Balancing quality and quaternary care imperative using a high-risk case review committee in adults.

OBJECTIVES: Quaternary care centres have an imperative to serve as hospitals of last resort and must also meet professional quality targets. We developed a high-risk committee (HRC) to evaluate cases meeting pre-defined predicted risk cut-offs as a part of an overall quality improvement drive. METHODS: We describe the structure, outcomes and effects of the Penn HRC. Using propensity-matching, we investigated whether the committee modifies or screens risk. We used multivariable analysis to examine the impact of unmeasured variables on clinical outcomes in this cohort. RESULTS: Institutional predicted and observed mortality had already been in decline prior to HRC institution in 2017, due to a multi-faceted quality improvement initiative. Between 2017 and 2020, the HRC discussed 205 patients with a median predicted risk of mortality of 10.6% (range 0.4-66%). Coronary artery bypass grafting was the most commonly presented operation. A total of 155 patients underwent operation (risk 10.3%), 12 had surgery deferred for optimization (risk 6%), 50 had surgery declined (risk 11.7%) and 12 patients had a deferred decision for further investigation. Overall 30-day survival was 86% for the entire cohort and 89% for operated patients. A matched analysis of similar patients prior to and following the HRC showed that the HRC did not directly modify outcomes. Most patients had better than expected survival (observed:expected mortality < 1). Predicted risk did not predict 30-day mortality among this high-risk cohort. CONCLUSIONS: HRCs serve as an important element in quality improvement by encouraging a thoughtful approach and channelling the collective experience of a group of senior surgeons. It may improve patient selection by identifying a cohort with extremely poor survival, while allowing safe operation with acceptable outcomes among a group with very high operative risk.

Transparency, Public Reporting, and a Culture of Change to Quality and Safety in Cardiac Surgery.

Academic medical centers have a duty to serve as hospitals of last resort for advanced cardiac surgical care and therefore manage patients at elevated risk of postoperative morbidity and mortality. They must also meet state and professional quality targets devised to protect the public. The tension between these imperatives can be managed by a multidimensional quality improvement program that aims to manage risk, optimize outcomes, and exclude futile operations. We here share our approach to this process, its impact on our institution, and discuss pertinent issues relevant to institutions in a similar situation.

A Roadmap for Industry to Harness Biotechnology for a More Circular Economy.

Biotechnology methods and applications have the potential to accelerate a transition to a more circular economy. This article identifies five distinct points within a typical product lifecycle as areas where biotechnology can be impactful, starting with so-called 'beginning-of-life', with the ability to make many widely-used chemicals and materials using renewable feedstocks to reduce greenhouse gas emissions. This extends into a discussion of novel materials; a holistic approach to designing for improved lifecycle outcomes; compostability; and the potential for reuse and up-cycling at end-of-life, to enable a circular flow of materials. We propose specific steps that can be taken by chemical and materials manufacturers, designers and brands.

Incidence and Duration of Continuously Measured Oxygen Desaturation During Emergency Department Intubation.

STUDY OBJECTIVE: Desaturation during intubation has been associated with serious complications, including dysrhythmias, hemodynamic decompensation, hypoxic brain injury, and cardiac arrest. We seek to determine the incidence and duration of oxygen desaturation during emergency department (ED) rapid sequence intubation. METHODS: This study included adult rapid sequence intubation cases conducted between September 2011 and July 2012 in an urban, academic, Level I trauma center ED. We obtained continuous vital signs with BedMasterEX data acquisition software. Start and completion times of rapid sequence intubation originated from nursing records. We defined oxygen desaturation as (1) cases exhibiting SpO2 reduction to less than 90% if the starting SpO2 was greater than or equal to 90%, or (2) a further reduction in SpO2 in cases in which starting SpO2 was less than 90%. We used multivariable logistic regression to predict oxygen desaturation during rapid sequence intubation. RESULTS: During the study period, there were 265 rapid sequence intubation cases. The study excluded 99 cases for failure of electronic data acquisition, inadequate documentation, or poor SpO2 waveform during rapid sequence intubation, and excluded cases managed by anesthesia providers, leaving 166 patients in the analysis. After preoxygenation, starting SpO2 was greater than 93% in 124 of 166 cases (75%) and SpO2 was less than 93% in the remaining 46 cases. Oxygen desaturation occurred in 59 patients (35.5%). The median duration of desaturation was 80 seconds (interquartile range 40, 155). Multivariable analysis demonstrated that oxygen desaturation was associated with preintubation SpO2 less than 93% (odds ratio [OR] 5.1; 95% confidence interval (CI) 2.3 to 11.0), multiple intubation attempts (>1 attempt) (OR 3.4; 95% CI 1.4 to 6.1), and rapid sequence intubation duration greater than 3 minutes (OR 2.7; 95% CI 1.2 to 6.1). CONCLUSION: In this series, 1 in 3 patients undergoing ED rapid sequence intubation experienced oxygen desaturation for a median duration of 80 seconds. Preintubation saturation less than 93%, multiple intubation attempts, and prolonged intubation time are independently associated with oxygen desaturation. Clinicians should use strategies to prevent oxygen desaturation during ED rapid sequence intubation.

The use of chemical restraints reduces agitation in patients transported by emergency medical services.

BACKGROUND: Agitated patients are the primary source of injury to patients and providers during ambulance transport. OBJECTIVE: Our primary hypothesis was that the addition of a chemical restraint agent (midazolam) to a restraint protocol would reduce agitation to a greater extent than a restraint protocol with physical restraint alone. METHODS: The local emergency medical services restraint protocol (RP) was implemented on October 1, 2006. It included a form for data collection about each restrained patient. On April 1, 2007, chemical restraint (CR) using midazolam in addition to physical restraints was made available through the RP, and paramedics were educated in its use. Transported patients were divided into pre-CR and post-CR. The post-CR group was split into those who received and those who did not receive midazolam. Agitation was measured on a validated agitation behavior scale with a parametric (Rasch) adjustment. RESULTS: There were 96 patients in the pre-CR group and 522 patients in the post-CR group. Forty-three percent of the pre-CR group and 49% of the post-CR group had a decrease in agitation during transport (NS). Of the 522 in the post-CR group, 110 were physically restrained and given midazolam (21%) and 412 were physically restrained without midazolam (79%). There was a significantly greater decrease in agitation scores (-17 ± 21 vs. -7 ± 17) in the subjects receiving midazolam compared to those who did not. CONCLUSION: If available, CR is used in about 20% of restrained patients. When CR is used, there is a decrease in the subject's agitation.

Education effects on the International HIV Dementia Scale.

Human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) within the Indian subcontinent continues to spread. Although the primary clade of HIV in India differs from that of most Western countries, recent evidence suggests that the Indian clade (Clade C) also impacts neurocognitive functioning. India also has extremely high illiteracy rates that may confound detection of neurocognitive impairment, since many assessments to detect such impairment are heavily influenced by formal schooling. Among those with HIV/AIDS who have had limited educational opportunities and who are in the early stage of infection, the confounding effects of education on tests for neurocognitive impairment may be particularly salient. We therefore tested influence of HIV serostatus and education on a commonly used tool to screen for cognitive impairment, the International HIV Dementia Scale (IHDS), among Indian men and women in the catchment area of the Post Graduate Institute of Medical Education and Research (PGIMER) located in Chandigarh, India. Adjusted analyses showed that from a sample of 295 HIV-positive and HIV-negative individuals, only education was significantly associated with performance on the IHDS. HIV-negative and HIV-positive individuals, who were in the early stages of infection, performed similarly. Further development of this test to account for the effects of education on cut-off scores used to indicate possible dementia are needed, particularly for use in resource-limited settings such as India where low levels of education are widespread.

Development of a screen for ongoing intimate partner violence.

A five-question Ongoing Abuse Screen (OAS) was developed to evaluate ongoing intimate partner violence. Our hypothesis was that the OAS was more accurate and more likely to reflect ongoing intimate partner violence than the AAS when compared to the Index of Spouse Abuse (ISA). The survey included the ISA, the OAS, and the AAS. During the busiest emergency department hours, a sampling of 856 patients completed all aspects of the survey tool. Comparisons were made between the two scales and the ISA. The accuracy, positive predictive value, and positive likelihood ratio were 84%, 58%, and 6.0 for the OAS and 59%, 33%, and 2.0 for the AAS. The OAS was more accurate, had a better positive predictive value, and was three times more likely to detect victims of ongoing intimate partner violence than the AAS. Because the OAS was still not accurate enough, we developed a new screen, based on the ISA, titled the Ongoing Violence Assessment Tool (OVAT).

Comparison of three instruments for assessing ongoing intimate partner violence.

BACKGROUND: Active injury surveillance programs need to address 'ongoing' intimate partner violence (IPV). While the Abuse Assessment Screen (AAS) has been validated for 'present'(within a year) IPV it is not clear that it is valid for 'present' (ongoing) IPV. We have created an OAS (Ongoing Abuse Screen, OAS) by changing the AAS to specifically request information related to 'ongoing' IPV. The hypothesis of this study was that the OAS represents a construct that is different from either the original AAS or a single question asking about ongoing IPV. MATERIAL/METHODS: All patients presenting to the ED during a convenience sampling of shifts completed the survey. The survey included the OAS, the AAS, and the question 'Are you presently a victim of IPV?' Comparisons were made between these 3 using the kappa statistic for agreement. RESULTS: A total of 488 surveys were completed. The AAS was positive in 288/488 (59%, 95%CI= 55-63%), the OAS was positive in 78/488 (16%, 95%CI=13-19%), and the single question for DV was positive in 14/488 (3%, 95%CI=2-5%). Kappa was 0.28 for the AAS and the OAS. When compared to the single question about present DV, kappa was 0.05 for the AAS and 0.27 for the OAS. CONCLUSIONS: The OAS may be a useful tool for evaluating ongoing IPV. The OAS resulted in rates different from that of the AAS and may be more specific to ongoing IPV than the AAS and more sensitive than a single question about DV.