Simulation of "North Carolina Protocol for Allocating Scarce Inpatient Critical Care Resources in a Pandemic" in a Multi-hospital Health Care System.

BACKGROUND An integrated nonprofit health care system with 13 North Carolina medical centers conducted a time-pressured quality improvement simulation of its plan to implement the "North Carolina Protocol for Allocating Scarce Inpatient Critical Care Resources in a Pandemic" attendant to pandemic scenario planning. Simulation objectives included assessing the plan in terms of a) efficiency and effectiveness; b) comorbidity scoring validity; c) impact by race/ethnicity, gender, age, and payer status; and d) simulation participant impressions of potential impact on clinicians.METHOD The simulation scenario involved scoring 14 patients with the constraint that only 10 could be afforded critical care resources. Also included were independent scoring validation by four clinicians, structured debriefs with simulation participants and observers, and tracking patient outcomes for 30 days.RESULTS Triage scoring was identical among four triage teams. Lack of concordance in clinician comorbidity scoring did not alter patient prioritization for withdrawal of treatment in this small cohort. Protocol scoring was not correlated with resource utilization or near-term mortality.LIMITATIONS The simulation sample was small and selected when COVID-19 census was temporarily waning. No protocol for pediatric patients was tested.CONCLUSIONS The simulation yielded resource allocation concordance using comorbidity scoring by attending physicians, which significantly accelerated triage team decision-making and did not result in notable disparities by race/ethnicity, gender, or advanced age. Qualitative findings surfaced tensions in balancing de-identified data with individualized assessment and in trusting the clinical judgments of other physicians. Additional research is needed to validate the protocol's predictive value related to patient outcomes.

Flexible transbronchial needle aspiration in the diagnosis of sarcoidosis.

The histopathologic diagnosis of sarcoidosis requires the presence of noncaseating granulomas. Transbronchoscopic lung biopsy (TBLB) has been considered the procedure of choice when less invasive tissue samples are unavailable. A total of 51 consecutive patients suspected of having sarcoidosis underwent combined TBLB and flexible transbronchial needle aspirate (TBNA). In 18 of the 30 patients (60 percent) with stage I disease, the diagnosis was confirmed by TBLB and 16 (53 percent) were confirmed by TBNA. The combined use of both procedures increased the diagnostic yield to 83 percent. The remaining 21 patients with stage II disease had their diagnosis confirmed in 16 (76 percent) cases by TBLB and 10 (48 percent) by TBNA with a combined diagnostic yield of 86 percent. Seven (23 percent) patients with stage I disease and 2 (10 percent) with stage II disease had their conditions diagnosed by TBNA. We conclude that combining TBNA with TBLB increases the diagnostic yield in pulmonary sarcoidosis; TBNA should complement TBLB in the diagnosis of this disease.

Assessment of injury in transplanted and nontransplanted lungs after 6 h of cold storage with glutathione.

Single-lung transplantation after 3 h of hypothermic storage produces bilateral lung injury [pulmonary reimplantation response (PRR)]. We hypothesized that glutathione (GSH) hypothermic storage would protect both lungs from PRR for extended preservation times and that differences in injury and protection would be realized between the graft and the nontransplanted lung. Mongrel dogs underwent left single-lung autotransplantation after preservation for 5-6 h in Euro-Collins (EC) solution, EC plus exogenous GSH (EC+GSH), or Viaspan (VIA) at 4 degrees C. Lung injury was measured in both lungs after 1 h of reperfusion. EC dogs demonstrated significant increases in lung edema, lipid peroxidation, and alveolar neutrophil recruitment in the lung graft and to a less extent in the nontransplanted right lung compared with control dogs (P < 0.05). Edema, lipid peroxidation, and alveolar neutrophils were significantly reduced in both lungs from EC+GSH and VIA dogs compared with lungs from EC dogs (P < 0.05). An increase in large-pore permeability was measured in the lung graft from EC dogs compared with all other lungs. Bronchoalveolar lavage fluid lactate dehydrogenase and total protein concentrations were elevated in both lungs from all three groups of tranplanted dogs compared with those of control dogs (P < 0.05). These data suggest that GSH-containing solutions attenuate the PRR after 6 h of ischemic hypothermic storage but that the protection is incomplete. Mechanisms of injury affecting the lung graft during the PRR appear to differ from those affecting the nontransplanted lung.

Comparison of the Wang 19-gauge and 22-gauge needles in the mediastinal staging of lung cancer.

Transbronchial needle aspiration (TBNA) offers the unique opportunity to pathologically stage patients with lung cancer at the time of diagnostic bronchoscopy. The purpose of this study was to compare the staging sensitivities of the Wang 22-gauge and 19-gauge needles. We studied 64 patients with bronchogenic carcinoma and mediastinal adenopathy. Before bronchoscopy each patient underwent chest CT. Three to four aspirates were obtained with each needle from endotracheal sites adjacent to paratracheal lymphadenopathy. In 47 patients malignant mediastinal adenopathy was confirmed by the 19-gauge needle. A total of 29 patients had malignant 22-gauge needle aspirates. Of the 64 patients, 9 had benign, reactive mediastinal lymph nodes. There were 20 patients in whom only the 19-gauge needle demonstrated malignancy and 2 patients with malignant 22-gauge needle aspirates as the sole identifier of paratracheal malignancy. As a staging tool, the 19-gauge needle was significantly more sensitive than the 22-gauge needle, 85.5 versus 52.7% (p = 0.0001). Overall, in 49 of 55 patients (89.1%) with malignant mediastinal lymphadenopathy paratracheal tumor was confirmed by TBNA. The 19-gauge TBNA staging of the mediastinum is an effective, safe, and cost-saving alternative to surgical mediastinal exploration that can be performed during initial diagnostic bronchoscopy.