Length of Stay, Mortality, Cost, and Perceptions of Care Associated With Transition From an Open to Closed Staffing Model in the Cardiac Intensive Care Unit.

BACKGROUND: Organizational models in the intensive care unit (ICU) have classically been described as either closed or open, depending on the presence or absence of a dedicated ICU team. Although a closed model has been shown to improve patient outcomes in medical and surgical ICUs, the merits of various care models have not been previously explored in the cardiac ICU (CICU) setting. METHODS: From November 2012 to March 2014, data were prospectively collected on all admissions before and after transition from an open to closed CICU at our institution. Baseline clinical variables, illness severity, admission and discharge diagnoses, resource use, and outcomes were recorded. Anonymous surveys were also collected from nursing and resident trainee participants to evaluate the influence of unit structure on perceptions of care. Descriptive statistics were used, and logistic regression modeling was performed to examine the impact of unit structure on mortality. RESULTS: The study consisted of 670 patients, 332 (49.6%) of whom were admitted to the open CICU model and 338 (50.4%) of whom were admitted to the closed model. Neither CICU nor hospital mortality differed between the open and closed units, though length of stay was shorter in the closed CICU. Additionally, nurses and resident trainees reported that the closed CICU allowed for better communication, collaboration, and education. CONCLUSIONS: Although there was no significant impact of unit structure on patient outcomes in this single-center study, the closed CICU model was associated with better perceptions of care.

Revascularization Strategies in Patients with Diabetes Mellitus and Acute Coronary Syndrome.

Patients with diabetes mellitus (DM) have more severe CAD and higher mortality in acute coronary syndrome (ACS) than patients without DM. The optimal mode of revascularization-coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI)-remains controversial in this setting. For patients with DM and ST-segment elevation myocardial infarction, prompt revascularization of the culprit artery via PCI is generally preferable. In non-ST-elevation ACS, the decision on mode of revascularization is more challenging. Trials comparing CABG with percutaneous transluminal coronary angioplasty, bare metal stents, and first-generation drug-eluting stents in DM patients with multivessel have demonstrated decreased mortality in those receiving CABG. On the other hand, trials and retrospective analyses comparing CABG to PCI with second-generation drug-eluting stents have not shown a statistically significant mortality benefit favoring CABG. This potentially narrowed that gap between CABG and PCI requires further investigation.

Complete Resolution of Tumor Burden of Primary Cardiac Non-Hodgkin's Lymphoma.

Primary cardiac tumors are a rare set of benign and malignant neoplasms found in the heart or pericardium. We describe a patient presenting with nonspecific symptoms and ultimately diagnosed with primary cardiac non-Hodgkin's lymphoma (PCL). Our patient had extensive tumor in the right ventricle, which extended into the right atrium and right ventricular outflow tract. The tumor also encased the right coronary artery, which manifested as ischemic changes on EKG and cardiac MRI. The patient was treated with chemotherapy and achieved complete remission, with dramatic and full resolution of the mass on repeat echocardiography in nine weeks. More studies are needed to understand the optimal management and prognosis of patients with PCL.

Putting class IIb recommendations to the test: the influence of unwitnessed and Non-VT/VF arrests on resource consumption and outcomes in therapeutic hypothermia and targeted temperature management.

Therapeutic hypothermia (TH) and targeted temperature management improve neurologic recovery, and survival for patients resuscitated from witnessed out-of-hospital ventricular tachycardia (VT) and ventricular fibrillation (VF) cardiac arrest. The American Heart Association recently gave a class IIb recommendation for the use of TH for non-VT/VF and unwitnessed arrests. We explored changes in baseline characteristics, resource use, and outcomes after expanding indications for TH at our institution based on these guidelines. Fifty-six consecutive patients treated with TH for out-of-hospital cardiac arrest were retrospectively evaluated based on whether they received treatment before (protocol 1) or after (protocol 2) broadening inclusion criteria. In protocol 1, TH was indicated after a witnessed VT/VF arrest. In protocol 2, TH was indicated for unwitnessed arrests, pulseless electrical activity, or asystole. Both populations undergoing TH had similarly extensive medical comorbidities and consumed considerable hospital resources. Overall, 64% of the patients from both protocols died in the hospital, although nominally lower mortality was seen in patients treated under protocol 1 compared with protocol 2 (59% vs. 67%, P = 0.57). Lower mortality was observed after VT/VF than after pulseless electrical activity or asystole (47% vs. 93% vs. 56%, P = 0.017). No patient survived following an unwitnessed arrest, and age (odds ratio per 10 years = 2.59; 95% confidence interval, 1.34-4.81) was independently associated with increased mortality. In an evolving field where best practice is still poorly defined, these data, along with future prospective studies in larger populations, should help to enhance care delivery and optimize cost-effectiveness strategies.