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1.
Am J Respir Crit Care Med ; 208(3): 312-321, 2023 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-37276608

RESUMO

Rationale: Predictors of adverse outcome in pulmonary hypertension (PH) are well established; however, data that inform survival are lacking. Objectives: We aim to identify clinical markers and therapeutic targets that inform the survival in PH. Methods: We included data from patients with elevated mean pulmonary artery pressure (mPAP) diagnosed by right heart catheterization in the U.S. Veterans Affairs system (October 1, 2006-September 30, 2018). Network medicine framework was used to subgroup patients when considering an N of 79 variables per patient. The results informed outcome analyses in the discovery cohort and a sex-balanced validation right heart catheterization cohort from Vanderbilt University (September 24, 1998-December 20, 2013). Measurements and Main Results: From an N of 4,737 complete case patients with mPAP of 19-24 mm Hg, there were 21 distinct subgroups (network modules) (all-cause mortality range = 15.9-61.2% per module). Pulmonary arterial compliance (PAC) drove patient assignment to modules characterized by increased survival. When modeled continuously in patients with mPAP ⩾19 mm Hg (N = 37,744; age, 67.2 yr [range = 61.7-73.8 yr]; 96.7% male; median follow-up time, 1,236 d [range = 570-1,971 d]), the adjusted all-cause mortality hazard ratio was <1.0 beginning at PAC ⩾3.0 ml/mm Hg and decreased progressively to ∼7 ml/mm Hg. A protective association between PAC ⩾3.0 ml/mm Hg and mortality was also observed in the validation cohort (N = 1,514; age, 60.2 yr [range = 49.2-69.1 yr]; 48.0% male; median follow-up time, 2,485 d [range = 671-3,580 d]). The association was strongest in patients with precapillary PH at the time of catheterization, in whom 41% (95% confidence interval, 0.55-0.62; P < 0.001) and 49% (95% confidence interval, 0.38-0.69; P < 0.001) improvements in survival were observed for PAC ⩾3.0 versus <3.0 ml/mm Hg in the discovery and validation cohorts, respectively. Conclusions: These data identify elevated PAC as an important parameter associated with survival in PH. Prospective studies are warranted that consider PAC ⩾3.0 ml/mm Hg as a therapeutic target to achieve through proven interventions.


Assuntos
Hipertensão Pulmonar , Artéria Pulmonar , Humanos , Masculino , Idoso , Pessoa de Meia-Idade , Feminino , Estudos Retrospectivos , Cateterismo Cardíaco , Modelos de Riscos Proporcionais , Hemodinâmica
2.
J Nurs Care Qual ; 33(1): 53-60, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-28505056

RESUMO

Patient safety checklists are ubiquitous in health care. Nurses bear significant responsibility for ensuring checklist adherence. To report nonadherence to a checklist and stop an unsafe procedure, a workplace climate of psychological safety is needed. Thus, an analysis of organizational data was conducted to examine the relationship between psychological safety and reports of nonadherence to the central line bundle checklist. Results showed varied perceptions of psychological safety but no relationship with nonadherence. Considerations for this finding and assessing psychological safety are provided.


Assuntos
Lista de Checagem/estatística & dados numéricos , Erros Médicos/estatística & dados numéricos , Papel do Profissional de Enfermagem , Segurança do Paciente/normas , Enfermagem de Cuidados Críticos , Coleta de Dados , Humanos , Erros Médicos/psicologia , Cultura Organizacional , Estados Unidos , United States Department of Veterans Affairs , Local de Trabalho/organização & administração , Local de Trabalho/psicologia
3.
Am J Infect Control ; 46(5): 587-589, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-29254610

RESUMO

Nurses satisfied with their jobs report less job stress, more effective nurse-physician collaboration, and higher patient satisfaction scores. It is unknown if job satisfaction influences adherence to best practices or patient outcomes. This secondary data analysis investigated the relationship between job satisfaction, adherence to the central line insertion checklist, and central line-associated bloodstream infections (CLABSIs). Results showed a decreased risk of CLABSI with higher job satisfaction, on average. No relationship was observed with checklist adherence.


Assuntos
Fidelidade a Diretrizes , Controle de Infecções/métodos , Satisfação no Emprego , Enfermeiras e Enfermeiros/psicologia , Cuidados de Enfermagem/métodos , Sepse/prevenção & controle , Humanos , Controle de Infecções/normas , Cuidados de Enfermagem/normas , Guias de Prática Clínica como Assunto , Medição de Risco , Sepse/epidemiologia , Inquéritos e Questionários , Saúde dos Veteranos
4.
Am J Med Qual ; 33(2): 147-153, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-28691503

RESUMO

Veterans are often transferred from "spoke" Veterans Administration (VA) clinics or hospitals to "hub" tertiary VA hospitals for advanced inpatient care, but they face significant barriers to safe transitions home. The Transitions Nurse Program was developed as an intervention to address the unique needs of this population. A difference-in-differences (DiD) analysis was used to compare outcomes between 303 veterans enrolled in this program and veterans transferred from the same spoke sites to a second, similar tertiary VA hub. Veterans enrolled in the program had significantly increased rates of follow-up with their primary care clinic within 14 days of discharge (DiD estimate: 10.43%, 95% confidence interval = 1.20 to 19.66), and a trend toward fewer unplanned 30-day readmissions (DiD estimate: -6.9%, 95% confidence interval = -14.2 to 0.31%, P = .06). There were no significant differences in 30-day emergency department visits or costs. Lessons learned from this preliminary intervention can inform implementation at other VA and non-VA sites.


Assuntos
Transferência de Pacientes/normas , Melhoria de Qualidade/organização & administração , Centros de Atenção Terciária , Veteranos , Idoso , Feminino , Hospitais de Veteranos , Humanos , Entrevistas como Assunto , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente , Pesquisa Qualitativa , Estados Unidos
5.
JACC Cardiovasc Interv ; 11(9): 879-888, 2018 05 14.
Artigo em Inglês | MEDLINE | ID: mdl-29747919

RESUMO

OBJECTIVES: The aim of this study was to evaluate temporal trends in characteristics and outcomes among patients referred for invasive coronary procedures within a national health care system for veterans. BACKGROUND: Coronary angiography and percutaneous coronary intervention remain instrumental diagnostic and therapeutic interventions for coronary artery disease. METHODS: All coronary angiographic studies and interventions performed in U.S. Department of Veterans Affairs cardiac catheterization laboratories for fiscal years 2009 through 2015 were identified. The demographic characteristics and management of these patients were stratified by time. Clinical outcomes including readmission (30-day) and mortality were assessed across years. RESULTS: From 2009 to 2015, 194,476 coronary angiographic examinations and 85,024 interventions were performed at Veterans Affairs facilities. The median numbers of angiographic studies (p = 0.81) and interventions (p = 0.22) remained constant over time. Patients undergoing these procedures were progressively older, with more comorbidities, as the proportion classified as having high Framingham risk significantly increased among those undergoing angiography (from 20% to 25%; p < 0.001) and intervention (from 24% to 32%; p < 0.001). Similarly, the median National Cardiovascular Data Registry CathPCI risk score increased for diagnostic (from 14 to 15; p = 0.005) and interventional (from 14 to 18; p = 0.002) procedures. Post-procedural medical management was unchanged over time, although there was increasing adoption of transradial access for diagnostic (from 6% to 36%; p < 0.001) and interventional (from 5% to 32%; p < 0.001) procedures. Complications and clinical outcomes also remained constant, with a trend toward a reduction in the adjusted hazard ratio for percutaneous coronary intervention mortality (hazard ratio: 0.983; 95% confidence interval: 0.967 to 1.000). CONCLUSIONS: Veterans undergoing invasive coronary procedures have had increasing medical complexity over time, without attendant increases in mortality among those receiving interventions. As the Department of Veterans Affairs moves toward a mix of integrated and community-based care, it will be important to account for these demographic shifts so that quality can be maintained.


Assuntos
Angiografia Coronária/tendências , Doença da Artéria Coronariana/terapia , Intervenção Coronária Percutânea/tendências , Idoso , Angiografia Coronária/efeitos adversos , Angiografia Coronária/mortalidade , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/mortalidade , Bases de Dados Factuais , Prestação Integrada de Cuidados de Saúde/tendências , Feminino , Necessidades e Demandas de Serviços de Saúde/tendências , Humanos , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente/tendências , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/instrumentação , Intervenção Coronária Percutânea/mortalidade , Valor Preditivo dos Testes , Sistema de Registros , Stents/tendências , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia , United States Department of Veterans Affairs/tendências
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