Cynthia T. French

Effects of a multifaceted, multidisciplinary, hospital-wide quality improvement program on weaning from mechanical ventilation

ObjectiveTo examine the effects of a mechanical ventilation weaning management protocol that was implemented as a hospital-wide, quality improvement program on clinical and economic outcomes. DesignProspective, before-and-after intervention study. Data from a preimplementation year are compared with those of the first 2 yrs after protocol implementation. Patients and SettingPatients older than 18 yrs in diagnosis-related group 475 and group 483, who were admitted to the adult medical, surgical, and cardiac intensive care units (ICU) in a university hospital. InterventionsAfter the baseline year, a weaning management program was implemented throughout our institution. Primary endpoints were mortality, days on mechanical ventilation, ICU and hospital lengths of stay, hospital costs, and the percentage of patients requiring tracheostomy. Main ResultsThe number of patients increased from 220 in the baseline year (year 0) to 247 in the first year (year 1), then to 267 in the second year (year 2). The mean Acute Physiology and Chronic Health Evaluation (APACHE) II score increased from 22.2 to 24.4 in year 1 (p = .006) and to 26.2 in year 2 (p < .0005). When year 0 was compared with year 1, mean days on mechanical ventilation decreased from 23.9 to 21.9 days (p = .608), hospital length of stay decreased from 37.5 to 31.6 days (p = .058), ICU length of stay decreased from 30.5 to 25.9 days (p = .133), and total cost per case decreased from

Chronic cough due to gastroesophageal reflux disease: efficacy of antireflux surgery.

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Overview of the Management of Cough: CHEST Guideline and Expert Panel Report

78,624 (p = .061). When year 0 was compared with year 2, mean days on mechanical ventilation decreased from 23.9 days to 17.5 days (p = .004), mean hospital length of stay decreased from 37.5 to 24.7 days, mean ICU length of stay decreased from 30.5 to 20.3 days, total cost per case decreased from

A prospective global measure, the Punum Ladder, provides more valid assessments of quality of life than a retrospective transition measure.

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Assessment of Intervention Fidelity and Recommendations for Researchers Conducting Studies on the Diagnosis and Treatment of Chronic Cough in the Adult: CHEST Guideline and Expert Panel Report

63,687, and percentage of patients requiring tracheotomy decreased from 61% to 41% (all p < .0005). There was also a reduction in the percentage of patients requiring more than one course of mechanical ventilation during the hospitalization from 33% to 26% (p = .039), a total cost savings of

Cough and gastroesophageal reflux: identifying cough and assessing the efficacy of cough-modifying agents

3,440,787 and a decrease in mortality between all 3 yrs from 32% to 28% (p = .062). ConclusionsA multifaceted, multidisciplinary weaning management program can change the process of care used for weaning patients from mechanical ventilation throughout an acute care hospital and across multiple services. This change can lead to large reductions in the duration of mechanical ventilation, length of stay, and hospital costs, even at a time when patients are sicker.

Cough in the Athlete: CHEST Guideline and Expert Panel Report

BackgroundGastroesophageal reflux disease (GERD) can be overlooked as the cause of chronic cough (CC) when typical gastrointestinal symptoms are absent or minimal. We analyzed the outcomes of Nissen fundoplication (NF) for patients who failed medical therapy for CC attributable only to GERD (G-CC). We performed a prospective outcome evaluation of 21 consecutive patients with G-CC undergoing NF from 1997 to 2000 at a tertiary care university hospital.Materials and MethodsTwenty-one patients without prior antireflux surgeries had G-CC diagnosed by a clinical profile and 24-h pH monitoring showing a cough-reflux correlation. Respiratory symptoms alone were present in 53% of patients. NF was performed when G-CC persisted despite intensive medical therapy, including an antireflux diet. Preoperatively, all patients underwent 24-h pH monitoring, esophageal manometry, barium swallow, gastric emptying study, bronchoscopy, and upper endoscopy. NF was utilized in all cases, laparoscopically in 18. Before and after surgery, patients graded their cough severity using the Adverse Cough Outcome Survey (ACOS). Quality of life was measured using the Sickness Impact Profile (SIP).ResultsPostoperatively, 18 patients (86%) reported an improvement of their cough. G-CC considerably improved in 16/21 patients (76%), with complete resolution in 13 patients (62%). Mild to moderate improvement was found in 2 patients (10%). Patient-reported cough severity (ACOS) and quality of life (SIP) both significantly improved early (6–12 weeks) postoperatively and persisted during the long-term (1 year) follow-up. The average hospital length of stay was 1.78±0.2 (1–4) days for the laparoscopic (n=18) and 6.3±1.2 (4–8) days for the open surgery (n=3) groups.ConclusionTwenty-four-hour esophageal pH monitoring is a valuable tool for preoperative cough—reflux correlation. Antireflux surgery is effective in carefully selected patients whose refractory CC is attributable only to GERD. NF controls the severity of cough while improving the quality of life. Outcomes are further enhanced using laparoscopic procedures with shorter hospital stays.

Symptomatic Treatment of Cough Among Adult Patients With Lung Cancer: CHEST Guideline and Expert Panel Report

This overview will demonstrate that cough is a common and potentially expensive health-care problem. Improvement in the quality of care of those with cough has been the focus of study for a variety of disciplines in medicine. The purpose of the Cough Guideline and Expert Panel is to synthesize current knowledge in a form that will aid clinical decision-making for the diagnosis and management of cough across disciplines and also identify gaps in knowledge and treatment options.

Occupational and Environmental Contributions to Chronic Cough in Adults: Chest Expert Panel Report

OBJECTIVES We assessed the reliability and validity of two measures of change, one retrospective (the Global Rating of Change Scale [GRCS]) and one prospective (the Punum Ladder), and the relative utility of the two methods of assessing change and establishing the minimal important difference (MID) of the Cough Quality of Life Questionnaire (CQLQ), a reliable and valid cough-specific quality-of-life (QoL) instrument. STUDY DESIGN AND SETTING A prospective, longitudinal study assessing the change in cough-related QoL over 6 months in participants with chronic cough was carried out in a tertiary care cough clinic. Before seeing a physician, subjects completed eight Punum Ladders and the CQLQ. At 1 and 6 months, eight Punum Ladders, the CQLQ, and seven GRCSs were completed. Punum Ladders and GRCSs were psychometrically tested, and MIDs were calculated. RESULTS Reliability and validity of GRCSs and Punum Ladders were acceptable. However, closer analysis of the relation between change scores and CQLQ pretest and posttest scores showed that the GRCS was only related to patients present state, whereas the Punum Ladder was associated with both initial and present states. This compromises the validity of the GRCS. Crosstab comparisons revealed that GRCS ratings made more liberal estimates of change in the CQLQ than the Punum Ladder; this is reflected in their respective MIDs (10.58+/-10.63 vs. 21.89+/-15.38). CONCLUSION The prospective Punum Ladder is likely to be more useful, because it reflects the actual change in QoL over time in a less biased and more accurate way than the retrospective GRCS.

Anatomy and Neurophysiology of Cough

BACKGROUND Successful management of chronic cough has varied in the primary research studies in the reported literature. One of the potential reasons relates to a lack of intervention fidelity to the core elements of the diagnostic and/or therapeutic interventions that were meant to be used by the investigators. METHODS We conducted a systematic review to summarize the evidence supporting intervention fidelity as an important methodologic consideration in assessing the effectiveness of clinical practice guidelines used for the diagnosis and management of chronic cough. We developed and used a tool to assess for five areas of intervention fidelity. Medline (PubMed), Scopus, and the Cochrane Database of Systematic Reviews were searched from January 1998 to May 2014. Guideline recommendations and suggestions for those conducting research using guidelines or protocols to diagnose and manage chronic cough in the adult were developed and voted upon using CHEST Organization methodology. RESULTS A total of 23 studies (17 uncontrolled prospective observational, two randomized controlled, and four retrospective observational) met our inclusion criteria. These articles included 3,636 patients. Data could not be pooled for meta-analysis because of heterogeneity. Findings related to the five areas of intervention fidelity included three areas primarily related to the provider and two primarily related to the patients. In the area of study design, 11 of 23 studies appeared to be underpinned by a single guideline/protocol; for training of providers, two of 23 studies reported training, and zero of 23 reported the use of an intervention manual; and for the area of delivery of treatment, when assessing the treatment of gastroesophageal reflux disease, three of 23 studies appeared consistent with the most recent guideline/protocol referenced by the authors. For receipt of treatment, zero of 23 studies mentioned measuring concordance of patient-interventionist understanding of the treatment recommended, and zero of 23 mentioned measuring enactment of treatment, with three of 23 measuring side effects and two of 23 measuring adherence. The overall average intervention fidelity score for all 23 studies was poor (20.74 out of 48). CONCLUSIONS Only low-quality evidence supports that intervention fidelity strategies were used when conducting primary research in diagnosing and managing chronic cough in adults. This supports the contention that some of the variability in the reporting of patients with unexplained or unresolved chronic cough may be due to lack of intervention fidelity. By following the recommendations and suggestions in this article, researchers will likely be better able to incorporate strategies to address intervention fidelity, thereby strengthening the validity and generalizability of their results that provide the basis for the development of trustworthy guidelines.