Medical Floor Research Articles

Registered Nurses’ Use of Physical Restraints on the Medical Floor in a Jamaican Hospital

Objectives: To explore registered nurses use of physical restraints on the medical floor of an acute care hospital in Kingston, Jamaica Methods: This descriptive cross-sectional study included 90 registered nurses working on the medical floor. Data collection utilized a 17-item self – administered adapted version of the Perceptions of Restraint Use Questionnaire (PRUQ). Data were analyzed using the Statistical Package for Social Sciences SPSS® version 20 for Windows®. Results: The response rate was 85.7% f (N=90). Participants were female (97%) and ages ranged between 20-29 years (60%). The majority (88%) had baccalaureate degree (88%) and 40% of this number had worked as a registered nurse for less than two years. Registered nurses reported using physical restraints to reduce the likelihood of patients either falling out of bed (4.41±0.95), breakage of sutures (4.26±0.88) or pulling out intravenous line (4.14±0.79) out of a maximum score of 5. Nurses indicated that the time of day influenced physical restraint usage with the night shift accounting for 71.1%. Confused patients were more likely to be restrained (78.9%). The majority (76.7%) of study participants were knowledgeable of the institution’s physical restraint policy but (83% reportedly received no training in its application. Conclusion: Nurses on the medical wards utilized physical restraints to ensure patient safety and facilitate treatment continuation. Patient characteristics, lack of training and institutional support were contributing factors to physical restraint usage. When institutional support is inadequate, nurses’ intention to prevent patient harm and meet professional obligation might contribute to the reliance on the use of physical restraint.

Knowledge, Attitudes, Beliefs and Perceived Risk of Acute Coronary Syndrome among Jordanian Patients

Background: Acute Coronary Syndrome (ACS)-associated mortality is considered high and still raising, where outcomes can be improved through immediate treatment initiation. Knowledge, attitudes, beliefs and perceived risk are cognitive factors that can affect patient’s decision to seek care immediately. Therefore, this study aimed to explore knowledge, attitudes, beliefs, and perceived risk for future ACS event among Jordanian ACS patients. Methods: A descriptive, cross-sectional, correlational design was used to conveniently recruit 160 ACS patients from CCUs and medical floors at three Jordanian hospitals using the Modified ACS Response Questionnaire. Results: Almost, 65% of participants had low level of ACS knowledge, specifically regarding untraditional ACS symptoms. Some negative attitudes and beliefs toward ACS were found. There was a moderate positive correlation between knowledge score and all of attitudes, beliefs and perceived risk score (r = 0.549, p < 0.01, r = 0.563, p < 0.01, r = 0.545, p < 0.01). Conclusion: Inadequate ACS knowledge, negative attitudes and beliefs toward ACS were associated with low perceived risk for future ACS event. Therefore, it is a priority to develop strategies that consider improving ACS patients’ knowledge, attitudes, beliefs and perceived risk. This could be effective to enhance patient’s decision to seek care and reduce ominous outcomes.

Integrating quality and safety education into clinical nursing education through a dedicated education unit

The Institute of Medicine and American Association of Colleges of Nursing are calling for curriculum redesign that prepares nursing students with the requisite knowledge and skills to provide safe, high quality care. The purpose of this project was to improve nursing students' knowledge of quality and safety by integrating Quality and Safety Education for Nurses into clinical nursing education through development of a dedicated education unit. This model, which pairs nursing students with front-line nursing staff for clinical experiences, was implemented on a medical floor in an acute care hospital. Prior to implementation, nurses and students were educated about the dedicated education unit and quality and safety competencies. During each clinical rotation, students collaborated with their nurses on projects related to these competencies.Students' knowledge was assessed using questions related to quality and safety. Students who participated in the dedicated education unit had higher scores than those with traditional clinical rotations. Focus groups were held mid-semester to assess nurses' perceptions of the experience. Five themes emerged from the qualitative data including thirsting for knowledge, building teamwork and collaboration, establishing trust and decreasing anxiety, mirroring organization and time management skills, and evolving confidence in the nursing role.

Are We Doing Too Many HIT Tests? II

Back Ground: Heparin Induced Thrombocytopenia is a complex immune disorder related to exposure to heparin that results in arterial and venous thrombosis and moderate to severe thrombocytopenia. Incidence is 0.8-1% in hospitalized patients exposed to heparin. However there is a problem with over testing for HIT syndrome that it is not only financially burdensome but that treating false positive patients with anticoagulation can increase their risk for bleeding.Objective: To determine the actual incidence of Type II-HIT compared to the frequency and necessity of testing in a single urban, teaching, community hospital in Chicago.Methods: A retrospective review of lab records for patients who were tested for HIT syndrome by H-PF4 -ELISA through 2 years Jan 2013-Dec 2014. Then each patient's chart was reviewed. Patients were categorized according to requesting department (i.e. ICU, ED, Medical and surgical floors) then screened for date of admission, date of onset of platelet drop, degree of platelet drop, incidence of DVT, PE, arterial thrombosis and bleeding and finally for possible reasons of platelet count drop other than HIT for calculation of Pretest probability by the 4T score. According to the 4T criteria patients were categorized as low (score 0-3), intermediate (score 4, 5) and high probability (score 6-8). All charts with positive ELISA were reviewed for SRA (Serotonin Release Assay) results. Also contacted lab and pharmacy for cost of HIT testing, confirmatory test with SRA and the cost of Argatroban to be able to determine the economic burden of over testing for HIT syndrome.Results: an average of about 20,000 admissions per year. Over the year 2013, 110 patients were screened for HIT. Over the year 2014, 87 patients were tested for HIT. Of total of 197 tests ordered over the 2 years period 19 Patients did not have enough data in the charts for determination of 4T score and were so excluded. Of the remaining 178, 85(45%) were sent from ICU, 61(32.6%) from Medical floors, 28(15%) from CCU, 9(4.8%) from Surgical floors, 1(0.5%) from Rehab unit, 1(0.5%) from ED and 1(0.5%) from Observation Unit. 17(9.5%) Patients had proven DVT, PE or arterial thrombosis. 2(1%) Patients had evidence of bleeding. According to 4T score139 (74.3%) of 178 were low, 34(18%) intermediate and 5(2.6%) were high probability. ELISA test was positive for only 34(19%) patients of the 178 of which only 3(1.6%) were proven true positive by SRA, 12(6%) had no SRA result in their chart and 19(10.6%) had negative SRA results. ELISA was positive in 22 cases with Low Probability score, 9 Intermediate probability and 3 high probability. Of the 22 low probability ELISA positive cases only 1 (4%) was SRA positive, 15(68%) were SRA negative and 6(27%) did not have SRA in the chart. ELISA test costs 233$, SRA test costs 50$ and one day of Argatroban costs average of 663.44$.Thus the calculated cost of testing for low probability patients reached 32,387 $ for ELISA and 800$ for SRA. Cost of treating false positive patients with Argatroban for an average of 3 days until SRA results are available is 43,758$.Conclusion: From this study we concluded that in our facility we continue to do too many HIT studies without appropriate prescreening with added cost of testing and treatment for low probability patients of almost 77,000$ over the period of two years. In planning to avoid unnecessary testing and treatment for false positive patients we plan to build a 4T score calculator into our Electronic Medical Record System that is started once a HIT test is ordered to improve the screening process. We will also continue work with the Internal Medicine residency program and medical staff to improve teaching on HIT syndrome and other conditions with similar presentations.Table 1Number of Tests per DepartmentDepartmentNumber of tests sentICU86(45%)CCU28(15%)Medical Floors61(32.6%)Surgical Floors9(4.8%)Rehab Unit1(0.5%)ED1(0.5%)Observation Unit1(0.5%)Total187Table 2Tests Categorized into Low, Intermediate and High Probability according to 4T scoreLow ProbabilityIntermediate ProbabilityHigh Probability139(74.3%)34(18%)5(2.6%)Table 3SRA Results for ELISA positive patients per Each Probability CategoryLow ProbabilityIntermediate ProbabilityHigh Probability22(64.7%)9(26.4%)3(8%)SRA PositiveSRA NegativeSRA UnavailableSRA PositiveSRA NegativeSRA UnavailableSRA PositiveSRA NegativeSRA Unavailable1(4%)15(68%)6(27%)2(22%)4(44%)3(33%)01(33%)2(66.6%) DisclosuresNo relevant conflicts of interest to declare.

Hospital delirium treatment: Continuation of antipsychotic therapy from the intensive care unit to discharge

The rate of continuation of antipsychotics for the management of delirium during hospital transitions of care in a tertiary care medical center was investigated. A retrospective chart review was conducted for adult patients admitted to the medical intensive care unit (MICU) between June 1, 2011, and May 31, 2012, who were initiated on antipsychotic therapy at least 24 hours before transfer out of the MICU. The primary outcome evaluated was the percentage of patients initiated on an antipsychotic in the MICU who were continued on therapy after transfer to a medical ward. Secondary outcomes included the appropriateness of continuing antipsychotic therapy during transitions of care and the percentage of patients continued on an antipsychotic after hospital discharge. Of the 87 patients who met the study inclusion criteria, 23 (26%) were continued on antipsychotic therapy after their transfer from the MICU to the medical ward. Of the 23 patients continued on antipsychotic therapy, 9 (39%) were discharged from the hospital with an antipsychotic. Fourteen of the 23 patients were eligible for assessment of inappropriate antipsychotic continuation upon transfer from the MICU. Of these 14 patients, 9 (64%) were inappropriately continued on an antipsychotic. Patients continued on antipsychotic therapy at hospital discharge were more likely to be discharged to a facility (rehabilitation, skilled nursing facility, or healthcare institution) (p = 0.049).Future areas for study should include (1) prospective analysis to understand the clinical decision-making of providers when treating delirium, (2) evaluation of the long-term impact of continuing antipsychotic therapy for delirium, and (3) ways to improve communication of medication regimens during transitions of care. Plans to reduce antipsychotic continuation could involve reassessing patients on the medical wards, improving documentation of the indication for use in the medical record, or developing protocols to taper off antipsychotics before patients are discharged from the hospital. The continuation of antipsychotics for the management of delirium during transitions of care was a common practice at a tertiary care medical center. Patients receiving antipsychotics for treatment of delirium in the MICU were inappropriately continued on these agents when transferred from the MICU to the medical floor or discharged from the hospital.

Medical stabilization of adolescents with nutritional insufficiency: a clinical care path.

Nutritional insufficiency (NI) is a potential consequence of restrictive eating disorders. NI patients often require hospitalization for refeeding to restore medical stability and prevent complications such as refeeding syndrome. Limited information is available on the optimal approach to refeeding. In this study, we describe an inpatient NI care path and compare treatment outcomes at an academic medical center and a community hospital. A retrospective chart review was conducted on inpatients treated using a standardized NI care path at either the academic site, from August 2012 to July 2013 (n=51), or the community site, from August 2013 to July 2014 (n=39). Demographic information, eating disorder history, and treatment variables were recorded for each patient. Data were compared using the Kruskal-Wallis test and Fisher's exact test. Patients admitted to the community site had shorter hospital stays than patients admitted to the academic site (IQR 2-4 vs. 2-7days, p=0.03). All patients were discharged in <14days with a median stay of 3days. The median initial calorie prescription was 2200 calories for both groups. No clinical cases of refeeding syndrome occurred, with only one patient developing hypophosphatemia during refeeding. A standardized care path with a higher-calorie intervention allows for short-term hospitalization of NI patients without increasing the risk of refeeding syndrome, regardless of treatment site. This study demonstrates the efficiency and safety of treating NI patients on a regular medical floor at a community hospital.

Lactococcus Septicemia With Perihepatic Fluid Collection in End-Stage Renal Disease Patient

A 38 year old African American male presented to the emergency room with complaints of having chills, fever, and shortness of breath. His past medical history was significant for sickle cell disease SS-type, end-stage renal disease dialysis dependent, diastolic congestive heart failure, and hemochromatosis. The patient stated that while receiving dialysis he started having the above symptoms. Blood cultures were taken at the dialysis center, and he was administered vancomycin and gentamicin. His temperature was recorded as 101.1, and he was hypotensive. The patient also admitted to gradual onset of abdominal pain, primarily on the right side and dull in nature;also, he had productive cough and rhinorrhea that started 3 to 4 days prior to admission. Of significance, this patient was in a hospital 2 weeks prior for symptomatic anemia and shortness of breath. He was admitted for severe sepsis perhaps secondary to healthcare-associated pneumonia and transaminitis possibly secondary to hemochromatosis vs hypoperfusion due to sepsis. He received hemodialysis, additional blood cultures were drawn, and placed on broad spectrum antibiotics, which included vancomycin, zosyn, and levofloxacin. Chest x-ray showed cardiomegaly and increased interstitial markings likely related to cardiac decompensation. CT abdomen and pelvis without contrast showed airspace opacity in the right lung base, enlarged liver with nodular contour compatible with cirrhosis, moderate amount of loculated perihepatic collection, and a calcified failed right sided kidney transplant. Laboratory data included a white blood cell count of 62,700, neutrophil percentage of 90.1%, and 14% bands on manual differential. Lactic acid 4.3 mm/l, procalcitonin 91.46 ng/ml, ammonia 64 μM/l. The patient's hepatic panel showed an albumin of 2.7 gm/dl, alkaline phosphatase 193 mu/ml, alanine transaminase 98 mu/ml, aspartate transaminase 242 mu/ml, direct bilirubin 5.9 mg/dl, and total bilirubin 10.9 mg/dl. The patient had a CT-guided drainage of the inferior perihepatic fluid collection. Approximately 200cc of amber colored fluid was removed and a drainage bag was placed. Fluid analysis and chemistries were consistent with exudative process. Infectious diseases was consulted for documented blood culture positivity for Lactococcus and Escherichia coli, with recommendation to continue vancomycin and zosyn, discontinue levofloxacin, and send perihepatic fluid for gram stain, culture, and cytology. The patient's fevers resolved and his white blood cell count continued to trend downwards from a peak of 62, 700. He was transferred from the medical intensive care unit to the medical floor for further management.

Increased Post-Prandial Intragastric and Duodenal Acidity in Patients With Chronic Pancreatitis Could Result in Duodenitis

A 29 year old Hispanic male with history of DM type 1, Type V hyperlipoproteinemia, and chronic pancreatitis with exocrine insufficiency came to the ER complaining of abdominal pain. His abdominal pain had started 2 days ago, 6/10, periumbilical, radiated to the back, dull in nature, not related to food, intermittent at first, but was constant for the last 1 day. On review of systems, he complained of subjective fever, chills, diaphoresis, nausea, 2-3 episodes of non-bloody, non-bilious vomiting, loss of appetite, about 20 lbs wt loss over 3 months, and dark-colored stools. Pertinent findings on physical examination were no pallor or icterus, diffuse abdominal tenderness on palpation without rebound or guarding with good bowel sounds and no organomegaly, and digital rectal examination showed good anal sphincter with no gross blood. His significant laboratory findings were hemoglobin and hematocrit of 8.7/25.4 with lipase of 28. He was admitted to general medical floor for acute on chronic pancreatitis. He was aggressively treated with intravenous normal saline. In view of his anemia, esophagogastroduodenoscopy (EGD) was performed. EGD showed erythema antrum of the stomach and duodenitis and biopsy showed mild chronic inflammation in the gastric mucosa but no helicobacter pylori and no villous blunting in the duodenum. Subsequently, he was started on protonix 40mg po daily and iron supplements. Furthermore, his symptoms improved and he tolerated oral diet and was discharged home to follow-up in GI clinic. In the postprandial periods intraduodenal pH has been shown to be markedly reduced in chronic pancreatitis patients. Intragastric pH is also lower in chronic pancreatitis patients. When focusing on the percentage of postprandial time with pH below five in the duodenum and pH below three in the stomach, chronic pancreatitis patients were exposed to acid in stomach and duodenum for a significantly longer period. Several previous studies have measured intraduodenal pH in patients with chronic pancreatitis and all have observed an abnormally low intraduodenal pH with reduced acid neutralizing capacity.

Acid Suppressive Therapy for Stress Ulcer Prophylaxis in Noncritically Ill Patients.

The current literature discourages the use of acid suppressive therapy (AST) for stress ulcer prophylaxis (SUP) in noncritically ill patients. However, several sources indicate that the majority of noncritically ill patients are given AST for SUP while there may only be a small proportion of high-risk patients who need SUP therapy. There is a new scoring system to aid practitioners in stratifying the risk of stress ulcer-related gastrointestinal bleeding in noncritically ill patients developed by Herzig et al and appropriately prescribe AST for SUP in this population. Our primary objective was to determine the current usage of AST in noncritically ill patients at a tertiary teaching hospital and use the new scoring system to identify non-intensive care unit patients who were inappropriately given AST. We retrospectively determined the percentage of noncritically ill patients who were given AST on medical floors between January 2010 and December 2012. After identifying these patients, we randomly selected a sample and retrospectively collected data from their medical record to determine the gastrointestinal bleeding risk score to determine if the patient was appropriately given AST. Of the 42 600 admissions, 22 949 (53.7%) noncritically ill patients were given AST. A total of 442 patients were randomly selected for data collection and 156 patients were excluded. Gastrointestinal bleeding risk score was calculated in 286 patients. This new risk stratification tool identified 253 (88.5%) patients to have a low (≤7) and low-medium risk score (8-9). A large percentage of noncritically ill patients were given AST during their hospital stay; 88.5% of these medications were given inappropriately to patients who were at extremely low risk of gastrointestinal bleeding. Using the above information and the AST prescribing patterns at our institution, we estimate a potential inpatient medication cost savings of $114 622 for the study period.

Development of a collaborative transitions-of-care program for heart failure patients.

The development and implementation of a pharmacy-led transitions-of-care program to reduce the risk of readmission and increase satisfaction for heart failure (HF) patients are described. A transitions-of-care committee was established at Providence St. Peter Hospital, a 390-bed community teaching facility in Olympia, Washington, and focused on implementing standardized workflow processes for conducting admission medication review and discharge medication review and providing discharge counseling for patients with HF. All HF patients were to have admission medication reconciliation performed within 48 hours of admission. All HF patients were assigned a readmission risk complexity score after being admitted to the medical floor. The pharmacist, resident, and student performed daily patient medication profile reviews on all HF patients to ensure the use of optimal doses of appropriate HF medication regimens. The pharmacist proactively monitored for patient discharges using reports available in the electronic medical record. The pharmacist, resident, student, or HF nurse navigator counseled each patient on the discharge medications and answered any questions or addressed concerns regarding medications. Input from the quality-improvement specialist and data abstracter was used to ensure compliance with HF core measures. The program has resulted in an increase in core measure compliance and a reduction of HF, 30-day, and all-cause readmissions, and patient satisfaction scores have improved. For each avoided readmission, there was an associated decrease of $5652 in variable costs. The implementation of a pharmacy-led transitions-of-care program improved patient care by prioritizing those who needed medication reconciliation and led to increases in HF core measure compliance and patient satisfaction scores.

Predictors of Repeat Epinephrine Administration for Emergency Department Patients with Anaphylaxis

Risk factors that predict which patients with anaphylaxis might require repeat doses of epinephrine are poorly understood. The objective of this study was to identify risk factors associated with the need for multiple doses of epinephrine during an anaphylactic reaction. Patients were included if they met diagnostic criteria for anaphylaxis on presentation to the emergency department (ED) at our academic medical center between April 2008 and February 2014. Data were collected on allergic history, presenting signs and symptoms, anaphylaxis management, and disposition. Univariable and multivariable analyses were performed to estimate associations between possible risk factors and the need for multiple doses. Of 582 ED patients with anaphylaxis, 45 (8%) required multiple doses of epinephrine. By multivariable analysis, factors associated with the need for repeat doses were a history of anaphylaxis (odds ratio [OR], 2.5 [95% CI, 1.3-4.7]; P = .005), the presence of flushing or diaphoresis (OR, 2.4 [95% CI, 1.3-4.5]; P = .007), and the presence of dyspnea (OR, 2.2 [95% CI, 1.0-5.0]; P = .046). Patients who received more than 1 dose were more likely to be admitted to the general medical floor (OR, 2.8 [95% CI, 1.1-7.2]; P = .03) or intensive care unit (OR, 7.6 [95% CI, 3.7-15.6]; P < .001). Patients with a history of anaphylaxis, flushing or diaphoresis, or dyspnea may require multiple doses of epinephrine to treat anaphylactic reactions. Patients who require more than 1 dose are more likely to be admitted to the hospital, thus increasing health care resource utilization.

Creating a sustainable, interprofessional-team training program: initial results.

The purpose of this program evaluation was to explore whether incorporating deliberate learning concepts, through the use of simulated patient scenarios to teach interprofessional collaboration skills to a healthcare team on one acute-care hospital unit, would improve the resuscitation response in the first 5 minutes on that unit. This was a pilot program evaluation utilizing a unit-based, clinical nurse specialist in the deployment of an interprofessional educational program involving simulation on an acute medical floor in a large tertiary-care hospital. Eighty-four staff members participated in 17 simulations. The sample included first-year internal-medicine residents, registered nurses, respiratory therapists, and patient care technicians. This was a program evaluation that used the TeamSTEPPS Teamwork Perceptions Questionnaire (T-TPQ) (Classroom slides: TeamSTEPPS essentials; http://www.ahrq.gov/professionals/education/curriculum-tools/teamstepps/instructor/essentials/slessentials.html#s3) during the presimulation/postsimulation sessions to assess the participants' perceptions of teamwork. Expected intervention behaviors were collected through observations of participants in the simulations and compared with the American Heart Association guidelines (Circulation 2010;122:S685-S670, S235-S337). Common perceptions of participants regarding the experience were obtained through open-ended evaluation questions. Fifty-three participants completed the pre- and post-T-TPQ. Mean scores in the leadership category of T-TPQ decreased significantly (P = .003) from the pretest (median, 2.167) to the T-TPQ posttest (median, 2.566). Only 35% of the groups administered a defibrillation during the ventricular fibrillation simulation scenario, and only 1 group delivered this shock within the American Heart Association's recommended time frame of 2 minutes (Circulation 2010;122:S235-S337). A single resuscitation simulation was not enough interventional dosage for staff to improve the resuscitation process. A longitudinal study should be conducted to determine the effectiveness of the program after staff members have repeated the program multiple times. A unit-based quality-improvement simulation training program could help improve the first-5-minute response and resuscitation skills of staff by increasing the frequency of unit-based training overseen by the unit's clinical nurse specialist.

A "Sound" Approach.

A "Sound" Approach.

Hospital nurses' lived experience of power.

The purpose of this study was to explore hospital nurses' lived experience of power. A hermeneutic phenomenological approach informed by Merleau-Ponty's philosophy of the phenomenology of perception was used to further an understanding of nurses' embodiment of power. Fourteen hospital clinical nurses employed in intensive care units and on medical floors in two major medical centers in the northeastern United States participated in 1-hr semistructured interviews about their lived experience of power. A hermeneutic analytic approach and reflexive (cultural) bracketing produced three relational themes of power: (a) knowing my patients and speaking up for them; (b) working to build relationships that benefit patients; and (c) identifying my powerful self. Hospital clinical nurses develop a sense of power. Nurses believe power develops through acquisition of knowledge, experience, and self-confidence; this process is enhanced by exposure to good mentors. Nurses use their power to build relationships and advocate for patients. They consciously use power to improve patient care. Nurses' voices need to be heard and acknowledged. To do this in the clinical setting and beyond, hospital nurses must invite themselves or find ways to be invited into the authoritative discourse of hospital organizations. Nurses use their power to advocate for positive outcomes for patients and families. The satisfaction that comes from these positive relationships may improve nurses' perceptions of their work environment. Nurses' understanding and use of sociopolitical knowing needs further study, so that nurses may understand how to participate in current and future debates and decisions about our changing healthcare delivery systems and services.

Abstract T P271: Establishment of Stroke Ward Results in Immediate Reduction of Major Complications

Background and Purpose: Randomized controlled trials have consistently shown that stroke units decrease both mortality and morbidity compared with conventional care in general medical wards. There are however limited data on the specific types of in-hospital medical complications and their effect on outcomes. The objective of this study was to determine whether establishing a specialized geographically defined Stroke Ward results in reducing the major complications in patients suffering from acute stroke within the same hospital system. Methods: This is a prospective study from January 2014 till July 2014. Data was collected from a web-based stroke registry in two phases. In phase 1 (from January 1, 2014 till March 08, 2014), we collected data of stroke patients admitted at in the medical wards. In phase 2, a protocol-based multidisciplinary care Stroke Ward became operational where most of the patients were admitted. Outcomes measures were number and type of complications, mortality, discharge disposition, and length of stay, and were adjusted for age, sex, and medical co-morbidities. Results: There were 130 admissions in phase 1 and 345 in phase 2. Commonest complications included, aspiration pneumonia 29% vs 12% (p&lt;0.001) and pressure ulcers in 35% vs 11% (p&lt;0.001). Average length of stay decreased from 12 days to 4 days (p&lt;0.001). In phase 1, 70 % of patients were discharged home, while 23% were transferred to rehabilitation while in phase 2, 75% of patients were discharged home, while 18% patients were sent to rehabilitation. Ninety percent of complications happened in medical wards, mainly in patients who over stayed in emergency department (more than 8 hours) waiting for bed in Stroke Ward or medical floor. Conclusion: A protocol based multidisciplinary care Stroke Ward care significantly reduces common early complications of acute stroke. It also helps in significantly reducing the length of stay, saving total bed days at a tertiary care hospital, hence improving the overall care of these patients.

Pelvic Pain of Pudendal Nerve Origin: Surgical Outcomes and Learning Curve Lessons

When pudendal nerve dysfunction fails to improve after medical and pelvic floor therapy, a surgical approach may be indicated. "Traditional," "posterior," transgluteal nerve decompression fails in an unacceptably high percentage of patients. Insights into pudendal neuroanatomy and pathophysiology offer improved microsurgical outcomes. To evaluate results of a peripheral nerve approach to the pudendal nerve, 55 patients were prospectively evaluated. This cohort included 25 men and 30 women. Surgical approach was posterior, transgluteal if symptoms included rectal pain; or "anterior," inferior pubic ramus approach if symptoms excluded rectal pain. Surgical approach was "resection," if trauma created a neuroma, and "decompression," if there were no neuroma. Effect of comorbidities was analyzed. At 14.3 months postoperatively, untreated anxiety/depression correlated with outcome failure, regardless of surgical approach, p < 0.002. There was no difference in results, men versus women, "anterior" versus "posterior" approach, or neuroma resection versus neurolysis. Success correlated with the "learning curve" of the surgeon. Self-rated success was significantly better (p < 0.0001) for patients operated on during the second year of the study than the first year of the study, and improved again in the final year of the study (p < 0.04), with 86% of the patients in final year achieving an excellent result and 14% achieving a good result. There is hope for surgical relief from pudendal nerve problems by distinguishing neuroma from compression in the diagnosis, and then choosing a site-specific surgical approach related to which pudendal nerve branches are involved.

Liver Mass as a First Presentation of Missed Malignant Melanoma

Here we present a case of multiple systemic metastasis of missed malignant melanoma in a 26 year old male who was admitted to medical floor because of abdominal pain and B- symptoms. Abdominal Ultrasound revealed Right liver lobe mass with hepatomegaly. True cut biopsy of liver mass revealed an undifferntiated malignant tumor. The tumor cells were immunoreactive for Melan-A, Vimentin and focally for S-100 protein where the diagnosis of metastatic malignant melanoma was made.

My Headache is not Migraine

Introduction: Reversible posterior Leukoencehalopathy syndrome (RPLS) or PRES (Posterior Reversible Encephalopathy Syndrome) is a clinical radiographic syndrome of heterogeneous etiologies. A 46 year old female with past medical history of chronic pain, chronic pancreatitis, hypertension, anxiety, fibromyalgia and migraines with multiple admissions in the last 3 months for acute migraine attacks presented with headache. It started 3 days ago with typical involvement of frontal region along with nausea and non-bloody emesis. Headache was accompanied by diffuse abdominal pain 10/10 with no diarrhea or fever. She was unable to take her medications due to persistent vomiting episodes. She denied any focal weakness, tingling, numbness or vision problems. At presentation in emergency room, her systolic blood pressure was >200 and heart rate of 120. She was given intravenous hydralazine along with intravenous dialudid. She was about to be transferred to medical floor when she had blurry vision and later was unable to seen anything. Later she developed generalized tonic clonic seizures lasting less than 30 sec, responded well to intravenous valium. Her initial labs were normal in ER. An urgent MRI Brain showed interval development of non-enhancing bihemispheric and bilateral cerebellar hyper intense foci likely reflective of posterior reversible encephalopathy syndrome with no evidence of acute cerebral infarction or intracranial brain lesions (Figure 1a and 1b). The patient was started on patient controlled analgesia for control of migraine headaches and abdominal pain was attributed to opioid withdrawal given her normal labs. She did very well with control of blood pressure and outpatient MRI few weeks later showed reversal of MRI changes. PRES syndrome is a well-known condition which is under diagnosed and can be easily missed in presence of other conditions like Migraine and is really easy to miss. Early recognition and removal of precipitating factors is key to treat and prevent neurological compromise

Fidaxomicin therapy in critically ill patients with Clostridium difficile infection.

Fidaxomicin use to treat proven Clostridium difficile infection (CDI) was compared between 20 patients receiving care in critical care units (CCUs) and 30 patients treated on general medical floors. At baseline, the CCU patients had more initial CDI episodes, more severe and complicated disease, and more concurrent broad-spectrum antibiotic coverage. On multivariate analysis, the response to fidaxomicin therapy among the critically ill patients was comparable to that among patients in the general medical wards.

The Prospective Use of Prothrombin Complex Concentrates in an Administrative Region of the Province of Quebec.

Introduction:Prothrombin complex concentrates (PCCs) are used in the rapid reversal of warfarin and all other vitamin K deficiencies in patients with a major bleed or who require an urgent procedure. The Local Advisory Committee on Transfusion Medicine standardised a protocol for the use of PCCs, outlining the indications and contra-indications for their use.Methods:The charts of all patients having received PCCs between a two year period at the 4 hospital centers of region 12 were reviewed to evaluate the respect of guidelines, adherence to the protocol, and the clinical outcomes of patients.Results:From Nov. 2009 to Nov. 2011, 129 patients were treated with PCCs: 97 (75%) in the emergency department, 14 (11%) in the intensive care unit, 16 (12%) on medical or surgical floors, and 2 (1.5%) in the operating room. 116 prescriptions (90%) respected the guidelines; among the extra, 4 (3%) were for elective surgeries and 3 (2.3%) for an elevated INR without evidence of bleeding. One patient did not have an INR prior to administration, 10 (8%) did not have a repeat INR 30-minutes post-administration, and Vitamin K was omitted in 10 cases (8%). The prescription is based on weight: 120 (93%) received the correct dose, 3 (2.3%) received too high a dose, and 5 (3.8%) received too low a dose. The clinical outcome was favourable in 94 cases (73%), with rapid reversal of the INR and eventual discharge from hospital. 22 (17%) died during hospitalization and 10 (8%) were lost to follow-up due to transfer to a neurosurgical facility. The INR was less than 1.4 in 86% of cases 30-minutes post-administration. 6 (4.6%) thromboembolic complications occurred: two pulmonary embolisms, two deep vein thrombosis, one stroke, one disseminated intravascular coagulation. Five had resumed warfarin, but none had a therapeutic INR.Conclusion:Our review demonstrates that the majority of physicians correctly apply the recommended practice guidelines for the use of PCCs, that these are effective at rapidly reversing the INR, and are associated with favourable clinical outcomes in the majority of cases. However, thromboembolic events are frequent, emphasizing that anticoagulation therapy should be resumed quickly once clinically appropriate DisclosuresNo relevant conflicts of interest to declare.