Our experience with two cardioplegic solutions: dextrose versus non-dextrose in adult cardiac surgery.

Intraoperative hyperglycemia has been observed to be associated with increased morbidity and mortality after cardiac surgery. Dextrose cardioplegia is used for its cardioprotective effects but may lead to intraoperative hyperglycemia and more postoperative complications. This was a retrospective observational study. Patient records (n = 2301) were accessed from a large database at a tertiary care facility. The two groups (dextrose vs. nondextrose) were then matched using preoperative variables of age, sex, body mass index, wound exposure time, preoperative HbA1c levels, renal failure, hypertension, and prior cerebrovascular disease. The following outcomes were recorded: 30-day mortality, sternal wound infection, stroke, and highest glucose level on cardiopulmonary bypass. The dextrose cardioplegia group showed statistically higher intraoperative glucose levels (272.76 +/- 55.92 vs. 182.79 +/- 45, p value = .0001). There was no difference in postoperative mortality, sternal wound infections or stroke incidence, nor in other secondary outcomes. The type of cardioplegia solution was shown to affect glucose levels; however, there was no effect on postoperative complication rates.

The impact of a palliative care unit on mortality rate and length of stay for medical intensive care unit patients.

OBJECTIVE: This study evaluates the impact of a 10-bed inpatient palliative care unit (PCU) on medical intensive care unit (MICU) mortality and length of stay (LOS) for terminally ill patients following the opening of an inpatient PCU. We hypothesized that MICU mortality and LOS would be reduced through the creation of a more appropriate location of care for critically ill MICU patients who were dying. METHOD: We performed a retrospective electronic database review of all MICU discharges from January 1, 2006 through December 31, 2009 (5,035 cases). Data collected included MICU mortality, MICU LOS, and mean age. The PCU opened on January 1, 2008. We compared location of death for MICU patients during the 2-year period before and the 2-year period after the opening of the PCU. RESULTS: Our data showed that the mean MICU mortality and MICU LOS both significantly decreased following the opening of the PCU, from 21 to 15.8% (p = 0.003), and from 4.6 to 4.0 days (p = 0.014), respectively. SIGNIFICANCE OF RESULTS: The creation of an inpatient PCU resulted in a statistically significant reduction in both MICU mortality rate and MICU LOS, as terminally ill patients were transitioned out of the MICU to the PCU for end-of-life care. Our data support the hypothesis that a dedicated inpatient PCU, capable of providing care to patients requiring mechanical ventilation or vasoactive agents, can protect terminally ill patients from an ICU death, while providing more appropriate care to dying patients and their loved ones.

Palliative medicine consultation impacts DNR designation and length of stay for terminal medical MICU patients.

OBJECTIVE: The purpose of this study was to assess the impact of a palliative medicine consultation on medical intensive care unit (MICU) and hospital length of stay, Do Not Resuscitate (DNR) designation, and location of death for MICU patients who died during hospitalization. METHOD: A comparison of two retrospective cohorts in a 17-bed MICU in a tertiary care university-affiliated hospital was conducted. Patients admitted to the MICU between January 1, 2003 and June 30, 2004 (N = 515) were compared to MICU patients who had had a palliative medicine consultation between January 1, 2005 and June 1, 2009 (N = 693). To control for disease severity, only patients in both cohorts who died during their hospitalization were considered for this study. RESULTS: Palliative medicine consultation reduced time until death during the entire hospitalization (log-rank test, p < 0.01). Time from MICU admission until death was also reduced (log-rank test, p < 0.01), further demonstrating the impact of the palliative care consultation on the duration of dying for hospitalized patients. The intervention group contained a significantly higher percentage of patients with a DNR designation at death than did the control group (86% vs. 68%, χ2 test, p < 0.0001). SIGNIFICANCE OF RESULTS: Palliative medicine consultation is associated with an increased rate of DNR designation and reduced time until death. Patients in the intervention group were also more likely to die outside the MICU as compared to controls in the usual care group.

The impact of an end-of-life communication skills intervention on physicians-in-training.

The palliative medicine literature consistently documents that physicians are poorly prepared to help patients experience a "good death" and are often unaware of their ill patients' preferences for end-of-life care. The present study, enrolling 150 physicians, sought to improve their communication skills for end-of-life care. We found significant attitudinal changes and a greater degree of self-rated competence in delivering end-of-life care for those in the intervention group. This study used a novel approach to train physicians to be better equipped to conduct difficult goals of care conversations with patients and their families at end-of-life.

Transforming the mortality review conference to assess palliative care in the acute care setting: a feasibility study.

OBJECTIVE: This project sought to evaluate the impact of a hospital-based Palliative Care Consultation (PCC) service utilizing a common practice: the resident mortality review conference. METHOD: Internal Medicine residents used a revised chart audit tool during the mortality review conference, which included domains described in the Clinical Practice Guidelines for Quality Palliative Care (2004). This study attempted to transform the common practice into a methodology for collecting data that could be used as a platform to assess the quality of hospital care near the end of life. In this review, the residents were asked not only "what care was delivered appropriately?" but "what could we have done?" to relieve the patient's and family's suffering. RESULTS: The results showed that the mortality review process could be used to assess care at the end of life. It also showed that those patients who received a PCC received better care. Symptoms were addressed at a significantly higher rate for those patients who received a PCC than for those who did not. Specifically, these were symptoms of pain (75% vs. 51%, p < .0001), dyspnea (75% vs. 59%, p < 0.0001), nausea (28% vs. 18%, p < 0.0001), and agitation (53% vs. 33%, p < 0.0001). SIGNIFICANCE OF RESULTS: The mortality review process was found to be valuable in assessing care delivery for patients near the end of life. The tool yielded results that were consistent with findings of other studies looking at pain and symptom management, advance care planning, and the rate of palliative care consults across major diagnostic categories, supporting the face validity of the mortality review process.

Comprehensive perinatal safety initiative to reduce adverse obstetric events.

A comprehensive perinatal safety initiative (PSI) was incrementally introduced from August 2007 to July 2009 at a large tertiary medical center to reduce adverse obstetrical outcomes. The PSI introduced: (1) evidence-based protocols, (2) formalized team training with emphasis on communication, (3) standardization of electronic fetal monitoring with required documentation of competence, (4) a high-risk obstetrical emergency simulation program, and (5) dissemination of an integrated educational program among all healthcare providers. Eleven adverse outcome measures were followed prospectively via modification of the Adverse Outcome Index (MAOI). Additionally, individual components were evaluated. The logistic regression model found that within the first year, the MAOI decreased significantly to 0.8% from 2% (p<.0004) and was maintained throughout the 2-year period. Significant decreases over time for rates of return to the operating room (p<.018) and birth trauma (p<.0022) were also found. Finally, significant improvements were found in staff perceptions of safety (p<.0001), in patient perceptions of whether staff worked together (p<.028), in the management (p<.002), and documentation (p<.0001) of abnormal fetal heart rate tracings, and the documentation of obstetric hemorrhage (p<.019). This study demonstrates that a comprehensive PSI can significantly reduce adverse obstetric outcomes, thereby improving patient safety and enhancing staff and patient experiences.

Quantifying internal medicine resident clinical experience using resident-selected primary diagnosis codes.

BACKGROUND: While experiential learning is a desirable goal of residency education, little is known regarding the actual clinical experience of internal medicine residents during their training. METHODS: We modified an electronic patient handoff tool to include a system for resident entry of a primary diagnosis for each of their patients. Using the International Classification of Diseases, Ninth Revision (ICD-9) system, we created two methods to select the code: 1) an organ system-based dropdown list containing frequently used codes; and 2) a search option for the complete ICD-9 database. The codes were then grouped using ICD-9 categorization. RESULTS: A total of 7562 resident-patient diagnostic encounters were studied. A wide spectrum of clinical conditions was observed, with symptoms and ill-defined conditions, circulatory disorders, respiratory disorders, neoplasms, genitourinary disorders, digestive disorders, diseases of the blood/blood forming organs, endocrinologic/nutritional/metabolic/immune disorders, and disorders of the skin and subcutaneous tissue accounting for about 86% of resident clinical experience. Symptoms and ill-defined conditions were noted to represent a sizable portion of resident clinical experience. Within this category, the most common conditions were fever; abdominal pain; and chest pain, unspecified. CONCLUSIONS: Analysis of resident-selected ICD-9 codes might serve as a method to attempt to define resident clinical experience, and may be useful in the development of innovative experiential learning-based residency curricula. This might also be used to assess gaps in experiential learning at the program or resident level, and may serve to identify topics that require additional teaching supplementation.

Hand hygiene in long-term care facilities: a multicenter study of knowledge, attitudes, practices, and barriers.

An anonymous survey of 1143 employees in 17 nursing facilities assessed knowledge of, attitudes about, self-perceived compliance with, and barriers to implementing the 2002 Centers for Disease Control and Prevention hand hygiene guidelines. Overall, employees reported positive attitudes toward the guidelines but differed with regard to knowledge, compliance, and perceived barriers. These findings provide guidance for practice improvement programs in long-term care settings.