Deterioration Events Research Articles

Accuracy of Bedside Paediatric Early Warning System (BedsidePEWS) in a Pediatric Stem Cell Transplant Unit.

Hospital mortality in children who undergo stem cell transplant (SCT) is high. Early warning scores aim at identifying deteriorating patients and at preventing adverse outcomes. The bedside pediatric early warning system (BedsidePEWS) is a pediatric early warning score based on 7 clinical indicators, ranging from 0 (all indicators within normal ranges for age) to 26. The aim of this case-control study was to assess the performance of BedsidePEWS in identifying clinical deterioration events among children admitted to an SCT unit. Cases were defined as clinical deterioration events; controls were all the other patients hospitalized on the same ward at the time of case occurrence. BedsidePEWS was retrospectively measured at 4-hour intervals in cases and controls 24 hours before an event (T4-T24). We studied 19 cases and 80 controls. The score significantly increased in cases from a median of 4 at T24 to a median of 14 at T4. The proportion of correctly classified cases and controls was >90% since T8. The area under the curve receiver operating characteristic was 0.9. BedsidePEWS is an accurate screening tool to predict clinical deterioration in SCT patients.

Using Combined Teaching Modalities to Enhance Nursing Students’ Recognition and Response to Clinical Deterioration

Abstract Newly licensed registered nurses are confronted with complex patient situations on a daily basis. As nurse educators, it is imperative that we prepare nursing students to manage clinical deterioration events as newly licensed registered nurses in order to achieve optimum patient outcomes. This article describes the components of an innovative elective nursing course titled Acute Patient Deterioration. The course uses a variety of teaching modalities to teach nursing students to quickly recognize and respond to acute patient deterioration events.

Efficacy and safety of intravenous nimodipine administration for treatment of hypertension in patients with intracerebral hemorrhage

BackgroundNicardipine (NC) is the most commonly used antihypertensive drug in neurological patients with hypertension. Although nimodipine (NM) is widely used to treat cerebral vasospasm in patients with aneurysmal subarachnoid hemorrhage, trials exploring its antihypertensive effect after intravenous administration in subjects with intracerebral hemorrhage (ICH) are scarce.MethodsA retrospective study was carried out to compare the safety and efficacy of NC and NM administered intravenously in patients with ICH. Therapeutic responses were assessed by achievement of goal blood pressure (BP); use of additional medications for BP control; proportion of time spent within goal; variability in BP; time to goal BP; number of dose adjustments; variability in ICH volume, Glasgow Coma Scale score, and intracranial pressure; and drug-related complications.ResultsA total of 87 patients were eligible for analysis (n=46 [NC]; n=41 [NM]), and baseline characteristics between groups were similar. Both agents were effective in achieving goal BP during infusion, with 93.5% and 87.8% patients in the NC and NM groups achieving goal, respectively. Fewer additional medications were needed to control BP in the NC group. BP variability was similar and no differences were observed in the mean time to goal BP and mean numbers of dose adjustments between both groups. Interestingly, intracranial pressure declined (P=0.048) during NC administration but increased (P=0.066) after NM treatment. Finally, the incidences of hematoma expansion, neurological deterioration, and adverse drug events were similar in both groups.ConclusionNM is effective and safe for BP control in patients with ICH.

The detection of high-strength concrete exposed to high temperatures using infrared thermal imaging technique

Based on the detection principle regarding physical and chemical changes of the internal structure of concrete at elevated temperatures, and with the application of infrared thermal imaging technique, laboratory investigations related to infrared thermal image inspection and compressive strength test on C80 high-strength concrete (with or without polypropylene fibres) were carried out under thoroughly heated conditions. With the application of SEM and XRD analysis, the microstructure and organisational structure of the concrete could be seen. Also, data analysis could help identify their relationship in cases with polypropylene fibres added or not. The results showed that the elevated temperature through infrared images generally exhibits an upward trend with increasing temperature. Only slight damages were detected below 400°C, whereas more and more severe deterioration events were expected when the temperature was over 500°C. Meanwhile, the compressive strength kept decreasing as the temperature increased. Additionally, the addition of polypropylene fibres with appropriate length, diameter and quantity contributed to the improvement of high-temperature resistance of high-strength concrete.

もやもや病に対する血行再建術後 過灌流に対するミノサイクリンを用いた周術期管理の現状と問題点

Background: Cerebral hyperperfusion syndrome is a potential complication of superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis for moyamoya disease (MMD). Prophylactic blood pressure lowering in combination with the use of minocycline, a neuroprotective antibiotic agent, has been suggested to reduce the risk of cerebral hyperperfusion. We therefore aimed to evaluate the results of this procedure in our larger series.Methods: N-isopropyl-p-[123I]iodoamphetamine single-photon emission computed tomography was performed 1 and 7 days after STA-MCA anastomosis on 89 hemispheres from 75 consecutive patients with MMD (10-66, mean 38 years old). Postoperative systolic blood pressure was strictly controlled under 130 mmHg with the intra-operative and postoperative intravenous administration of minocycline hydrochloride (200 mg/day). Then we investigated the incidence of perioperative neurological deterioration and radiological adverse events such as delayed intracranial hemorrhage.Results: All patients underwent technically successful revascularization surgeries, and none of them suffered permanent neurological deterioration postoperatively. Three patients suffered transient ischemic attack in the acute stage (3.4%), and one patient suffered delayed intracerebral hemorrhage (ICH), which caused transient aphasia (1.1%). Six patients (mean age of 51.3 years) demonstrated delayed intracranial hemorrhage (subarachnoid hemorrhage in 5, and ICH in one) (6.7%) while five of them remained asymptomatic.Conclusion: The administration of minocycline with strict blood pressure control may represent secure and effective postoperative management after STA-MCA anastomosis for MMD, while delayed intracranial hemorrhage, either symptomatic or asymptomatic, is a potential complication of this procedure.

Abstract 18150: Prediction of Imminent Deterioration of Children after Stage I Palliation Using Real-Time Processing of Physiological Data

Patients after stage 1 palliation (S1P) for hypoplastic left heart syndrome (HLHS) and related lesions are at risk of life threatening deterioration resulting in shock, cardiac arrest, & hypoxemia. We hypothesize that these sudden deteriorations may be forecast by subtle, previously unidentified changes in cardiorespiratory dynamics. Identification of these precursors may provide an opportunity for early, life-saving intervention. We created complete high-resolution physiological recordings for all patients who had a primary admission of S1P after Jan. 1, 2013. We used the SickbayTM system (Medical Informatics Corp, Houston, TX) to collect high frequency physiological waveforms including EKG, ABP, LAP, SpO2 and Chest Impedance (60Hz - 240Hz), as well as HR, RR, Temp. and ST segment vital signs (0.5 Hz) during the patient’s interstage hospitalization. A logistic regression model was constructed to discriminate between physiological characteristics observed in the hours prior to deterioration from the characteristics observed >24 hours prior to or >96 hours after a clinical deterioration. Model validation was done using a standard bagging approach with a REPtree classifier and 10 fold cross validation. Twenty five patients were included in the study. Of these, 15 (60%) were found to have one or more deterioration events (arrest, CPR, unplanned intubation), with 24 total events observed during the interstage period. Characteristics associated with imminent deterioration were low SpO2 and depressed ST segment. Changes in physiological dynamics could be detected 1-2 hours before overt deterioration occurs (ROC area = 0.89) (Figure 1). This altered physiological state remains for ~96 hours after deterioration. In conclusion, it is possible to identify clinical deterioration in HLHS patients during their interstage period ~1-2 hours before overt deterioration occurs, providing an opportunity for early, life-saving intervention to be administered.

Abstract 16851: ST Segment Variability as a Predictor of Clinical Deterioration in Hypoplastic Left Heart Syndrome

Introduction: The interstage mortality rate for hypoplastic left heart syndrome (HLHS) is high at 12%. Modalities to predict clinical decline would be useful in this high risk population. Due to cardiac conduction system anomalies in HLHS, electrocardiogram (ECG) monitoring of the ST segment is confounded. Our aim is to develop a monitor of ST variability that predicts deterioration despite the presence of an abnormal ST segment baseline. Hypothesis: Increased ST variability is associated with clinical deterioration in HLHS. Methods: A prospective, observational study was conducted at Texas Children’s Hospital using interstage recordings of 5 lead ECG. From January 2013 to January 2014, 25 subjects were admitted with HLHS; 21 had requisite ECG data for inclusion. In 11 subjects, there were 17 deterioration events, defined as rapid response team (RRT) activation. Events included 13 instances of respiratory failure with intubation and 4 instances of chest compressions. The control group included 10 subjects with no deterioration. An approach to quantify variability was developed where the ST segment vector was resolved using 3 orthogonal leads (II, V5, and aVF) and variability quantified with two metrics: 1) Displacement: distance between ST vector tips at 30 s intervals and 2) Component range: sum of ST vector tip movement in 3 dimensions over 10 min intervals. Comparison was made with the four hour window prior to RRT activation in the deterioration group against the four hour window prior to ICU discharge in the control group. Results: Four hours prior to clinical deterioration, increased ST variability was noted in both methods. For the 30 s displacement method, subjects with deterioration had a median value of 0.059 mm [IQR: 0.039 - 0.075] compared with 0.037 mm [IQR: 0.025 - 0.053] in the control group (p = 0.023). For the 10 min component range method, subjects with deterioration had a median value of 3.0 mm [IQR: 1.8 - 4.5] compared with 1.9 mm [IQR: 1.0 - 2.8] in the control group (p = 0.031). Conclusions: ST variability is increased in HLHS subjects prior to deterioration. Although conduction abnormalities limit the utility of ST monitoring in this population, quantification of ST variability may have a role in advanced systems to monitor clinical deterioration.

Clinicians' Perspectives on Negative Effects of Psychological Treatments

Negative effects of psychological treatments is a fairly unexplored area of clinical research. Previous investigations have indicated that a portion of all patients experience negative effects in terms of deterioration and various adverse events. Meanwhile, evidence suggests that many clinicians are untrained in identifying negative effects and unaware of the current research findings. The objective of the current study is thus to investigate clinicians' own perspectives and experiences of possible negative effects of psychological treatments. An invitation to participate in an anonymous online survey consisting of 14 open-ended questions was distributed via three mailing lists used by clinicians that primarily identify themselves as cognitive behavior therapists. The responses were analyzed using a qualitative method based on thematic analysis. In total, 74 participants completed the survey. A majority agreed that negative effects of psychological treatments exist and pose a problem, and many reported having experienced both deterioration and adverse events among patients in their own practice. The thematic analysis resulted in three core themes: characteristics of negative effects, causal factors, as well as methods and criteria for evaluating negative effects. The clinicians recognize that negative effects exist, but many are unaware of the current research findings and are unfamiliar with methods and criteria for identifying and preventing deterioration and adverse events. The results provide evidence for further dissemination of the present knowledge regarding negative effects, particularly during basic clinical training, as well as the need for raising awareness of the available methods for identifying and preventing negative effects.

Identifying Significant and Relevant Events During Pediatric Transport

Children must often be transported to dedicated pediatric centers to receive specialized medical and surgical care, which places them at risk for significant deterioration and life-threatening events. Studies designed to identify and mitigate these events have been limited by variability in the selection and definition of significant events. The objective of this study was to identify and evaluate indicators that represent significant events during the transport of pediatric patients and are relevant to future research initiatives in transport medicine. We conducted a modified Delphi study consisting of four iterations. The expert panel included Canadian, interdisciplinary healthcare providers with transport experience. In the first Delphi iteration, experts suggested indicators for consideration and evaluated proposed indicators from the literature and introduced by the study steering committee. In subsequent iterations, respondents reevaluated all indicators that had not yet achieved a priori-defined consensus; group comments and aggregate scores for each indicator from previous iterations were provided. The expert panel consisted of 16 physicians and 17 nonphysician healthcare providers from 10 Canadian institutions. In total, the panel evaluated 57 indicators, including 26 not previously presented in the literature. The expert panel determined 52 were significant and relevant to future studies in pediatric transport. The final indicator list includes trigger tools (interventions, physiological markers, and laboratory values) and team member safety and process issues. Using a systematic, modified Delphi approach, we developed an inclusive list of indicators for application to pediatric transport-related quality improvement and clinical research projects.

Cost-benefit analysis of a medical emergency team in a children's hospital.

Medical emergency teams (METs) can reduce adverse events in hospitalized children. We aimed to model the financial costs and benefits of operating an MET and determine the annual reduction in critical deterioration (CD) events required to offset MET costs. We performed a single-center cohort study between July 1, 2007 and March 31, 2012 to determine the cost of CD events (unplanned transfers to the ICU with mechanical ventilation or vasopressors in the 12 hours after transfer) as compared with transfers to the ICU without CD. We then performed a cost-benefit analysis evaluating varying MET compositions and staffing models (freestanding or concurrent responsibilities) on the annual reduction in CD events needed to offset MET costs. Patients who had CD cost $99,773 (95% confidence interval, $69,431 to $130,116; P < .001) more during their post-event hospital stay than transfers to the ICU that did not meet CD criteria. Annual MET operating costs ranged from $287,145 for a nurse and respiratory therapist team with concurrent responsibilities to $2,358,112 for a nurse, respiratory therapist, and ICU attending physician freestanding team. In base-case analysis, a nurse, respiratory therapist, and ICU fellow team with concurrent responsibilities cost $350,698 per year, equivalent to a reduction of 3.5 CD events. CD is expensive. The costs of operating a MET can plausibly be recouped with a modest reduction in CD events. Hospitals reimbursed with bundled payments could achieve real financial savings by reducing CD with an MET.

Pilot study for home monitoring of cough capacity in amyotrophic lateral sclerosis: A case series

BackgroundCough capacity derangement is associated with a high risk of pulmonary complications in amyotrophic lateral sclerosis patients when cough assistance is not routinely performed at home. The primary aim of this study was to evaluate the feasibility of a long-term home based daily self-monitoring cough capacity. MethodsEighteen subjects were enrolled in a 9-month study at home. Changes in peak cough expiratory flow, oxygen saturation, respiratory discomfort and incidence of respiratory deterioration events were evaluated. In subjects presenting respiratory deterioration events, decline in the abovementioned respiratory variables was evaluated (#NCT00613899). ResultsDuring an average follow-up of 125±102 days, a total of 1175 measures were performed on 12 subjects. Mean compliance to proposed evaluations was 37±32% which worsened over time. Peak cough expiratory flow decreased by 15.08±32.43L/min monthly. Five subjects reported 6 episodes of respiratory deterioration events, after a mean period of 136±108 days. They had poor respiratory function and more years of disease. There was no difference in peak cough expiratory flow and its decline whether subjects presented respiratory deterioration events or not. In 4 subjects the respiratory discomfort score significantly worsened after respiratory deterioration events from 3.0±1.41 to 4.25±1.71. ConclusionDaily self-monitoring of peak cough expiratory flow, oxygen saturation and respiratory discomfort seems difficult to obtain because of poor adherence to measures; this protocol does not seem to add anything to current practice of advising on clinical derangements. Confirmatory larger studies are necessary.

Pilot study for home monitoring of cough capacity in amyotrophic lateral sclerosis: A case series

BackgroundCough capacity derangement is associated with a high risk of pulmonary complications in amyotrophic lateral sclerosis patients when cough assistance is not routinely performed at home. The primary aim of this study was to evaluate the feasibility of a long‐term home based daily self‐monitoring cough capacity. MethodsEighteen subjects were enrolled in a 9‐month study at home. Changes in peak cough expiratory flow, oxygen saturation, respiratory discomfort and incidence of respiratory deterioration events were evaluated. In subjects presenting respiratory deterioration events, decline in the abovementioned respiratory variables was evaluated (#NCT00613899). ResultsDuring an average follow‐up of 125±102 days, a total of 1175 measures were performed on 12 subjects. Mean compliance to proposed evaluations was 37±32% which worsened over time. Peak cough expiratory flow decreased by 15.08±32.43L/min monthly. Five subjects reported 6 episodes of respiratory deterioration events, after a mean period of 136±108 days. They had poor respiratory function and more years of disease. There was no difference in peak cough expiratory flow and its decline whether subjects presented respiratory deterioration events or not. In 4 subjects the respiratory discomfort score significantly worsened after respiratory deterioration events from 3.0±1.41 to 4.25±1.71. ConclusionDaily self‐monitoring of peak cough expiratory flow, oxygen saturation and respiratory discomfort seems difficult to obtain because of poor adherence to measures; this protocol does not seem to add anything to current practice of advising on clinical derangements. Confirmatory larger studies are necessary.

Medical‐surgical nurses' perceived self‐confidence and leadership abilities as first responders in acute patient deterioration events

To explore and understand medical-surgical nurses' perceived self-confidence and leadership abilities as first responders in recognising and responding to clinical deterioration prior to the arrival of an emergency response team. Patients are admitted to hospitals with multiple, complex health issues who are more likely to experience clinical deterioration. The majority of clinical deterioration events occur on medical-surgical units, and medical-surgical nurses are frequently the first healthcare professionals to identify signs and symptoms of clinical deterioration and initiate life-saving interventions. A prospective, cross-sectional, descriptive quantitative design using a survey method was used. Nurses were recruited from an integrated healthcare system located in the south-east United States. Nurses completed a demographic, a self-confidence and a leadership ability questionnaire. One hundred and forty-eight nurses participated in the study. Nurses felt moderately self-confident in recognising, assessing and intervening during clinical deterioration events. In addition, nurses felt moderately comfortable performing leadership skills prior to the arrival of an emergency response team. A significant, positive relationship was found between perceived self-confidence and leadership abilities. Age and certification status were significant predictors of nurses' leadership ability. Although nurses felt moderately self-confident and comfortable with executing leadership abilities, improvement is needed to ensure nurses are competent in recognising patients' deterioration cues and making sound decisions in taking appropriate, timely actions to rescue patients. Further strategies need to be developed to increase nurses' self-confidence and execution of leadership abilities in handling deterioration events for positive patient outcomes. Educational provisions should focus on various clinical deterioration events to build nurses' self-confidence and leadership abilities in handling clinical deterioration. Nurses should obtain national certification to increase their knowledge and clinical reasoning skills.

The Effect of Unit-Based Simulation on Nurses’ Identification of Deteriorating Patients

Patients are admitted to healthcare organizations with multiple, complex conditions that can lead to acute deterioration events. It is imperative that nurses are adequately trained to recognize and respond appropriately to these events to ensure positive patient outcomes. The purpose of this pilot research study was to examine the effects of a unit-based, high-fidelity simulation initiative on cardiovascular step-down unit registered nurses' identification and management of deteriorating patients.

Are Critical Deterioration Events the Right Metric to Determine the Impact of Rapid Response Systems?

Are Critical Deterioration Events the Right Metric to Determine the Impact of Rapid Response Systems?

Impact of Rapid Response System Implementation on Critical Deterioration Events in Children

Rapid response systems aim to identify and rescue deteriorating hospitalized patients. Previous pediatric rapid response system implementation studies have shown variable effectiveness in preventing rare, catastrophic outcomes such as cardiac arrest and death. To evaluate the impact of pediatric rapid response system implementation inclusive of a medical emergency team and an early warning score on critical deterioration, a proximate outcome defined as unplanned transfer to the intensive care unit with noninvasive or invasive mechanical ventilation or vasopressor infusion in the 12 hours after transfer. Quasi-experimental study with interrupted time series analysis using piecewise regression. At an urban, tertiary care children's hospital in the United States, we evaluated 1810 unplanned transfers from the general medical and surgical wards to the pediatric and neonatal intensive care units that occurred during 370,504 non-intensive care patient-days between July 1, 2007, and May 31, 2012. Implementation of a hospital-wide rapid response system inclusive of a medical emergency team and an early warning score in February 2010. Rate of critical deterioration events, adjusted for season, ward, and case mix. Rapid response system implementation was associated with a significant downward change in the preintervention trajectory of critical deterioration and a 62% net decrease relative to the preintervention trend (adjusted incidence rate ratio = 0.38; 95% CI, 0.20-0.75). We observed absolute reductions in ward cardiac arrests (from 0.03 to 0.01 per 1000 non-intensive care patient-days) and deaths during ward emergencies (from 0.01 to 0.00 per 1000 non-intensive care patient-days), but these were not statistically significant (P = .21 and P = .99, respectively). Among all unplanned transfers, critical deterioration was associated with a 4.97-fold increased risk of death (95% CI, 3.33-7.40; P < .001). Rapid response system implementation reversed an increasing trend of critical deterioration. Cardiac arrest and death were extremely rare at baseline, and their reductions were not statistically significant despite using nearly 5 years of data. Hospitals seeking to measure rapid response system performance may consider using valid proximate outcomes like critical deterioration in addition to rare, catastrophic outcomes.

Universal glove and gown use for healthcare workers: what is the role of visitors?

Critical illness is a life-threatening course of the disease affecting almost all human organs; unfortunately, it can lead to significant morbidity or mortality. Critical illness is mostly heralded by physiological deterioration. It is globally accepted that all clinical staff are extremely influential through their vigilance and intensive care provided for the critically-ill.1 Early-weaning systems and modes have contributed immensely to the prevention of deterioration and serious adverse events in these patients.2 Outcome depends vastly on prompt identification, diagnosis and treatment; hence, all doctors should have the knowledge to identify the critically-ill patient and initiate the situation management as soon as possible. The use of gloves and gowns for all contacts versus routine care among patients in medical and surgical ICUs has recently been shown not to be associated with a significant difference in the MRSA or VRE acquisition1. In their study, Harris et al. reported that all health care workers (nurses, physicians, respiratory therapist, etc.) wore gloves and gowns for all contacts with patients and when entering each patient’s room.3 Admission to an intensive care unit is per se a highly-stressful event for both patients and their relatives. Traditionally, infection control concerns and a belief that liberal visiting by patients’ relatives interferes with the provision of patient care has led many units to impose restricted visiting policies. However, recent studies suggest that partially-unrestricted vs. restricted visiting policy not only improves visitors’ satisfaction and reduces anxiety but also does not result in an increase in ICU-acquired infections.4,5 Hence, considering the increase in the popularity of open and partially-restricted visitor policies, provision of infection control (gowns and gloves) for visitors’ contacts with the patients seems to be of great important in decreasing infection in the critically-ill patients.

The United Kingdom Glaucoma Treatment Study: A Multicenter, Randomized, Double-masked, Placebo-controlled Trial: Baseline Characteristics

The United Kingdom Glaucoma Treatment Study (UKGTS) tests the hypothesis that treatment with a topical prostaglandin analog, compared with placebo, reduces the frequency of visual field (VF) deterioration events in patients with open-angle glaucoma (OAG) by 50% over a 2-year period. Additional goals are to evaluate study power with novel clinical trial outcomes: (1) VF deterioration velocity and (2) VF and quantitative imaging measurements modeled as joint outcomes. The UKGTS is a randomized, double-masked, placebo-controlled, multicenter treatment trial for OAG. A total of 516 patients with newly diagnosed (previously untreated) OAG were prospectively recruited at 10 UK centers between 2007 and 2010. Eligible patients were randomly assigned to treatment with latanoprost 0.005% or placebo. The observation period was 2 years, with subjects monitored by VF testing, quantitative imaging, optic disc photography, and tonometry at 11 visits. The primary outcome measure is time to VF deterioration within 24 months. Secondary outcomes include the deterioration velocity of VF and quantitative imaging measures. The main source of referrals was optometrists (88%). A total of 777 subjects were assessed for eligibility, and 261 were excluded because they did not meet the inclusion criteria or declined to participate. The mean age of the 516 participants was 66 years, and 52.9% were male; 90.1% of the participants were white, and approximately one third (32.2%) reported a family history of glaucoma. A total of 777 eyes were eligible at initial assessment. Both eyes were eligible for 265 participants. Mean (standard deviation) intraocular pressure (IOP) at baseline for the eyes with better versus worse mean deviation (MD) was 18.9 (4.1) and 19.9 (4.7) mmHg, respectively (P = 0.0053). Some 56.1% of all eligible eyes had IOP <20 mmHg at baseline. The median (interquartile range) VF MD for all eligible eyes was -2.9 dB (-1.6 to -4.8 dB). This is the first randomized, placebo-controlled trial to evaluate the efficacy of medical treatment in reducing VF deterioration in OAG. The baseline characteristics for eligible patients and eyes from this cohort are presented and compared with those of previous trials. The baseline characteristics are similar to those of the largely population-based Early Manifest Glaucoma Trial. The early stage of the glaucoma and relatively low IOP at diagnosis suggest remarkably sensitive case findings by community optometrists in the United Kingdom.

Porcine Bioprosthetic Valve in the Pulmonary Position: Mid-Term Results in the Right Ventricular Outflow Tract Reconstruction

Pulmonary valve replacement (PVR) for pulmonary valve insufficiency (PVI) currently represents the most frequent reoperation performed for adults with congenital heart disease. A variety of pulmonary valve substitutes have been used, but none has proved to be ideal. This report reviews the authors' experience using a porcine prosthetic valve in the pulmonary position. Between January 2001 and December 2011, 76 patients (mean age, 36 years; range, 18-64 years) underwent PVR for chronic PVI using a porcine bioprosthesis. All the patients had previously undergone surgery: 65 for repair of tetralogy of Fallot and 11 for pulmonary surgical valvotomy. Magnetic resonance imaging (MRI) evaluations before surgery and at the 1-year postoperative follow-up evaluation were compared. Aside from the PVR, 59 patients (59/65, 78 %) received 94 associated cardiac surgical procedures. Two hospital deaths occurred. The mean hospital stay was 13 days (range, 7-48 days). At the 1-year control MRI, pulmonary regurgitation fraction, right ventricular end diastolic volume (RVEDV), and RV/LV EDV had improved significantly. During a mean follow-up period of 52 months (range, 6-132 months), one patient died. All the patients were categorized as New York heart association (NYHA) functional class 1. No episodes of structural valve deterioration, endocarditis, or thromboembolic event were noted. Echocardiography showed trivial or no PVI in all the patients. The porcine bioprosthetic valves demonstrated excellent midterm results in the RV outflow tract reconstruction. The hemodynamic characteristics of this valve are comparable with those of homografts or valved conduits. It is easy to implant and allows for avoiding extensive dissection, especially of the pulmonary arteries.

Improving Situation Awareness to Reduce Unrecognized Clinical Deterioration and Serious Safety Events

Failure to recognize and treat clinical deterioration remains a source of serious preventable harm for hospitalized patients. We designed a system to identify, mitigate, and escalate patient risk by using principles of high-reliability organizations. We hypothesized that our novel care system would decrease transfers determined to be unrecognized situation awareness failures events (UNSAFE). These were defined as any transfer from an acute care floor to an ICU where the patient received intubation, inotropes, or ≥ 3 fluid boluses in first hour after arrival or before transfer. The setting for our observational time series study was a quaternary care children's hospital. Before initiating tests of change, 2 investigators reviewed recent serious safety events (SSEs) and floor-to-ICU transfers. Collectively, 5 risk factors were associated with each event: family concerns, high-risk therapies, presence of an elevated early warning score, watcher/clinician gut feeling, and communication concerns. Using the model for improvement, an intervention was developed and tested to reliably and proactively identify patient risk and mitigate that risk through unit-based huddles. A 3-times daily inpatient huddle was added to ensure risks were escalated and addressed. Later, a "robust" and explicit plan for at-risk patients was developed and spread. The rate of UNSAFE transfers per 10,000 non-ICU inpatient days was significantly reduced from 4.4 to 2.4 over the study period. The days between inpatient SSEs also increased significantly. A reliable system to identify, mitigate, and escalate risk was associated with a near 50% reduction in UNSAFE transfers and SSEs.