Frank J. Villamaria

Using simulation to orient code blue teams to a new hospital facility.

Objectives: Prompt and successful cardiopulmonary resuscitation during a sudden cardiac arrest can be hindered by multiple variables, ie, ineffective communication, stress, lack of training, and an unfamiliar environment, such as a new hospital facility. The main objective of the study was to use high-fidelity simulations to orient Code Blue Teams (CBTs) to critical events in a new hospital facility. A secondary objective was to elucidate factors that may have contributed to responses by debriefing teams. Methods: Mock Code Blue exercises using high-fidelity simulation were implemented in real workplace settings to orient CBTs to critical events. We measured arrival time of first responder, crash cart to code site, first six CBT responders, first chest compression, and first electrical shock. After each mock code, participants were debriefed to assess any barriers to effective response and decision making. Results: Twelve mock codes were conducted at different locations of the new facility. Sixty-nine percent of the participants reported that the training was beneficial. The median time of arrival of the first responders was 42 seconds and the first CBT member was 66 seconds. The median time to initiation of chest compressions was 80 seconds, crash cart arrival was 68 seconds, and first electrical shock was 341 seconds. An additional outcome of the study was the identification of facility and systems issues that had the potential to impact patient safety. Conclusions: Clinical simulation can be effectively used to orient CBTs and identify critical safety issues in a newly constructed healthcare facility.

A Multicenter, Randomized, Blind Comparison of Amrinone with Milrinone After Elective Cardiac Surgery

Amrinone and milrinone are phosphodiesterase inhibitors with positive inotropic effects useful for the treatment of ventricular dysfunction after cardiac surgery.Forty-four patients undergoing elective cardiac surgery at four centers received either amrinone (n = 22) or milrinone (n = 22) in a randomized, blind fashion. Immediately after separation from cardiopulmonary bypass (CPB), two bolus doses of either amrinone 0.75 mg/kg or milrinone 25 [micro sign]g/kg were administered over 30 s, separated by 5 min. Hemodynamic measurements were recorded before each dose and at the end of the 10-min study. Both amrinone and milrinone increased the cardiac index (48% vs 52%, P = not significant [NS] for amrinone and milrinone, respectively). There was a small increase in mean arterial pressure (MAP) after amrinone administration (from 68 +/- 3 to 72 +/- 3 mm Hg at 10 min, P < 0.05) with no significant change in MAP after milrinone administration. Central venous pressure was significantly higher in the amrinone group at baseline and 5 min (12 vs 10 mm Hg and 11 vs 10 mm Hg, respectively; P < 0.05). Systemic and pulmonary vascular resistances decreased significantly and to a similar extent after either amrinone or milrinone administration. Phenylephrine was required in 11 of 22 patients receiving amrinone and in 11 of 22 patients receiving milrinone to maintain arterial blood pressure. The proportion of patients requiring an intravascular volume infusion (15 of 22 vs 17 of 22, P = NS) and the total fluid volume infused were similar (402 +/- 57 vs 350 +/- 49 mL, P = NS for amrinone and milrinone, respectively). Amrinone and milrinone seem to have similar hemodynamic effects after CPB, with the exception of blood pressure, although the need for vasopressor support of blood pressure did not differ. Selection between these two drugs may include nonhemodynamic considerations such as cost. Implications: Amrinone and milrinone are drugs that improve cardiac contraction. Their effects have never been directly compared in patients. We found that amrinone and milrinone produced similar hemodynamic effects in adult patients undergoing cardiac surgery. Choice between the two drugs can be based on nonhemodynamic considerations such as cost. (Anesth Analg 1998;86:683-90)

Accuracy of Noninvasive Estimated Continuous Cardiac Output (esCCO) Compared to Thermodilution Cardiac Output: A Pilot Study in Cardiac Patients

OBJECTIVE To compare the noninvasive estimated continuous cardiac output (esCCO), device-derived cardiac output (CO) to simultaneous pulmonary artery catheter (PAC) thermodilution (TD) CO. DESIGN A prospective study comparing pulse wave transit time (estimated continuous cardiac output, esCCO; Nihon Kohden, Tokyo, Japan) to intermittent TD CO. SETTING One academic hospital. PARTICIPANTS Patients presenting for cardiac surgery. INTERVENTIONS Intraoperative CO measurements at 4 distinct time points (after induction, after sternotomy, after cardiopulmonary bypass, and after chest closure). MEASUREMENTS AND MAIN RESULTS The study population consisted of American Society of Anesthesiologists (ASA) IV subjects, 27 (77%) males and 8 (23%) females, with a mean age of 64.6 ± 12.2 years. Data points from esCCO and TD were collected simultaneously and means per time point compared using Bland-Altman, Pearson R coefficient, and percent error. Mean TD CO for the study was 5.4 L/min. The Pearson R coefficient, percent error, and bias in L/min were: 0.57, 44%, 0.66 (after induction); 0.54, 51%, 0.88 (after sternotomy); 0.60, 60%, 0.95 (after cardiopulmonary bypass); and 0.57, 60%, 0.75 (after chest closure) respectively. CONCLUSIONS esCCO is easy to use and provides continuous CO measurements, but has wide limits of agreement and large percentage errors with a consistently positive bias in comparison to TD.

Forced-air warming is no more effective than conventional methods for raising postoperative core temperature after cardiac surgery

OBJECTIVE To determine whether postoperative forced-air warming of cardiac bypass patients in the intensive care unit (ICU) results in faster rate of warming and improved outcomes compared with more conventional ICU warming methods. DESIGN Prospective randomized effectiveness study. SETTING Three hundred fifty-bed university-affiliated hospital. PARTICIPANTS Sixty consenting randomized patients from a consecutive series of 84 patients undergoing routine adult cardiac surgery. INTERVENTIONS One group of patients received usual patient care, which includes warm blankets and overhead heat lamps. Patients in the other group were placed under forced-air warming devices on arrival in the ICU. Sixty consenting patients (30 in each group) were randomly assigned to one or the other method of warming. The remaining 24 patients refused randomization and self-selected a treatment group. MEASUREMENTS AND MAIN RESULTS Results are presented for the randomized groups. Core temperature, measured by pulmonary artery catheter thermistor, increased in both groups at the rate of 0.25 degree C per hour. No statistically or clinically significant differences were found between the group for whom the warming device was used and the standard care group in the incidence of postoperative cardiac arrhythmia, duration of time in the ICU, or any other clinical variable. CONCLUSIONS There is no evidence from this study to warrant use of forced-air warming devices for the care of postoperative cardiac surgical patients in the ICU.

Developing a Checklist: Consensus Via a Modified Delphi Technique

OBJECTIVE To create a universal checklist of key preparatory steps to aid anesthesiologists in patient separation from cardiopulmonary bypass. DESIGN Multistep, iterative survey with statistically guided refinement of survey items using a modified Delphi technique. SETTING Internet-based surveys. PARTICIPANTS Ninety active members of the Society of Cardiovascular Anesthesiologists volunteered to participate, including geographically distributed private practice and academic physicians. INTERVENTIONS A series of checklist items was created and distributed to 90 anesthesiologists, who assessed each items importance in preparing for patient separation from cardiopulmonary bypass and added, deleted, or modified any items as they saw fit. Items meeting a threshold of greater than 90% group acceptance were carried forward to a second survey. These items then were evaluated using a 5-point Likert scale to grade relative importance and then compared with the groups responses, creating a third survey with refined checklist items. The results then were used to generate a final survey based on each item achieving certain predefined statistical criteria, which then were scored again by the participants, generating a final checklist via statistically guided consensus. MEASUREMENTS AND MAIN RESULTS An initial checklist containing 28 possible items was proposed to the participants. After the iterative process was completed, a final checklist of 10 items deemed essential to prepare for bypass separation was created. CONCLUSIONS A checklist to aid in bypass separation was created with key steps derived from a statistically driven Delphi process. This technique of iterative consensus building may be useful in developing additional safety checklists.

Three years of experience with prospective randomized effectiveness studies

We developed methodology for prospective randomized effectiveness studies using a demonstration project at a multispecialty practice, health maintenance organization, and hospital in academic medical center. An operational unit called the effectiveness registry was developed to design and support comparisons of potential practice improvements with standard care. The studies differ from observational effectiveness studies in that they provide long-term follow-up of randomized comparison groups. Physician involvement in data collection is limited. No tests or observations are made other than those required for clinical care. Follow-up and data collection are modeled after tumor registry procedures. Patients who refuse randomization enter the study in whichever treatment arm they choose. The protocol for each study is approved by the institutional review board (IRB) before recruitment begins, and all patients, randomized and nonrandomized, sign an informed consent document. Between its beginning on October 7, 1993 and April 7, 1997, the IRB approved 14 trials. Four were terminated after entering at most a few patients. Recruitment is complete in four trials and continues in six. Randomization was accepted by 74% (596/804) of the patients. Over 800 patients in 10 studies are being followed at least annually. Major peer-reviewed journals have accepted reports of initial findings for two studies. Prospective randomized effectiveness studies are feasible in the multipractice setting and have potential to provide useful and reliable assessment of treatment outcomes. Collaborative arrangements between several institutions are needed to provide larger sample sizes.

PS1-07: Evaluating the Status of “Translating Research into Practice” at a Major Academic Healthcare System

Background: This survey was conducted to assess the status of translating research findings into practice at a major academic healthcare system in Central Texas. Methods: We conducted a cross-sectional survey addressing knowledge of and participation in translational research of physicians, residents, nurses, and third and fourth year medical students in a major academic healthcare system in Central Texas. Some of the research questions were adapted from an in-house HMORN survey (personal communication). Results: Out of 508 respondents, 428 (84.3%) completed all questions. A total of 68.9% of faculty reported having sufficient education and training to conduct research vs. 44.4% of residents and 35.6% of nurses. Fifty-eight percent of faculty, 53% of residents and 9% of nurses reported current involvement in research activity. A total of 55.6% of residents reported that their departments provide them with protected time for research vs. 18.4% of faculty and 10.3% of nurses. In addition, 33.9% of nurses reported interest in participating in research but do not know how to start. A majority of faculty and residents and 58% of nurses indicated they were familiar with translational research. Yet only 42.7% of residents and 35% of faculty, 46.7% of residents and 35.6% of nurses indicated they were aware of any changes in delivery of care that resulted from research projects. Conclusions: The study results suggested failure to leverage members of the healthcare team in a systematic process to ensure translation of research findings into practice. Results highlighted the need to merge the culture of safety and quality improvement with research while dealing with the daily pressures of patient care.