Renae E. Stafford

Treatment of Complicated Skin and Soft Tissue Infections

BACKGROUND Skin and soft tissue infections (SSTIs) may produce substantial morbidity and mortality rates, particularly those classified as complicated or necrotizing. OBJECTIVE To weigh the strength of recommendations using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) methodology and to provide evidence-based recommendations for diagnosis and management for SSTIs. DATA SOURCES Computerized identification of published research and review of relevant articles. STUDY SELECTION All published reports on the management of complicated and necrotizing SSTIs were evaluated by an expert panel of members of the Surgical Infection Society according to published guidelines for evidence-based medicine. The quality of the evidence was judged by the GRADE methodology and criteria. Practice surveys, pharmacokinetic studies, and reviews or duplicative publications presenting primary data already considered were excluded from analysis. DATA EXTRACTION Information on demographics, study dates, microbiology findings, antibiotic type, surgical interventions, infection-related outcomes, and the methodologic quality of the studies was extracted. Results were submitted to the Therapeutic Agents Committee of the Surgical Infection Society for review prior to creation of the final consensus document. DATA SYNTHESIS Current surgical and antibiotic management of complicated SSTIs is based on a small number of studies that often have insufficient power to draw well-supported conclusions, with the exception of antimicrobial therapy for non-necrotizing soft tissue infections, for which ample data are available.

Evaluating Efforts to Optimize TeamSTEPPS Implementation in Surgical and Pediatric Intensive Care Units

BACKGROUND An evidence-based teamwork system, Team-STEPPS, was implemented in an academic medical centers pediatric and surgical ICUs. METHODS A multidisciplinary change team of unit- and department-based leaders was formed to champion the initiative; develop a customized action plan for implementation; train frontline staff; and identify process, team outcome, and clinical outcome objectives for the intervention. The evaluation consisted of interviews with key staff, teamwork observations, staff surveys, and clinical outcome data. RESULTS All PICU, SICU, and respiratory therapy staff received TeamSTEPPS training. Staff reported improved experience of teamwork posttraining and evaluated the implementation as effective. Observed team performance significantly improved for all core areas of competency at 1 month postimplementation and remained significantly improved for most of the core areas of competency at 6 and 12 months postimplementation. Survey data indicated improvements in staff perceptions of teamwork and communication openness in both units. From pre- to posttraining, the average time for placing patients on extracorporeal membrane oxygenation (ECMO) decreased significantly. The average duration of adult surgery rapid response team events was 33% longer at postimplementation versus pre-implementation. The rate of nosocomial infections at postimplementation was below the upper control limit for seven out of eight months in both the PICU and the SICU. CONCLUSIONS The implementation of a customized 2.5-hour version of the TeamSTEPPS training program in two areas--the PICU and SICU--that had demonstrated successful ability to innovate suggests that the training was successful.

Inhaled nitric oxide for primary pulmonary hypertension in pregnancy

BACKGROUND Primary pulmonary hypertension is a rare and dangerous entity in pregnancy. Previous studies have found a 35–50% maternal mortality rate in the peripartum period. To date, most reports have described treatment of these patients with diuretics, digoxin, and calcium-channel blockers. CASE We describe the successful treatment of a primigravida with severe primary pulmonary hypertension. We used elective intubation before labor, inhaled nitric oxide therapy, and assisted vaginal delivery with epidural anesthesia that resulted in a viable infant and survival of the mother. CONCLUSION Nitric oxide can be used to successfully treat primary pulmonary hypertension in pregnancy.

American College of Surgeons Guidelines Program: a process for using existing guidelines to generate best practice recommendations for central venous access.

BACKGROUND Many professional organizations help their members identify and use quality guidelines. Some of these efforts involve developing new guidelines, and others assess existing guidelines for their clinical usefulness. The American College of Surgeons Guidelines Program attempts to recognize useful surgical guidelines and develop research questions to help clarify existing clinical guidelines. We used existing guidelines about central venous access to develop a set of summary recommendations that could be used by practitioners to establish local best practices. STUDY DESIGN A comprehensive literature search identified existing clinical guidelines for short-term central venous access. Two reviewers independently rated the guidelines using the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument. Highly scored guidelines were analyzed for content, and their recommendations were compiled into a summary table. The summary table was reviewed by an independent panel of experts for clinical utility. RESULTS Thirty-two guidelines were identified, and 23 met inclusion criteria. The AGREE rating resulted in four guidelines that were strongly recommended and five that were recommended with alterations. Three comprehensive tables of recommendations were produced: procedural, maintenance, and infectious assessment. A panel of experts came to consensus agreement on the final format of the best practice recommendations, which included 30 summary recommendations. CONCLUSIONS Our process combined assessing existing guidelines methodology with expert opinion to produce a best practice list of guidelines that could be fashioned into local care routines by practicing physicians. The American College of Surgeons guidelines program believes this process will help validate the clinical utility of existing guidelines and identify areas needing further investigation to determine practical validity.

Utilization of rapid response resources and outcomes in a comprehensive cancer center

Objective:To compare the differences in characteristics and outcomes of cancer center patients with other subspecialty medical patients reviewed by rapid response teams. Design:A retrospective cohort study of hospitalized general medicine patients, subspecialty medicine patients, and oncology patients requiring rapid response team activation over a 2-year period from September 2009 to August 2011. Patients:Five hundred fifty-seven subspecialty medical patients required rapid response team intervention. Setting:A single academic medical center in the southeastern United States (800+ bed) with a dedicated 50-bed inpatient comprehensive cancer care center. Interventions:Data abstraction from computerized medical records and a hospital quality improvement rapid response database. Measurements and Main Results:Of the 557 patients, 135 were cancer center patients. Cancer center patients had a significantly higher Charlson Comorbidity Score (4.4 vs 2.9, < 0.001). Cancer center patients had a significantly longer hospitalization period prior to rapid response team activation (11.4 vs 6.1 d, p < 0.001). There was no significant difference between proportions of patients requiring ICU transfer between the two groups (odds ratio, 1.2; 95% CI, 0.8–1.8). Cancer center patients had a significantly higher in-hospital mortality compared with the other subspecialty medical patients (33% vs 18%; odds ratio, 2.2; 95% CI, 1.50–3.5). If the rapid response team event required an ICU transfer, this finding was more pronounced (56% vs 23%; odds ratio, 4.0; 95% CI, 2.0–7.8). The utilization of rapid response team resources during the 2-year period studied was also much higher for the oncology patients with 37.34 activations per 1,000 patient discharges compared with 20.86 per 1,000 patient discharges for the general medical patients. Conclusions:Oncology patients requiring rapid response team activation have a significantly higher in-hospital mortality rate, particularly if the rapid response team requires ICU transfer. Oncology patients also utilize rapid response team resources at a much higher rate.

To Drain or Not to Drain: An Evidence-Based Approach to Palliative Procedures for the Management of Malignant Pleural Effusions

Malignant pleural effusions are often symptomatic and diagnosed late in the course of cancer. The optimal management strategy is controversial and includes both invasive and non-invasive strategies. Practitioners have the option of invasive procedures such as intermittent drainage or more permanent catheter drainage to confirm malignancy and to palliate symptoms. Because these effusions are often detected late in the course of disease in patients who may have limited life expectancy, procedural management may be associated with harms that outweigh benefits. We performed a literature review to examine the available evidence for catheter drainage of malignant pleural effusions in advanced cancer and reviewed alternative management strategies for the management of dyspnea. We provide a clinical case within the context of the research evidence for invasive and non-invasive management strategies. Our intent is to help inform decision making of patients and families in collaboration with their health care practitioners and interventionists by weighing the risks and benefits of catheter drainage versus alternative medical management strategies for malignant pleural effusions.