Norfolk General Hospital Research Articles

Conversion to tacrolimus alone compared to full immunosuppression following cardiac transplantation (TACTFUL).

Cardiac transplantation requires lifelong immunosuppressant medications to prevent rejection. However, some patients may not tolerate multiple immunosuppressants due to adverse effects. At our institution, patients may be converted to monotherapy with tacrolimus if unable to tolerate a combination regimen. This study evaluated the outcomes among patients converted to tacrolimus monotherapy compared with those maintained on combination immunosuppression. This single-center, retrospective cohort study included patients who received heart transplants at Sentara Norfolk General Hospital between January 2015 and July 2021. Patients were classified as receiving tacrolimus monotherapy (Mono) or combination immunosuppression (Combo). The primary outcome was all-cause mortality with key secondary outcomes including incidence of 2R/3R rejection, necessity for renal replacement therapy, and infection. 112 patients were included (Mono=25, Combo=87). Median age at transplant was 53.8 years (Mono) and 52.1 years (Combo). The most common reasons for conversion to monotherapy were leukopenia, infection, and gastrointestinal (GI) distress. There was no difference in mortality (0 in Mono, 11 in Combo; p=.09) or percentage of patients with 2R/3R rejection (24% in Mono, 32.2% in Combo; p=.43). No Mono group patients experienced rejection after converting from combination therapy. 24% of Mono group patients resumed at least one additional immunosuppressive medication during the study period. Median time to monotherapy was 9.0 months, with a total median duration on monotherapy of 16.0 months. A median of 3.3 years of follow-up was observed for patients in Mono and 3.4 years in Combo (p=.29). Selected patients who do not tolerate combination immunosuppression can be safely transitioned to tacrolimus monotherapy as a means of controlling adverse events without an increased risk of mortality or rejection.

In basilar-artery occlusion stroke, thrombectomy improved functional outcome at 90 d but increased ICH.

Tao C, Nogueira RG, Zhu Y, et al. Trial of endovascular treatment of acute basilar-artery occlusion. N Engl J Med. 2022;387:1361-72. 36239644.

Utility of Thromboelastography in Detecting NOAC-Related Coagulopathy in Traumatic Brain Injury

IntroductionNovel oral anticoagulants (NOACs) have gained popularity as a vitamin K antagonist alternative without regular monitoring. There has been an increase in elderly patients on NOACs admitted for traumatic brain injury (TBI). The aim of this study is to determine the efficacy of thromboelastography (TEG) in detecting NOAC-related coagulopathy among TBI patients. MethodsA retrospective chart review of 456 TBI patients admitted to Sentara Norfolk General Hospital from 2015 to 2020 was performed. Inclusion criteria comprised patients on NOACs with a TEG performed at presentation (66 patients). Analysis included TEG values, use of prothrombin complex concentrate factor 4 (PCC4), increased intracranial hemorrhage on repeat head computed tomography within 24 h of admission, and mortality. ResultsTEG results showed 0% elevated reaction time, 1.5% elevated kinetics time, 1.5% low alpha angle, 4.5% low max amplitude, and 3.0% elevated clot lysis percent at 30 min in our cohort. Despite overwhelmingly normal TEG results, 42.42% of patients received PCC4. A subset analysis of these patients compared to those who did not receive PCC4, revealed a higher frequency of increased intracranial hemorrhage on repeat head computed tomography within 24 h of admission (42.86% versus 18.42%, P = 0.03), and increased mortality (25.0% versus 5.26%, P = 0.0219). Patients who did not receive PCC4 had no increased frequency of operative intervention or worsening of Glasgow Coma Score. ConclusionsResults suggest that TEG does not reliably assess NOAC-related coagulopathy in TBI patients. Caution must be used when interpreting TEG data to determine reversal strategies in TBI patients on NOACs.

Failure of Nonoperative Management of Splenic Injuries in Trauma Patients on Anticoagulation

Although nonoperative management or embolization with preservation of splenic tissue is preferable, there is a significant risk of continued bleeding ultimately requiring splenectomy. It has been established that elderly patients on anticoagulation (AC) have an increased risk of splenic injury, but there are little data to show whether AC plays a role in outcomes of splenic injury in the setting of trauma. This is a retrospective cohort study, including 168 adults aged 50 to 79 years who presented as a trauma patient to Sentara Norfolk General Hospital from January 1, 2010, to March 31, 2018. The primary outcome is the management of the splenic injury. Of the 168 patients, 30 were presently taking AC at the time of their injury, and 138 were not taking any AC. These groups were similar in average Injury Severity Score, average grade of splenic injury, and average systolic blood pressure on arrival. However, the groups differed significantly in age and hemoglobin on arrival. We found that patients taking AC at the time of injury underwent splenectomy 23.3 per cent of the time, whereas patients not taking AC underwent splenectomy 11.6 per cent of the time (P = 0.045). Patients taking AC failed nonoperative management 20 per cent of the time, whereas patients not taking AC failed 0.7 per cent of the time (P < 0.05). We found that patients taking AC at the time of their traumatic injury were more likely to undergo splenectomy than patients not taking AC. We also found that patients taking AC were more likely to fail nonoperative management.

Moderate Sedation or Monitored Anesthesia Care for Colonoscopies: Is There a Difference?

To determine whether monitored anesthesia care (MAC) results in shorter colonoscopy time. A retrospective chart review from electronic medical records at Sentara Norfolk General Hospital was performed of all patients seen by the Eastern Virginia Medical School Department of Surgery who underwent a screening or diagnostic colonoscopy from December 2015 to July 2017. The primary end point is procedure time, with secondary end point of sedation time. There is a statistically significant difference in time to cecum between moderate sedation (MOD) and MAC (P = 0.002). Operator perceived difficulty is statistically associated with increased time to cecum (P < 0.0001). Time to cecum between MOD and MAC over the levels of difficulty was not significant (P = 0.403). A subanalysis looking at time to cecum between MOD and MAC for each level of difficulty showed a significant effect when difficulty was described as no difficulty. There is a statistically significant difference in time to scope insertion between MOD and MAC (P < 0.0001). Our data show that, taken as a conglomerate, the procedure and sedation time is shorter in MAC than in MOD. The use of MAC is associated with decrease time to scope insertion and overall time to cecum.

Effect of substrate coating material on spontaneous activity of human-induced pluripotent stem cell-derived neuronal stem cells

Effect of substrate coating material on spontaneous activity of human-induced pluripotent stem cell-derived neuronal stem cells

DHA Director Describes Integration of Military Health Care Services

Back to table of contents Previous article Next article Professional NewsFull AccessDHA Director Describes Integration of Military Health Care ServicesMark MoranMark MoranSearch for more papers by this authorPublished Online:5 Jul 2017https://doi.org/10.1176/appi.pn.2017.7a12AbstractVice Adm. Raquel Bono directs an agency mandated to standardize best health care practices across military service lines and create a more globally integrated health care system. “We are strongest when we work together across service lines,” said Navy Vice Adm. Raquel Bono, director of the Defense Health Agency (DHA). “As a surgeon, I am not going to ask for a scalpel in a different way because the patient is in the Army or the Navy. Our common mission is the patient we serve, regardless of what kind of boots he or she wears.” Raquel Bono, M.D., said the military seeks the expertise of psychiatrists in the civilian sector in treating the “invisible wounds of war.”David HathcoxBono made her remarks at APA’s 2017 Annual Meeting in San Diego, where her theme was partnerships—across military service lines and, importantly, with physicians in the civilian sector.“As director of the DHA, I have the opportunity to oversee where our best practices are occurring and work to expand, integrate, and standardize those practices across the military,” Bono said. “If we do this the right way, we have a real opportunity to create a robust system serving all of our military service men and women and their families.”Bono said that the integration of health care across service lines is codified now in the most recent National Defense Authorization Act. Under the law, the mission of the DHA is to do the following: Create a more globally integrated health system, accountable as a combat support agency.Direct enterprise-wide shared services, standardizing clinical and business practices that produce better health and better care. Manage TRICARE for 9.4 million beneficiaries around the world. TRICARE is the health care program for uniformed service members and their families around the world.Deliver coordinated health care and support high-quality coordinated care in all multiservice markets.Regarding the visible wounds of battle, Bono said that the integration of the services is producing results. In the years since the wars in Afghanistan and Iraq started, the case fatality rate per battle injury has dropped. The invisible wounds have been more challenging. Bono solicited the help of psychiatrists in the civilian community to treat returning soldiers with traumatic brain injury and posttraumatic stress disorder. “We are very concerned about the suicide rate,” she said. “We are not dealing with a single, unitary phenomenon, but one that is very complex depending on the individual. We recognize that we don’t have all the answers, and we can’t do it alone. Partnering with others is going to be invaluable.” Vice Adm. Bono brings to her role a distinguished career in medicine and the military. She obtained her baccalaureate degree from the University of Texas at Austin and attended medical school at Texas Tech University. She completed a surgical internship and a general surgery residency at Naval Medical Center Portsmouth and a trauma and critical care fellowship at the Eastern Virginia Graduate School of Medicine in Norfolk. Shortly after training, Bono saw duty in Operations Desert Shield and Desert Storm as head of Casualty Receiving at Fleet Hospital 5 in Saudi Arabia from August 1990 to March 1991. Upon returning, she was stationed at Naval Medical Center Portsmouth as a surgeon in the General Surgery Department and attending surgeon at the Burn Trauma Unit at Sentara Norfolk General Hospital. Before becoming the director of the DHA, Bono served as director of the National Capital Region Medical Directorate of the DHA and as the 11th Chief of the Navy Medical Corps from September 2013 to October 2015.Bono said military and civilian health care providers share a common overarching mission and have much to offer each other. The military is prepared to reach out to the civilian sector, she said, such as when Patrick Downes and Jessica Kensky—victims of the 2013 Boston Marathon bombing—were invited to Walter Reed National Military Army Hospital in Washington, D.C., and partnered with “battle buddies” who had lost limbs in battle. Bono showed a video clip of a moving interview with Downes, who said, “We feel like we were embraced by the military family in a home that was meant for them.”Said Bono: “We have a sacred mission to care for our military service men and women and their families, but we also have a mission to share our experience and expertise with others. We hope you will share your experience and expertise with us.” ■ ISSUES NewArchived

Saving Lives for 35 Years: Sentara Nightingale Looks Forward

The Nightingale Regional air Ambulance program, operated by Norfolk, VA-based not-for-profit Sentara Healthcare, is marking its 35th year of operation in 2017, having surpassed 20,000 safe flights. Looking ahead, the program is adding IFR capabilities, designated landing zones to rendezvous with EMS partners and clinical training in a simulation lab, and collaborating with cardiac and neurology services to provide quicker interventions for STEMI and stroke patients at Sentara Norfolk General Hospital.

Gaining Trust Through Certification.

Certification Test Prep| December 01 2016 Gaining Trust Through Certification Carol Rauen, RN-BC, MS, CCRN, PCCN, CEN; Carol Rauen, RN-BC, MS, CCRN, PCCN, CEN Search for other works by this author on: This Site PubMed Google Scholar Pamela Shumate, RN, DNP, CCRN, CNE; Pamela Shumate, RN, DNP, CCRN, CNE Search for other works by this author on: This Site PubMed Google Scholar Nicole Gendron-Trainer, RN, MSN, CNS-BC, CCRN-K Nicole Gendron-Trainer, RN, MSN, CNS-BC, CCRN-K Search for other works by this author on: This Site PubMed Google Scholar Crit Care Nurse (2016) 36 (6): 70–74. https://doi.org/10.4037/ccn2016885 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Share Icon Share Facebook Twitter LinkedIn Email Tools Icon Tools Cite Icon Cite Get Permissions Citation Carol Rauen, Pamela Shumate, Nicole Gendron-Trainer; Gaining Trust Through Certification. Crit Care Nurse 1 December 2016; 36 (6): 70–74. doi: https://doi.org/10.4037/ccn2016885 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search nav search search input Search input auto suggest search filter All ContentCritical Care Nurse Search Advanced Search Carol Rauen, rn-bc, ms, ccrn, pccn, cen, the department editor, is an independent clinical nurse specialist in The Outer Banks of North Carolina and a staff nurse in the burn trauma intensive care unit at Sentara Norfolk General Hospital in Virginia. Carol welcomes feedback from readers and practice questions from potential contributors at rauen.carol104@gmail.com. RAUEN Pamela Shumate, rn, dnp, ccrn, cne, assistant professor at the University of Maryland School of Nursing, wrote the introduction and the adult CCRN review questions. SHUMATE Nicole Gendron-Trainer, rn, msn, cns-bc, ccrn-k, educational coordinator for critical care and emergency service lines, Inova Health System, Fairfax, Virginia, contributed the PCCN review questions. GENDRON-TRAINER For the 14th year in a row, nursing is regarded as the most trusted profession in the United States. According to the annual Gallup poll,1 85% of Americans... ©2016 American Association of Critical-Care Nurses2016 You do not currently have access to this content.

Critical Care Nurses Cannot "Phone It In".

Critical Care Nurses Cannot "Phone It In".

We Do It for Our Patients.

We Do It for Our Patients.

Certification: A C edential of Competence.

Certification: A C edential of Competence.

Change Is the Only Constant in Critical Care.

Certification Test Prep| August 01 2015 Change Is the Only Constant in Critical Care Carol Rauen, RN, MS, CCRN, PCCN, CEN, RN-BC; Carol Rauen, RN, MS, CCRN, PCCN, CEN, RN-BC Search for other works by this author on: This Site PubMed Google Scholar Cheryl Herrmann, RN, MS, APN, CCRN, CCNS-CSC-CMC; Cheryl Herrmann, RN, MS, APN, CCRN, CCNS-CSC-CMC Search for other works by this author on: This Site PubMed Google Scholar Mychell Zepeda, RN, BSN, MSN, PCCN Mychell Zepeda, RN, BSN, MSN, PCCN Search for other works by this author on: This Site PubMed Google Scholar Crit Care Nurse (2015) 35 (4): 67–71. https://doi.org/10.4037/ccn2015897 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Share Icon Share Twitter LinkedIn Tools Icon Tools Cite Icon Cite Get Permissions Citation Carol Rauen, Cheryl Herrmann, Mychell Zepeda; Change Is the Only Constant in Critical Care. Crit Care Nurse 1 August 2015; 35 (4): 67–71. doi: https://doi.org/10.4037/ccn2015897 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search nav search search input Search input auto suggest search filter All ContentCritical Care Nurse Search Advanced Search Carol Rauen, rn, ms, ccrn, pccn, cen, rn-bc, the department editor, is an independent clinical nurse specialist in The Outer Banks of North Carolina and a staff nurse in the burn trauma intensive care unit at Sentara Norfolk General Hospital in Virginia. She developed the CCRN questions. Carol welcomes feedback from readers and practice questions from potential contributors at rauen.carol104@gmail.com. RAUEN Cheryl Herrmann, rn, ms, apn, ccrn, ccns-csc-cmc, cardiac clinical nurse specialist, UnityPoint Health Methodist, Peoria, Illinois, submitted PCCN questions 1 through 4. HERRMANN Mychell Zepeda, rn, bsn, msn, pccn, clinical lead nurse and preceptor, UnityPoint Health Methodist, submitted PCCN question 5. ZEPEDA In order for certification examinations to accurately reflect current clinical practice, the content outline (blueprint) and test questions must change with... ©2015 American Association of Critical-Care Nurses2015 You do not currently have access to this content.

Fresh Frozen Plasma Dosing for Warfarin Reversal: A Practical Formula

ObjectiveTo provide a practical formula for fresh frozen plasma (FFP) dosing for warfarin reversal. Patients and MethodsWe reviewed data on all adult patients who received a total of 7778 units of FFP for warfarin reversal at Sentara Norfolk General Hospital (Norfolk, VA) between April 1, 2009, and March 31, 2010. Patients with advanced liver disease, consumptive or dilutional coagulopathy, and administration of activated factor VII or prothrombin complex concentrate were excluded. First, we used regression analysis on the FFP1 subset (patients whose international normalized ratio [INR] was checked before and after 1 FFP administration) and derived a simple formula: DeltaINR (PreINR – PostINR) after 1 FFP =a × PreINR +b, where PreINR and PostINR are the INR values before and after FFP administration, respectively, and a and b are constants. In the validation step, the formula obtained for the FFP1 subset was repeatedly applied to the FFP2 (patients who received 2 units of FFP back-to-back without an intervening INR check), FFP3, and FFP4 subsets. ResultsA total of 956 patients were included. The formula DeltaINR after 1 FFP = 0.57 × PreINR – 0.72 explained 82.6% of the total variance in INR change in the FFP1 subset (n=308; P<.01). Including age, sex, weight, FFP-to-PostINR interval, or administration of vitamin K marginally improved the model. Repeated application of the FFP1 formula to the FFP2 to 4 subsets combined confirmed the accuracy of the FFP1 formula across the entire data set (n=643; R2=95% between predicted and actual DeltaINR; P<.01). ConclusionThis formula provides a practical and accurate method for FFP dosing for warfarin reversal.

Building and Sustaining a Systemwide Culture of Safety

In 2002, Sentara launched a systemwide initiative to significantly reduce events of harm to patients and employees. The initiative began at Sentara Norfolk General Hospital. Since then, the safety principles piloted there have been instituted throughout Sentara's integrated health care system of hospitals, nursing homes, and physician practices. Implementation at each local site begins with a thorough assessment of its safety culture. Four core areas of focus include (1) establishing safety as a core value, (2) creating Behavior-Based Expectations (BBEs) for error prevention that are tailored for staff, leaders, and physicians, (3) developing a state-of-the-art root and common-cause analysis program, and (4) implementing an approach to focus and simplify work processes and procedure documentation. Senior leadership demonstrated a commitment to making safety a core value by embedding safety into strategic priorities, incentives, rewards and recognition, and human resources policies and procedures; prioritization of operational goals to ensure the availability of time and resources to make the safety initiative the key focus; involvement of employees and medical staff each step of the way; establishment of site-based safety initiative teams of operational leaders with the responsibility for leading the safety initiative implementation and ensuring effective communication across the organization; and a willingness to learn and try successful techniques from high-reliability organizations outside health care.

Sentara Norfolk General Hospital: Accelerating Improvement by Focusing on Building a Culture of Safety

To accelerate progress in improving patient safety, Sentara Norfolk General Hospital (SNGH) supplemented its improvement programs with an initiative to strengthen its organizational culture of safety. SNGH established and intternalized behaviors in the organization that would result in safer and more reliable and productive human erformance. Four areas of focus were identified: (1) creating Behavior-Based Expectations (BBEs) for error prevention for all positions, (2) establishing Red Rules to focus employees on rules with the highest level of consequence and risk if not followed exactly, (3) develping a technically based Root Cause and Common Cause Analysis process, and (4) implementing an appproach to focus and simplify policies and procedures. The senior leadership made the safety initiative the number-one priority; operational goals were prioritized to ensure the availability of time and resources for the safety initiative. A team of five operational leaders led implementation and ensured efffective communication across the organization. Medical staff provided support to the safety initiative; for example, it developed and implemented its own BBEs list. Finally, employees were engaged in all phases of the initiative. SNGH's largest challenge remains to continue to accelerate improvement while simultaneously holding gains previously made.

Hospitals honored for innovations in patient safety efforts.

New technologies for monitoring and recordkeeping systems were among the innovations highlighted in the American Hospital Association’s (AHA) annual prize program for U.S. hospitals. Top honors in the American Hospital Quest for Quality Prize and a $75,000 cash award went to Sentara Norfolk General Hospital in Norfolk, VA. In announcing the award, AHA recognized Norfolk General and three other hospitals for their leadership and innovation in quality, safety, and commitment to patient care. Technology lauded by judges included Norfolk General’s realtime, behavior-based monitor program, the first of its kind to be implemented in a health care environment. The program provides data to reveal symptoms of organizational and programmatic issues before they become adverse events. “This prize culminates two years of hard work by leadership and staff to create a culture of safety,” said Sentara Administrator Rodney Hochman, MD, in a news release. Gary Yates, MD, Sentara vice president for clinical effectiveness, added that the safety program piloted at Norfolk General, will soon be employed in all of Sentara’s six hospitals and other sites of care. “It’s about every employee learning our systems to prevent errors, patient injuries, and workplace accidents—and actively applying that knowledge in their work,” Yates explained. Finalists for the prize—The Johns Hopkins Hospital, Baltimore, MD, and Mary Lanning Memorial Hospital, Hastings, NE—received a $12,500 award. In addition, Advocate Health System in Oakbrook, IL, was awarded a Citation of Merit. Judges pointed to a three-year-old bar coding system at Mary Lanning Memorial as part of an institutionwide financial commitment to technology designed to improve safety. Advocate Health System was also recognized for implementing patient safety technologies, including an integrated system-wide electronic medical record with computerized physician order entry. “Each hospital recognized...has taken a slightly different path to achieving a culture of safety,” said AHA President Dick Davidson in a statement. “But each has a strong commitment to a new culture based on trust, understanding, and openness. That culture goes a long way to improving the care patients receive.” Hospitals Honored for Innovations in Patient Safety Efforts

The Long-term Results of Gastric Bypass on Indexes of Sleep Apnea

Weight loss improves obstructive sleep apnea (OSA), and clinicians regularly recommend dieting to their patients with OSA; however, many morbidly obese patients may be unable to lose weight without medical or surgical intervention. Gastric bypass surgery (GB) facilitates weight loss for morbidly obese patients. Studies show GB will improve symptoms associated with OSA, but little is known regarding the long-term effects of GB on this population. Historical, retrospective, cohort study. Sleep Disorders Center, Sentara Norfolk General Hospital, Norfolk, VA. A list of subjects who underwent vertical Roux-en-Y GB was cross-referenced with the Sleep Disorders Center at Sentara Norfolk General Hospital to identify patients with a diagnosis of OSA during the preoperative evaluation prior to undergoing GB. GB. Our primary end point was the respiratory disturbance index (RDI). Secondary variables were body mass index (BMI), mean oxygen saturation, low oxygen saturation, a standardized depression scale, and the continuous positive airway pressure (CPAP) requirement. Thirty-four subjects with a diagnosis of OSA prior to GB were identified. Of these, 28 subjects were located and offered follow-up polysomnography after GB. Eight subjects returned for repeat polysomnography. The subjects were re-evaluated an average of 28 months after GB. Seven subjects had a lower BMI after GB. Mean BMI was reduced by 31% (p = 0.001). The mean decrease in RDI was 75% (p = 0.01), and five of the eight subjects no longer required nasal CPAP. Mean nocturnal oxygen saturation improved from 95 to 97% (p = 0.04). Weight reduction following GB is associated with significant improvements in sleep apnea indexes an average of 28 months after GB. Re-evaluation after GB is necessary to identify and treat those patients who, despite subjective improvement, may continue to require CPAP for residual OSA.

Burn Pain and Anxiety: The Use of Relaxation Music during Range of Motion Therapy

Journal Article Burn Pain and Anxiety: The Use of Relaxation Music during Range of Motion Therapy Get access S. L. Ferguson, PT, S. L. Ferguson, PT 1Sentara Norfolk General Hospital, Norfolk, VA Search for other works by this author on: Oxford Academic Google Scholar K. V. Voll, OTR/L K. V. Voll, OTR/L 1Sentara Norfolk General Hospital, Norfolk, VA Search for other works by this author on: Oxford Academic Google Scholar The Journal of Burn Care & Rehabilitation, Volume 23, Issue suppl_2, March-April 2002, Page S154, https://doi.org/10.1097/00004630-200203002-00224 Published: 01 March 2002

Sentara Norfolk General Hospital

Sentara Norfolk General Hospital