Donald L. Helman

Effect of standardized orders and provider education on head-of-bed positioning in mechanically ventilated patients

ObjectiveSemirecumbent head-of-bed positioning in mechanically ventilated patients decreases the risk of developing ventilator-associated pneumonia (VAP). The purpose of this study was to determine whether the addition of a standardized order followed by the initiation of a provider education program would increase the frequency with which our patients were maintained in the semirecumbent position. DesignProspective, pre-, and postintervention observational study. SettingA tertiary care, U.S. Army teaching hospital. PatientsMechanically ventilated medical and surgical intensive care unit patients. InterventionsThe first intervention involved the addition of an order for semirecumbent head-of-bed positioning to our intensive care unit order sets. This was followed 2 months later with a second intervention, which was a nurse and physician education program emphasizing semirecumbent positioning. Measurements and Main ResultsData regarding head-of-bed positioning were collected on 100 patient observations at baseline and at 1 and 2 months after each of our interventions. The mean angle of head of bed increased from 24 ± 9 degrees at baseline to 35 ± 9 degrees (p < .05) 2 months after the addition of the standard order. The percentage of observations with head of bed >45 degrees increased from 3% to 16% 2 months after the standardized order (p < .05). Two months after our provider education program, the mean angle of the head of bed was 34 ± 11 degrees and the percentage of patients with head of bed >45 degrees was 29% (p = NS compared with values after the first intervention). Data collected 6 months after completion of our education programs showed that these improvements were maintained. ConclusionsStandardizing the process of care via the addition of an order specifying head-of-bed position significantly increased the number of patients who were placed in the semirecumbent position. In an era of cost-conscious medicine, interventions that utilize protocols and education programs should be emphasized.

New Choices for Central Venous Catheters

Objective To determine the cost-effectiveness of the newer antiseptic and antibiotic-impregnated central venous catheters (CVCs) relative to uncoated CVCs and to each other. Design Decision model analysis of the cost and efficacy of CVCs coated with either chlorhexidine silver sulfadiazine (CSS) or rifampin-minocycline (RM) at preventing catheter-related bloodstream infections (CRBSIs). The primary outcome is the incremental cost (or savings) to prevent one additional CRBSI. Model estimates are derived from prospective trials of the CSS and RM CVCs and from other studies describing the costs of CRBSIs. Setting and patients Hypothetical cohort of 1,000 patients requiring placement of a CVC. Interventions In the model, patients were managed with either an uncoated CVC, CSS CVC, or RM CVC. Measurements and main results The incremental cost-effectiveness of the treated CVCs was calculated as the savings resulting from CRBSIs averted less the additional costs of the newer devices. Sensitivity analysis of the effect of the major clinical inputs was performed. For the base case analysis, we assumed the incidence of CRBSIs was 3.3% with traditional catheters and that the CSS and RM CVC conferred a relative risk reduction for the development of CRBSIs of 60% and 85%, respectively. Despite their significantly higher cost than older catheters, both novel CVCs yield significant savings. Employing either of the treated CVCs saves approximately

Preliminary ReportDepreotide Scanning in Sarcoidosis: A Pilot Study

10,000 per CRBSI prevented (relative to standard catheters). Comparing the RM CVC to the CSS CVC revealed the RM product to be economically superior, saving nearly

Fludarabine-Related Pulmonary Toxicity: A Distinct Clinical Entity in Chronic Lymphoproliferative Syndromes

9,600 per CRBSI averted and

Analyzing the Short-term Effect of Placebo Therapy in Pulmonary Arterial Hypertension: Potential Implications for the Design of Future Clinical Trials

81 per patient in the cohort. For sensitivity analysis, we adjusted all model variables by 50% individually and then simultaneously. This demonstrated the model to be most sensitive to the cost of a CRBSI; however, with all inputs skewed by 50% against both the CSS CVC and the RM CVC, these devices remained economically attractive. Under this scenario, use of either treated device was less costly. Conclusions Utilization of antiseptic and antibiotic-impregnated CVCs represent an attractive alternative for the prevention of CRBSIs and may lead to significant savings. Of the two newer, coated devices, the RM CVC performs better financially. These observations hold over a range of estimates for our model inputs.

Role for Transbronchial Biopsy in the Diagnosis of Usual Interstitial Pneumonia

radiographs (CXRs). The results of 99m Tc-DP scintigraphy were positive for sarcoidosis in 18 individuals (81.8%; 95% confidence interval, 59.7 to 94.8%). Of the four persons lacking 99m Tc-DP uptake, all had normalized their CXRs since the time of presentation. In the entire sample, the intraclass correlation between radiographic stage determined by CXR vs that determined by 99m Tc-DP scintigraphy was robust ( 0.79; p 0.0005). Among patients with positive 99m Tc-DP scan findings, the correlation was stronger ( 0.94; p < 0.0001). Flow rates and lung volumes were lower in patients with parenchymal activity on 99m Tc-DP scintigraphy (mean FEV1, 68.6 13.9% predicted vs 84.5 10.7% predicted, respectively [p 0.012]; mean FVC, 74.0 16.0% predicted vs 88.4 12.7% predicted [p 0.041]). 99m Tc-DP scintigraphy correctly identified all sites of known nonpulmonary visceral involvement with sarcoidosis. Conclusions: The results of 99m Tc-DP imaging are often positive in sarcoidosis patients, and correlate with disease stage determined by CXR and pulmonary function. 99m Tc-DP scintigraphy does not preclude the need for biopsy if this is indicated to confirm the diagnosis of sarcoidosis or to exclude the possibility of malignancy. 99m Tc-DP scintigraphy merits further study in the evaluation and management of sarcoidosis. (CHEST 2004; 126:1337–1343)