Daniel Drake Center

Background: Information technology, including clinical decision support systems (CDSS), have an increasingly important and growing role in identifying opportunities for antimicrobial stewardship-related interventions. Objective: The aim of this study was to describe and compare types and outcomes of CDSS-built antimicrobial stewardship alerts. Methods: Fifteen alerts were evaluated in the initial antimicrobial stewardship program (ASP) review. Preimplementation, alerts were reviewed retrospectively. Postimplementation, alerts were reviewed in real-time. Data collection included total number of actionable alerts, recommendation acceptance rates, and time spent on each alert. Time to de-escalation to narrower spectrum agents was collected. Results: In total, 749 alerts were evaluated. Overall, 306 (41%) alerts were actionable (173 preimplementation, 133 postimplementation). Rates of actionable alerts were similar for custom-built and prebuilt alert types (39% [53 of 135] vs 41% [253 of 614], P = .68]. In the postimplementation group, an intervention was attempted in 97% of actionable alerts and 70% of interventions were accepted. The median time spent per alert was 7 minutes (interquartile range [IQR], 5-13 minutes; 15 [12-17] minutes for actionable alerts vs 6 [5-7] minutes for nonactionable alerts, P < .001). In cases where the antimicrobial was eventually de-escalated, the median time to de-escalation was 28.8 hours (95% confidence interval [CI], 10.0-69.1 hours) preimplementation vs 4.7 hours (95% CI, 2.4-22.1 hours) postimplementation, P < .001. Conclusions: CDSS have played an important role in ASPs to help identify opportunities to optimize antimicrobial use through prebuilt and custom-built alerts. As ASP roles continue to expand, focusing time on customizing institution specific alerts will be of vital importance to help redistribute time needed to manage other ASP tasks and opportunities.

Our clinical experience suggests that the effectiveness of negative pressure wound therapy is enhanced by adding collagen alginate to the dressing regimen, applying foam over areas that are undermined or tunneled, and approximating and securing wound edges prior to applying foam. The use of this combined technique is described in 4 cases, including 2 patients with spinal cord injury and category IV pressure ulcers and 2 patients with extensive postsurgical wounds. Our outcomes demonstrate the feasibility of this technique and suggest that patients with significant wound size benefit from adding collagen alginate to negative pressure wound therapy and by applying foam over areas that are undermined or tunneled and/or approximating and securing wound edges prior to applying foam.

We examined the efficacy of a remotely based arm rehabilitation regimen. A 62-year-old man participated in occupation-based, task-specific practice of activities of daily living (ADLs) >3 years after stroke. The entire regimen was administered over the Internet using personal computer-based cameras and free network meeting software. Fugl-Meyer Assessment (FM), Action Research Arm Test (ARA), and Canadian Occupational Performance Measure (COPM) were administered before intervention. One week after treatment, FM, ARA, and COPM were readministered. The participant exhibited reduced impairment and reduced functional limitation. He also expressed enhanced satisfaction with his ability to perform ADLs and rated his ADL performance better after intervention. The participant could now drive using both hands, use eating utensils, and catch and throw a ball. Data suggest feasibility and efficacy of a remotely based, inexpensive approach using functional electrical stimulation for affected arm rehabilitation after stroke.

INTRODUCTION/SIGNIFICANCE: Many wounds classified as Stage I and Stage II pressure ulcers may actually be attributable to IAD and not to pressure. There are reports of IAD prevalence in both acute care (Junkin, 2005; Gray, 2006) and in nursing homes (Bliss, 2006). However, there are no published reports regarding IAD in long-term acute care. In 2007, the Drake Center Advanced Wound Team performed a cross-sectional pilot study among LTAC patients. The results from this pilot study suggested the need for additional investigation. PURPOSE/AIM: This study has three specific aims Describe the prevalence of IAD and PUs. Describe the nosocomial incidence of IAD and PUs. Describe factors associated with development of IAD and PUs. METHOD SUMMARY: The study utilizes an observational repeated measured design. Data will be collected prospectively for twelve consecutive weeks on the LTAC units at Drake Center utilizing a modified Sage data collection form that incorporates components of Brown's perineal dermatitis grading scale (Brown, 1993). Data collection ends November 15, 2008. PLANNED STATISTICS: In Aim 1, the prevalence of IAD or PUs will be summarized by descriptive statistics of frequency. In Aim 2, the development of IAD or PUs will be assessed using a Kaplan-Meier survival curve. In Aim 3, two or more survival curves recognized by a risk factor will be assessed and compared using log-rank tests. Multiple Cox proportional hazard models will be used to assess the association of development of IAD or PUs to multiple risk factors and their interactions. Statistical analyses will be performed using a SAS version 9.1 software (SAS, Cary, NC) package. P-values < 0.05 will be considered statistically significant.

PROBLEM: Five patients with differing wounds suffered issues with exudates, maceration and pain. Patient A was admitted 5/07 with thoracic surgical wound. Exudates increased with activity, as did frequency of dressing changes and patient's complaints of pain. Patient B was admitted 11/07 after multiple surgeries following near complete traumatic amputation of right leg. Patient had dressing change-related pain, fragile newly epithelialized skin and edema-related exudates. Patient C was admitted 10/08 with left lower extremity ulcer complicated by generalized edema and cellulitis. Had significant exudates, fragile peri-wound skin and dressing change-related pain. Patient D was admitted 10/08 postsurgical repair of right ankle. The wound drained copious serosanguineous fluid. Peri-wound skin was compromised by maceration, erythema and ecchymosis. Patient E was admitted 11/08 with nonhealing surgical wounds to back. Wounds were highly exudative with macerated and fragile peri-wound skin. The patient had dressing change-related pain. PAST MANAGEMENT: Patient A was managed with a dry dressing. Patient B had multiple treatments, including negative pressure wound therapy and silver hydrofiber.* Patient C was managed with silver hydrofiber* and gauze overwhelmed by edema-related exudates volume. Patient D was managed with 2% Chlorhexidine Gluconate 70% Isopropyl Alcohol*** pad over incision line with a gauze secondary dressing. Patient E was managed with silver hydrofiber* often adhering to the wound. CURRENT APPROACH: All patients had SSETD** initiated as primary or secondary dressing. PATIENT OUTCOMES: All patients had improvements in peri-wound skin condition. Patient B requested the “soft gentle dressing” when discharged. Patient D's maceration resolved within twenty-four hours of SSETD** use. All patients reported decreases in pain. The nurses caring for patients A and C reported decreased use of pain medication and need for dressing changes. CONCLUSION: SSETD** is an excellent option for managing wound exudates while maintaining/improving peri-wound skin condition and managing pain.

Studies have suggested that peroneal nerve functional electrical stimulation (peroneal FES) during walking improves gait in patients with chronic stroke. The effect of peroneal FES during the acute stages of stroke recovery is not known. The purposes of this case report are: (1) to describe differences between walking with and without a neuroprosthesis during the first few weeks after stroke, (2) to offer a clinical perspective on decision making for the use of peroneal FES during acute rehabilitation, and (3) to determine the feasibility of rehabilitation with peroneal FES neuroprostheses during the acute phases of stroke recovery. This case report describes 2 patients with different clinical presentations but both receiving inpatient rehabilitation less than 2 weeks after stroke. Each patient received peroneal FES via a neuroprothesis as tolerated while gait training in therapy. One patient immediately increased gait speed (128%) and decreased time to perform the Timed "Up & Go" Test (40%) using the neuroprothesis. Both patients immediately increased the 6-Minute Walk Test distance using the neuroprothesis (121% and 101%). The patient who underwent testing with the instrumented walking system also demonstrated improved gait symmetry. After 1 to 3 weeks of using the neuroprothesis, the difference between outcomes with and without the neuroprothesis decreased. It is possible that peroneal FES delivered through a neuroprosthesis during acute stroke recovery may improve gait outcomes. Research is needed to determine proper duration and timing.

Background and Purpose: Repetitive practice improves function and facilitates cortical plasticity after stroke. Virtual reality (VR) systems have the potential to provide motivating and safe repetitive practice with minimal supervision. The purpose of this case study is to look at the effect of a VR system, activated by surface electromyography of dorsiflexors and plantarflexors, on gait velocity, function, and kinematics. Method: The first person randomized to the treatment group of a larger study was chosen for this case. She was 51 years old and 9 months poststroke. She received treatment 3 times per week for 8 weeks. Each 60-minute session consisted of both structured lower extremity exercise and VR ankle activities. Results: After intervention, the subject demonstrated increased gait speed and decreased time to perform the modified Emory Functional Ambulation Profile. Gait kinematics demonstrated improved ankle motion and plantarflexion moments at push off. Discussion: The improved gait speed, possibly due to increased ankle plantarflexion motion and moments, resulted in a more normalized trailing limb posture. This case study suggests that ankle to computer VR systems may help stroke patients improve gait function. This VR system has potential as an adjunctive therapy or home program requiring minimal supervision.