Complex Clinical Intersection: Palliative Care in Patients with Dementia.

Because of the rapidly growing older population and increases in longevity, rates of dementia have been rising. Clinical challenges of treating dementia include limited resources and lack of curative therapies. Palliative care approaches improve quality of life and alleviate suffering for dementia patients at the end of life, although implementation may be limited by societal acceptance and feasibility. This review examines the published literature on pain assessments, pain and behavior interventions, tools for advanced care planning, and clinical concerns in dementia patients. Ultimately, modification of the traditional palliative care model may improve outcomes and functioning for dementia patients at all stages of their illness.

Atypical Fibroxanthoma in a 13-Year-Old Guatemalan Girl with Xeroderma Pigmentosum.

Xeroderma pigmentosum (XP) is a rare, autosomal recessive disease involving a defect in DNA repair leading to the premature development of numerous aggressive cutaneous malignancies. Although atypical fibroxanthoma (AFX) is a neoplasm typically found in the setting of extensive sun exposure or therapeutic radiation, AFXs are rarely associated with children with XP. We report the case of a 13-year-old Guatemalan girl with the XP type C variant who developed one of the largest AFXs reported on a child's finger.

Intensive Care Utilization for Hematopoietic Cell Transplant Recipients.

Blood and marrow transplantation (BMT) is a potentially curative therapy for a number of malignant and nonmalignant diseases. Multiple variables, including age, comorbid conditions, disease, disease stage, prior therapies, degree of donor-recipient matching, type of transplantation, and dose intensity of the preparative regimen, affect both morbidity and mortality. Despite tremendous gains in supportive care, BMT remains a high-risk medical therapy. A critically ill BMT recipient may require transfer to an intensive care unit (ICU) and the specialized medical and nursing care that can be provided, such as mechanical ventilation and vasopressor support. Mortality for BMT recipients requiring care in an ICU is high. This paper will describe the experience of the Stanford Blood and Marrow Transplant Program in developing and implementing guidelines to maximize the benefit of intensive care for critically ill BMT recipients.

Interventional Procedures Outside of the Operating Room: Results From the National Anesthesia Clinical Outcomes Registry.

OBJECTIVES: This study examines the impact of procedural locations and types of anesthetics on patient outcomes in non-operating room anesthesia (NORA) locations. The National Anesthesia Clinical Outcomes Registry database was examined to compare OR to NORA anesthetic complications and patient demographics. METHODS: The National Anesthesia Clinical Outcomes Registry database was examined for all patient procedures from 2010 to 2013. A total of 12,252,846 cases were analyzed, with 205 practices contributing information, representing 1494 facilities and 7767 physician providers. Cases were separated on the basis of procedure location, OR, or NORA. Subgroup analysis examined outcomes from specific subspecialties. RESULTS: NORA procedures were performed on a higher percentage of patients older than 50 years (61.92% versus 55.56%, P < 0.0001). Monitored anesthesia care (MAC) (20.15%) and sedation (2.05%) were more common in NORA locations. The most common minor complications were postoperative nausea and vomiting (1.06%), inadequate pain control (1.01%), and hemodynamic instability (0.62%). The most common major complications were serious hemodynamic instability (0.10%) and upgrade of care (0.10%). There was a greater incidence of complications in cardiology and radiology locations. Overall mortality was higher in OR versus NORA (0.04% versus 0.02%, P < 0.0001). Subcategory analysis showed increased incidence of death in cardiology and radiology locations (0.05%). CONCLUSIONS: NORA procedures have lower morbidity and mortality rates than OR procedures, contrary to some previously published studies. However, the increased complication rates in both the cardiology and radiology locations may need to be the target of future safety investigations. Providers must ensure proper monitoring of patients, and NORA locations need to be held to the same standard of care as the main operating room. Further studies need to identify at-risk patients and procedures that may predispose patients to complications.

Non-operating Room Anesthesia: The Principles of Patient Assessment and Preparation.

A significant number of anesthetics are performed outside of the operating room (OR). Despite the increased requirement for anesthesia services, the framework to perform the necessary preprocedural anesthesia assessments to optimize patients has not been uniformly developed. Performing anesthesia in non-OR locations poses significant and distinct challenges compared with the procedures in the OR. Anesthesiologists are faced with patients with increasingly complicated comorbidities undergoing novel, complex interventional procedures. With unique training in preoperative triaging, and an expertise in intraoperative and postoperative management of complex patients, anesthesiologists can contribute to greater efficiency and patient safety in the non-OR setting.

Examining Health Care Costs: Opportunities to Provide Value in the Intensive Care Unit.

As health care costs threaten the economic stability of American society, increasing pressures to focus on value-based health care have led to the development of protocols for fast-track cardiac surgery and for delirium management. Critical care services can be led by anesthesiologists with the goal of improving ICU outcomes and at the same time decreasing the rising cost of ICU medicine.

Analysis of patient injury based on anesthesiology closed claims data from a major malpractice insurer.

INTRODUCTION: The analysis of malpractice claims can provide risk managers with a detailed view of patient mortality and morbidity. The data comes from many institutions, encompasses a diverse group of practitioners and practice settings, and contains detailed clinical information. Analysis can help identify patterns of injury, risk factors, and rare and sentinel events. METHODS: We examined most recent anesthesia closed claims data collected by The Doctors Company, a large national malpractice insurer. We analyzed data from claims closed between 2007 and 2012. Each claim underwent a review by physician and nurse experts, and was then coded using the Comprehensive Risk Intelligence Tool. Injury distribution and association between the injury and patient comorbidity were also examined. RESULTS: A total of 607 claims were analyzed. Most frequent injuries were teeth damage (20.8%), death (18.3%), nerve damage (13.5%), organ damage (12.7%), pain (10.9%), and arrest (10.7%). Obesity was most frequently identified as a contributing factor leading to a claim. Injury-to-claim rates were highest in hospitals with fewer than 100 beds, while ambulatory surgery centers had the lowest death-to-claim rate (12%). Average indemnity for an anesthesia claim was $309 066, compared to $291 000 for all physician specialties. CONCLUSIONS: The most frequent claims were death and nerve damage when teeth damage was excluded. Obesity impacted anesthesia outcomes more frequently than did other comorbidities. Although there were fewer claims from the smaller hospitals, those claims had higher rates of mortality and nerve damage compared to larger-size hospitals. Further analysis is needed to evaluate these trends as well as impact of specific patient comorbidities on anesthesia outcomes.

Emotional intelligence in the operating room: analysis from the Boston Marathon bombing.

INTRODUCTION: The Boston Marathon terrorist bombing that occurred on April 15, 2013 illustrates the importance of a cohesive, efficient management for the operating room and perioperative services. Conceptually, emotional intelligence (EI) is a form of social intelligence used by individuals in leadership positions to monitor the feelings and emotions of their team while implementing a strategic plan. OBJECTIVE: To describe the experience of caring for victims of the bombing at a large tertiary care center and provide examples demonstrating the importance of EI and its role in the management of patient flow and overall care. METHODS: A retrospective review of trauma data was performed. Data regarding patient flow, treatment types, treatment times, and outcomes were gathered from the hospital's electronic tracking system and subsequently analyzed. Analyses were performed to aggregate the data, identify trends, and describe the medical care. RESULTS: Immediately following the bombing, a total of 35 patients were brought to the emergency department (ED) with injuries requiring immediate medical attention. 10 of these patients went directly to the operating room on arrival to the hospital. The first victim was in an operating room within 21 minutes after arrival to the ED. CONCLUSION: The application of EI in managerial decisions helped to ensure smooth transitions for victims throughout all stages of their perioperative care. EI provided the fundamental groundwork that allowed the operating room manager and nurse leaders to establish the calm and coordinated leadership that facilitated patient care and teamwork.