Improved Outcomes With Integrated Intensivist Consultation for Cardiac Surgery Patients.

This study examined the impact of integrated intensivist consultation in the immediate postoperative period on outcomes for cardiac surgery patients. A retrospective cohort study was conducted in 1711 adult cardiac surgery patients from a single quaternary care center in Minnesota. Outcomes were compared across 2 consecutive 2-year time periods reflecting an elective intensivist model (n = 801) and an integrated intensivist model (n = 910). Patients under the 2 models were comparable with respect to demographics, comorbidities, procedure types, and Society for Thoracic Surgery predicted risk of mortality score; however, patients in the earlier cohort were slightly older and more likely to have chronic kidney disease ( P = .003). Integrated intensivist involvement was associated with reduced postoperative ventilator time, length of stay (LOS), stroke, encephalopathy, and reoperations for bleeding (all P < .01) but was not associated with mortality. Intensivist integration into the postoperative care of cardiac surgery patients may reduce ventilator time, LOS, and complications but may not improve survival.

Percutaneous Venoarterial Extracorporeal Membrane Oxygenation for Refractory Cardiogenic Shock Is Associated with Improved Short- and Long-Term Survival.

Mortality due to refractory cardiogenic shock (RCS) exceeds 50%. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) has become an accepted therapy for RCS. The aim of our study was to evaluate outcomes of patients with RCS treated with percutaneous VA-ECMO (pVA-ECMO). Retrospective review of patients supported with VA-ECMO at our institution in 2012-2013. Clinical characteristics, bleeding, vascular complications, and outcomes including survival were assessed. A total of 37 patients were supported with VA-ECMO for RCS. The majority of VA-ECMO (76%) was placed in the catheterization laboratory. Nearly half (49%) of the patients presented with acute myocardial infarction. Seven patients (19%) underwent insertion of pVA-ECMO in the setting of cardiopulmonary resuscitation with mechanical chest compression device. Median duration of support was 5 days. Index hospitalization, 30-day, and 1-year survival were 65%, 65%, and 57%, respectively. Survival rate for discharged patients was 87.5% with a median follow-up of 450 days. Refractory cardiogenic shock supported with pVA-ECMO is associated with an improved survival in patients with a traditionally poor prognosis.

Development and pilot testing of an OSCE for difficult conversations in surgical intensive care.

OBJECTIVES: To describe the development and results of an Objective Structured Clinical Exam (OSCE) for leading family conferences in the surgical intensive care unit (SICU). DESIGN: Pilot demonstration and reliability assessment. SETTING: General surgery residency program at a major academic teaching hospital. PARTICIPANTS: PGY-2 and PGY-4 categorical general surgery residents (n=8). RESULTS: The SICU Family Conference OSCE consists of two 20-minute stations, one requiring residents to lead an end-of-life discussion and the other to disclose an iatrogenic complication. Actual case scenarios and trained actors were used; the examinations were videotaped in a standardized setting. Two professional raters as well as the participating actors assessed each resident performance using rating tools developed for each station and based on guiding principles gleaned from the literature. Resident debriefings and evaluation surveys were also conducted. Resident perception of the OSCE overall was positive. Analysis of the videotapes revealed the need for greater standardization of the actors' roles. The rating tools showed strong internal consistency (0.77-0.85), but inter-rater agreement of scores was generally low (<0.70) within rater groups. Family actors consistently gave residents higher global assessment scores than did the professional raters. Second- and fourth-year residents scored equally well on the examination. CONCLUSIONS: This pilot provided residents with a positive learning experience and valid formative feedback. Case materials developed for each station served their function well. More work in actor and rater training is needed before the examination scores can be reliably used in summative evaluation.