A scoping review of new implementations of interprofessional bedside rounding models to improve teamwork, care, and outcomes in hospitals.

Poor communication within healthcare teams occurs commonly, contributing to inefficiency, medical errors, conflict, and other adverse outcomes. Interprofessional bedside rounds (IBR) are a promising model that brings two or more health professions together with patients and families as part of a consistent, team-based routine to share information and collaboratively arrive at a daily plan of care. The purpose of this systematic scoping review was to investigate the breadth and quality of IBR literature to identify and describe gaps and opportunities for future research. We followed an adapted Arksey and O'Malley Framework and PRISMA scoping review guidelines. PubMed, CINAHL, PsycINFO, and Embase were systematically searched for key IBR words and concepts through June 2020. Seventy-nine articles met inclusion criteria and underwent data abstraction. Study quality was assessed using the Mixed Methods Assessment Tool. Publications in this field have increased since 2014, and the majority of studies reported positive impacts of IBR implementation across an array of team, patient, and care quality/delivery outcomes. Despite the preponderance of positive findings, great heterogeneity, and a reliance on quantitative non-randomized study designs remain in the extant research. A growing number of interventions to improve safety, quality, and care experiences in hospital settings focus on redesigning daily inpatient rounds. Limited information on IBR characteristics and implementation strategies coupled with widespread variation in terminology, study quality, and design create challenges in assessing the effectiveness of models of rounds and optimal implementation strategies. This scoping review highlights the need for additional studies of rounding models, implementation strategies, and outcomes that facilitate comparative research.

6-Minute walk test predicts prolonged hospitalization in patients undergoing transcatheter mitral valve repair by MitraClip.

BACKGROUND: The 6-minute walk test (6MWT) is a simple functional test that can predict exercise capacity and is widely employed to assess treatment outcomes. Although mortality with transcatheter mitral valve repair (TMVr) using the MitraClip (Abbott Vascular, Menlo Park, CA) is significantly less than for open mitral valve surgery in high-risk patients, identifying which patient will benefit the most from TMVr remains a concern. There are limited prognostic metrics guiding patient selection and, no studies have reported relationship between prolonged hospitalization and 6MWT. This study aimed to determine if the 6MWT can predict prolonged hospitalization in patients undergoing TMVr by MitraClip. METHODS: We retrospectively reviewed 162 patients undergoing 6MWT before TMVr. Patients were divided into three groups according to the 6MWT distance (6MWTD) using the median (6MWTD ≥219 m, 6MWTD <219 m, and Unable to Walk). Multivariate logistic regression model was applied to select the demographic characteristics that were associated with the prolonged hospitalization defined as total length of stay ≥4 days in the study. RESULTS: We found that 6MWT (odds ratio 3.64, 95% confidence interval 2.03-6.52, P < 0.001) was independently associated with prolonged hospitalization after adjustment in multivariate analysis. Area under the curve of 6MWT for predicting prolonged hospitalization was 0.79 (95% confidence interval 0.72-0.85). CONCLUSIONS: Our study demonstrates that 6MWT was independently associated with prolonged hospitalization in patients with TMVr, and has a good discriminatory performance for predicting prolonged hospitalization.

The Clinical Anatomy and Imaging Laboratory: Vertical Integration in the Preclerkship Curriculum.

Introduction: As medical schools implement integrated curricula, anatomy education especially has experienced increased pressure to make foundational content clinically relevant. We designed a novel type of integrative anatomy laboratory experience where students could use foundational anatomy concepts in concert with modern imaging/diagnostic techniques to enhance important clinical concepts. Methods: We selected a process called Lesson Study to develop the multidisciplinary Clinical Anatomy and Imaging Laboratory (CAIL) in the cardiovascular and gastrointestinal systems. We utilized soft-embalmed cadavers extensively for their highly realistic tissue appearance and texture, which allowed instructors and students to perform a wide array of procedures in case-based scenarios similar to practicing clinicians. We conducted field observations of participating students, focus-group discussions, and knowledge-based exams to examine efficacy of the CAIL. Results: Approximately 150 first- and second-year students participated in each of the CAIL activities on an annual basis. Most focus-group participants felt the CAIL was a great learning experience. They commented on how the lab provided relevance to anatomy knowledge and helped integrate prior classroom learning more deeply. Instructors noted that students asked more advanced, clinically relevant questions than in a typical anatomy lab. Knowledge improved significantly after the CAIL, although it is unclear if this translates to summative exams. Discussion: The CAIL creates a unique learning experience where students use prior foundational anatomy knowledge in conjunction with modern imaging and diagnostic techniques to reinforce important clinical concepts. We have continued to integrate CAIL experiences into more clinical systems in our medical school curriculum.

Percutaneous transthoracic ventricular puncture for diagnostic and interventional catheterization.

OBJECTIVE: To describe our experience in a case series of patients requiring percutaneous direct ventricular puncture and sheath placement for diagnosis or intervention. BACKGROUND: Access to the right or left ventricle for percutaneous interventions is limited in patients with mechanical prostheses in either the tricuspid, or mitral and aortic positions. METHODS: After coronary angiography, direct ventricular puncture under ultrasound and fluoroscopic guidance was performed. At end of case, protamine was given to reverse the heparin, and sheaths were pulled with purse-string suture closure of the skin entrance. RESULTS: For right ventricular access, 8- to 9-F sheaths were placed from subxiphoid approach in 2 patients to allow conduit and pulmonary artery interventions. For left ventricular access in patients with mitral and aortic prostheses, 4- to 8-F sheaths were placed from apical approach to allow diagnostic evaluation in 1 and interventions in 5 to occlude perivalvular mitral leaks and postoperative ventricular septal defect. Complication in one consisted of intercostal vein injury resulting in hemothorax requiring chest tube drainage. CONCLUSION: In this small cases series, direct ventricular puncture allowed the intervention to proceed with up to 9-F sheath size. Attention to puncture site relative to intercostal vascular anatomy is warranted.

Perceptions of Teamwork in the Interprofessional Bedside Rounding Process.

Patient perceptions of teamwork have been a relatively undiscovered domain. Our study investigated the use of the Patients' Insights and Views of Teamwork (PIVOT) survey on an acute cardiology unit in an academic teaching hospital with patients receiving Rounding with Heart, an interprofessional bedside rounding initiative, and others receiving traditional rounding processes. Sixty-three subjects were surveyed during their hospital stay. We found a significant difference (p = .006) in PIVOT scores between those receiving interprofessional rounding and those not receiving this rounding structure. In an item-by-item analysis, four specific items were found to be significant which were supported by analysis of qualitative data. Observations of the structured interprofessional rounding process by our research team reveal themes that emerged from observations: (1) openness/inclusivity, (2) patient-centeredness, (3) attending role/shared leadership, (4) nonconfrontational learning, (5) efficacy, and (6) team at bedside. Our results indicate that patients may be able to recognize the teamwork in the structured bedside rounding process and that interfacing with the team may be an important component to patients. We conclude that patient perceptions of teamwork are a valuable informant to modeling collaborative practices, and there are key observable components to the structured rounding model that may foster collaboration among different disciplines.

Progressive Mitral Stenosis After MitraClip Implantation in a Patient With Systemic Inflammatory Disease.

We describe a patient at high surgical risk who was successfully treated with a MitraClip (Abbott Vascular, Menlo Park, CA) without transmitral gradient. She received corticosteroid therapy for systemic lupus erythematosus, and progressive mitral stenosis developed late after MitraClip implantation. It gradually increased and reached 23 mm Hg at 28 months after the procedure; during the same period, her dose of prednisone had to be increased owing to lupus flare. Systemic inflammatory disease has the potential to result in mitral valve inflammation and fibrosis, ultimately causing thickening of the tissue bridge and worsening of the mitral valve obstruction. Preprocedural counseling regarding durability may help in this population.

Usefulness of Psoas Muscle Area to Predict Mortality in Patients Undergoing Transcatheter Aortic Valve Replacement.

Frailty has become high-priority theme in cardiovascular diseases because of aging and increasingly complex nature of patients. Low muscle mass is characteristic of frailty, in which invasive interventions are avoided if possible because of decreased physiological reserve. This study aimed to determine if the psoas muscle area (PMA) could predict mortality and to investigate its utility in patients who underwent transcatheter aortic valve replacement (TAVR). We retrospectively reviewed 232 consecutive patients who underwent TAVR. Cross-sectional areas of the psoas muscles at the level of fourth lumbar vertebra were measured by computed tomography and normalized to body surface area. Patients were divided into tertiles according to the normalized PMA for each gender (men: tertile 1, 1,708 to 1,178 mm(2)/m(2); tertile 2, 1,176 to 1,011 mm(2)/m(2); and tertile 3, 1,009 to 587 mm(2)/m(2); women: tertile 1, 1,436 to 962 mm(2)/m(2); tertile 2, 952 to 807 mm(2)/m(2); and tertile 3, 806 to 527 mm(2)/m(2)). Smaller normalized PMA was independently correlated with women and higher New York Heart Association classification. After adjustment for multiple confounding factors, the normalized PMA tertile was independently associated with mortality at 6 months (adjusted hazard ratio 1.53, 95% confidence interval 1.06 to 2.21). Kaplan-Meier analysis showed that tertile 3 had higher mortality rates than tertile 1 at 6 months (14% and 31%, respectively, p = 0.029). Receiver-operating characteristic analysis showed that normalized PMA provided the increase of C-statistics for predicting mortality for a clinical model and gait speed. In conclusion, PMA is an independent predictor of mortality after TAVR and can complement a clinical model and gait speed.

The role of transesophageal echocardiography in atrial fibrillation.

Transesophageal echocardiography (TEE) is very useful in the evaluation and management of selected patients with atrial fibrillation, primarily by clear visualization of left atrial appendage thrombus. Insights gained from two-dimensional and Doppler interrogation of the appendage include recognition of the association of dense spontaneous contrast and reduced mechanical appendage function with increased risk of thromboembolism. TEE-guided cardioversion has been shown to be safe and effective for a subset of patients, provided it is performed by experienced operators familiar with imaging the appendage and recognizing artifacts.

Congenital heart disease and exercise.

Though initially challenging, the process of determining appropriate levels of exercise for patients with congenital heart disease can be broken down into several practical steps: List 1: Summary of approach to CHD patients and exercise Get the records: Surgical reports, diagnostic test results, office visits, admissions [table: see text] Obtain family history: Family members with sudden death increase risk. Thorough physical exam: Special attention to auscultation of murmurs Appropriate diagnostic testing: Noninvasive testing is usually adequate. Review guidelines: 26th Bethesda Conference, 1994 [13] Make recommendation: Be specific about types of exercise allowed. Reassess at least annually: Patients' status may change over time [24]. The use of this algorithm and review of available guidelines, in combination with selected consultation with other specialists, should allow the sports physician to prescribe exercise for the majority of these patients confidently. Examples of several congenital defects of varying severity, and the appropriate exercise prescription, are listed in Table 1.

Impending paradoxical embolism presenting as myocardial infarction.

We present a spectrum of findings with transthoracic echocardiography, coronary angiography, and open surgical exploration in a 54-year-old man who presented with an acute ST segment elevation myocardial infarction and was diagnosed with impending paradoxical emboli. He underwent successful surgical removal of the thrombus. LEARNING OBJECTIVE: Impending paradoxical embolism, a biatrial thromboembolus in transit across a patent foramen ovale, is associated with a 20% mortality rate. Very rarely does it present as a ST segment elevation myocardial infarction. The optimal management (medical or surgical) for those who present with it remains a subject of debate, although surgery has been associated with less systemic embolization.

Design, rationale, and initiation of the Surgical Interventions for Moderate Ischemic Mitral Regurgitation Trial: a report from the Cardiothoracic Surgical Trials Network.

OBJECTIVE: Patients with coronary artery disease complicated by moderate ischemic mitral regurgitation have demonstrably poorer outcome than do patients with coronary artery disease but without mitral regurgitation. The optimal treatment of this condition has become increasingly controversial, and a randomized trial evaluating current practices is warranted. METHODS: We describe the design and initial execution of the Cardiothoracic Surgical Trials Network Surgical Interventions for Moderate Ischemic Mitral Regurgitation Trial. RESULTS: This is an ongoing prospective, multicenter, randomized, controlled clinical trial designed to test the safety and efficacy of mitral repair in addition to coronary artery bypass grafting in the treatment of moderate ischemic mitral regurgitation. CONCLUSIONS: The results of the Cardiothoracic Surgical Trials Network Surgical Interventions for Moderate Ischemic Mitral Regurgitation Trial will provide long-awaited information on controversial therapies for this morbid disease process.