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Open Access Publications from the University of California

Scholarly Works (5 results)

  • Article
  • Peer Reviewed
Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health, Volume 16, Issue 4 (2015)

Introduction: The emergency department (ED) plays a critical role in the management of life-threatening infection. Prior data suggest that ED vancomycin dosing is frequently inappropriate.The objective is to assess the impact of an electronic medical record (EMR) intervention designed to improve vancomycin dosing accuracy, on vancomycin dosing and clinical outcomes in critically ill ED patients.

Methods: Retrospective before-after cohort study of all patients (n=278) treated with vancomycin in a 60,000-visit Midwestern academic ED (March 2008 and April 2011) and admitted to an intensive care unit. The primary outcome was the proportion of vancomycin doses defined as “appropriate” based on recorded actual body weight. We also evaluated secondary outcomes of mortality and length of stay.

Results: The EMR dose calculation tool was associated with an increase in mean vancomycin dose ([14.1±5.0] vs. [16.5±5.7] mg/kg, p<0.001) and a 10.3% absolute improvement in first-dose appropriateness (34.3% vs. 24.0%, p=0.07). After controlling for age, gender, methicillin-resistant staphylococcus aureus (MRSA) infection, and Acute Physiology and Chronic Health Evaluation II (APACHE-II) score, 28-day in-hospital mortality (odds ratio OR 1.72; 95% CI [0.76-3.88], p=0.12) was not affected.

Conclusion: A computerized decision-support tool is associated with an increase in mean vancomycin dose in critically ill ED patients, but not with a statistically significant increase in therapeutic vancomycin doses. The impact of decision-support tools should be further explored to optimize compliance with accepted antibiotic guidelines and to potentially affect clinical outcome.

    Cover page: Importance of Decision Support Implementation in Emergency Department Vancomycin DosingCreative Commons 'BY' version 4.0 license
    • Article
    • Peer Reviewed
    Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health, Volume 18, Issue 5 (2017)

    Introduction: Pneumonia impacts over four million people annually and is the leading cause of infectiousdisease-related hospitalization and mortality in the United States. Appropriate empiric antimicrobialtherapy decreases hospital length of stay and improves mortality. The objective of our study was to testthe hypothesis that the presence of an emergency medicine (EM) clinical pharmacist improves the timingand appropriateness of empiric antimicrobial therapy for community-acquired pneumonia (CAP) andhealthcare-associated pneumonia (HCAP).

    Methods: This was a retrospective observational cohort study of all emergency department (ED) patientspresenting to a Midwest 60,000-visit academic ED from July 1, 2008, to March 1, 2016, who presentedto the ED with pneumonia and received antimicrobial therapy. The treatment group consisted of patientswho presented during the hours an EM pharmacist was present in the ED (Monday-Friday, 0900-1800).The control group included patients presenting during the hours when an EM clinical pharmacist was notphysically present in the ED (Monday-Friday, 1800-0900, Saturday/Sunday 0000-2400 day). We definedappropriate empiric antimicrobial therapy using the Infectious Diseases Society of America consensusguidelines on the management of CAP, and management of HCAP.

    Results: A total of 406 patients were included in the final analysis (103 treatment patients and 303 controlpatients). During the hours the EM pharmacist was present, patients were significantly more likely toreceive appropriate empiric antimicrobial therapy (58.3% vs. 38.3%; p<0.001). Regardless of pneumoniatype, patients seen while an EM pharmacist was present were significantly more likely to receiveappropriate antimicrobial therapy (CAP, 77.7% vs. 52.9% p=0.008, HCAP, 47.7% vs. 28.8%, p=0.005).There were no significant differences in clinical outcomes.

    Conclusion: The presence of an EM clinical pharmacist significantly increases the likelihood ofappropriate empiric antimicrobial therapy for patients presenting to the ED with pneumonia. [West JEmerg Med. 2017;18(5)856-863.]

      Cover page: Antimicrobial Therapy for Pneumonia in the Emergency Department: The Impact of Clinical Pharmacists on AppropriatenessCreative Commons 'BY' version 4.0 license
      • Article
      • Peer Reviewed
      UC San Francisco Previously Published Works (2023)
      BACKGROUND: Protection against symptomatic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection (coronavirus disease 2019 [COVID-19]) can limit transmission and the risk of post-COVID conditions, and is particularly important among healthcare personnel. However, lower vaccine effectiveness (VE) has been reported since predominance of the Omicron SARS-CoV-2 variant. METHODS: We evaluated the VE of a monovalent messenger RNA (mRNA) booster dose against COVID-19 from October 2021 to June 2022 among US healthcare personnel. After matching case-participants with COVID-19 to control-participants by 2-week period and site, we used conditional logistic regression to estimate the VE of a booster dose compared with completing only 2 mRNA doses >150 days previously, adjusted for multiple covariates. RESULTS: Among 3279 case-participants and 3998 control-participants who had completed 2 mRNA doses, we estimated that the VE of a booster dose against COVID-19 declined from 86% (95% confidence interval, 81%-90%) during Delta predominance to 65% (58%-70%) during Omicron predominance. During Omicron predominance, VE declined from 73% (95% confidence interval, 67%-79%) 14-60 days after the booster dose, to 32% (4%-52%) ≥120 days after a booster dose. We found that VE was similar by age group, presence of underlying health conditions, and pregnancy status on the test date, as well as among immunocompromised participants. CONCLUSIONS: A booster dose conferred substantial protection against COVID-19 among healthcare personnel. However, VE was lower during Omicron predominance, and waning effectiveness was observed 4 months after booster dose receipt during this period. Our findings support recommendations to stay up to date on recommended doses of COVID-19 vaccines for all those eligible.
        Cover page: Effectiveness of a Messenger RNA Vaccine Booster Dose Against Coronavirus Disease 2019 Among US Healthcare Personnel, October 2021-July 2022.
        • Article
        • Peer Reviewed
        UC San Francisco Previously Published Works (2021)

        Study objective

        Among a comprehensive range of frontline emergency department health care personnel, we assessed symptoms of anxiety and burnout, specific coronavirus disease 2019 (COVID-19) work-related stressors, and risk for post-traumatic stress disorder (PTSD). We also determined whether COVID-19 serologic testing of HCP decreased their self-reported anxiety.

        Methods

        In a prospective cohort study from May 13, 2020, to July 8, 2020, we used electronic surveys to capture participant self-reported symptoms before and after serologic testing for anti-SARS-CoV-2 immunoglobulin G antibodies. Participants were physicians, nurses, advanced practice providers, and nonclinical ED personnel at 20 geographically diverse United States EDs. We evaluated these domains: 1) the effects of the COVID-19 pandemic on overall stress and anxiety; 2) COVID-19-related work stressors; 3) burnout; and 4) PTSD risk (measured using the Primary Care-PTSD Screen for DSM-5, a 5-item screening instrument in which a score of ≥3 signifies high risk for PTSD). We also assessed perceptions of whether results of COVID-19 antibody testing decreased participants' self-reported anxiety.

        Results

        Of 1,606 participants, 100% and 88% responded to the baseline and follow-up surveys, respectively. At baseline, approximately half (46%) reported symptoms of emotional exhaustion and burnout from their work, and 308 (19.2%, 95% confidence interval [CI] 17.3% to 21.1%) respondents screened positive for increased PTSD risk. Female respondents were more likely than males to screen positive (odds ratio [OR] 2.03, 95% CI 1.49 to 2.78). Common concerns included exposing their family and the health of coworkers diagnosed with COVID-19. After receiving antibody test results, 54% (95% CI 51.8 to 56.7) somewhat agreed, agreed, or strongly agreed that knowledge of their immune status had decreased their anxiety. A positive serology result indicating prior SARS-CoV-2 infection was associated with a higher likelihood of reporting decreased anxiety (2.83, 95% CI 1.37 to 5.83).

        Conclusion

        Symptoms of anxiety and burnout were prevalent across the spectrum of ED staff during the COVID-19 pandemic. One-fifth of ED personnel appeared to be at risk for PTSD. Increased provision of serologic testing may help to mitigate anxiety.
          Cover page: Symptoms of Anxiety, Burnout, and PTSD and the Mitigation Effect of Serologic Testing in Emergency Department Personnel During the COVID-19 Pandemic
          • Article
          • Peer Reviewed
          UC San Francisco Previously Published Works (2023)

          Objective

          To compare secondary patient reported outcomes of perceptions of treatment success and function for patients treated for appendicitis with appendectomy vs. antibiotics at 30 days.

          Summary background data

          The Comparison of Outcomes of antibiotic Drugs and Appendectomy trial found antibiotics noninferior to appendectomy based on 30-day health status. To address questions about outcomes among participants with lower socioeconomic status, we explored the relationship of sociodemographic and clinical factors and outcomes.

          Methods

          We focused on 4 patient reported outcomes at 30 days: high decisional regret, dissatisfaction with treatment, problems performing usual activities, and missing >10 days of work. The randomized (RCT) and observational cohorts were pooled for exploration of baseline factors. The RCT cohort alone was used for comparison of treatments. Logistic regression was used to assess associations.

          Results

          The pooled cohort contained 2062 participants; 1552 from the RCT. Overall, regret and dissatisfaction were low whereas problems with usual activities and prolonged missed work occurred more frequently. In the RCT, those assigned to antibiotics had more regret (Odd ratios (OR) 2.97, 95% Confidence intervals (CI) 2.05-4.31) and dissatisfaction (OR 1.98, 95%CI 1.25-3.12), and reported less missed work (OR 0.39, 95%CI 0.27-0.56). Factors associated with function outcomes included sociodemographic and clinical variables for both treatment arms. Fewer factors were associated with dissatisfaction and regret.

          Conclusions

          Overall, participants reported high satisfaction, low regret, and were frequently able to resume usual activities and return to work. When comparing treatments for appendicitis, no single measure defines success or failure for all people. The reported data may inform discussions regarding the most appropriate treatment for individuals.

          Trial registration

          Clinicaltrials.gov Identifier: NCT02800785.
            Cover page: Perception of Treatment Success and Impact on Function with Antibiotics or Appendectomy for Appendicitis
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