Dev Jayaraman

At the Crossroad with Morbidity and Mortality Conferences: Lessons Learned through a Narrative Systematic Review

Objective. To determine the process and structure of Morbidity and Mortality Conference (MMC) and to provide guidelines for conducting MMC. Methods. Using a narrative systematic review methodology, literature search was performed from January 1, 1950, to October 2, 2012. Original articles in adult population were included. MMC process and structure, as well as baseline study demographics, main results, and conclusions, were collected. Results. 38 articles were included. 10/38 (26%) pertained to medical subspecialties and 25/38 (66%) to surgical subspecialties. 15/38 (40%) were prospective, 14/38 (37%) retrospective, 7/38 (18%) interventional, and 2/38 (5%) cross-sectional. The goals were quality improvement and education. Of the 10 medical articles, MMC were conducted monthly 60% of the time. Cases discussed included complications (60%), deaths (30%), educational values (30%), and system issues (40%). Recommendations for improvements were made frequently (90%). Of the 25 articles in surgery, MMCs were weekly (60% of the time). Cases covered mainly complications (72%) and death (52%), with fewer cases dedicated to education (12%). System issues and recommendations were less commonly reported. Conclusion. Fundamental differences existed in medical versus surgical departments in conducting MMC, although the goals remained similar. We provide a schematic guideline for MMC through a summary of existing literature.

Reduction of inappropriate exit prescriptions for proton pump inhibitors: A before‐after study using education paired with a web‐based quality‐improvement tool

BACKGROUND Proton pump inhibitors (PPIs) are overprescribed despite concerns regarding associated adverse drug events. OBJECTIVE To reduce inappropriate PPI prescriptions using hospitalization as the point of contact to effect meaningful change. DESIGN Before-after study design. SETTING Forty-six-bed medical clinical teaching unit in a 417-bed university teaching hospital in Montreal, Canada. PATIENTS Four hundred sixty-four consecutively admitted patients in the preintervention control group, and 640 consecutively admitted patients in the intervention group. INTERVENTION A monthly educational intervention paired with a Web-based quality improvement tool. MEASUREMENTS We determined the proportion of patients admitted on PPIs, their indications, and appropriateness of use. We then compared the proportion of patients whose PPIs were discontinued at discharge before and after our intervention. RESULTS Forty-four percent of patients were already using a PPI prior to their hospitalization. In evaluated patients, only 54% of these patients had an evidence-based indication for ongoing use. The proportion of PPIs discontinued at hospital discharge increased from 7.7% per month in the 6 months prior to intervention, to 18.5% per month postintervention (P = 0.03). CONCLUSIONS Strategies to combat PPI overuse are needed to improve the overall quality of patient care. We significantly reduced discharge prescriptions for PPIs through the implementation of an educational initiative paired with a Web-based quality improvement tool. An active interventional strategy is likely required considering the increasingly recognized and preventable adverse events associated with PPI misuse.

Novel low-resource intervention reduces urinary catheter use and associated urinary tract infections: Role of outcome measure bias?

BACKGROUND Previous interventions targeting nosocomial urinary tract infections have reduced catheterization and infections, but they require significant resources and may be susceptible to misclassification and surveillance bias. We sought to determine the effectiveness of a novel intervention at reducing catheterization and infections while exploring the potential for bias. METHODS We conducted a prospective study of a brief monthly in-person educational intervention focusing on appropriate urinary catheter use. RESULTS We studied 1,335 patients (13,753 patient days) on 1 control and 1 intervention ward. After the intervention, the device utilization rate was significantly reduced, with a relative risk of 0.49 (95% confidence interval [CI], 0.32-0.76; P = .001) versus 1.02 (95% CI, 0.58-1.82; P = .93) for controls. Both wards demonstrated a reduction in catheter-associated infections after intervention, with an intervention relative risk of 0.42 (95% CI, 0.16-1.08; P = .07) and 0.51 (95% CI, 0.22-1.20; P = .12) for controls. There was no change in the rate of all nosocomial urine infections, with an intervention relative risk of 0.79 (95% CI, 0.38-1.65; P = .53) and 0.89 (95% CI, 0.48-1.67; P = .72) for controls. CONCLUSION Our study demonstrates that our novel educational intervention significantly reduces urinary catheter use in hospitalized patients. The trend towards reduced catheter-associated infections after intervention, coupled with the absence of an improvement in all nosocomial infections supports a potential role of misclassification bias. We suggest that future prospective investigations explore this phenomenon using more robust outcome measures.

Ability of Nurse Clinicians to Predict Unplanned Returns to Hospital Within Thirty Days of Discharge

Abstract Objective: To evaluate the ability of nurse clinician discharge flow coordinators (DFCs) to identify medical patients at risk of unplanned return to the hospital emergency department within 30 days of discharge and whether a higher predicted risk of return was correlated with preventability. Design: Prospective cohort study of patients discharged from medical wards at 2 hospital sites of the McGill University Health Center between September 1, 2011, and January 1, 2012. Methods: Univariate and multivariate analyses of factors including the ability of DFCs to predict 30-day unplanned returns to the hospital. Assessment of the preventability of returns to the hospital was performed by chart review using prespecified criteria. The ability of DFCs to predict returns was compared to the LACE criteria (length of stay, acute admission through the emergency department, comorbidities, and emergency department visits in the past 6 months). Results: We found that 25.0% (95% CI, 21.3–28.5) of our patients returned to the emergency department within 30 days. The DFC predictions were found to be significant in both univariate and multivariate analysis. Patient age, sex, and length of stay were not significant predictors in univariate or multivariate analysis; 13.9% (95% CI, 8.2–19.6) of returns were preventable and a further 25.8% (95% CI, 18.1–33.5) were potentially preventable with added services in the community. There was a trend toward more preventable or potentially preventable returns with higher predicted probability of return. In contrast the LACE criteria did not have a good predictive capacity in our patient population. Conclusion: In a large urban center, experienced nurse clinician DFCs were able to predict 30-day emergency department returns with reasonable accuracy. They were also able to identify the returns to the hospital that were most likely to be preventable. Our data suggests that DFCs can be used to target patients identified as having an increased probability of return with interventions that may be able to reduce the burden of return to hospital.

Early left ventricular ejection fraction as a predictor of survival after cardiac arrest

ABSTRACT Background: Cardiopulmonary resuscitation and early defibrillation have been shown to improve outcomes of cardiac arrest. The significance of the post-arrest echocardiogram, specifically the left ventricular ejection fraction (LVEF) is unknown. Methods: We performed a retrospective cohort study of patients who suffered from cardiac arrest between 1 January 2009 and 31 December 2013. We included all patients who achieved return of spontaneous circulation (ROSC), and were admitted to the intensive care unit (ICU) or coronary care unit (CCU) of a tertiary care academic center. Patients who underwent echocardiography within 24 h of cardiac arrest were included for analysis. The primary outcome was survival. Results: We identified 151 patients who achieved ROSC of which 97 underwent post-arrest echocardiogram within 24 h. 70.8% were males and the mean age was 67.8 years (SD: 15.9). The mean LVEF at 24 h was 35.7 (SD: 17.8). LVEF > 40% was not a predictor of survival at 30 days or hospital discharge. The only significant predictors on multivariate analyses were age, presence of shockable rhythm and time to ROSC. Conclusion: Although echocardiograms are frequently ordered, LVEF greater than 40% in patients who are resuscitated after a cardiac arrest is not a predictor of survival.

Duration of corticosteroid use in chronic obstructive pulmonary disease exacerbations: improving prescribing practices on clinical teaching units with peer-to-peer teaching

Introduction The most recent Global Initiative for Chronic Obstructive Lung Disease consensus recommends a 5-day course of corticosteroid (CS) therapy for acute chronic obstructive pulmonary disease exacerbations (ACOPDE). As inappropriate use of CS therapy is associated with adverse events, we implemented a peer-to-peer education intervention to improve adherence to guidelines for patients with ACOPDE admitted to a medical clinical teaching unit at a tertiary care university centre. Methods Our study was a before–after design study with a concurrent control of a 15 min peer-to-peer educational intervention targeting medical residents at the beginning of a 4-week rotation for 12 consecutive months. Another medical teaching unit within the same university network, but at a different site, served as a concurrent control. The primary outcome was the proportion of patients who received appropriate duration of CS therapy (5 days) for ACOPDE during the intervention period as compared with the 12-month preintervention period at the intervention and control hospitals. Results Following the intervention, there was an increase in the proportion of patients receiving appropriate duration of CS therapy (34.2% to 51.3%, p=0.02) at the intervention hospital and no significant difference at the control hospital (22.8% to 34.1%, p=0.15). This effect was maintained at the intervention hospital 3 months postintervention period. Conclusion A short peer-to-peer educational intervention targeting medical residents on a clinical teaching unit improved adherence to appropriate duration of CS therapy for ACOPDE.

67: POINT OF CARE ULTRASOUND IN THE MANAGEMENT OF HEART FAILURE

Crit Care Med 2015 • Volume 43 • Number 12 (Suppl.) who underwent CTS at Children’s National Health System from January 2010 to December 2013. Via CardioAccess©, deep SSI cases meeting the CDC’s definition were identified. Controls without SSI were matched 2:1 by age, gender, Risk Adjustment for Congenital Heart Surgery score (RACHS-1) and Society of Thoracic Surgeons risk category (STS-EACTS). Primary variables were 6, 24 and 48 hour post-operative fluid resuscitation and thoracostomy output. Conditional logistic regression, Wilcoxon matched pairs sign rank test and McNemar’s exact test were used in statistical analysis. Results: 2,021 children underwent CTS during the study period. Twelve deep SSI cases were matched to 24 controls and did not differ in age, gender, weight, RACHS-1, STS-EACTS category, bypass time or antibiotic prophylaxis. Deep SSIs received more fluid resuscitation at six (22.5 vs. 17.5ml/kg), 24 (27.7 vs. 18ml/kg) and 48 (35.2 vs. 18ml/kg) hr (all p<0.01). Deep SSIs had larger thoracostomy output at six (20.8 vs. 15.6ml/kg), 24 (44.8 vs. 33.6 ml/kg) and 48 (77.5 vs. 43.1 ml/kg) hr (all p<0.01). Conditional logistic regression of 48 hour post-operative fluid resuscitation on deep SSIs yielded odds of 1.013 (p=0.04, CI: 1–1.03). Conditional logistic regression of six hour thoracostomy output on deep SSIs yielded odds of 1.126 (p=0.04, CI: 1.01–1.26). Conclusions: Analysis of our results suggests that volume of fluid resuscitation and thoracostomy output are risk factors for deep SSI following CTS. Future research will analyze pharmacokinetics to determine if redosing of prophylactic antibiotics may reduce SSI risk by maintaining therapeutic drug concentrations.