Nurse working conditions were associated with all outcomes measured. Improving working conditions will most likely promote patient safety. Future researchers and policymakers should consider a broad set of working condition variables.

Background:The impact of intraoperative erythrocyte transfusion on outcomes of anemic patients undergoing noncardiac surgery has not been well characterized. The objective of this study was to examine the association between blood transfusion and mortality and morbidity in patients with severe anemia (hematocrit less than 30%) who are exposed to one or two units of erythrocytes intraoperatively. Methods: This was a retrospective analysis of the association of blood transfusion and 30-day mortality and 30-day morbidity in 10,100 patients undergoing general, vascular, or orthopedic surgery. We estimated separate multivariate logistic regression models for 30-day mortality and for 30-day complications. Results: Intraoperative blood transfusion was associated with an increased risk of death (odds ratio [OR], 1.29; 95% CI, 1.03-1.62). Patients receiving an intraoperative transfusion were more likely to have pulmonary, septic, wound, or thromboembolic complications, compared with patients not receiving an intraoperative transfusion. Compared with patients who were not transfused, patients receiving one or two

BackgroundCentral line-associated bloodstream infections (CLABSI) represent a serious patient safety issue. To prevent these infections, bundled interventions are increasingly recommended. We examine the extent of adoption of Central Line (CL) Bundle elements throughout US intensive care units (ICU) and determine their effectiveness in preventing CLABSIs.Methodology/Principal FindingsIn this cross-sectional study, National Healthcare Safety Network (NHSN) hospitals provided the following: ICU-specific NHSN-reported rates of CLABSI/1,000 central line days; policies and compliance rates regarding bundle components; and other setting characteristics. In 250 hospitals the mean CLABSI rate was 2.1 per 1000 central line days and 49% reported having a written CL Bundle policy. However, of those that monitored compliance, only 38% reported very high compliance with the CL Bundle. Only when an ICU had a policy, monitored compliance, and had ≥95% compliance did CLABSI rates decrease. Complying with any one of three CL Bundle elements resulted in decreased CLABSI rates (β = -1.029, p = 0.015). If an ICU without good bundle compliance achieved high compliance with any one bundle element, we estimated that its CLABSI rate would decrease by 38%.Conclusions/SignificanceIn NHSN hospitals across the US, the CL Bundle is associated with lower infection rates only when compliance is high. Hospitals must target improving bundle implementation and compliance as opposed to simply instituting policies.

Opioid use disorders are a significant public health problem, affecting over 2 million individuals in the US. Although opioid agonist treatment, predominantly offered in licensed methadone clinics, is both effective and cost-effective, many individuals do not receive it. Buprenorphine, approved in 2002 for prescription by waivered physicians, could improve opioid agonist treatment access for individuals unable or unwilling to receive methadone. We examine the extent to which the geographic distribution of waivered physicians has enhanced potential opioid agonist treatment access, particularly in non-metropolitan areas with fewer methadone clinics. We found that while the approximately 90% of counties classified as methadone clinic shortage areas remained constant, buprenorphine shortage areas fell from 99% of counties in 2002 to 51% in 2011, lowering the US population percentage residing in opioid treatment shortage counties to approximately 10%. The increase in buprenorphine-waivered physicians has dramatically increased potential access to opioid agonist treatment, especially in non-metropolitan counties.

T here is a strong association between a reduced estimated glomerular filtration rate (eGFR) and an increase in cardiovascular disease and all-cause mortality. Associations with morbidity in elective moderate-risk noncardiac surgery have not been examined. It was hypothesized that chronic kidney disease (CKD) would be associated with excess morbidity after elective, moderate-risk orthopedic surgery. Because they represent a large proportion of global surgical procedures and are characterized by highly homogeneous anesthetic and surgical practice, patients undergoing elective orthopedic joint replacement procedures were studied. Calculation of eGFR was done based on routine creatinine measurements using the Modification of Diet in Renal Disease equation. Chronic kidney disease was defined as eGFR G60 mL/min per 1.73 m 2 . Cardiac risk (Revised Cardiac Risk Index) and evidence-based preoperative factors associated with perioperative morbidity, such as operative time, blood loss, and perioperative temperature, were prospectively recorded using the postoperative morbidity survey. Differences in morbidity were analyzed between patients with CKD and normal preoperative renal function (W 2 test for trend) and presented as a hazard ratio (HR) or odds ratio (OR) with 95% confidence intervals (95% CIs). Secondary end points were time to hospital discharge and freedom from morbidities (analyzed by the log-rank test), both between and within CKD patients compared with those with normal renal function. Multiple regression analysis was performed to assess the association of CKD and perioperative factors with morbidity and length of hospital stay. A morbidity survey was conducted postoperatively in 526 patients undergoing elective orthopedic surgery. Chronic kidney disease patients (n = 142; 27%) sustained excess morbidity on postoperative day 5 (OR, 2.1 [95% CI, 1.2Y3.7]). It took longer (HR, 1.6 [95% CI, 1.2Y1.9]) for CKD patients to become free of morbidities (log-rank test). Time to hospital discharge was delayed by 4 days in CKD patients (HR, 1.4 [95% CI, 1.2Y1.7], log-rank test). Such patients sustained more pulmonary (OR, 2.2 [95% CI, 1.3Y3.6]), infectious (OR, 1.7 [95% CI, 1.1Y2.7]), cardiovascular (OR, 2.4 [95% CI, 1.2Y4.8]), renal (OR, 2.3 [95% CI, 1.5Y3.5]), neurological (OR, 4.3 [95% CI, 1.3Y17.7]), and pain (OR, 1.8 [95% CI, 1.03Y3.1]) morbidities.Additional stratification of CKD patients showed a preoperative eGFR of 50 mL/min per 1.73 m 2 or less to be associated with more frequent morbidity and a longer hospital stay, independent of age. Multiple regression analysis revealed CKD and congestive cardiac failure to be preoperative factors associated with a prolonged hospital stay. A sizable minority of CKD patients undergoing elective orthopedic procedures are at greater risk of prolonged morbidity and a longer hospital stay. Preoperative eGFR may enhance perioperative risk stratification beyond traditional risk factors. COMMENTIn recent years, the cardiovascular literature has focused on the relationship between C...