A Pilot Randomized Controlled Trial of the Feasibility of a Multicomponent Delirium Prevention Intervention Versus Usual Care in Acute Stroke.

BACKGROUND: Delirium after acute stroke is a serious complication. Numerous studies support a benefit of multicomponent interventions in minimizing delirium-related complications in at-risk patients, but this has not been reported in acute stroke patients. The purpose of this study was to explore the feasibility of conducting a randomized (delirium care) versus usual standardized stroke care (usual care) in reducing delirium in acute stroke. OBJECTIVE: This pilot study assessed the feasibility of (1) enrollment within the 48-hour window when delirium risk is greatest, (2) measuring cognitive function using the Montreal Cognitive Assessment, (3) delivering interventions 7 days per week, and (4) determining delirium incidence in stroke-related cognitive dysfunction. METHODS: A 2-group randomized controlled trial was conducted. Patients admitted with ischemic and hemorrhagic strokes and 50 years or older, English speaking, and without delirium on admit were recruited, consented, and randomized to usual care or delirium care groups. RESULTS: Data from 125 subjects (delirium care, n = 59; usual care, n = 66) were analyzed. All Montreal Cognitive Assessment subscales were completed by 86% of subjects (delirium care, mean [SD], 18.14 [6.03]; usual care, mean [SD], 17.61 [6.29]). Subjects in the delirium care group received a mean of 6.10 therapeutic activities (range, 2-23) and daily medication review by a clinical pharmacist using anticholinergic drug calculations. Delirium incidence was 8% (10/125), 3 in the delirium care group and 7 in the usual care group. CONCLUSION: Findings support the feasibility of delivering a multicomponent delirium prevention intervention in acute stroke and warrants testing intervention effects on delirium outcomes and anticholinergic medication administration.

Ultrasound-guided popliteal sciatic nerve blockade in the severely and morbidly obese: a prospective and randomized study.

PURPOSE: Limited research data exist regarding optimal block techniques in the severely and morbidly obese patient population. We compared two approaches to sciatic nerve blockade at the popliteal fossa in severely and morbidly obese patients. The purpose of this study was to identify differences in pain scores, block onset characteristics, and adverse events between the proximal (prebifurcation) and the distal (postbifurcation) sites. METHODS: Patients with a body mass index ≥35 scheduled for unilateral foot surgery with a popliteal block were randomized to receive an ultrasound-guided popliteal block proximal or distal to the bifurcation of the sciatic nerve. The primary endpoint was numerical rating scale (NRS) scores in the post anesthesia care unit (PACU). RESULTS: Thirty patients were enrolled in each group for a total of 60 participants. Patients in the distal group had lower NRS scores upon entry into the PACU (0.70 ± 1.91) compared with the proximal group (2.17 ± 3.37), had a faster onset of sensorimotor blockade, and were less likely to require a repeat block procedure, conversion to general anesthesia, or local anesthetic supplementation by the surgical team. There was no difference in block procedure times or incidence of nerve injury between the two groups. CONCLUSIONS: The distal approach to the popliteal block provided several intraoperative and analgesic benefits without a difference in block procedural times in the severely and morbidly obese. It is a cost-free intervention that results in a higher likelihood of a successful block in a population where avoidance of opioids is desirable.

Blood pressure goal attainment according to JNC 7 guidelines and utilization of antihypertensive drug therapy in MCO patients with type 1 or type 2 diabetes.

OBJECTIVE: Controlling hypertension (HTN) in patients with diabetes mellitus (DM) can reduce complications such as nephropathy, cerebrovascular disease, and cardiovascular disease. As part of a quality improvement project with a managed care organization (MCO), we evaluated blood pressure (BP) control relative to the type of drug therapy for patients with type 1 or type 2 DM who were identified from pharmacy claims for antihyperglycemic drug therapy. METHODS: Pharmacy claims for antihyperglycemic drugs, including insulin, were used to identify a random sample of commercial members in an MCO comprising 30 health plans across the United States. Retrospective medical record review was conducted in October 2003 to collect data from 4,814 patient charts. BP goal attainment according to The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) guidelines was determined for each patient from the most recent BP reading documented in the medical chart. RESULTS: The distribution by type of DM was 21.0% (n = 1,011) for type 1, 75.7% (n = 3,644) for type 2, and 3.3% (n = 159) for cases not documented in the medical chart. Excluding 590 charts (12.3%) without BP values, there were 1,328 of 4,224 DM patients (31.4%) at JNC 7 BP goal (< 130/80 mm Hg). Of the 1,328 patients at JNC 7 BP goal, 577 (43.4%) were at JNC 7 BP goal with no drug therapy. Excluding the 577 patients who did not require drug therapy to reach JNC 7 goal, 751 (20.6%) of the remaining 3,647 patients who required antihypertensive drug therapy were at JNC 7 BP goal, and 788 (21.6%) received no antihypertensive drug therapy. For the population of 4,224 DM patients with a BP value recorded in the chart, application of the lower BP goals in the JNC 7 guidelines reduced the proportion with controlled BP to 31.4% (1,328/4,224) from 42.6% (1,799/4,224) according to the former JNC 6 guidelines (P < 0.01). The proportion of DM patients with HTN was 59.6% (n = 2,870), and 28.4% (n = 814) of these patients were not taking either an angiotensin-converting enzyme inhibitor (ACEI) or an angiotensin receptor blocker (ARB). There were 704 patients with albuminuria or nephropathy (14.6%), of which 35.4% (n = 249) were not taking either an ACEI or an ARB, preferred therapy in these patients. CONCLUSION: In this population of MCO members with DM for whom a BP value was recorded in the medical chart, 13.7% met JNC 7 BP goal with no antihypertensive drug therapy. For the patients with DM who received antihypertensive drug therapy and had a BP value recorded in the medical chart, only 26.3% were at JNC 7 BP goal. The application of JNC 7 guidelines significantly reduced the proportion of DM patients at target BP goal from 42.6%% to 31.4%

Results of retrospective chart review to determine improvement in lipid goal attainment in patients treated by high-volume prescribers of lipid-modifying drugs.

BACKGROUND: There is a primary focus in cholesterol management on the elevated low-density lipoprotein cholesterol (LDL-C) component of dyslipidemia and a secondary focus on the other components of dyslipidemia, such as low high-density lipoprotein cholesterol (HDL-C), high triglycerides (TGs), and high non-HDL-C. OBJECTIVE: This was a physician practice analysis to examine the real-world therapeutic management of patients diagnosed with hyperlipidemia and/or hypercholesterolemia according to the guidelines of the National Cholesterol Education Program (NCEP) Adult Treatment Panel Third Report (ATP III) and the American Heart Association (AHA). Additionally, the number of patients who should be diagnosed with mixed hyperlipidemia instead of hyperlipidemia or hypercholesterolemia was estimated. METHODS: A total of 600 high-volume prescribers of lipid-modifying drugs were identified in 6 metropolitan areas using the IMS Health prescription database. A total of 101 physician prescribers (about 17%) agreed to participate in the study and had the necessary medical records available. The participating prescribers were asked to identify all patients aged between 18 and 79 years who were seen in their practice in the last 2 years having a diagnosis of hyperlipidemia (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] code 272.4) and/or hypercholesterolemia (ICD-9-CM code 272.0). ICD-9-CM code 272.2 (mixed hyperlipidemia) was purposely excluded from the criteria for patient chart selection in order to estimate the prevalence of mixed hyperlipidemia in patients previously diagnosed with hyperlipidemia and/or hypercholesterolemia. A random number generator was used to select 25 patient medical records from each office. A common instrument was used to collect data on patient demographics; clinical history; comorbid disease states; laboratory test results, including liver function; and 4 values for serum cholesterol (total cholesterol, LDL-C, HDL-C, TG). Total cholesterol was recorded to permit calculation of non-HDL-C. Data collection via patient chart abstraction occurred from March 2004 through August 2004, performed by a staff member in each physician practice who had been trained for this purpose. Drug prescribing was identified from the patient chart. RESULTS: For the physician practice assessment portion of the project, we used patient charts if there was a complete (total cholesterol, TG, HDL-C, and LDL-C) lipid profile for baseline and follow-up, and a minimum of 6 weeks between baseline and follow-up values. At follow-up, the proportion of patients meeting goal lipid values according to the guidelines for LDL-C was 68%, 63% for HDL-C, 59% for TG, and 68% for non-HDL-C. Only 32% of patients met all 3 goals (LDL-C, HDL-C, and TG). The average time between the baseline and follow-up lipid profile was 3.7 years, with a median of 2.9 years, and a minimum of 6 weeks and a maximum of 42 years. Compared with baseline, the most recent follow-up lipid assessment for HDL-C goal attainment showed improvement by an absolute 6%, from 57% to 63% of patients. TG goal attainment improved an absolute 18% (from 41% to 59%), LDL-C goal attainment improved an absolute 45% (from 23% to 68%), non-HDL-C goal attainment improved an absolute 46% (from 22% to 68%), and the combined goals of LDL-C, HDL-C, and TG improved from 8% of patients at baseline to 32% at follow-up. Of the 2,119 patients in the study population, 1,784 (84%) at the time of chart review had been prescribed at least 1 lipid-modifying medication: 1,552 (87%) a single lipid-modifying medication and 232 (13%) combination therapy. The hydroxymethylglutaryl (HMG) coenzyme-A reductase class (statins) accounted for 89% of the monotherapy regimens. Of the patients with baseline LDL-C, HDL-C, and TG readings, 40% could have been diagnosed as having mixed hyperlipidemia, defined as having (a) baseline LDL-C greater than their NCEP ATP III goal and (b) either baseline TG of >150 mg/dL or a baseline HDL-C of <40 mg/dL for males or <50 mg/dL for females. Of the 40% of patients estimated to have mixed hyperlipidemia, 69% were prescribed lipid-modifying monotherapy, 18% were prescribed combination drug therapy, and 14% were not prescribed drug therapy. CONCLUSION: Attainment of therapeutic goals for serum lipids improved from baseline to follow-up, but approximately one third of patients did not achieve individual lipid goals and two thirds of patients did not attain goal for all 3 targets (LDL-C, HDL-C, and TG).

Tailoring the Blood Ordering Process for Cardiac Surgical Cases Using an Institution-Specific Version of the Maximum Surgical Blood Order Schedule.

BACKGROUND: Excess ordering of blood products for surgical cases is expensive and wasteful. Evidence has shown that institution-specific versions of the Maximum Surgical Blood Order Schedule (MSBOS) lead to better ordering practices. Most MSBOSs recommend a crossmatch for a minimum of 2 units of packed red blood cells (PRBCs) for cardiac surgical cases; however, studies have shown that >50% of these patients receive no transfusions. Our aim was to create a blood order algorithm for cardiac surgical cases that would decrease unnecessary crossmatching. METHODS: Retrospective data was collected for 264 patients from January 2011 through April 2012. The crossmatch-to-transfusion ratio (C:tx), transfusion probability (%T), and transfusion index (TI) were calculated for each type of procedure. RESULTS: All 264 patients were crossmatched and 98 patients were transfused, resulting in an overall transfusion probability (%T) of 37.12% (95% confidence interval 31.52-43.09). A total of 1175 units of blood were crossmatched, but only 370 units of blood were transfused, resulting in a C:tx of 3.17 (95% confidence interval 2.61-4.03). The average number of units transfused per procedure (transfusion index) was 1.40. C:tx was highest and TI was lowest for CABG, where approximately 11 units of blood were ordered for every 1 unit transfused (C:tx =11.70 ± 3.04), and the TI was 0.32. CONCLUSIONS: Using the gold standard C:tx of >2:1 as an indicator of inappropriate blood utilization, our analysis confirmed that excessive crossmatching occurred for several procedures. Now a subset of cardiac surgical cases only requires a type and screen order prior to surgery.

The Smoking Cessation Trust Program of Louisiana: The Pediatrician's Role in Identifying and Referring Eligible Caregivers.

BACKGROUND: A pilot study was conducted to determine whether the caregivers of children being seen at the Ochsner for Children health center were eligible for and using services provided by the Smoking Cessation Trust (SCT). METHODS: The study population consisted of pediatric patients' caregivers who visit the Ochsner for Children health center. Caregivers were offered a questionnaire to assess their age, sex, relationship to the child, medical insurance, smoking status, and prior cessation attempts and aids. Data about 3 other caregivers were also requested from the visiting caregiver. RESULTS: Of the 84 caregivers assessed, 26 (30.95%) smoked, of whom 12 (46.15%) began smoking prior to 1988 and were eligible for SCT services. The cohort of eligible caregivers included 4 grandmothers (33.33%), 2 grandfathers (16.67%), and 3 fathers (25.00%). Smoking prevalence in our cohort was higher than the national average (31% vs 18%). During the previous 12 months, 3 of 12 (25.00%) SCT-eligible caregivers had tried to quit smoking. Four (33.33%) SCT-eligible caregivers were interested in smoking cessation. CONCLUSION: Pediatricians are in a unique position to screen, counsel, and refer caregivers who smoke to the SCT.