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Going the Extra Mile: Roadtrip to Improved Outcomes
No full textBackground
Patient mobility is a critical factor in improving patient outcomes. Nurse leaders at a Milwaukee, Wisconsin, community hospital identified concerning trends: increasing discharges to subacute facilities, prolonged length of stay (LOS), and rising rates of healthcare-acquired pressure injuries (HAPI). Concurrently, the hospital was underperforming in nurse-driven mobility compared to similar-sized hospitals.
Purpose
This initiative, dubbed “Mobility Roadtrip,” aimed to increase nurse-driven patient mobility, distance, and ambulation frequency to evaluate its effectiveness on key outcomes including LOS, HAPI rates, and discharge destination.
Implementation Plan
Over three months, four inpatient units (two medical-surgical, one observation, and one intensive care) participated in an initiative linking ambulation distances to local destinations, including Purple Door Ice Cream, American Family Field, Mars Cheese Castle, and Six Flags. Units earned themed rewards for reaching each destination, including tickets and prizes. Weekly data focused on patients with activity orders, excluding non-ambulatory or patients with orders for bedrest. Safe ambulation was achieved by using the Comprehensive Mobility Evaluation Tool and additional Level of Assistance Tool.
Outcomes
Median miles ambulated by nursing increased from 9.3 to 12.8 miles/month, and patients with hallway ambulation rose from 63.9% to 76.7%. LOS decreased 5.2 to 4.9 days, home discharges increased 51.8% to 54.2%, and HAPI rates per 1,000 patient days decreased 3.18 to 0.60. Statistical analysis revealed significant differences in miles ambulated (p = 0.010), distance documented (p = 0.002), and HAPI rates (p = 0.031). However, LOS, hallway ambulation, and discharge home showed insignificant differences (p = 0.468, p = 0.198, p = 0.453, respectively).
Implications
The Mobility Roadtrip demonstrated that themed competitions boost staff engagement, improving patient mobility and clinical outcomes. Ongoing efforts include weekly mobility tracking and quarterly themed competitions, focusing on ambulation distance and consistency, with nursing surpassing therapy miles for eight consecutive months
Abstract 4364741: Real-world assessment of the efficacy of inclisiran in lowering low-density lipoprotein cholesterol: Outcomes from AAH tertiary cardiovascular clinics
No full textAbstract 4368638: Comparable one-year efficacy and safety of spironolactone versus amiloride in resistant hypertension: A Retrospective Cohort Analysis
No full textAbstract 4365052: Bedtime versus morning dosing of antihypertensives: A systematic review and meta-analysis of randomized controlled trials
No full textAbstract Sat605: Changing relative distribution of out-of-hospital cardiac arrest cases by sex
No full textAwakening a patient with congenital deafness from general anesthesia
No full textIntroduction: Emergence from general anesthesia signifies the waning of the anesthetic effect and the recovery of consciousness. After general anesthesia, one criterion for extubation is the ability to follow simple commands. The ability to follow commands demonstrates that the patient has adequate consciousness, can protect their airway, and can coordinate basic movements, which suggests an ET tube can be safely removed. Congenital deafness thus presents an obstacle for the Anesthesiologist to communicate with a patient as they awaken from general anesthesia. Case Presentation: A 44-year-old female with a history of congenital deafness and bilateral DCIS S/P bilateral mastectomy presents for breast reconstruction with implants. An in-person ASL interpreter was present to assist in facilitating a safe induction of general anesthesia, which was occurred without issue. Muscle relaxation was achieved with rocuronium and maintenance of general anesthesia was achieved with sevoflurane. The case concluded without complication. An ASL interpreter was not available for extubation. Neuromuscular blockade was reversed with Sugammadex. As sevoflurane weaned, patient was breathing spontaneously without pressure support. Because commands were unable to be communicated to the patient, we waited for patient to spontaneously open her eyes. To keep the patient comfortable and prevent coughing against the endotracheal tube after breast surgery, we administered 25 mg of transtracheal lidocaine via the ETT. After approximately 20 minutes, the patient opened her eyes, at which point her end tital sevoflurane concentration was 0%. She was extubated safely and was taken to the PACU without issue. Conclusion: To safely remove an endotracheal tube after general anesthesia, it is important to assess whether the patient has regained adequate consciousness and basic motor coordination to ensure they can maintain their own airway after extubating. To assess the return of these functions, patients are asked to perform basic motor commands prior to extubating (1). Congenital deafness presents an obstacle in communicating these commands to the patient. There is an absence of literature regarding anesthestic management of patient with deafness. A prior report has utilized BIS monitoring to assess levels of consciousness in an adolescent patient (2). We recommend extubating at your own comfort level while preserving the safety of the patient. 1. Benham-Hermetz J, et al. (2021) BJA Educ. 21(12):446-454. 2. Yi-Chun Chen, et al. (2010) Acta Anaesthesiologica Taiwanica 48(4):185-18
Breaking age barriers: Neuroaxial anesthesia for intramedullary rod insertion of right femur in a 99-year-old patient
No full textIntroduction: Neuraxial anesthesia is a commonly utilized technique for lower extremity surgeries by offering significant benefits such as reduced cardiovascular and respiratory risks compared to general anesthesia. Femoral rod fixation often poses unique anesthetic challenges in the elderly due to their advanced age, comorbidities, and reduced physiological reserves [1]. For a 99-year-old patient, extensive discussion between healthcare providers and patient’s family, as well as having a tailored anesthetic plan is crucial to optimize patient outcomes and minimize potential complications. Case Presentation: The case represents a 99-year-old female with a BMI of 18.8 and a significant past medical history of atrial fibrillation on Eliquis, sick sinus syndrome status post pacemaker placement in 2008, systolic congestive heart failure with a recovered ejection fraction of 35% to 55%, multivessel coronary artery disease, tricuspid valve regurgitation, pulmonary hypertension with a PASP of 60 mmHg, chronic kidney disease, hypertension, GERD, hypothyroidism, hyperlipidemia, and legal blindness in the left eye. Patient presented for an insertion of intramedullary rod fixation of the right femur following a mechanical fall. Prior to surgery, medical and cardiac clearance was obtained, which revealed the patient’s high intraoperative risk and a NSQIP risk of mortality estimated at approximately 33.2%. From the cardiology perspective, the patient was deemed medically optimized to the best extent possible. Once clearance was finalized, discussions were held with the patient’s power of attorney (POA) to ensure alignment on the surgical plan. Initially, general anesthesia (GA) was intended for the procedure; however, significant concerns were raised regarding the patient’s cardiac history and the risks associated with GA. After thorough discussions among the surgical, anesthesia, and POA teams, it was decided to proceed with a trial of a spinal block, reserving GA as a backup if necessary. Intraoperatively, an L2-L3 spinal anesthesia was administered using the C-arm and 1.1 mL of 0.75% bupivacaine in dextrose. An arterial line was placed in the left radial artery for close blood pressure monitoring. The patient tolerated the procedure well and received a total of 75 mcg of fentanyl, 1.5 liters of intravenous fluids, and some phenylephrine boluses for blood pressure support. After the surgery, she was transferred to the PACU for monitoring where she had an uneventful recovery. Subsequently, she was discharged home later that day. Conclusion: A thorough preoperative evaluation and use of clear, closed-loop communication among the care team-including anesthesia, surgery, cardiology, and patient’s POA, are essential in ensuring alignment and addressing potential complication. Equally as important is having a well-prepared backup plan to managed unexpected situations effectively. This collaborative approach minimizes risks and enhances patient’s safety. 1. Guay, J. et al. (2016). Cochrane Database Syst Rev 22: 1-8
Research Authorization and Protocol Review (RAPR) : A centralized research review model for Advocate Health Midwest
No full textAdvocate Aurora Research Institute (AARI) has implemented a Research Authorization and Protocol Review (RAPR) process to streamline the review and authorization of research conducted within Advocate Health (AH) Midwest. RAPR aims to facilitate the submission and review of various types of research, coordinates scientific and administrative reviews, ensures proposals are compliant with AH policies and procedures, and, when applicable, authorizes research support services to studies that are meritorious as well as operationally and financially feasible. The process uses a Research Electronic Data Capture (REDCap) platform for submission, review, scoring, and tracking of clinical research requests. Unique REDCap workflows were customized for Academic Research, Graduate Medical Education Research, Nursing Research, and Sponsored Clinical Trials. Research studies are reviewed by scientific and clinical experts, as well as research administrators, and are evaluated based on standard scoring criteria, including organizational priority, patient impact, qualifications of the study team, funding, resource availability, research quality, contracting/legal support, and cybersecurity considerations. RAPR determinations are communicated to the study team and key personnel through REDCap notifications. RAPR authorization is a mandatory requirement at AH Midwest and a prerequisite for submitting a research study to the Institutional Review Board
Transcatheter aortic valve replacement outcomes in patients with high gradient versus low ejection fraction low gradient severe aortic stenosis: A meta-analysis of randomized controlled trials
No full textBackground: The outcome of Low Flow-Low Gradient (LF-LG) severe aortic stenosis (AS) patients who underwent Transcatheter Aortic Valve Replacement (TAVR) procedure is not well defined. We conducted a systematic review of the literature to compare the outcomes of TAVR in LF-LG AS patients to the more traditional high gradient (HG) aortic stenosis.
Methods: We comprehensively searched for controlled randomized and non-randomized studies from 4 online databases. We are presenting the data using risk ratios (95 % confidence intervals) and measuring heterogeneity using Higgins\u27 I2 index.
Results: Our analysis included 4380 patients with 3425 HG patients and 955 LF-LG patients from 6 cohort (5 retrospective and 1 prospective) studies. When compared to LFLG; TAVR was associated with significantly lower 30 days mortality in HG patients (5.1 % vs 7.4 %; relative risk [RR]: 0.55; 95 % confidence interval [CI]: 0.35 to 0.86; p \u3c 0.01). Similar findings were also observed in 12-month cardiovascular (CV) mortality (5.5 % vs. 10.4 %; RR: 0.47; 95 % CI: 0.38 to 0.60; p \u3c 0.01 and 12-month all-cause mortality (15.9 % vs 20.9 %; RR: 0.70; 95 % CI: 0.49 to 1.00; p \u3c 0.05). There was no significant difference in myocardial infarction (MI) after TAVR between HG and LF-LG at 30 days (0.16 % vs. 0.95 %; p \u3c 0.09) or 12 months (0.43 % vs. 0.95 %; p = 0.20). Similarly, there was no difference in stroke rates at 30 days (2.9 % vs. 2.86 %) or at 12 months (3.6 % vs. 3.06 %).
Conclusions and relevance: Patients with LF-LG severe AS who underwent TAVR had worse 1-year all-cause mortality, 30-day all-cause, and 1-year CV mortality when compared to TAVR in HG severe AS. There was no difference in MI or stroke rates. Therefore, with heart team discussion and informed patient decision regarding the risk and benefit, TAVR would still offer better outcomes in LFLG AS compared to conservative medical management