Albert Chi

Safety, efficiency, and cost-effectiveness of a multidisciplinary percutaneous tracheostomy program.

Objective:The frequency of bedside percutaneous tracheostomies is increasing in intensive care medicine, and both safety and efficiency of care are critical elements in continuing success of this procedure. Prioritizing patient safety, a tracheostomy team was created at our institution to provide bedside expertise in surgery, anesthesiology, respiratory, and technical support. This study was performed to evaluate the metrics of patient outcome, efficiency of care, and cost-benefit analysis of the multidisciplinary Johns Hopkins Percutaneous Tracheostomy Program. Design:A review was performed for patients who received tracheostomies in 2004, the year before the Johns Hopkins Percutaneous Tracheostomy Program was established, and those who received tracheostomies in 2008, the year following the program’s establishment. Comparative outcomes were evaluated, including the efficiency of procedure and intensive care unit length of stay, complication rate including bleeding, hypoxia, loss of airway, and a financial cost-benefit analysis. Setting:Single-center, major university hospital. Patients:The sample consisted of 363 patients who received a tracheostomy in the years 2004 and 2008. Measurements and Main Results:The number of percutaneous procedures increased from 59 of 126 tracheostomy patients in 2004, to 183 of 237 in 2008. There were significant decreases in the prevalence of procedural complications, particularly in the realm of airway injuries and physiologic disturbances. Regarding efficiency, the structured program reduced the time to tracheostomy and overall procedural time. The intensive care unit length of stay in nonpulmonary patients and improvement in intensive care unit and operating room back-fill efficiency contributed to an overall institutional financial benefit. Conclusions:An institutionally subsidized, multi-disciplinary percutaneous tracheostomy program can improve the quality of care in a cost-effective manner by decreasing the incidence of tracheostomy complications and improving both the time to tracheostomy, duration of procedure, and postprocedural intensive care unit stay.

Outcome of selective non-operative management of penetrating abdominal injuries from the North American National Trauma Database

The aim of this study was to investigate trends in the practice of selective non‐operative management (SNOM) for penetrating abdominal injury (PAI) and to determine factors associated with its failure.

Increased mortality associated with EMS transport of gunshot wound victims when compared to private vehicle transport

BACKGROUND Recent studies suggest that mode of transport affects survival in penetrating trauma patients. We hypothesised that there is wide variation in transport mode for patients with gunshot wounds (GSW) and there may be a mortality difference for GSW patients transported by emergency medical services (EMS) vs. private vehicle (PV). STUDY DESIGN We studied adult (≥16 years) GSW patients in the National Trauma Data Bank (2007-2010). Level 1 and 2 trauma centres (TC) receiving ≥50 GSW patients per year were included. Proportions of patients arriving by each transport mode for each TC were examined. In-hospital mortality was compared between the two groups, PV and EMS, using multivariable regression analyses. Models were adjusted for patient demographics, injury severity, and were adjusted for clustering by facility. RESULTS 74,187 GSW patients were treated at 182 TCs. The majority (76%) were transported by EMS while 12.6% were transported by PV. By individual TC, the proportion of patients transported by each category varied widely: EMS (median 78%, interquartile range (IQR) 66-85%), PV (median 11%, IQR 7-17%), or others (median 7%, IQR 2-18%). Unadjusted mortality was significantly different between PV and EMS (2.1% vs. 9.7%, p<0.001). Multivariable analysis demonstrated that EMS transported patients had a greater than twofold odds of dying when compared to PV (OR=2.0, 95% CI 1.73-2.35). CONCLUSIONS Wide variation exists in transport mode for GSW patients across the United States. Mortality may be higher for GSW patients transported by EMS when compared to private vehicle transport. Further studies should be performed to examine this question.

Safety and efficiency of interventional pulmonologists performing percutaneous tracheostomy.

Background: The steady rise in the number of critically ill patients in the USA has led to an increase in the need for tracheostomies in patients requiring chronic ventilatory support. There is a matched need for experienced operators to safely and efficiently perform these procedures. Objectives: We evaluated the effects on procedural outcomes and efficiency of percutaneous dilatational tracheostomy (PDT) placement in the medical intensive care unit (MICU) by the surgical team (ST) or interventional pulmonologists (IP). The IP team joined the PDT team in September 2007 and became primarily responsible for all PDT in the MICU. Methods: A retrospective analysis of prospectively collected data of patients who received PDT in the MICU by ST and IP from September 2007 to August 2010 was made. Outcomes including safety, efficacy, and procedural efficiency were compared. Results: One hundred seven patients underwent bedside PDT in the MICU during this period. Forty-three procedures (40.2%) were performed by the ST and 64 procedures (59.8%) were performed by IP. There was no statistical difference between the incidence of airway injury and infection between the two procedural groups. There were no deaths related to the performance of PDT in our series. PDT was completed within 48 h of request in 100% of IP patients and 95% of ST patients (p = 0.08). Conclusions: There were no statistical differences in PDT between the ST and IP groups when comparing complications. There was a trend towards an increased efficiency in time to PDT after consultation within the IP PDT group. Trained IP can safely and effectively perform PDT.

A pilot study of eye-tracking devices in intensive care

BACKGROUND Eye-tracking devices have been suggested as a means of improving communication and psychosocial status among patients in the intensive care unit (ICU). This study was undertaken to explore the psychosocial impact and communication effects of eye-tracking devices in the ICU. METHODS A convenience sample of patients in the medical ICU, surgical ICU, and neurosciences critical care unit were enrolled prospectively. Patients participated in 5 guided sessions of 45 minutes each with the eye-tracking computer. After completion of the sessions, the Psychosocial Impact of Assistive Devices Scale (PIADS) was used to evaluate the device from the patients perspective. RESULTS All patients who participated in the study were able to communicate basic needs to nursing staff and family. Delirium as assessed by the Confusion Assessment Method for the Intensive Care Unit was present in 4 patients at recruitment and none after training. The devices overall psychosocial impact ranged from neutral (-0.29) to strongly positive (2.76). Compared with the absence of intervention (0 = no change), patients exposed to eye-tracking computers demonstrated a positive mean overall impact score (PIADS = 1.30; P = .004). This finding was present in mean scores for each PIADS domain: competence = 1.26, adaptability = 1.60, and self-esteem = 1.02 (all P < .01). CONCLUSION There is a population of patients in the ICU whose psychosocial status, delirium, and communication ability may be enhanced by eye-tracking devices. These 3 outcomes are intertwined with ICU patient outcomes and indirectly suggest that eye-tracking devices might improve outcomes. A more in-depth exploration of the population to be targeted, the devices limitations, and the benefits of eye-tracking devices in the ICU is warranted.

Investigating the relationship between weather and violence in Baltimore, Maryland, USA

BACKGROUND It is a common refrain at major urban trauma centers that caseloads increase in the heat of the summer. Several previous studies supported this assertion, finding trauma admissions and crime to correlate positively with temperature. We examined links between weather and violence in Baltimore, MD, through trauma presentation to Johns Hopkins Hospital and crime reports filed with the Baltimore Police Department. METHODS Crime data were obtained from the Baltimore City Police Department from January 1, 2008 to March 31, 2013. Trauma data were obtained from a prospectively collected registry of all trauma patients presenting to Johns Hopkins Hospital from January 1, 2007 to March 31, 2013. Weather data were obtained from the National Climatic Data Center. Correlation coefficients were calculated and negative binomial regression was used to elucidate the independent associations of weather and temporal variables with the trauma and crime data. RESULTS When adjusting for temporal and meteorological factors, maximum daily temperature was positively associated with total trauma, intentional injury, and gunshot wounds presenting to Johns Hopkins Hospital along with total crime, violent crime, and homicides in Baltimore City. Associations of average wind speed, daily precipitation, and daily snowfall with trauma and crime were far weaker and, when significant, nearly universally negative. CONCLUSION Maximum daily temperature is the most important weather factor associated with violence and trauma in our study period and location. Our findings suggest potential implications for hospital staffing to be explored in future studies.

Nutritional Management of Gastroenterocutaneous Fistulas

Despite significant improvements in medical and surgical treatments of gastroenterocutaneous fistulas (ECFs), they remain a significant cause of morbidity and mortality for patients who develop them. A hypermetabolic response and profound disturbances in fluid and electrolyte levels, leading to dehydration, hyponatraemia, hypokalemia, and metabolic acidosis, are common, making this patient population a unique subgroup of critically ill patients vulnerable to further decline in nutritional status. In general, medical treatment and stabilization precede attempts at surgical intervention and remain a hallmark of therapy for ECFs. The most challenging aspect of ECF management is nutritional repletion because there is no standard protocol, and each patient and case is unique. The management requires patient- as well as fistula-specific factors to be considered for optimizing the best treatment regimen. Currently, there are no well-established, evidence-based clinical guidelines for managing the medications and nutrition care of these patients. Although it is often difficult and sometimes impossible to provide adequate enteral nutrition in the presences of an ECF, nutritional support should be implemented whenever possible. Many questions have been answered; however, there is no uniformity to these answers. This chapter reviews the roles of enteral and supplemental parenteral nutrition, somatostatin, and immune-modulating nutritional supplementation.

Blunt Aortic Injury in a Patient With Prior Coronary Artery Bypass Surgery

Traumatic aortic rupture is a significant challenge, further complicated by prior coronary artery bypass graft surgery with a left internal mammary artery anastomosis. We present a patient with prior coronary artery bypass graft and valve replacement who sustained multiple injuries, including an aortic rupture, after a motor vehicle crash. This report describes successful treatment of a patient with a thoracic endograft and carotid subclavian bypass to preserve the left internal mammary artery inflow.

Erratum: Outcome of selective non-operative management of penetrating abdominal injuries from the North American National Trauma Database (British Journal of Surgery (2012) 99:1 (155-164)

Sir Ideally, a trial should have a single endpoint based on just one outcome measure. However, as the art of trial design has evolved, most large trials have a primary (composite) endpoint consisting of multiple outcome measures. In our trial both the prevalence of recurrent hyperthyroidism and changes in Graves’ ophthalmopathy were defined at the beginning of the trial as primary outcome measures because of their clinical importance in the field1. The sample size calculation was performed separately for each primary outcome measure as described in detail in the methods section. To detect an estimated absolute difference in recurrent hyperthyroidism rate of 5 per cent (a reduction from 5 per cent after bilateral subtotal thyroidectomy to 0 per cent after total thyroidectomy), 71 patients were required in each group to give the study a power of 80 per cent. On the other hand, to detect an estimated absolute difference in Graves’ ophthalmopathy progression rate of 8 per cent (a reduction from 16 per cent after bilateral subtotal thyroidectomy to 8 per cent after total thyroidectomy), 83 patients were required in each group to give the study a power of 80 per cent. Anticipating 15 per cent loss to follow-up, it was decided to include a total of 200 patients (100 in each group) in the trial. Thus, this study had a predefined power needed to detect an assumed difference in the primary outcome measures. M. Barczynski Third Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland (e-mail: marbar@mp.pl) DOI: 10.1002/bjs.8829