educational experience (3.2 to 3.5 of a 4-point Likert scale, P<.05), supervision, and quality of life on the pediatrics wards also improved significantly, as did their self-assessments of skills and knowledge related to general pediatrics training. Senior residents' ratings were generally unchanged. Three hundred seventy-one (63%) of the 593 attending physicians' surveys were completed. Compared with nonhospitalist attendings, hospitalists were rated more effective role models (4.7 vs 4.5 points, P<.05) and teachers (4.7 vs 4.4 points, P<.01). They were rated more knowledgeable (4.8 vs 4.5 of 5, P<.001) and accessible (4.7 vs 4.5 points, P<.05), involved housestaff more in the learning process (4.7 vs 4.4 points, P<.05), and gave better feedback (4.5 vs 4.2 points, P<.01). Hospitalists' bedside teaching, however, was rated lower (3.7 vs 4.2 points, P<.001). CONCLUSIONS: Overall, hospitalists were rated significantly higher as educators than were traditional attending physicians. Introduction of a hospitalist system was associated with improved intern experience and quality of life on general pediatrics wards, and with improved self-reported skills and knowledge in general pediatrics.

Educational Measurement↗
PubMed2002

Blood-borne pathogens and nosocomial infections.

Guidelines to prevent the transmission of blood-borne infections have evolved rapidly since the recognition that "serum hepatitis" could be transmitted to health care personnel via percutaneous exposure to blood. The HIV epidemic focused renewed attention on the problem of protecting health care personnel, culminating in "standard precautions" for patient care, which emphasized the use of gloves for all contact with blood and body fluids. This focus on protection of the health care worker sometimes obscures the other important functions of gloves: protection of patients from microorganisms on the hands of providers and prevention of patient-to-patient transmission of nosocomial pathogens. The risk of infection after percutaneous exposure to the 3 major blood-borne viruses-hepatitis B virus (HBV), hepatitis C virus (HCV), and HIV-varies greatly. The risk for a nonimmune individual exposed to HBV may be >30% if the source is Hb(e)Ag-positive. The average infection rate for HCV is 1.8%. For HIV, the average risk is 0.3%, but is higher with deep injury, when there is visible blood on the device, when a needle has been in an artery or vein, or when the source patient is in the terminal phase of HIV. Prompt administration of anti-HIV therapy reduces risk by about 80%. Mucous membrane and cutaneous exposures carry less risk. Recent efforts to reduce needlestick injuries in hospitals have reduced the risk to health care providers. Surgeons and other health care professionals who are infected with HIV or HCV pose a very small risk to their patients, although a number of outbreaks have been traced to surgeons who are HBV carriers; most have been Hb(e)Ag-positive.

Blood-Borne Pathogens↗
PubMed2002

Interventional study to evaluate the impact of an alcohol-based hand gel in improving hand hygiene compliance.

OBJECTIVE: To evaluate the effects of the introduction of an alcohol-based hand gel and multifaceted quality improvement (QI) interventions on hand hygiene (HH) compliance. DESIGN: Interventional, randomized cohort study with four study phases (baseline; limited intervention in two units; full intervention in three units; washout phase), performed in three intensive care units at a pediatric referral hospital. METHODS: During 724 thirty-minute daytime monitoring sessions, a nonidentified observer witnessed 12,216 opportunities for HH and recorded compliance. INTERVENTIONS: Introduction of an alcohol-based hand gel; multifaceted QI interventions (educational program, opinion leaders, performance feedback). RESULTS: Baseline compliance decreased after the first 2 weeks of observation from 42.5% to 28.2% (presumably because of waning of a Hawthorne effect), further decreased to 23.3% in the limited intervention phase and increased to 35.1% after the introduction of a hand gel with QI support in all three units (P < 0.001). The rise in compliance persisted in the last phase (compliance, 37.2%); however, a gradual decline was observed during the final weeks. Except for the limited intervention phase, compliance achieved through standard handwashing and glove use remained stable around 20 and 10%, respectively, whereas compliance achieved through gel use increased to 8% (P < 0.001). After adjusting for confounding, implementation of the hand gel with QI support remained significantly associated with compliance (odds ratio, 1.6; 95% confidence interval, 1.4 to 1.8). In a final survey completed by 62 staff members, satisfaction with the hand gel was modest (45%). CONCLUSIONS: We noted a statistically significant, modest improvement in compliance after introduction of an alcohol-based hand gel with multifaceted QI support. When appropriately implemented, alcohol-based HH may be effective in improving compliance.

Alcohols↗
PubMed2002

Immunochemical properties of the staphylococcal poly-N-acetylglucosamine surface polysaccharide.

Staphylococcus aureus and Staphylococcus epidermidis often elaborate adherent biofilms, which contain the capsular polysaccharide-adhesin (PS/A) that mediates the initial cell adherence to biomaterials. Biofilm cells produce another antigen, termed polysaccharide intercellular adhesin (PIA), which is composed of a approximately 28 kDa soluble linear beta(1-6)-linked N-acetylglucosamine. We developed a new method to purify PS/A from S. aureus MN8m, a strain hyperproducing PS/A. Using multiple analytical techniques, we determined that the chemical structure of PS/A is also beta(1-6)-N-acetylglucosamine (PNAG). We were unable to find N-succinylglucosamine residues in any of our preparations in contrast to previously reported findings (D. McKenney, K. Pouliot, Y. Wang, V. Murthy, M. Ulrich, G. Doring, J. C. Lee, D. A Goldmann, and G. B. Pier, Science 284:1523-1527, 1999). PNAG was produced with a wide range of molecular masses that could be divided into three major fractions with average molecular masses of 460 kDa (PNAG-I), 100 kDa (PNAG-II), and 21 kDa (PNAG-III). The purified antigens were not soluble at neutral pH unless first dissolved in 5 M HCl and then neutralized with 5 M NaOH. PNAG-I was very immunogenic in rabbits, but the responses of individual animals were variable. Immunization of mice with various doses (100, 50, or 10 microg) of PNAG-I, -II, and -III demonstrated that only PNAG-I was able to elicit an immunoglobulin G (IgG) immune response with the highest titers obtained with 100-microg dose. When we purified a small fraction of PNAG with a molecular mass of approximately 780 kDa (PNAG-780) from PNAG-I, significantly higher IgG titers than those in mice immunized with the same doses of PNAG-I were obtained, suggesting the importance of the molecular mass of PNAG in the antibody response. These results further clarify the chemical structure of PS/A and help to differentiate it from PIA on the basis of immunogenicity, molecular size, and solubility.

Acetylglucosamine↗
PubMed2002

Impact of a health maintenance organization hospitalist system in academic pediatrics.

OBJECTIVE: Hospitalist systems decrease length of stay (LOS) and cost for hospitalized adults. Whether hospitalist systems decrease LOS and cost for hospitalized children has not been conclusively established. We wanted to determine whether a health maintenance organization's (HMO's) implementation of a pediatric hospitalist system affected LOS, costs, mortality, readmission rate, follow-up rate, and parents' ratings of care. DESIGN: Interrupted time-series study of general pediatric patients admitted to a freestanding pediatric teaching hospital from 1993 to 1998. The intervention group consisted of all patients admitted to a staff model not-for-profit HMO that began using hospitalists in October 1996. Patients in other HMOs and traditional insurance groups were studied for comparison. The main outcomes were mean LOS and inflation-adjusted costs. Other outcomes included parents' ratings of care and mortality, readmission, and follow-up rates. RESULTS: Immediately after the introduction of the hospitalist system, mean LOS for staff model not-for-profit HMO fell 12% (0.3 days), and mean cost of hospitalization decreased 16% ($217) compared with prehospitalist levels. Parental ratings of care, initially somewhat low, improved substantially. Seven-day follow-up rates, mortality, and readmission rates did not change. Comparison groups experienced no concurrent improvements in LOS, cost, parental ratings, mortality, or readmission rates. CONCLUSIONS: A pediatric hospitalist system within a staff-model HMO significantly improved LOS, cost, and parental ratings of care without affecting rates of posthospitalization follow-up. Additional studies are needed both to measure broader aspects of quality and to assess the impact of such a program on patients being cared for through other types of delivery and insurance systems.

Adolescent↗
PubMed2002

Binary cumulative sums and moving averages in nosocomial infection cluster detection.

Clusters of nosocomial infection often occur undetected, at substantial cost to the medical system and individual patients. We evaluated binary cumulative sum (CUSUM) and moving average (MA) control charts for automated detection of nosocomial clusters. We selected two outbreaks with genotyped strains and used resistance as inputs to the control charts. We identified design parameters for the CUSUM and MA (window size, k, alpha, Beta, p(0), p(1)) that detected both outbreaks, then calculated an associated positive predictive value (PPV) and time until detection (TUD) for sensitive charts. For CUSUM, optimal performance (high PPV, low TUD, fully sensitive) was for 0.1 < or = alpha < or = 0.25 and 0.2 < or = Beta < or = 0.25, with p(0) = 0.05, with a mean TUD of 20 (range 8-43) isolates. Mean PPV was 96.5% (relaxed criteria) to 82.6% (strict criteria). MAs had a mean PPV of 88.5% (relaxed criteria) to 46.1% (strict criteria). CUSUM and MA may be useful techniques for automated surveillance of resistant infections.

Cluster Analysis↗
PubMedDate not supplied

Hospital-acquired neonatal infections in developing countries.

Hospital-born babies in developing countries are at increased risk of neonatal infections because of poor intrapartum and postnatal infection-control practices. We reviewed data from developing countries on rates of neonatal infections among hospital-born babies, range of pathogens, antimicrobial resistance, and infection-control interventions. Reported rates of neonatal infections were 3-20 times higher than those reported for hospital-born babies in industrialised countries. Klebsiella pneumoniae, other gram-negative rods (Escherichia coli, Pseudomonas spp, Acinetobacter spp), and Staphylococcus aureus were the major pathogens among 11,471 bloodstream isolates reported. These infections can often present soon after birth. About 70% would not be covered by an empiric regimen of ampicillin and gentamicin, and many might be untreatable in resource-constrained environments. The associated morbidity, mortality, costs, and adverse effect on future health-seeking behaviour by communities pose barriers to improvement of neonatal outcomes in developing countries. Low-cost, "bundled" interventions using systems quality improvement approaches for improved infection control are possible, but should be supported by evidence in developing country settings.

Cross Infection↗