Stepped care versus center-based cardiopulmonary rehabilitation for older frail adults living in rural MA: Design of a feasibility randomized controlled trial.

Background: Cardiac and pulmonary rehabilitation programs are grossly underutilized, and participation is particularly low in rural regions. Methods: We are conducting a 2-arm, randomized controlled feasibility trial. Eligible participants include older frail adults with cardiac or pulmonary disease living in a predominantly rural county in western Massachusetts. Participants are randomized 1:1 to treatment as usual or stepped care. Patients randomized to treatment as usual participate in twice weekly center-based rehabilitation sessions over eight weeks and are encouraged to exercise at home in between sessions. Patients randomized to the stepped-care arm are offered/enrolled in the center-based rehabilitation program followed by possible step up to three interventions based on prespecified non-response criteria: 1) Transportation-assisted center-based rehabilitation, 2) Home-based telerehabilitation, and 3) Community health worker-supported home-based telerehabilitation. The primary feasibility outcomes are average number of eligible patients randomized per month, baseline measure completion, proportion attending at least 70% of the prescribed sessions, average number of sessions attended in the stepped-care arm, and proportion in the stepped-care arm completing patient reported outcome measures. Each of these process indicators is evaluated by preset "Stop" and "Go" thresholds. Conclusion: The proposed stepped-care model is an efficient, patient-centered, approach to expanding access to cardiac and pulmonary rehabilitation. Meeting the "Go" thresholds for the prespecified process indicators will justify conducting a definitive full-scale randomized controlled trial to compare the effectiveness and value (cost-effectiveness) of stepped-care versus center-based rehabilitation in older frail adults living rural counties.

Project HANDS: A Bundled Approach to Increase Short Peripheral Catheter Dwell Time.

Increasing short peripheral catheter (SPC) dwell time is becoming common practice. A number of variables lead to unscheduled restarts and significant complications with SPCs. Preventing complications is important to patient outcomes as dwell time increases. This quality improvement project compared the use of a manufactured securement device versus tape and transparent occlusive dressing while instituting a standardized insertion and care bundle with a 96-hour dwell time. Major findings included no statistically significant difference in restart rates in SPCs secured with a device compared with those secured with tape and transparent occlusive dressing (P = .06). These results differ from other published studies and may be due to the traditional nature of the hospital's infusion team and patients' average length of stay.

Ideal timing of surgery for acute uncomplicated appendicitis.

BACKGROUND: Early surgery for appendicitis is thought to avoid complications associated with appendiceal rupture. AIMS: This study was to evaluate the effect of timing of surgery on complications, length of stay (LOS) and cost in patients undergoing appendectomy. MATERIALS AND METHODS: Retrospective review of 396 patients with appendectomies from January 1, 2005 to December 31, 2007 was performed. Demographic data, time of presentation, physical findings, diagnostic data, operating room times, LOS, cost and complications were collected. Patients were divided into 4 groups based on time from presentation to appendectomy. RESULTS: Pathology confirmed appendicitis in 354 (89%) patients. Most patients (90%) had surgery within 18 h of presentation. Timing of surgery did not affect the incidence of purulent peritonitis (P = 0.883), abscess (P = 0.841) or perforation (P = 0.464). LOS was significantly shorter for patients with emergency department registration to operating room times less than 18 h (P < 0.0001). Costs were significantly higher for patients with times to operating room greater than 18 h (P < 0.001). CONCLUSION: Timing of surgery did not affect the incidence of complications or perforated appendicitis. However, delay in surgical consultation and surgery are associated with increased LOS and increased hospital costs. The optimal timing of appendectomy for uncomplicated acute appendicitis appears to be within 18 h of emergency department presentation.

Relationship of plasma gelsolin levels to outcomes in critically ill surgical patients.

OBJECTIVE: To examine the relationship between plasma gelsolin levels and mortality following surgery or trauma. BACKGROUND: Few simple predictive diagnostic tests are available to predict mortality following surgery or trauma. We hypothesize that plasma concentrations of gelsolin, a protein that responds to injured tissue, might be a predictor of patient outcomes. METHODS: We conducted a prospective, observational study in the surgical intensive units (ICU) at a tertiary care teaching hospital. A total of 31 patients were enrolled in the study. Chart abstraction was used to gather data about patient demographics, clinical characteristics, and clinical outcomes. Plasma gelsolin concentrations were assessed serially on day 0 through day 5. RESULTS: Low plasma gelsolin levels were associated with increased risk of death occurring in the ICU. Plasma gelsolin levels lower than 61 mg/L predicted longer ICU stay, prolonged ventilator dependence, and increased overall in-hospital mortality. CONCLUSION: Plasma gelsolin is a potential prognostic biomarker for critically ill surgical patients. Plasma gelsolin replacement may have therapeutic application.