week to the Internal Medicine and Family Medicine services combined. Expediting MRI testing for suspected osteomyelitis in those patients not otherwise meeting admission criteria for high risk lower extremity infections would also streamline disposition decisions for admission versus discharge. Infectious Disease recommends that almost all osteomyelitis patients receive a bone biopsy. At UNMH, the bone biopsy rate for osteomyelitis in 2013 was 8.22% versus the AAMC comparison (6.58%) and Non-AAMC community hospitals (3.16%). Bone biopsies are associated with a longer average length-of-stay (16.6 vs 14.0 days) at UNMH. Current PICC Line Insertion practice is to wait 48 hours for negative blood cultures, even in absence of indicators of bacteremia, prior to placement. This delays ALOS by 2 days or more for many patients. A literature review has been performed and discussions are ongoing with Infectious Disease about the potential for identifying a more limited subset of patients in which to undertake this practice. II Recommendations – Implement ED Clinical Pathway (see Appendix C) for workup and admission decision-making for suspected osteomyelitis of the lower extremity Negotiate inter-service agreements that medicine services (IM/FM) primarily admit all osteomyelitis patients of the lower extremity, and also admit patient with suspected osteomyelitis of the lower extremity who otherwise meet admission criteria, given the role of It is critical that criteria for admission of underlying medical co-morbidities in these patients. high risk infections (in absence of confirmed osteo) be used to drive early admission from the ED and that waiting for the results of ED MRIs be reserved for patients who otherwise would not meet admission criteria and may be able to be discharged if negative. Inter-service communication improvements will also be required for inpatients requiring surgery who are on a primary medical team. Implement Inpatient Early Discharge to LTACH for Osteo Pathway (EDLO) (see Appendix D) Establish criteria for early PICC line insertion in patients without clear risk factors for bacteremia. Future issues to be addressed: Targeted bone biopsy recommendations from Infectious Disease Identify an osteomyelitis/diabetic foot infection multidisciplinary team to take leadership for moving forward with these changes and to address the link with outpatient processes OPAT access issues Direct discharge from ED to LTACH process
week to the Internal Medicine and Family Medicine services combined. Expediting MRI testing for suspected osteomyelitis in those patients not otherwise meeting admission criteria for high risk lower extremity infections would also streamline disposition decisions for admission versus discharge. Infectious Disease recommends that almost all osteomyelitis patients receive a bone biopsy. At UNMH, the bone biopsy rate for osteomyelitis in 2013 was 8.22% versus the AAMC comparison (6.58%) and Non-AAMC community hospitals (3.16%). Bone biopsies are associated with a longer average length-of-stay (16.6 vs 14.0 days) at UNMH. Current PICC Line Insertion practice is to wait 48 hours for negative blood cultures, even in absence of indicators of bacteremia, prior to placement. This delays ALOS by 2 days or more for many patients. A literature review has been performed and discussions are ongoing with Infectious Disease about the potential for identifying a more limited subset of patients in which to undertake this practice. II – Recommendations Implement ED Clinical Pathway (see Appendix C) for workup and admission decision-making for suspected osteomyelitis of the lower extremity Negotiate inter-service agreements that medicine services (IM/FM) primarily admit all osteomyelitis patients of the lower extremity, and also admit patient with suspected osteomyelitis of the lower extremity who otherwise meet admission criteria, given the role of underlying medical co-morbidities in these patients. It is critical that criteria for admission of high risk infections (in absence of confirmed osteo) be used to drive early admission from the ED and that waiting for the results of ED MRIs be reserved for patients who otherwise would not meet admission criteria and may be able to be discharged if negative. Inter-service communication improvements will also be required for inpatients requiring surgery who are on a primary medical team. Implement Inpatient Early Discharge to LTACH for Osteo Pathway (EDLO) (see Appendix D) Establish criteria for early PICC line insertion in patients without clear risk factors for bacteremia. Future issues to be addressed: Targeted bone biopsy recommendations from Infectious Disease Identify an osteomyelitis/diabetic foot infection multidisciplinary team to take leadership for moving forward with these changes and to address the link with outpatient processes OPAT access issues Direct discharge from ED to LTACH process
UNMMLA%20Project%20Group%209.docx