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Bipolar disorder (BD) during pregnancy is known to be a morbid condition associated with poor outcomes for both the mother and her infant. We aimed to determine if women with BD and their children have higher charges and health service utilization than mother-infant dyads with and without other mental health (MH) diagnoses. The International Classification of Diseases, Ninth Revision (ICD9) codes were used to identify mutually exclusive groups of women who gave birth between January 1, 2011, and December 31, 2012, coding first for BD, then diagnoses that comprised an “other MH diagnoses group” that included post-traumatic stress disorder, anxiety, and depression. Health service utilization and related charges were obtained for the dyad for delivery and for 2 years post-delivery at a single tertiary care center. Analyses included 4440 dyads. A BD diagnosis occurred in 1.8% of medical record codes, other MH diagnoses in 10%, and no known MH diagnosis in 88%. Compared with women with both other MH and no known MH diagnoses, women with BD had higher delivery charges (p < 0.001), higher cumulative charges in the 2 years postpartum (p < 0.001), higher preterm birth and low birthweight rates (15.5% v. 6.9% and 20.8% v. 6.4%, p < 0.001, BD v. no known MH, respectively), and greater utilization of inpatient and emergency psychiatric care services (p < 0.001). Compared with women with and without other mental health diagnoses, women with BD have the highest care utilization and charges. They also have higher preterm birth and low birthweight infant rates, two clinically relevant predictors of long-term health for the child. Given the low prevalence of BD and severity of the disease versus the magnitude of systems costs, women with BD, and their children, deserve the heightened attention afforded to other high-risk perinatal conditions.

Exploratory study to examine inpatient medication administration patterns.Data from multiple sources were utilized for this study. The outcome was time difference between medication schedule and administration. A 3-level hierarchical linear regression approach, both unadjusted and adjusted, was considered for this study where medication administration events are nested within patients nested within nurses or units. Intraclass correlation coefficients (ICCs) were calculated and compared.On average, medications were delayed by 12 (SD, 48.8) minutes. From the full model, patient ICCs decreased when "unit" replaced "nurse" as the 3rd level (0.541 vs 0.444). Patients who spoke Spanish had a significant 2.3- to 4.2-minute delay in medication administration. Certified nurses significantly give medications earlier compared with noncertified nurses by 1.6 minutes.Optimal medication administration is a multifactorial concern with nurses playing a role. Nursing leaders should also consider patient demographics and unit conditions, such as culture, for medication administration optimization.

This study tests the feasibility of using a large (big) clinical data set to test the ability to extract time-referenced data related to medication administration to identify late doses and as-needed (PRN) administration patterns by RNs in an inpatient setting.The study is a secondary analysis of a set of data using bar-code medication administration time stamps (n = 3043812) for 50883 patients admitted to a single, urban, 525-bed hospital in 11 inpatient units by 714 nurses between April 1, 2013, and March 31, 2015.The large majority of scheduled medications (43.3%) were administered between 9 to 10 AM and 9 to 10 PM accounting for the most amount of delayed doses. On average, patients received 8.9 medications per day, and nurses administered 19.7 medications per shift. The average full-time nurse administered 3414 medications per year.The findings support use of time-referenced data to identify clinical processes and performance in administering scheduled and PRN medications.

From 2011 to 2015, a series of quality improvement interventions were developed that targeted pediatric persistent asthmatics that included recalls for those overdue for care and access to specialist care. The objective of this study was to assess the impact on urgent care and emergency department visits and hospitalizations from enrollment into at least one intervention during the time period.Persistent asthmatics were identified through electronic medical records, with patients having an asthma designation containing "persistent," asthma control containing "poor", and asthma risk being "high risk." Asthma utilization events were identified for these patients between January 1, 2011, and June 30, 2015 using ICD-9 diagnosis codes. Evaluation focused on differences in utilization for patients before and after receiving interventions through the use of logistic regression for each utilization outcome.The interventions were delivered to 1060 children out of a total of 2046 identified as having the persistent asthmatic criteria. The intervention group consisted of 389 (36.7%) moderate persistent asthmatics and 643 (60.7%) mild persistent asthmatics, with 976 (92.1%) identifying as a minority. Analysis of 60692 months of data showed patients who received the intervention were less likely to visit the urgent care (OR [0.80, 0.96]) or be hospitalized (OR [0.37, 0.75]) than those who did not receive any interventions. Adjustment for provider referral into the interventions resulted in slight changes for both hospitalizations (OR [0.38, 0.79]) and urgent care (OR [0.68, 0.94]).Children receiving interventions were less likely to be hospitalized or visit urgent care clinics.

OBJECTIVE To evaluate the effect of a postpartum risk-based low-molecular-weight heparin protocol for venous thromboembolism prevention. METHODS We conducted a retrospective cohort study of postpartum women at a safety net hospital before (2013), during (2014), and after (2015) implementation of a risk-based enoxaparin thromboembolism prevention protocol. The calculated sample size was based on a primary outcome of enoxaparin administration rate. Secondary outcomes included incidence of postpartum thromboembolism, wound complications, and 30-day readmission rates. The prevalence of thromboembolism risk factors and protocol adherence was evaluated in two groups of women before (May 2013) and after (May 2015) protocol implementation. Exact χ or Cochran-Armitage trend tested differences in rates. RESULTS Over 3 years, 9,766 deliveries were included. Enoxaparin was administered to 0.28% (95% CI 0.14-0.55) of postpartum women in 2013 (before) compared with 33.46% (95% CI 31.89-35.07%) after protocol implementation (P

Background: Anticoagulant-based prophylaxis in atrial fibrillation patients at high-risk for stroke remains underutilized in clinical practice despite extensive literature supporting its benefits. The recent 2014 AHA/ACC/HRS Atrial Fibrillation Guidelines emphasize risk stratification to target anticoagulation to those who would derive the most benefit. Rapid guideline implementation could be achieved through patient registries and decision support that provide actionable information at the point of care. Our objective is to risk-stratify primary care patients with atrial fibrillation at Denver Health (DH), an integrated safety net health system, and to characterize patterns of anticoagulation use and non-use as the first phase of a quality improvement initiative that includes development of a disease registry. Methods: We identified patients diagnosed with atrial fibrillation who made one or more visits over a two-year period to a primary care site at DH. We utilized the CHA2DS2VASc score to stratify patients as low-risk (score = 0 or 1 if female gender was the sole risk factor), intermediate-risk (score = 1), or high-risk (score = 2+) of stroke. We examined the use of anticoagulant therapy within each stratum. For patients at high-risk, we compared characteristics between those who were on any anticoagulant and those who were not. We examined differences in age, gender, payer, HAS-BLED score, and modifiable factors that contribute to the HAS-BLED score. HAS-BLED score was calculated using ICD9 codes, vital signs, and laboratory values drawn from electronic medical record data. Results: The study population of 867 patients had a median age of 64 years (interquartile range: 56-73) and 373 (43%) were women. Of the 867 patients, 168 (19.4%) were uninsured, 227 (26.2%) were covered by Medicaid, and 425 (49%) by Medicare. CHA2DS2VASc score-based stratification indicated 59 (6.8%), 71 (8.2%), and 737 (85%) patients were at low, intermediate, and high-risk, respectively. Of the low-risk patients, 13 (22%) were on anticoagulants, despite guidelines recommending no therapy for these patients. Anticoagulation rates among the intermediate and high-risk strata were 60.6% (43 of 71) and 64.5% (475 of 737), respectively. Among high-risk patients, those not on anticoagulation were more likely to have uncontrolled hypertension, abnormal liver function, or were on medications that predispose to bleeding. There were no significant differences in the proportion of patients with a HAS-BLED score of 3+ among those high-risk patients receiving anticoagulation and those not. Conclusions: A baseline assessment of stroke prophylaxis among atrial fibrillation patients in a safety net health system demonstrates nonguideline-concordant anticoagulation use among low-risk patients and suboptimal anticoagulation use among high-risk patients, patterns that could not be explained by HAS-BLED score.