ASA Physical Status Determination by General Internists and Impact on Cardiac Risk Assessment.

OBJECTIVES: Estimating cardiac risk is important for preoperative evaluation, and several risk calculators incorporate the American Society of Anesthesiologists (ASA) physical status score. The purpose of this study was to determine the concordance of ASA scores assigned by general internists and anesthesiologists and assess whether discrepancies affected cardiac risk estimation. METHODS: This observational study included military veterans evaluated in a preoperative evaluation clinic at a single center during a 12-month period. ASA scores were recorded by General Internal Medicine residents under the supervision of a General Internal Medicine attending, performing a preoperative medical consultation, and were compared with ASA scores assigned by an anesthesiologist on the day of surgery. ASA scores and Gupta Cardiac Risk Scores incorporating each ASA score were compared. RESULTS: Data were collected on 206 patients, 163 of whom had surgery within 90 days and were included. ASA scores were concordant in 60 patients (37.3%), whereas the ASA scores were rated lower by the general internist in 101 (62.0%) and higher in 2 (1.2%). Interrater reliability was low (κ = 0.08), and general internist scores were significantly lower than anesthesiologist scores (P < 0.01). Gupta Cardiac Risk Scores were calculated for 160 patients, and they exceeded 1% in 14 patients using the anesthesiologist ASA score, compared with 5 patients using the general internist score. CONCLUSIONS: ASA scores assigned by general internists in this study were significantly lower than those assigned by anesthesiologists, and these discrepancies in the ASA score can lead to substantially different conclusions about cardiac risk.

A Description of Outcomes Experienced by Patients Whose Orders for Peripheral Artery Revascularization Were Reviewed by a Nondenial Prior Authorization Program.

OBJECTIVE: After a nondenial prior authorization program evaluates orders for peripheral artery revascularization (PAR), ordering physicians sometimes withdraw their orders based upon program recommendations. Some patients with withdrawn orders receive PAR if claudication does not resolve. To characterize patient outcomes under this program, we evaluated whether associations existed between the withdrawal of patients' initial PAR orders and the presence of claims for PAR and claims mentioning intermittent claudication (IC) in the following 16 weeks. METHODS: Orders for PAR placed from 1/1/19 to 9/30/19 for patients with Medicare Advantage health plans were extracted from a national healthcare organization's database. Claims data from 0 to 16 weeks following the order were reviewed to determine if patients had downstream PAR claims, or if they had emergency department or hospital claims mentioning IC. Chi-square tests were used to assess the association between order withdrawal and downstream PAR, as well as claims mentioning IC. Multivariate logistic regressions were run to assess the same, controlling for patient age, sex, urbanicity, local median income, state obesity rate, type of PAR, ordering physician specialty, and whether PAR was ordered in a hospital setting. RESULTS: Of 1588 orders meeting inclusion criteria, 71.9% (1038/1444) of authorized orders and 61.1% (88/144) of withdrawn orders were followed by PAR within 16 weeks, a significant difference (P < .01). Relatedly, 69.8% (1008/1444) of authorized orders and 70.8% (102/144) of withdrawn orders were followed by IC claims, an insignificant difference. Multivariate logistic regressions showed patients with withdrawn PAR orders had significantly lower adjusted odds of PAR (OR: 0.63; 95% CI: 0.44-0.91), but an insignificant difference in their adjusted odds of IC (OR: 1.10; CI: 0.76-1.64). CONCLUSIONS: Although patients with withdrawn PAR orders were significantly less likely to receive PAR in the subsequent 16 weeks, no association was found between withdrawn PAR orders and subsequent claims mentioning IC.

Antibacterial activities of physiologically stable, self-assembled peptide nanoparticles.

In this study, we report that host defense protein-derived ten amino acid long disulfide-linked peptides self-assemble in the form of ß-sheets and ß-turns, and exhibit concentration-dependent self-assembly in the form of nanospheres, termed as disulfide linked nanospheres (DSNs). As expected, bare DSNs are prone to aggregation in ionic solutions and in the presence of serum proteins. To yield physiologically stable self-assembled peptide-based materials, DSNs are stabilized in the form of supramolecular assemblies using ß-cyclodextrins (ß-CD) and fucoidan, as delivery carriers. The inclusion complexes of DSNs with ß-CD (ß-CD-DSN) and electrostatic complexation of fucoidan with DSNs (FC-DSN) stabilizes the secondary structure of DSNs. Comparison of ß-CD-DSNs with FC-DSNs reveals that inclusion complexes of DSNs formed in the presence of ß-CD are highly stable under physiological conditions, show high cellular uptake, exhibit bacterial flocculation, and enhance antibacterial efficacies of DSNs in a range of Gram-positive and Gram-negative bacteria.

Implementation of an enhanced recovery program for lower extremity bypass.

OBJECTIVE: Enhanced recovery programs (ERPs) have gained wide acceptance across multiple surgical disciplines to improve postoperative outcomes and to decrease hospital length of stay (LOS). However, there is limited information in the existing literature for vascular patients. We describe the implementation and early results of an ERP and barriers to its implementation for lower extremity bypass surgery. Our intention is to provide a framework to assist with implementation of similar ERPs. METHODS: Using the plan, do, check, adjust methodology, a multidisciplinary team was assembled. A database was used to collect information on patient-, procedure-, and ERP-specific metrics. We then retrospectively analyzed patients' demographics and outcomes. RESULTS: During 9 months, an ERP (n = 57) was successfully developed and implemented spanning preoperative, intraoperative, and postoperative phases. ERP and non-ERP patient demographics were statistically similar. Early successes include 97% use of fascia iliaca block and multimodal analgesia administration in 81%. Barriers included only 47% of patients achieving day of surgery mobilization and 19% receiving celecoxib preoperatively. ERP patients had decreased total and postoperative LOS compared with non-ERP patients (n = 190) with a mean (standard deviation) total LOS of 8.32 (8.4) days vs 11.14 (10.1) days (P = .056) and postoperative LOS of 6.12 (6.02) days vs 7.98 (7.52) days (P = .089). There was significant decrease in observed to expected postoperative LOS (1.28 [0.66] vs 1.82 [1.38]; P = .005). Variable and total costs for ERP patients were significantly reduced ($13,208 [$9930] vs $18,777 [$19,118; P < .01] and $29,865 [$22,110] vs $40,328 [$37,820; P = .01], respectively). CONCLUSIONS: Successful implementation of ERP for lower extremity bypass carries notable challenges but can have a significant impact on practice patterns. Further adjustment of our current protocol is anticipated, but early results are promising. Implementation of a vascular surgery ERP reduced variable and total costs and decreased total and postoperative LOS. We believe this protocol can easily be implemented at other institutions using the pathway outlined.

Material properties of disulfide-crosslinked hyaluronic acid hydrogels influence prostate cancer cell growth and metabolism.

Cells reside in vivo within three dimensional environments in which they interact with extracellular matrices (ECMs) that play an integral role in maintaining tissue homeostasis and preventing tumour growth. Thus, tissue culture approaches that more faithfully reproduce these interactions with the ECM are needed to study cancer development and progression. Many materials exist for modeling tissue environments, and the effects of differing mechanical, physical, and biochemical properties of such materials on cell behaviour are often intricately coupled and difficult to tease apart. Here, an optimized protocol was developed to generate low reaction volume disulfide-crosslinked hyaluronic acid (HA) hydrogels for use in cell culture applications to relate the properties of ECM materials to cell signalling and behaviour. Mechanically, HA hydrogels are comparable to other soft hydrogel materials such as Matrigel and agarose or to tissues lacking type I collagen and other fibrillar ECM components. The diffusion of soluble materials in these hydrogels is affected by unique mass transfer properties. Specifically, HA hydrogel concentration affects the diffusion of anionic particles above 500 kDa, whereas diffusion of smaller particles appears unimpeded by HA content, likely reflecting hydrogel pore size. The HA hydrogels have a strong exclusion effect that limits the movement of proteins into and out of the material once fully formed. Such mass transfer properties have interesting implications for cell culture, as they ultimately affect access to nutrients and the distribution of signalling molecules, affecting nutrient sensing and metabolic activity. The use of disulfide-crosslinked HA hydrogels for the culture of the model prostate cancer cell lines PC3 and LNCaP reveals correlations of protein activation linked to metabolic flux, which parallel and can thus potentially provide insights into cell survival mechanisms in response to starvation that occurs in cancer cell microenvironments.

Enhanced Recovery After Surgery: Intraoperative Fluid Management Strategies.

Ideal fluid management is a critical component of enhanced recovery after surgery protocols and should be considered throughout the perioperative period. The goal of preoperative fluid management is for the patient to arrive to the operating room euvolemic. Intraoperative goals of fluid management are to preserve intravascular volume and minimize salt and water uptake through intravenous crystalloid infusions. Postoperatively, once patients are tolerant of oral fluid intake, intravenous fluids are not required and should be restarted only if clinically necessary. This article reviews evidence-based, best practices for intraoperative fluid management for patients undergoing surgery within an enhanced recovery after surgery pathway.

Reducing Electrolyte Testing in Hospitalized Children by Using Quality Improvement Methods.

BACKGROUND AND OBJECTIVES: Despite studies indicating a high rate of overuse, electrolyte testing remains common in pediatric inpatient care. Frequently repeated electrolyte tests often return normal results and can lead to patient harm and increased cost. We aimed to reduce electrolyte testing within a hospital medicine service by >25% within 6 months. METHODS: We conducted an improvement project in which we targeted 6 hospital medicine teams at a large academic children's hospital system by using the Model for Improvement. Interventions included standardizing communication about the electrolyte testing plan and education about the costs and risks associated with overuse of electrolyte testing. Our primary outcome measure was the number of electrolyte tests per patient day. Secondary measures included testing charges and usage rates of specific high-charge panels. We tracked medical emergency team calls and readmission rates as balancing measures. RESULTS: The mean baseline rate of electrolyte testing was 2.0 laboratory draws per 10 patient days, and this rate decreased by 35% after 1 month of initial educational interventions to 1.3 electrolyte laboratory draws per 10 patient days. This change has been sustained for 9 months and could save an estimated $292 000 in patient-level charges over the course of a year. Use of our highest-charge electrolyte panel decreased from 67% to 22% of testing. No change in rates of medical emergency team calls or readmission were found. CONCLUSIONS: Our improvement intervention was associated with significant and rapid reduction in electrolyte testing and has not been associated with unintended adverse events.

Enhanced Recovery After Surgery (ERAS) Eliminates Racial Disparities in Postoperative Length of Stay After Colorectal Surgery.

OBJECTIVE: To investigate the effects of enhanced recovery after surgery (ERAS) on racial disparities in postoperative length of stay (pLOS) after colorectal surgery. BACKGROUND: Racial disparities in surgical outcomes exist. We hypothesized that ERAS would reduce disparities in pLOS between black and white patients. METHODS: Patients undergoing ERAS in 2015 were 1:1 matched by race/ethnicity, age, sex, and procedure to a pre-ERAS group from 2010 to 2014. After stratification by race/ethnicity, expected pLOS was calculated using the American College of Surgeons National Surgical Quality Improvement Project Risk Calculator. Primary outcome was the observed pLOS and observed-to-expected difference in pLOS. Secondary outcomes were National Surgical Quality Improvement Project postoperative complications including 30-day readmissions and mortality. Adjusted sensitivity analyses on pLOS were also performed. RESULTS: Of 420 patients (210 ERAS and 210 pre-ERAS) examined, 28.3% were black. Black and white patients were similar in age, body mass index, sex, American Anesthesia Association class, and minimally invasive approaches. Within the pre-ERAS group, black patients stayed a mean of 2.7 days longer than expected compared with white patients (P < 0.05). Overall, ERAS patients had a significantly shorter pLOS (5.7 vs 8 days) and observed-to-expected difference (-0.7 vs 1.4 days) compared with pre-ERAS patients (P < 0.01). In the ERAS group, disparities in pLOS were reduced with no differences in readmissions or mortality between black and white patients. On sensitivity analyses, race/ethnicity remained a significant predictor of pLOS among pre-ERAS patients, but not for ERAS patients. CONCLUSIONS: ERAS eliminated racial differences in pLOS between black and white patients undergoing colorectal surgery. Reduced pLOS occurred without increases in mortality, readmissions, and most postoperative complications. ERAS may provide a practical approach to reducing disparities in surgical outcomes.

Rapid cycle development of a multifactorial intervention achieved sustained reductions in central line-associated bloodstream infections in haematology oncology units at a children's hospital: a time series analysis.

BACKGROUND: Immunocompromised children are at high risk for central line-associated bloodstream infections (CLABSIs) and its associated morbidity and mortality. Prevention of CLABSIs depends on highly reliable care. PURPOSE: Since the summer of 2013, we saw an increase in patient volume and acuity in our centre. Additionally, CLABSIs rates more than tripled during this period. The purpose of this initiative was to rapidly identify and mitigate potential underlying drivers to the increased CLABSI rate. METHODS: Through small tests of change, we implemented a standard process for daily hygiene; increased awareness of high-risk patients with CLABSI; improved education/assistance for nurses performing high-risk central venous catheter procedures; and developed a system to improve allocation of resources to de-escalate system stress. RESULTS: The CLABSI rate from June 2013 to May 2014 was 2.03 CLABSIs/1000 line days. After implementation of our interventions, we saw a significant decrease in the CLABSI rate to 0.39 CLABSIs/1000 line days (p=0.008). Key processes have become more reliable: 100% of dressing changes are completed with the new two-person standard; daily hygiene adherence has increased from 25% to 70%; 100% of nurses are approached daily by senior nursing for assistance with high-risk procedures; and patients at risk for a CLABSI are identified daily. CONCLUSIONS: Stress to a complex system caring for high-risk patients can challenge CLABSI rates. Identifying key processes and executing them reliably can stabilise outcomes during times of system stress.

Using quality improvement to reduce continuous pulse oximetry use in children with wheezing.

BACKGROUND AND OBJECTIVES: Clinicians commonly use continuous pulse oximetry (CPOx) for hospitalized children with respiratory illnesses. The Choosing Wisely initiative recommended discontinuing CPOx for children on room air. We used quality improvement methods to reduce time on CPOx in patients with wheezing. METHODS: Our project took place on 1 unit of a children's hospital. We developed consensus-based criteria for CPOx discontinuation. Interventions included education, a checklist used during nurse handoff, and discontinuation criteria incorporated into order sets. We collected data on a second unit where we did not actively intervene to assess for secular trends and negative consequences of shorter monitoring. We followed time until medically ready, ICU transfers, hospital revisits, and medical emergency team calls on both units. We tracked the impact of interventions by using run charts and statistical process control charts. RESULTS: Median time per week on CPOx after meeting goals decreased from 10.7 hours to 3.1 hours on the intervention unit. Median time per week on CPOx on the control unit decreased from 11.5 hours to 6.9 hours. There was no decrease in time until medically ready on either unit. The percentage of patients needing transfer, revisit, or medical emergency team call was similar on both units. CONCLUSIONS: With interventions focused on clarity and awareness of CPOx discontinuation criteria, we decreased time on CPOx; however, we saw no impact on time until medically ready. We expect that other centers could use analogous methods to standardize and reduce oxygen monitoring to meet Choosing Wisely recommendations.

Role of financial and social hardships in asthma racial disparities.

BACKGROUND AND OBJECTIVES: Health care reform offers a new opportunity to address child health disparities. This study sought to characterize racial differences in pediatric asthma readmissions with a focus on the potential explanatory role of hardships that might be addressed in future patient care models. METHODS: We enrolled 774 children, aged 1 to 16 years, admitted for asthma or bronchodilator-responsive wheezing in a population-based prospective observational cohort. The outcome was time to readmission. Child race, socioeconomic status (measured by lower income and caregiver educational attainment), and hardship (caregivers looking for work, having no one to borrow money from, not owning a car or home, and being single/never married) were recorded. Analyses used Cox proportional hazards. RESULTS: The cohort was 57% African American, 33% white, and 10% multiracial/other; 19% were readmitted within 12 months. After adjustment for asthma severity classification, African Americans were twice as likely to be readmitted as whites (hazard ratio: 1.98; 95% confidence interval: 1.42 to 2.77). Compared with whites, African American caregivers were significantly more likely to report lower income and educational attainment, difficulty finding work, having no one to borrow money from, not owning a car or home, and being single/never married (all P ≤ .01). Hardships explained 41% of the observed racial disparity in readmission; jointly, socioeconomic status and hardship explained 49%. CONCLUSIONS: African American children were twice as likely to be readmitted as white children; hardships explained >40% of this disparity. Additional factors (eg, pollution, tobacco exposure, housing quality) may explain residual disparities. Targeted interventions could help achieve greater child health equity.

Trauma-Induced Coagulopathy.

Trauma is the leading cause of death among people under the age of 44. Hemorrhage is a major contributor to deaths related to trauma in the first 48 h. Accordingly, the management of these patients is a time-sensitive and critical affair that anesthesiologists responsible for surgical resuscitation will face. Coagulopathy associated with trauma exists in one-third of all severely injured patients upon presentation to the hospital. Trauma patients presenting with coagulopathy have significantly higher mortality. This trauma-induced coagulopathy (TIC) must be managed adroitly in the resuscitation of these patients. Recent advancements in our understanding of TIC have led to new protocols and therapy guidelines. Anesthesiologists must be aware of these to effectively manage this form of shock. TIC driven by a combination of endogenous biological processes, as well as iatrogenic causes, can ultimately lead to the lethal triad of hypothermia, acidemia, and coagulopathy. Providers should understand how to promptly diagnose TIC and be aware of the early indicators of massive transfusion. The use of common laboratory studies and patient vital signs serve as our current guide, but the importance of each is still under debate. Thromboelastography is a tool used often in the diagnosis of TIC and can be used to guide blood product transfusion. Certain pharmaceutical strategies and non-transfusion strategies also exist, which aid in the management of hemorrhagic shock. Damage control surgery, rewarming, tranexamic acid, and 1:1:1 transfusion protocols are promising methods used to treat the critically wounded. Though protocols have been developed, controversies still exist on the optimal resuscitation strategy.