Description of a pharmacist-driven safety algorithm in Staphylococcus aureus bacteremia: Compliance, interventions, and good saves

2020 ◽  
Vol 41 (8) ◽  
pp. 921-925
Author(s):  
Tara H. Lines ◽  
Whitney J. Nesbitt ◽  
Matthew H. Greene ◽  
George E. Nelson
Keyword(s):  
Staphylococcus Aureus ◽  
Adverse Events ◽  
Academic Medical Center ◽  
Tertiary Care ◽  
Safety Net ◽  
Definitive Therapy ◽  
Before And After ◽  
Bundle Compliance ◽  
The Impact ◽  
Major Adverse Events

AbstractObjective:To evaluate the impact of a pharmacist-driven Staphylococcus aureus bacteremia (SAB) safety bundle supported by leadership and to compare compliance before and after implementation.Design:Retrospective cohort study with descriptive and before-and-after analyses.Setting:Tertiary-care academic medical center.Patients:All patients with documented SAB, regardless of the source of infection, were included. Patients transitioned to palliative care were excluded from before-and-after analysis.Methods:A pharmacist-driven safety bundle including documented clearance of bacteremia, echocardiography, removal of central venous catheters, and targeted intravenous therapy of at least 2 weeks duration was implemented in November 2015 and was supported by leadership with stepwise escalation for nonresponse. A descriptive analysis of all patients with SAB during the study period included pharmacy interventions, acceptance rates, and escalation rates. A pre–post implementation analysis of 100 sequential patients compared bundle compliance and descriptive parameters.Results:Overall, 391 interventions were made in the 20-month period following implementation, including 20 “good saves” avoiding potentially major adverse events. No statistically significant differences in complete bundle compliance were detected between the periods (74% vs 84%; P = .08). However, we detected a significant increase in echocardiography after the bundle was implemented (83% vs 94%; P = .02) and fewer patients received suboptimal definitive therapy after the bundle was implemented (10% vs 3%; P = .045).Conclusions:This pharmacist-driven SAB safety bundle with leadership support showed improvement in process measures, which may have prevented major adverse events, even with available infectious diseases (ID) consultation. It provides a critical safety net for institutions without mandatory ID consultation or with limited antimicrobial stewardship resources.

scholarly journals Impact of Cefazolin Shortage on Clinical Outcomes of Adult Patients with Bacteremia Caused by Methicillin-Susceptible Staphylococcus aureus in a Tertiary Care University Hospital

Antibiotics ◽  
2021 ◽  
Vol 10 (10) ◽  
pp. 1247
Author(s):  
Atsushi Uda ◽  
Kenichiro Onuma ◽  
Katsumi Shigemura ◽  
Koichi Kitagawa ◽  
Yonmin Yan ◽  
...  
Keyword(s):  
Staphylococcus Aureus ◽  
Treatment Failure ◽  
Clinical Outcomes ◽  
Tertiary Care ◽  
Demographic Characteristics ◽  
University Hospital ◽  
Drug Reactions ◽  
First Line ◽  
Definitive Therapy ◽  
The Impact

Cefazolin is an essential antibiotic used for treating bacteremia; in particular, it is recommended as a first-line agent for infections caused by methicillin-susceptible Staphylococcus aureus (MSSA). In March 2019, problems with a major antibiotic supplier caused a critical shortage of cefazolin in Japan; however, the impact of the cefazolin shortage on clinical outcomes remains unknown. This study aimed to evaluate the effect of the cefazolin shortage in patients with MSSA bacteremia. Data from 75 patients were compared between the pre-shortage (March 2018–January 2019, n = 39) and post-shortage (March 2019–January 2020, n = 36) periods. There were no significant differences in the demographic characteristics between the two groups, and the cefazolin shortage did not worsen clinical outcomes such as adverse drug reactions, treatment failure, and 30-day mortality. In the post-shortage group, ampicillin/sulbactam and benzylpenicillin were more frequently administered as alternative antibiotics for empirical and definitive therapy (10% vs. 31%, p = 0.042; 0% vs. 19%, p = 0.004, respectively). Multivariate analysis revealed that the broad-spectrum antibiotics for definitive therapy, such as antipseudomonal penicillin, were associated with treatment failure in patients with MSSA bacteremia (OR = 17, p = 0.003). Hence, narrow-spectrum antibiotics should be prescribed for MSSA bacteremia as alternatives during a cefazolin shortage.

Implementation of a Leeches + Antimicrobial Prophylaxis Order Panel to Optimize Medicinal Leech Use at a Tertiary Care Academic Medical Center

2021 ◽  
pp. 089719002199368
Author(s):  
Nicole M. Palm ◽  
Jill C. Wesolowski ◽  
Janet Y. Wu ◽  
Pavithra Srinivas
Keyword(s):  
Antimicrobial Prophylaxis ◽  
Medical Center ◽  
Academic Medical Center ◽  
Tertiary Care ◽  
Medicinal Leech ◽  
Aeromonas Species ◽  
Leech Therapy ◽  
Before And After ◽  
Timing Of Initiation ◽  
Medicinal Leeches

Medicinal leech therapy promotes vascular flow and can be used to salvage grafts. Medicinal leeches have a symbiotic relationship with Aeromonas species and can therefore present a risk of bacterial transmission to patients. Antimicrobial prophylaxis is warranted for the duration of leech therapy, however, an institutional evaluation of 40 patients receiving medicinal leech therapy demonstrated poor adherence with recommendations. An electronic medical record order panel for antimicrobial prophylaxis with medicinal leech therapy was implemented, leading to a subsequent improvement in adherence to prophylaxis use, including significant increases in the ordering of antibiotics and the appropriate timing of initiation in the subsequent 10 patients receiving medicinal leech therapy after panel implementation. Aeromonas infections were rare before and after panel implementation, and developed only in the patient subset with non-optimized prophylaxis.

scholarly journals 600. Decreased Hospital Readmission After Programmatic Strengthening of an Outpatient Parenteral Antimicrobial Therapy (OPAT) Program

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S362-S363
Author(s):  
Gaurav Agnihotri ◽  
Alan E Gross ◽  
Minji Seok ◽  
Cheng Yu Yen ◽  
Farah Khan ◽  
...  
Keyword(s):  
Hospital Readmission ◽  
Multinomial Logistic Regression ◽  
Univariate Analysis ◽  
Tertiary Care ◽  
Intervention Group ◽  
Care Hospital ◽  
Full Time ◽  
Post Intervention ◽  
Before And After ◽  
The Impact

Abstract Background Although it is recommended that an OPAT program should be managed by a formal OPAT team that supports the treating physician, many OPAT programs face challenges in obtaining necessary program staff (i.e nurses or pharmacists) due to limited data examining the impact of a dedicated OPAT team on patient outcomes. Our objective was to compare OPAT-related readmission rates among patients receiving OPAT before and after the implementation of a strengthened OPAT program. Methods This retrospective quasi-experiment compared adult patients discharged on intravenous (IV) antibiotics from the University of Illinois Hospital before and after implementation of programmatic changes to strengthen the OPAT program. Data from our previous study were used as the pre-intervention group (1/1/2012 to 8/1/2013), where only individual infectious disease (ID) physicians coordinated OPAT. Post-intervention (10/1/2017 to 1/1/2019), a dedicated OPAT nurse provided full time support to the treating ID physicians through care coordination, utilization of protocols for lab monitoring and management, and enhanced documentation. Factors associated with readmission for OPAT-related problems at a significance level of p< 0.1 in univariate analysis were eligible for testing in a forward stepwise multinomial logistic regression to identify independent predictors of readmission. Results Demographics, antimicrobial indications, and OPAT administration location of the 428 patients pre- and post-intervention are listed in Table 1. After implementation of the strengthened OPAT program, the readmission rate due to OPAT-related complications decreased from 17.8% (13/73) to 6.5% (23/355) (p=0.001). OPAT-related readmission reasons included: infection recurrence/progression (56%), adverse drug reaction (28%), or line-associated issues (17%). Independent predictors of hospital readmission due to OPAT-related problems are listed in Table 2. Table 1. OPAT Patient Demographics and Factors Pre- and Post-intervention Table 2. Factors independently associated with hospital readmission in OPAT patients Conclusion An OPAT program with dedicated staff at a large academic tertiary care hospital was independently associated with decreased risk for readmission, which provides critical evidence to substantiate additional resources being dedicated to OPAT by health systems in the future. Disclosures All Authors: No reported disclosures

The impact of a multimodel approach to designing a new orthopedic department

2020 ◽  
pp. 1-6
Author(s):  
Elad Keren ◽  
Abraham Borer ◽  
Lior Nesher ◽  
Tali Shafat ◽  
Rivka Yosipovich ◽  
...  
Keyword(s):  
Hand Hygiene ◽  
Antibiotic Stewardship ◽  
Infection Prevention ◽  
Tertiary Care ◽  
Surgical Site Infections ◽  
Antibiotic Use ◽  
Prevention Measures ◽  
Orthopedic Department ◽  
Before And After ◽  
The Impact

Abstract Objective: To determine whether a multifaceted approach effectively influenced antibiotic use in an orthopedics department. Design: Retrospective cohort study comparing the readmission rate and antibiotic use before and after an intervention. Setting: A 1,000-bed, tertiary-care, university hospital. Patients: Adult patients admitted to the orthopedics department between January 2015 and December 2018. Methods: During the preintervention period (2015–2016), 1 general orthopedic department was in operation. In the postintervention period (2017–2018), 2 separate departments were created: one designated for elective “clean” surgeries and another that included a “complicated wound” unit. A multifaceted strategy including infection prevention measures and introducing antibiotic stewardship practices was implemented. Admission rates, hand hygiene practice compliance, surgical site infections, and antibiotic treatment before versus after the intervention were analyzed. Results: The number of admissions and hospitalization days in the 2 periods did not change. Seven-day readmissions per annual quarter decreased significantly from the preintervention period (median, 7 days; interquartile range [IQR], 6–9) to the postintervention period (median, 4 days; IQR, 2–7; P = .038). Hand hygiene compliance increased and surgical site infections decreased in the postintervention period. Although total antibiotic use was not reduced, there was a significant change in the breakdown of the different antibiotic classes used before and after the intervention: increased use of narrow-spectrum β-lactams (P < .001) and decreased use of β-lactamase inhibitors (P < .001), third-generation cephalosporins (P = .044), and clindamycin (P < .001). Conclusions: Restructuring the orthopedics department facilitated better infection prevention measures accompanied by antibiotic stewardship implementation, resulting in a decreased use of broad-spectrum antibiotics and a significant reduction in readmission rates.

scholarly journals Communications and Screening for 2019 Novel Coronavirus at a Tertiary-Care Medical Center

2020 ◽  
Vol 41 (S1) ◽  
pp. s84-s84
Author(s):  
Lorinda Sheeler ◽  
Mary Kukla ◽  
Oluchi Abosi ◽  
Holly Meacham ◽  
Stephanie Holley ◽  
...  
Keyword(s):  
Screening Tool ◽  
Medical Center ◽  
Academic Medical Center ◽  
Tertiary Care ◽  
The United States ◽  
World Health ◽  
Communication Campaign ◽  
Electronic Screening ◽  
Novel Coronavirus ◽  
The Impact

Background: In December of 2019, the World Health Organization reported a novel coronavirus (severe acute respiratory coronavirus virus 2 [SARS-CoV-2)]) causing severe respiratory illness originating in Wuhan, China. Since then, an increasing number of cases and the confirmation of human-to-human transmission has led to the need to develop a communication campaign at our institution. We describe the impact of the communication campaign on the number of calls received and describe patterns of calls during the early stages of our response to this emerging infection. Methods: The University of Iowa Hospitals & Clinics is an 811-bed academic medical center with >200 outpatient clinics. In response to the coronavirus disease 2019 (COVID-19) outbreak, we launched a communications campaign on January 17, 2020. Initial communications included email updates to staff and a dedicated COVID-19 webpage with up-to-date information. Subsequently, we developed an electronic screening tool to guide a risk assessment during patient check in. The screening tool identifies travel to China in the past 14 days and the presence of symptoms defined as fever >37.7°C plus cough or difficulty breathing. The screening tool was activated on January 24, 2020. In addition, university staff contacted each student whose primary residence record included Hubei Province, China. Students were provided with medical contact information, signs and symptoms to monitor for, and a thermometer. Results: During the first 5 days of the campaign, 3 calls were related to COVID-19. The number of calls increased to 18 in the 5 days following the implementation of the electronic screening tool. Of the 21 calls received to date, 8 calls (38%) were generated due to the electronic travel screen, 4 calls (19%) were due to a positive coronavirus result in a multiplex respiratory panel, 4 calls (19%) were related to provider assessment only (without an electronic screening trigger), and 2 calls (10%) sought additional information following the viewing of the web-based communication campaign. Moreover, 3 calls (14%) were for people without travel history but with respiratory symptoms and contact with a person with recent travel to China. Among those reporting symptoms after travel to China, mean time since arrival to the United States was 2.7 days (range, 0–11 days). Conclusion: The COVID-19 outbreak is evolving, and providing up to date information is challenging. Implementing an electronic screening tool helped providers assess patients and direct questions to infection prevention professionals. Analyzing the types of calls received helped tailor messaging to frontline staff.Funding: NoneDisclosures: None

scholarly journals Daily Bathing with Chlorhexidine-Based Soap and the Prevention of Staphylococcus aureus Transmission and Infection

2014 ◽  
Vol 35 (3) ◽  
pp. 243-250 ◽  
Author(s):  
Melissa A. Viray ◽  
James C. Morley ◽  
Craig M. Coopersmith ◽  
Marin H. Kollef ◽  
Victoria J. Fraser ◽  
...  
Keyword(s):  
At Risk ◽  
Staphylococcus Aureus ◽  
Tertiary Care ◽  
Control Unit ◽  
Post Intervention ◽  
Icu Patients ◽  
Chlorhexidine Bathing ◽  
Before And After ◽  
Surgical Icu ◽  
Time Series Methodology

Objective.Determine whether daily bathing with chlorhexidine-based soap decreased methicillin-resistant Staphylococcus aureus (MRSA) transmission and intensive care unit (ICU)-acquired S. aureus infection among ICU patients.Design.Prospective pre-post-intervention study with control unit.Setting.A 1,250-bed tertiary care teaching hospital.Patients.Medical and surgical ICU patients.Methods.Active surveillance for MRSA colonization was performed in both ICUs. In June 2005, a chlorhexidine bathing protocol was implemented in the surgical ICU. Changes in S. aureus transmission and infection rate before and after implementation were analyzed using time-series methodology.Results.The intervention unit had a 20.68% decrease in MRSA acquisition after institution of the bathing protocol (12.64 cases per 1,000 patient-days at risk before the intervention vs 10.03 cases per 1,000 patient-days at risk after the intervention; β, −2.62 [95% confidence interval (CI), −5.19 to −0.04]; P = .046). There was no significant change in MRSA acquisition in the control ICU during the study period (10.97 cases per 1,000 patient-days at risk before June 2005 vs 11.33 cases per 1,000 patient-days at risk after June 2005; β, −11.10 [95% CI, −37.40 to 15.19]; P = .40). There was a 20.77% decrease in all S. aureus (including MRSA) acquisition in the intervention ICU from 2002 through 2007 (19.73 cases per 1,000 patient-days at risk before the intervention to 15.63 cases per 1,000 patient-days at risk after the intervention [95% CI, −7.25 to −0.95]; P = .012)]. The incidence of ICU-acquired MRSA infections decreased by 41.37% in the intervention ICU (1.96 infections per 1,000 patient-days at risk before the intervention vs 1.15 infections per 1,000 patient-days at risk after the intervention; P = .001).Conclusions.Institution of daily chlorhexidine bathing in an ICU resulted in a decrease in the transmission of S. aureus, including MRSA. These data support the use of routine daily chlorhexidine baths to decrease rates of S. aureus transmission and infection.

scholarly journals 301. Penicillin Versus Cefazolin or Anti-staphylococcal Penicillins for Penicillin-Susceptible Staphylococcus aureus Bacteremia

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S149-S149
Author(s):  
Mohammed Aldhaeefi ◽  
Jeffrey Pearson ◽  
Sanjat Kanjilal ◽  
Brandon Dionne
Keyword(s):  
Staphylococcus Aureus ◽  
Blood Culture ◽  
Positive Blood Culture ◽  
Medical Center ◽  
Academic Medical Center ◽  
Similar Distribution ◽  
Clinical Failure ◽  
Staphylococcus Aureus Bacteremia ◽  
Definitive Therapy ◽  
Significant Difference

Abstract Background Staphylococcus aureus bacteremia is a significant cause of mortality. Penicillin (PCN) may have a role in the treatment of penicillin-susceptible Staphylococcus aureus (PSSA) bacteremia as it has a narrower spectrum of activity than cefazolin and is better tolerated than antistaphylococcal penicillins (ASPs). The aim of this study is to evaluate the safety and effectiveness of PCN versus cefazolin or ASPs in the treatment of PSSA bacteremia. Methods This is a single-center, retrospective study at a tertiary academic medical center. All patients with a PSSA blood culture from January 1, 2012 to September 1, 2019 were screened. Patients were excluded if they were treated with a definitive antibiotic (defined as antimicrobial therapy received 72 hours after positive blood culture) other than the study comparators, or if they received combination antibiotic therapy &gt;72 hours from the initial positive blood culture result. The primary outcome was 60-day clinical failure, which was a composite endpoint of change in antibiotic after 72 hours of definitive therapy, recurrence of PSSA bacteremia, infection-related readmission, or all-cause mortality. Results Of 277 patients with PSSA bacteremia, 101 patients were included in the study; 62 (61%) were male and 11 (11%) had a β-lactam allergy. At baseline, 40 patients (40%) had hardware, 25 (25%) had an intravenous line, 6 (6%) were on dialysis, and 4 (4%) had active IV drug use, with similar distribution across antibiotic groups. Penicillin was the most common antibiotic used (Table 1). There was a significant difference among groups with respect to the 60-day clinical failure (log-rank p=0.019). In terms of unadjusted 60-day clinical failure, penicillin had similar outcomes to cefazolin (95% CI -0.29 to 0.104, p=0.376), however, it had statistically significant better outcomes in comparison to the ASPs, nafcillin or oxacillin (95% CI 0.023 to 0.482, p=0.031) (Table 1). Table 1. 60-day outcomes of PSSA bacteremia Conclusion Penicillin is effective and safe in the treatment of PSSA bacteremia and may be preferable to antistaphylococcal penicillins Disclosures All Authors: No reported disclosures

scholarly journals Surgical Results of Retrograde Mastoidectomy with Primary Reconstruction of the Ear Canal and Mastoid Cavity

2015 ◽  
Vol 2015 ◽  
pp. 1-12 ◽  
Author(s):  
Chao-Yin Kuo ◽  
Bor-Rong Huang ◽  
Hsin-Chien Chen ◽  
Cheng-Ping Shih ◽  
Wei-Kang Chang ◽  
...  
Keyword(s):  
Adverse Events ◽  
Mastoid Cavity ◽  
Surgical Results ◽  
Ear Canal ◽  
Hearing Results ◽  
Hearing Gain ◽  
Before And After ◽  
Hearing Outcomes ◽  
The Impact

The aim of this study was to retrospectively review the long-term hearing results and the impact of mastoid exclusion/obliteration in patients with cholesteatoma (102 ears) who underwent retrograde tympanomastoidectomy and in whom bone chips/paté were applied as the sole materials during the procedure. In 79 ears, this was combined with ossiculoplasty in a single-stage procedure. In >71% of ears, the results of audiometric testing were monitored for more than 2 years. The results suggested there was a significant gain in hearing following surgery, with respect to the postoperative change in both air-conduction thresholds and air-bone gaps (P<0.001). Linear regression analyses of pure-tone averages at different frequencies, before and after surgery, demonstrated that patients benefitted from a postoperative hearing gain at low and middle frequencies, but their hearing often deteriorated at frequencies of 8000 Hz. As for the impact of the type of tympanoplasty on hearing outcomes, type III-interposition markedly increased hearing gain. The overall rate of postoperative adverse events was 8.8%. We conclude that reconstruction of the ear canal and mastoid via mastoid exclusion/obliteration using bone chips/paté can be considered as an alternative procedure following retrograde mastoidectomy. It gives excellent surgical results and has fewer postoperative adverse events.

Antimicrobial Resistance in Staphylococcus aureus at the University of Chicago Hospitals: A 15-Year Longitudinal Assessment in a Large University-Based Hospital

2003 ◽  
Vol 24 (6) ◽  
pp. 403-408 ◽  
Author(s):  
John B. Seal ◽  
Beatriz Moreira ◽  
Cindy D. Bethel ◽  
Robert S. Daum
Keyword(s):  
Staphylococcus Aureus ◽  
Methicillin Resistance ◽  
Tertiary Care ◽  
University Teaching ◽  
Annual Rate ◽  
University Of Chicago ◽  
Longitudinal Assessment ◽  
Beta Lactam ◽  
The University ◽  
The Impact

AbstractObjectives:To describe a longitudinal profile of resistance to beta-lactam antimicrobials among isolates of Staphylococcus aureus at a large university teaching hospital and to evaluate the impact of the methicillin resistance phenotype on resistance trends for non-beta-lactam antimicrobials.Design:Retrospective evaluation of antimicrobial susceptibility data for all 17,287 S. aureus isolates obtained from January 1986 through December 2000.Setting:The University of Chicago Hospitals, a family of tertiary-care, university-affiliated hospitals in Chicago, Illinois, consisting of 547 adult and pediatric beds.Results:The annual rate of resistance to methicillin increased from 13% in 1986 to 28% in 2000 (P < .001) and has not plateaued. For each non-beta-lactam antimicrobial tested, the annual rates of resistance were far higher among methicillinresistant S. aureus (MRSA) isolates than among methicillin-susceptible S. aureus (MSSA) isolates. The annual rates of resistance to the macrolide, lincosamide, and streptogramin (MLS) antimicrobials erythromycin and clindamycin increased among MSSA isolates (P < .01), but remained lower than 20%. Resistance to the MLS antimicrobials was higher among MRSA isolates (higher than 60%), but the annual rate decreased significantly during the study (P < .01).Conclusion:The prevalence of methicillin resistance among S. aureus isolates has continued to increase; resistance to non-beta-lactam antimicrobials is far more common among MRSA isolates. Recent decreases in the proportion of MRSA isolates resistant to non-beta-lactam antimicrobials suggest important changes in the epidemiology of this pathogen.

114 Allowing Overlapping Surgery Decreases Length of Stay in an Academic, Safety-Net Hospital

Neurosurgery ◽  
2017 ◽  
Vol 64 (CN_suppl_1) ◽  
pp. 224-224
Author(s):  
Anthony Michael DiGiorgio ◽  
Praveen V Mummaneni ◽  
Jonathan Lloyd Fisher ◽  
Adam Podet ◽  
Clifford Crutcher ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Tertiary Care ◽  
Wait Time ◽  
Multivariate Regression Analysis ◽  
Safety Net ◽  
Neurosurgical Procedures ◽  
Urgent Surgery ◽  
Period 2 ◽  
Safety Net Hospital ◽  
The Impact

Abstract INTRODUCTION The practice of surgeons performing overlapping surgery has recently come under scrutiny. We sought to examine the impact of overlapping rooms on surgery wait time and length of stay in patients admitted to a tertiary care, safety-net hospital for urgent neurosurgical procedures. METHODS Our hospital functions as a safety-net, tertiary care, level-1 trauma center in the Southern United States. The neurosurgery service transitioned from routinely allowing one room per day (period 1) to overlapping rooms (period 2), with the second room being staffed by the same attending surgeon. Patients undergoing neurosurgical intervention in each period were retrospectively compared. Case urgency, patient demographics, case type, indication, length of stay and time from admission to surgery were tracked. RESULTS >452 total cases were reviewed (201 in period 1 & 251 in period 2), covering 7 months in each period. 122 of the cases were classified as “urgent” (59 in period 1 and 63 in period 2). In the these patients, length of stay was significantly decreased in period 2 (13.09 days vs 19.52, p = .002) and the time from admission to surgery for urgent cases trended towards a shorter time (5.12 days vs 7.00, p = .084). Insurance status of these patients was 26.2% uninsured, 39.3% Medicaid, 18.9% Medicare, 9% commercial and the remainder workers compensation, liability or prisoner care. Multivariate regression analysis revealed that being in period 1, having Medicare, having trauma as the indication for surgery, and undergoing a non-cranial or non-spinal procedure as significant factors for increased length of stay. CONCLUSION Recent studies suggest overlapping surgeries are safe for patients. In the case of our safety net hospital, allowing the neurosurgery service to run overlapping rooms significantly reduces length of stay in a vulnerable population who is admitted in need of urgent surgery.

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