Bradley T. Rosen

The use of tissue models for vascular access training. Phase I of the procedural patient safety initiative.

INTRODUCTION: Following the Institute of Medicine report “To Err is Human,” the Agency for Healthcare Research and Quality identified proper central venous catheter (CVC) insertion techniques and wide sterile barriers (WSB) as 2 major quality indicators for patients safety. However, no standard currently exists to teach proper procedural techniques to physicians. AIM: To determine whether our nonhuman tissue model is an effective tool for teaching physicians proper wide sterile barrier technique, ultrasound guidance for CVC placement, and sharps safety. PARTICIPANTS: Educational sessions were organized for physicians at Cedars-Sinai Medical Center. Participants had a hands-on opportunity to practice procedural skills using a nonhuman tissue model, under the direct supervision of experienced proceduralists. PROGRAM EVALUATION: An anonymous survey was distributed to participants both before and after training, measuring their reactions to all aspects of the educational sessions relative to their prior experience level. DISCUSSION: The sessions were rated highly worthwhile, and statistically significant improvements were seen in comfort levels with ultra-sound-guided vascular access and WSB (P<.001). Given the revitalized importance of patient safety and the emphasis on reducing medical errors, further studies on the utility of nonhuman tissue models for procedural training should be enthusiastically pursued.

Thoracentesis outcomes: a 12-year experience

Background Despite a lack of evidence in the literature, several assumptions exist about the safety of thoracentesis in clinical guidelines and practice patterns. We aimed to evaluate specific demographic and clinical factors that have been commonly associated with complications such as iatrogenic pneumothorax, re-expansion pulmonary oedema (REPE) and bleeding. Methods We performed a cohort study of inpatients who underwent thoracenteses at Cedars-Sinai Medical Center (CSMC) from August 2001 to October 2013. Data were collected prospectively including information on volume of fluid removed, procedure side, whether the patient was on positive pressure ventilation, number of needle passes and supine positioning. Iatrogenic pneumothorax, REPE and bleeding were tracked for 24u2005h after the procedure or until a clinical question was reconciled. Demographic and clinical characteristics were obtained through query of electronic medical records. Results CSMC performed 9320 inpatient thoracenteses on 4618 patients during the study period. There were 57 (0.61%) iatrogenic pneumothoraces, 10 (0.01%) incidents of REPE and 17 (0.18%) bleeding episodes. Iatrogenic pneumothorax was significantly associated with removal of >1500u2005mL fluid (p<0.0001), unilateral procedures (p=0.001) and more than one needle pass through the skin (p=0.001). For every 1u2005mL of fluid removed there was a 0.18% increased risk of REPE (95% CI 0.09% to 0.26%). There were no significant associations between bleeding and demographic or clinical variables including International Normalised Ratio, partial thromboplastin time and platelet counts. Conclusions Our series of thoracenteses had a very low complication rate. Current clinical guidelines and practice patterns may not reflect evidence-based best practices.

Identification and team-based interprofessional management of hospitalized vulnerable older adults.

BACKGROUNDnExtended hospital stays and complications are common among older adults and may lead to morbidity and loss of independence. Specialized geriatric units have been shown to improve outcomes but, with the growing numbers of older adults, may be difficult to scale to meet needs.nnnPURPOSEnThe purpose was to evaluate a quality improvement initiative that redesigned unit-based workflow and trained interprofessional teams on general medical/surgical units to create care plans for vulnerable older adults using principles of comprehensive geriatric assessment and team management.nnnMETHODnThe evaluation included a cluster randomized controlled trial of 10 medical/surgical units and intention-to-treat analysis of all patients meeting risk screening criteria.nnnRESULTSnN = 1,384, median age = 80.9 years, and 53.5% female. Mean difference in observed vs. expected length of stay was 1.03 days shorter (p = .006); incidence of complications (odds ratio [OR] = 0.45; 95% confidence interval [CI] = 0.21-0.98) and transfer to intensive care (OR = 0.45; 95% CI = 0.25-0.79) lower among patients admitted to intervention units; incidence of discharge to institutional care was higher (OR = 1.43; 95% CI = 1.06-1.93). Mortality during hospitalization (OR = 0.64; 95% CI = 0.37-1.11) did not differ between groups.nnnCONCLUSIONnReorganizing general medical/surgical units to provide team-based interprofessional care can improve outcomes among hospitalized older adults.

Portable ultrasound: the next generation arrives.

PurposeA new category of handheld devices has recently emerged that are even smaller than current portable models, with their main advantages being increased portability and affordability relative to their counterparts. However, these new devices have not yet been thoroughly evaluated in the clinical setting.MethodsA prospective, non-blinded, three-phase study was designed to evaluate a handheld ultrasound device as compared to a common compact ultrasound machine for the performance of paracenteses and thoracenteses on human patients.ResultsFor the vast majority of straight-forward evaluations, the handheld device was sufficient to safely complete the procedure without further imaging. For difficult cases with smaller fluid collections or anatomic aberrations, further localization with the common compact machine continued to be useful to improve the operator’s confidence in the findings.ConclusionThis novice handheld device represents only one of what appears to be a growing number of new ultra-portable ultrasound devices on the market. These devices represent a new and exciting form of ultrasound technology that may benefit patients and physicians in multiple venues. While they are unlikely to replace standard ultrasound devices for many of the more complex applications, their extreme portability allows for ultrasound imaging in more diverse situations that has previously been practical. Based on our limited experience, the image quality is adequate and the learning curve is reasonable. Future integration of PDA technology could further the utility of these devices and additional study will be important to further define their appropriate niche and clinical utility.

The Enhanced Care Program: Impact of a Care Transition Program on 30-Day Hospital Readmissions for Patients Discharged From an Acute Care Facility to Skilled Nursing Facilities

BACKGROUND Increased acuity of skilled nursing facility (SNF) patients challenges the current system of care for these patients. OBJECTIVE Evaluate the impact on 30-day readmissions of a program designed to enhance the care of patients discharged from an acute care facility to SNFs. DESIGN An observational, retrospective cohort analysis of 30-day hospital readmissions for patients discharged to 8 SNFs between January 1, 2014, and June 30, 2015. SETTING A collaboration between a large, acute care hospital in an urban setting, an interdisciplinary clinical team, 124 community physicians, and 8 SNFs. PATIENTS All patients discharged from Cedars-Sinai Medical Center to 8 partner SNFs were eligible for participation. INTERVENTION The Enhanced Care Program (ECP) involved the following 3 interventions in addition to standard care: (1) a team of nurse practitioners participating in the care of SNF patients; (2) a pharmacist-driven medication reconciliation at the time of transfer; and (3) educational in-services for SNF nursing staff. MEASUREMENT Thirty-day readmission rate for ECP patients compared to patients not enrolled in ECP. RESULTS The average unadjusted, 30-day readmission rate for ECP patients over the 18-month study period was 17.2% compared to 23.0% among patients not enrolled in ECP (P < .001). After adjustment for sociodemographic and clinical characteristics, ECP patients had 29% lower odds of being readmitted within 30 days (P < .001). These effects were robust to stratified analyses, analyses adjusted for clustering, and balancing of covariates using propensity weighting. CONCLUSIONS A coordinated, interdisciplinary team caring for SNF patients can reduce 30-day hospital readmissions. Journal of Hospital Medicine 2018;13:229-235. Published online first October 4, 2017

Systems Addressing Frail Elder Care: Description of a Successful Model

OBJECTIVE The aim of this article is to describe the Systems Addressing Frail Elder (SAFE) Care model, features of the interprofessional team and reengineered workflow, and details of the intervention. BACKGROUND Older inpatients are vulnerable to adverse events related to frailty. SAFE Care, an interprofessional team-based program, was developed and evaluated in a cluster randomized controlled trial (C-RCT). Results found reduced length of stay and complications. The purpose of this article is to support and encourage the replication of this innovation or to help facilitate implementation of a similar process of organizational change. METHODS This was a review of model features and intervention data abstracted from electronic health records. RESULTS Salient features of team composition, training, and workflow are presented. The C-RCT intention-to-treat sample included 792 patients, of whom 307 received the SAFE Care huddle intervention. The most frequent problem was mobility (85.7%), and most frequent recommendation was fall precautions protocol (83.1%). CONCLUSIONS The SAFE Care model may provide a standardized framework to approach, assess, and address the risks of hospitalized older adults.

Vascular Ultrasonography: A Novel Method to Reduce Paracentesis Related Major Bleeding

&NA; Paracentesis is a core competency for hospitalists. Using ultrasound for fluid localization is standard practice and involves a low‐frequency probe. Experts recommend a “2‐probe technique,” which incorporates a high‐frequency ultrasound probe in addition to the low‐frequency probe to identify blood vessels within the intended needle path. Evidence is currently lacking to support this 2‐probe technique, so we performed a pre‐ to postintervention study to evaluate its effect on paracentesis‐related bleeding complications. From February 2010 to August 2011, procedures were performed using only lowfrequency probes (preintervention group), while the 2‐probe technique was used from September 2011 to February 2016 (postintervention group). A total of 5777 procedures were performed. Paracentesis‐related minor bleeding was similar between groups. Major bleeding was lower in the postintervention group (3 [0.3%], n = 1000 vs 4 [0.08%], n = 4777; P = .07). This clinically meaningful trend suggests that using the 2‐probe technique might prevent paracentesis‐related major bleeding. Journal of Hospital Medicine 2018;13:30‐33. Published online first October 18, 2017.

Out of Sight Should Not Be Out of Mind What Lurks Just Beneath the Surface of the Cirrhotic Abdominal Wall

Paracentesis is a commonly performed procedure in both inpatient and outpatient settings. Useful for diagnostic and therapeutic purposes, prior studies have documented the inherent safety of this procedure. In proper hands, modern techniques such as the use of safety (Turkel) tipped needles and ultrasound localization have reduced the risk of major complications to less than 1%. Nevertheless, major bleeding remains a dreaded complication of this procedure, especially in patients with liver failure. Our historical experience has been that this complication is unpredictable, likely because of procedural injury to an abdominal wall artery or peritoneal varix. The authors report a case where the risk of vascular injury was mitigated using portable ultrasound and suggest a simple procedure for future risk reduction.

Ultra-Large-Volume Paracentesis:

Total paracentesis with albumin replacement has become the mainstay of treatment for refractory ascites in patients with decompensated hepatic cirrhosis. The authors report one of the largest volume single-tap paracenteses in the literature (38.8 L), discuss issues surrounding the safety of this procedure, and review the challenges inherent to managing these complex patients.