The utility of impedance cardiography in hemodynamic monitoring of patients with sepsis.

BACKGROUND: Commonly used biochemical indicators and hemodynamic and physiologic parameters of sepsis vary with regard to their sensitivity and specificity to the diagnosis. The aim of this preliminary study was to evaluate non-invasive impedance cardiography as a monitoring tool of the hemodynamic status of patients with sepsis throughout their initial volume resuscitation to explore the possibility of identifying additional measurements to be used in the future treatment of sepsis. METHODS: Nine patients who presented to the emergency room and received a surgical consultation during a 3-month period in 2016, meeting the clinical criteria of sepsis defined by systemic inflammatory response syndrome in the 2012 Surviving Sepsis Campaign Guidelines, were included in this study. We applied cardiac impedance monitors to each patient's anterior chest and neck and obtained baseline recordings. Measurements were taken at activation of the sepsis alert and 1 hour after fluid resuscitation with 2 L of intravenous crystalloid solution. RESULTS: Nine patients met the inclusion criteria. The mean age was 60±17 years and two were female; eight were febrile, five were hypotensive, four were tachycardic, seven were treated for infection, and six had positive blood cultures. Hemodynamic parameters at presentation and 1 hour after fluid resuscitation were heart rate (beats per minute) (97±13 and 93±18; p=0.23), mean arterial pressure (mm Hg) (81±13 and 85±14; p=0.55), systemic vascular resistance (dyne-s/cm- 5) (861±162 and 1087±272; p=0.04), afterload measured as systemic vascular resistance index (dyne-s/cm- 5/m2) (1813±278 and 2283±497; p=0.04), and left cardiac work index (kg*m/m2) (3.6±1.4 and 3.3±1.3; p=0.69). DISCUSSION: Through measuring a patient's systemic vascular resistance and systemic vascular resistance index (afterload), statistical significance is achieved after intervention with a 2 L crystalloid bolus. This suggests that, along with clinical presentation and biochemical markers, impedance cardiography may show utility in providing supporting hemodynamic data to trend resuscitative efforts in patients with sepsis. LEVEL OF EVIDENCE: Level IV.

Increasing use of less-invasive hemodynamic monitoring in 3 specialty surgical intensive care units: a 5-year experience at a tertiary medical center.

INTRODUCTION: Less-invasive hemodynamic monitoring (eg, esophageal doppler monitoring [EDM] and arterial pressure contour analysis, FloTrac) is increasingly used as an alternative to pulmonary artery catheters (PACs) in critically ill intensive care unit (ICU). HYPOTHESIS: The decrease in use of PACs is not associated with increased mortality. METHODS: Five-year retrospective review of 1894 hemodynamically monitored patients admitted to 3 surgical ICUs in a university-affiliate, tertiary care urban hospital. Data included the number of admissions, diagnosis-related group discharge case mix, length of stay, insertion of monitoring devices (PAC, EDM, and FloTrac probes), administered intravenous vasoactive agents (ß-predominant agonists--dobutamine, epinephrine, and dopamine; vasopressors--norepinephrine and phenylephrine), and mortality. Data from hospital administrative databases were compiled to create patient characteristic and monitoring variables across a 5-year time period, 2005 to 2009 inclusive. Chi-square for independent proportions, 1-way analysis of variance, and Kruskal-Wallis tests were used; tests for trend were conducted. An α level of .05 was considered significant. Statistical Package for the Social Sciences v14 was used for all statistical testing. RESULTS: There was a significant change in the type of hemodynamic monitors inserted in 2 of the 3 surgical ICUs (in the general surgery and neurointensive care but not in the cardiac ICU) from PACs to less-invasive devices (FloTrac or EDM) during the 5-year study period (P < .001). There was no change in mortality rate over the time period (P = .492). There was an overall increase in the proportion of monitored patients who received intravenous vasoactive agents (P < .001) with a progressive shift from ß-agonists to vasopressors (P < .002). Multivariate analyses indicated that age, case mix, and use of vasoactive agents were all independent predictors of inhospital mortality (P = .001) but that type of monitoring was not (P = .638). CONCLUSIONS: In a 5-year period, the decreased insertions of PACs were replaced by increased utilization of less-invasive hemodynamic monitoring devices. This change in practice did not adversely impact mortality.

Implementation of an intern boot camp curriculum to address clinical competencies under the new Accreditation Council for Graduate Medical Education supervision requirements and duty hour restrictions.

IMPORTANCE: Today's general surgery interns are faced with increased duty hour restrictions and stringent competency-based supervision milestone requirements (ie, from direct to indirect supervision). Working within these constraints, we instituted a unique 2-month intern curriculum (boot camp) incorporating knowledge-based, experiential, and practical components. OBJECTIVES: To describe our curriculum and the effect on resident performance and teaching faculty and nursing staff perceptions. DESIGN: All interns underwent a 2-month (July and August 2011) boot camp curriculum consisting of two 2½-hour knowledge-based and procedural skills (SimMan) didactic sessions per week and completion of 25 core intensive introductory American College of Surgeons Fundamentals of Surgery web-based self-study modules, followed by a standardized patient clinical skills assessment. SETTING: Integrated general surgery residency program at the University of Connecticut School of Medicine, Farmington. PARTICIPANTS: Postgraduate year 1 general surgery categorical and preliminary residents. MAIN OUTCOMES AND MEASURES: We used several assessment tools, including an intern boot camp survey, clinical skills assessment scores, intern American Board of Surgeons In-Training Examination scores, and nursing staff and teaching faculty surveys of intern performance and aptitudes compared with the previous year's interns. Data were analyzed by independent group t test, χ2 tests of proportions, and Fisher exact test for small sample cross tables. RESULTS: In total, 84% (91 of 108) of intern respondents agreed or strongly agreed with the usefulness, relevance, and execution of the boot camp. Compared with the previous year's interns, the nursing staff agreed or strongly agreed that the cohort interns were better at patient assessment, collaboration, and effective communication and provided compassionate and respectful patient care. More than 40% (7 of 17) of surveyed teaching faculty agreed or strongly agreed that the cohort interns demonstrated better patient care and procedural skills and self-confidence compared with the previous year's interns. The clinical skills assessment scores after the 2-month boot camp paralleled the scores typically seen at the end of the previous 2 internship years (P > .25 for all). The proportion of nondesignated and categorical interns pursuing careers in general surgery scoring in the top quartile on the American Board of Surgery In-Training Examination increased from 7% (2 of 28) to 50% (5 of 10) compared with the previous 2 internship years (P = .01). CONCLUSIONS AND RELEVANCE: Recent changes in intern duty hours and supervision rules mandate that residency training programs must institute a competency-oriented curriculum to provide interns with the necessary knowledge and practical skills to attain clinical competence.

Development and implementation of an interactive, objective, and simulation-based curriculum for general surgery residents.

OBJECTIVE: A Steering Committee of residents and faculty initiated a systematic approach to curriculum development, focusing on competency-based education and emphasizing both resident and faculty engagement in the didactic process. SETTING: Integrated General Surgery Residency Program at the University of Connecticut School of Medicine, Farmington, Connecticut. PARTICIPANTS: Postgraduate year (PGY) 1 through 5 general surgery categorical and preliminary residents. METHODS: A Core Curriculum consisting of 45-minute blocks and 2.5 hours of resident time per week was developed by a steering committee composed of faculty and residents. Each block is assigned a faculty and resident moderator, and has defined competency and knowledge-based objectives. An anonymous online evaluation tool collected residents' perceptions of value and satisfaction with the curriculum utilizing 15 5-point Likert items focusing on conferences, objectives, preparation, and quality of presentations, and materials. Measures were taken at the close of the previous academic year (baseline) and at 6 months and 1 year after implementation. The analysis focused on the percent responding in the 2 highest Likert categories (good/excellent, almost always/always, agree/strongly agree). The resulting dichotomous outcomes were compared with time point using χ(2)-tests of proportion; Kruskal-Wallis statistic was also used to compare the full distribution of responses. All analyses were done using SPSS v. 14 with α = 0.05. RESULTS: One hundred two surveys were completed on-line (42 at baseline, 38 at 6 months, and 22 at 1 year). All 15 items showed increases from baseline to 1-year follow-up; 9 of the 15 were statistically significant with conferences and presentation quality and interaction showing the greatest improvement. CONCLUSIONS: Resident satisfaction with the core curriculum, and their self-reported clinical and academic abilities showed improvement after a systematic collaborative faculty-resident approach to curriculum development and implementation.

Optimizing advanced practitioner charge capture in high-acuity surgical intensive care units.

OBJECTIVE: To determine the impact of standardized critical care documentation tools on charge capture by intensive care unit (ICU) advanced practitioners (APs). DESIGN: Prospective charge capture analysis of AP critical care charges (Current Procedural Terminology codes 99291 or 99292). SETTING: Neurosurgical, general surgical, and cardiothoracic ICUs in a level I, 800-bed hospital. The AP provider to patient ratio was 1:6, with 24-hour surgical intensivist oversight. PARTICIPANTS: Advanced practice registered nurses and physician assistants in the ICU. INTERVENTIONS: Standardized templates were developed to simplify documentation and optimize billing of critical care. All APs participated in comprehensive educational sessions on billing compliance and documentation. MAIN OUTCOME MEASURES: Charge capture was collected for 3 years, and comparisons were made between the first quarter before (fiscal year [FY] 2008), during (FY 2009) and after (FY 2010) implementation. The number of ICU patient-days, length of stay, and of beds was collected. RESULTS: During the implementation/education phase (FY 2009), there were no differences in charge capture compared with FY 2008. Each unit demonstrated an increase in charge capture after implementation, and an overall increase of 48% for all 3 ICUs was seen. The number of admissions and length of stay were not statistically different. The total number of ICU beds increased from 42 to 45 during the evaluation period. The salary offset for APs increased from 62% to 80%. CONCLUSIONS: Advanced practitioners represent an important component of the critical care services provided to patients in high-acuity surgical ICUs. Standardized critical care documentation and comprehensive education on evaluation and management guidelines significantly increased charge capture.

Acute care surgery survey: opinions of surgeons about a new training paradigm.

HYPOTHESIS: The acute care surgery (ACS) 2-year training model, incorporating surgical critical care (SCC), trauma surgery, and emergency general surgery, was developed to improve resident interest in the field. We believed that analysis of survey responses about the new training paradigm before its implementation would yield valuable information on current practice patterns and on opinions about the ACS model. DESIGN: Two surveys. PARTICIPANTS: Members of the Surgery Section of the Society of Critical Care Medicine and SCC program directors. INTERVENTIONS: One survey was sent to SCC program directors to define the practice patterns of trauma and SCC surgeons at their institutions, and another survey was sent to all Surgery Section of the Society of Critical Care Medicine members to solicit opinions about the ACS model. MAIN OUTCOME MEASURES: Practice patterns of trauma and SCC surgeons and opinions about the ACS model. RESULTS: Fifty-seven of 87 SCC program directors responded. Almost all programs are associated with level I trauma centers with as many as 15 trauma surgeons. Most of these trauma surgeons cover SCC and emergency general surgery. Sixty-six percent of surgical intensive care units are semiclosed; 89.0% have surgeons as directors. Seventy percent of the staff in surgical intensive care units are surgeons. One hundred fifty-five of approximately 1100 Surgery Section of the Society of Critical Care Medicine members who responded to the other survey did not believe that the ACS model would compromise surgical intensive care unit and trauma care or trainee education yet would allow surgeons to maintain their surgical skills. Respondents were less likely to believe that the ACS fellowship would be important financially, increase resident interest, or improve patient care. CONCLUSIONS: In academic medical centers, surgical intensivists already practice the ACS model but depend on many nonsurgeons. Surgical intensivists believe that ACS will not compromise care or education and will help maintain the field, although the effect on resident interest is unclear.

Mannequin simulation identifies common surgical intensive care unit teamwork errors long after introduction of sepsis guidelines.

INTRODUCTION: Groups of evidence-based guidelines were developed into a comprehensive treatment bundle as part of an international-based Surviving Sepsis Campaign to improve treatment of severe sepsis and septic shock. Conventional educational strategies of this sepsis treatment "bundle" may not ensure acceptable knowledge or completion of these specific tasks and may overlook other dynamic factors present during critical moments of a crisis. Simulation using multidisciplinary teams of clinicians through mannequin-based simulations (MDMS) may improve "bundle" compliance by identifying sepsis guideline errors, reinforcing knowledge, and exposing other potential causes of poor performance. METHODS: Seventy-four clinicians participated in the MDMS 14 months after hospital-wide introduction of the sepsis bundle. Additionally, each team was given a sepsis treatment-learning packet before the training session. Twelve teams underwent a MDMS of a patient in septic shock. Two evaluators recorded completed sepsis guideline tasks in real time. Sessions were videotaped and reviewed with the team in a postscenario debriefing session. Pre/posttests were also administered. RESULTS: Individual participants' pretest scores averaged 64.6% correct. Despite all but one team having at least one knowledgeable member with a pretest score of at least 80%, team task completion averaged only 60.4%. Team mean pretest scores and proportion of tasks completed were significantly correlated (P = 0.007), but correlations between specific tasks and related questions showed no relationship to knowledge. CONCLUSION: Inadequate completion of the sepsis guideline tasks during the MDMS could not be explained by inadequate pretest knowledge alone. MDMS may be a useful tool in identifying and exploring these unknown factors.

Warfarin resistance after total gastrectomy and Roux-en-Y esophagojejunostomy.

Nutritional deficiencies due to malabsorption occur after major gastric resection, and drugs that are primarily absorbed in the stomach or duodenum also are likely to exhibit decreased absorption. However, we performed a MEDLINE search (1960-2007) and found no evidence in the literature regarding the specific effects of warfarin absorption after total gastrectomy with Roux-en-Y gastric bypass procedure. We describe a 71-year-old woman receiving warfarin therapy for chronic atrial fibrillation who underwent a completion gastrectomy and Roux-en-Y esophagojejunostomy for an invasive adenocarcinoma of her gastric remnant. Before surgery, her international normalized ratio (INR) had been stable in her target range of 2-3 with warfarin 5-6 mg/day. At the time of her admission for the surgery, however, her INR was subtherapeutic at 1.73; warfarin was discontinued, and heparin and, subsequently, enoxaparin were used throughout her admission. After the surgery, the patient was discharged to a skilled nursing facility to continue bridge therapy with enoxaparin while warfarin was restarted and adjusted to a therapeutic INR of 2-3. Three months after discharge, the patient was hospitalized again for shortness of breath and was found to have an INR of 1.30 on admission, despite good compliance with her drugs. During this admission, the patient demonstrated resistance to warfarin therapy, requiring doses up to 20 mg/day to reach a therapeutic INR. To our knowledge, this is the first case report to demonstrate that patients undergoing a complete gastric resection followed by a Roux-en-Y gastric bypass procedure may display warfarin resistance. Close monitoring and dosage adjustment may be necessary to maintain therapeutic anticoagulation in these patients.

A two-tiered quality management program: Morbidity and Mortality conference data applied to resident education.

The ACGME mandates a competency-based resident education curriculum. The Joint Commission (TJC) requires a quality improvement (QI) program in all hospitals with residency training programs. Our QI program, based on M&M conference data, provided the operational framework for peer review and resolution of adverse events. However, the conference focused on only three of the six ACGME core competencies (patient care, medical knowledge, practice-based learning and improvement) but not specifically on interpersonal and communication skills, professionalism or systems-based practice. To address this issue, we devised a two-tiered QI process that meets the reporting mandate of TJC and addresses all six ACGME core competencies. Adverse events are reported and discussed in the Department of Surgery's divisional M&M conferences. If an issue involving the ACGME core competencies is identified that requires nonconference discussion, ie, communication, professionalism or systems-based practice, the case is referred to the Department of Surgery Subcommittee for Quality Improvement (SCQI). A report is then returned to the divisional M&M for discussion and possible incorporation into the Resident Core Curriculum. Resident and attending surgeon surveys demonstrated the new format to be effective in addressing all six ACGME competencies.

Midlevel practitioner workforce analysis at a university-affiliated teaching hospital.

OBJECTIVE: To quantify midlevel practitioner (MLP) staffing requirements based on the volume and complexity of patient care and the duty-hour constraints of the Accreditation Council for Graduate Medical Education 80-hour workweek. DESIGN: Data extracted from Eclipsys Sunrise Decision Support Manager, the hospital financial budget, and census reports; and MLP, resident, and subspecialty fellow clinical, operative, and on-call schedules, and educational curriculum. Fiscal year 2005 patient census and hours of required care were defined by attending physician service and/or patient care location. Volume of patient care activity for MLPs, residents, and subspecialty fellows were established by verified self-reporting methodology. SETTING: Urban teaching hospital with 867 beds, of which 116 are surgical beds (which include 36 intensive care unit beds and 12 step-down beds). PARTICIPANTS: Attending physicians, MLPs, residents, and subspecialty fellows. MAIN OUTCOME MEASURES: Coverage index (available staffing hours [residents, subspecialty fellows, and MLPs] divided by the clinical coverage schedule), and the workload staffing efficiency index (number of clinical hours of patient care activities divided by the hours of available staff for a specific clinical service). RESULTS: The workload staffing efficiency index and the coverage index identified 4 services that benefited from the addition of new MLPs. CONCLUSION: We developed a quantitative MLP staffing methodology based on patient volume and the type and complexity of direct and indirect patient care activities, encompassing the roles and availability of residents, subspecialty fellows, and MLPs.

Postoperative day one: a high risk period for respiratory events.

BACKGROUND: In 2001, the Joint Commission on Accreditation of Healthcare Organizations released Pain Management Standards that has led to an increased focus on pain control. Since then the Institute for Safe Medication Practices has noted that overaggressive pain management has led to increases in oversedation and fatal respiratory depression. One of our previous studies found that postoperative patients may be reaching dangerously high levels of sedation as a result of pain management. Our hypothesis is that postoperative patients who have a respiratory event caused by analgesic use are more likely to have that event in the first postoperative day. METHODS: We performed a retrospective case-control analysis identifying 62 postoperative patients who had a respiratory event. A respiratory event was defined as respiratory depression caused by narcotic use in the postoperative period that was reversed by naloxone. Sixty-two postoperative patients with no such event were chosen randomly and frequency matched based on surgical procedure and diagnosis-related group. Risk factors for an event were identified. RESULTS: Of the cases, 77.4% had a respiratory event in the first 24 hours postoperatively. Significant risk factors for an event were as follows: 65 years of age or older, having chronic obstructive pulmonary disease, having 1 or more comorbidities, and being placed on hydromorphone. CONCLUSIONS: The first 24 hours after surgery represents a high-risk period for a respiratory event as a result of narcotic use. The realization of this risk can lead to the implementation of standards to increase patient safety in the first postoperative day.