Johns Hopkins Hospital

Identifying and preventing patient safety events is a goal for institutions that provide quality care; understanding and mitigating disparities in care is another. The mainstay of safety event detection, voluntary event reporting (VER), is prone to bias and under-reporting; previous research suggests this creates disparities in reported events. We aim to explore disparities in voluntary event reporting that may exist in a large, academic health system. We conducted a retrospective review of inpatient-associated safety events submitted to our health system's VER system from April 2021 to July 2022 and compared the cohort's demographics to those of all admitted patients during the same period. Pediatric patients, who are over-represented in the overall VER system (23% vs. 20%, P<0.001), are under-represented among most harmful events (P<0.001). Female patients, who are under-represented in the VER system (50.1% vs. 56.5%, P<0.001), remain so only in lower harm events. Other groups are over-represented in the VER system, including patients who are English-speaking (93.8% vs. 92.9%), non-Hispanic or Latino (88.9% vs. 82.4%), Black/African American (33.3% vs. 28.7%), and from areas of high neighborhood deprivation (23.5% vs. 18.9%) (all P<0.001). Disparities in VER were observed in a large academic health system. We conducted a broad analysis, including novel variables that have yet to be evaluated robustly in the literature, and we do find important disparities in these variables. Further research is needed to understand the mechanism for disparities to mitigate bias in reporting. Implementation of more objective methods of event detection may help reduce disparities.

Introduction: Prolonged respiratory failure (PRF) following initiation of invasive mechanical ventilation is associated with increased morbidity, mortality, and resource utilization. While predictive scoring systems such as iTRACH have been developed, the duration and determinants of PRF remain inadequately characterized across diverse hospital settings. Methods: We performed a retrospective cohort study using data from six CLIF Consortium hospital systems and the MIMIC-IV database, including adult MICU patients who received invasive mechanical ventilation ≥24 hours between January 2018 and December 2024. Patients with tracheostomies on admission were excluded. PRF was defined as ventilation >14 days, and early deaths as those occurring < 14 days post-intubation. The iTRACH score (0–5), based on tachycardia (HR >110), renal dysfunction (BUN >25, creatinine >2.0), and acidemia (pH < 7.25, HCO₃ < 20), was used to predict PRF, with a cutoff of ≥4. Demographic, clinical, and hospital-level data were extracted from each site’s EHR, and aggregated using a federated approach. Large language models assisted with coding and drafting; all outputs were author-reviewed. Results: The cohort consisted of 19,444 admissions (median age range across the 7 systems: 61–65 years, 43% Female, 28% Black, 7% Hispanic), with the median intubation duration ranging from 3.0-4.4 days and ICU stays ranging from 5.7-10 days. 12.2% of patients experienced PRF. 25% of patients had early death. Patients with COVID-19 had a longer median intubation duration (4-14 days), consistent with what has previously been described. The overall median ITRACH score was 1 (IQR: 0-2), and ranged from 1-2 across sites for those with PRF. Using an iTRACH cutoff of ≥4, specificity was high (0.96-0.98), but sensitivity was low (0.02–0.07). Conclusions: PRF is common among mechanically ventilated patients across seven hospital systems, with notable variation in duration by site. Existing tools like iTRACH showed poor predictive performance. Early identification of at-risk patients could improve prognostication and guide targeted interventions. More advanced approaches, such as machine learning, may offer greater promise in predicting PRF.

Short durations of anti-pseudomonal (Pa) antibiotic (ABX) therapy may seem low-risk; however, emerging data highlight subsequent multi-drug-resistant pathogens in previously treated patients. This study aims to evaluate the safety and efficacy of Pa versus non-pseudomonal (NPa) ABX prophylaxis in liver transplant (LT) recipients undergoing delayed biliary reconstruction (DBR). This is a single-center, retrospective study of LT recipients following a protocolized change in ABX prophylaxis when undergoing DBR between January 2017 and March 2023. Patients who received piperacillin-tazobactam or cefepime and metronidazole were assigned to the Pa cohort, and those who received ceftriaxone and metronidazole were assigned to the NPa cohort. Surgical site infection (SSI), any bacterial infection, total ABX days, and re-initiation or escalation of ABX therapy were compared between the Pa and NPa cohorts. Forty-eight patients were included in the study, with 27 in the Pa cohort and 21 in the NPa cohort. SSI at 30 days occurred in 10 (37.0%) compared with 4 (19.0%) patients in the Pa and NPa cohorts (p = 0.174), respectively. There were no differences in any bacterial infection, total ABX days, or re-initiation or escalation of ABX therapy. Thirty-day culture results yielded eight (72.7%) Enterococcus faecium species (seven in the Pa cohort) and no Pseudomonas aeruginosa. NPa ABX for peri-operative prophylaxis for patients who undergo DBR in LT was not associated with an increased infectious risk compared with broader-spectrum agents. The combined clinical and microbiological outcomes question the routine need for Pa therapy in this setting.