Standard Care Protocol Research Articles

Perinatal impact of cesarean delivery on maternal request compared with vaginal delivery among low-risk pregnancies in a university hospital: a prospective observational study in Bogotá, Colombia

Objetivo: existe evidencia insuficiente sobre el impacto de la cesárea por solicitud materna (CSM); este estudio evalúa el efecto de la CSM en los múltiples desenlaces maternos y neonatales comparando CSM con parto vaginal entre embarazos de bajo riesgo. Materiales y métodos: estudio observacional prospectivo que incluyó mujeres entre 18 y 45 años de edad, con un embarazo a término y de bajo riesgo, que tuvieron parto entre junio de 2008 y abril de 2012 en un hospital universitario en Bogotá, Colombia. Se comparó la ocurrencia de cualquiera de 5 eventos adversos maternos preespecificados, y de cualquiera de 17 eventos neonatales preespecificados, entre CSM y partos vaginales. Los partos vaginales inducidos fueron analizados separadamente. Todas las mujeres recibieron el mismo cuidado estandarizado. El efecto de variables confusoras se ajustó mediante regresión logística múltiple.Resultados: se incluyeron 214 mujeres con CSM, 341 con parto vaginal espontáneo (PVE) y 376 con parto vaginal inducido (PVI). Respecto al grupo PVE, el OR ajustado del desenlace materno fue 0,21 (IC 95 %: 0,05-0,97) en el grupo CSM y 0,93 (IC 95%: 0,42-2,06) en el grupo PVI. Los OR del desenlace neonatal fueron 0,59 (IC95%: 0,36-0,93) para CSM y 0,84 (IC95%: 0,59-1,21) para PVI. La frecuencia de hospitalización del neonato más baja fue en el grupo de CSM (10,3 % frente a 15,8 % para PVE, 16,2 % para PVI).Conclusiones: en pacientes con embarazo de bajo riesgo que ingresaron a un protocolo estándar de cuidado obstétrico, CSM se acompañó de una menor tasa de eventos adversos perinatales respecto al parto vaginal espontáneo. Sin embargo, se requieren estudios que evalúen la seguridad de CSM en el largo plazo.

Effects of fluid restriction on measures of circulatory efficacy in adults with septic shock

The haemodynamic consequences of fluid resuscitation in septic shock have not been fully elucidated. Therefore, we assessed circulatory effects in the first 24 h of restriction of resuscitation fluid as compared to standard care in intensive care unit (ICU) patients with septic shock. This was a post-hoc analysis of the multicentre CLASSIC randomised trial in which patients with septic shock, who had received the initial fluid resuscitation, were randomised to a protocol restricting resuscitation fluid or a standard care protocol in nine ICUs. The highest plasma lactate, highest dose of noradrenaline, and the urinary output were recorded in five time frames in the first 24 h after randomisation. We used multiple linear mixed effects models to compare the two groups. We included all 151 randomised patients; the cumulated fluid resuscitation volume in the first 24 h after randomisation was median 500 ml (Interquartile range (IQR) 0-1500) and 1250 ml (500-2500) in the fluid restriction group and standard care group, respectively. The estimated differences in the fluid restriction group vs. the standard care group were 0.1 mM (95% confidence interval -0.7 to 0.9; P = 0.86) for lactate, 0.01 μg/kg/min (-0.02 to 0.05; P = 0.48) for dose of noradrenaline, and -0.1 ml/kg/h (-0.3 to 0.2; P = 0.70) for urinary output during the first 24 h after randomisation. We observed no indications of worsening of measures of circulatory efficacy in the first 24 h of restriction of resuscitation fluid as compared with standard care in adults with septic shock who had received initial resuscitation.

Barriers and Benefits in Telemedicine Arising Between a High-Technology Hospital Service Provider and Remote Public Healthcare Units: A Qualitative Study in Brazil.

In Brazil, the Program for Institutional Development of the Unified Healthcare System (PROADI-SUS) has implemented a telemedicine service for urgent situations and emergencies. It is delivered by a high-technology (HT) hospital to 15 remote healthcare units (RUs) in 11 different Brazilian states. The aim of this study was to investigate possible barriers and benefits in telemedicine service among these units. We performed a qualitative study on the perceptions of physicians involved in telemedicine service in their role as providers and consultants. An individual, semistructured recorded interview was conducted with 28 physicians (17 HT; 11 RU) encompassing telemedicine resources and interaction among HT and RU physicians. Data analysis was performed by Discourse of Collective Subject. We identified the following barriers in the telemedicine service: (1) lack of experience in the use of technology or the quality of the internet signal; (2) the multiplicity of different telemedicine platforms; (3) the quality of the image sent to the HT hospital; (4) the misunderstanding that telemedicine is a time-consuming technology instead of a resource that may help to save lives; (5) not feeling comfortable exposing doubts to other HT colleagues; (6) problems in the management of telemedicine use in the RUs; and (7) political and legal issues. However, important benefits in telemedicine service were also described. The structural barriers should be the target of hospital managers. Development of standard remote care protocols may increase the use of telemedicine and create new work routines. Given the relationship difficulties among the RU and HT doctors during telemedicine consultations, other meetings should be organized to allow more interpersonal interactions. These meetings may also have the goal of sharing outcome indicators of their joint activity in telemedicine to stimulate and make them aware of the benefits of their interaction.

Prevention of central nervous system sequelae in sickle cell disease without evidence from randomized controlled trials: the case for a team-based learning collaborative.

Since 1998, the National Institutes of Health has funded 5 randomized controlled trials (RCTs) for primary and secondary prevention of strokes in children with sickle cell anemia (SCA). In a systematic fashion, these trials have significantly advanced the care of children with SCA. In the absence of an RCT, clinicians are often compelled to make decisions at the bedside, based on experience, observational studies, and principles of hematology. We will provide an initial example that describes how a team-based, learning collaborative developed a multisite standard care protocol with a low budget (<$10 000 per year) to overcome the intrinsic limitations of advancing the care of neurologic complications in sickle cell disease (SCD). The critical components of this approach include: (1) regular meetings with the multidisciplinary team from multiple sites; (2) consensus regarding the best evidence-based neurologic management in multiple SCD centers; (3) an Institutional Review Board-approved protocol based on consensus standard care; (4) minimizing and ensuring accurate data collection; and most importantly, (5) a spirit of collaboration to improve the care of individuals with SCD. Four common neurologic problems and strategies for management in children and adults with SCD will be discussed: (1) secondary stroke prevention in high-income countries; (2) primary stroke prevention in low- and middle-income countries (LMICs); (3) poor academic performance in students; and (4) cognitive disability in adults. With a commitment to a team-based learning collaborative, incremental advances are possible for the neurologic care of children and adults with SCD.

The Influence of Intermittent Compression Therapy Using Sphgymomanometer on Pressure Changes and Walking Ability on Individuals Affected with Peripheral Arterial Diseases of Lower Limbs

Background:&nbsp;To find out the influence of intermittent compression therapy using sphygmomanometer on pressure changes and walking ability on individuals affected with peripheral arterial diseases of lower limbs.Methods:&nbsp;Total thirty patients’ age 30 to 70 years post peripheral arterial diseases individuals included for study. These patients were randomly allocated to intervention group (n=15), which underwent a 6- weeks training program &amp; control group (n=15) that received standard care and unsupervised exercise protocol. Primary outcome was change in ABI levels as determined in before and after the intervention program. Secondary outcomes were intermittent claudicating distance and walking capacity as assessed by the walking impairment questionnaire.Results:&nbsp;Paired sample t- test was used to analyze changes from before and after intervention program. There is a statistically significant (p=0.000) improvement in both experimental group and control group but when compared to control group, experimental group shows improvement in the mean values in all parameters.Conclusion:&nbsp;In this study the Ankle Brachial Index (ABI), Intermittent Claudication Distance (ICD) and Walking Impairment Questionnaire (WIQ) improved significantly in experimental group than control group by applying the pneumatic compression therapy with the sphygmomanometer and graded walking exercise. Hence, the study recommends that intermittent pneumatic therapy along with graded exercise is most effective in improving Ankle Brachial Index (ABI), Intermittent Claudication Distance (ICD) and Walking capacity in PAD individuals.

Restricting volumes of resuscitation fluid in adults with septic shock after initial management: the CLASSIC randomised, parallel-group, multicentre feasibility trial.

We assessed the effects of a protocol restricting resuscitation fluid vs. a standard care protocol after initial resuscitation in intensive care unit (ICU) patients with septic shock. We randomised 151 adult patients with septic shock who had received initial fluid resuscitation in nine Scandinavian ICUs. In the fluid restriction group fluid boluses were permitted only if signs of severe hypoperfusion occurred, while in the standard care group fluid boluses were permitted as long as circulation continued to improve. The co-primary outcome measures, resuscitation fluid volumes at day 5 and during ICU stay, were lower in the fluid restriction group than in the standard care group [mean differences -1.2L (95% confidence interval -2.0 to -0.4); p<0.001 and -1.4L (-2.4 to -0.4) respectively; p<0.001]. Neither total fluid inputs and balances nor serious adverse reactions differed statistically significantly between the groups. Major protocol violations occurred in 27/75 patients in the fluid restriction group. Ischaemic events occurred in 3/75 in the fluid restriction group vs. 9/76 in the standard care group (odds ratio 0.32; 0.08-1.27; p=0.11), worsening of acute kidney injury in 27/73 vs. 39/72 (0.46; 0.23-0.92; p=0.03), and death by 90days in 25/75 vs. 31/76 (0.71; 0.36-1.40; p=0.32). A protocol restricting resuscitation fluid successfully reduced volumes of resuscitation fluid compared with a standard care protocol in adult ICU patients with septic shock. The patient-centred outcomes all pointed towards benefit with fluid restriction, but our trial was not powered to show differences in these exploratory outcomes. NCT02079402.

Postoperative Treatment of Distal Radius Fractures Using Sensorimotor Therapy

Objective/Hypothesis: Proprioception and sensorimotor modalities have been used in rehabilitation to treat neurological and joint injuries. Following distal radius fractures (DRF), there is a temporary sensorimotor loss that should be addressed during postoperative therapy. We designed an evaluation and treatment protocol aimed at sensorimotor evaluation and treatment and trialed it on a pilot series of patients following surgery for DRF. The purpose of this prospective study was to compare the outcomes of patients following surgery for DRF treated using our specific sensorimotor treatment protocol with patients treated after surgery according to postoperative standard of care. We hypothesized that patients treated using our treatment protocol will have better functional results at 3 months postsurgery. Methods: Because sensorimotor response loops are complex and it is difficult to isolate the effect of the different types of input, both the evaluation and the treatment protocols included a comprehensive sensorimotor panel. The patients were treated once a week in therapy and pursued a home therapy protocol. Thirty-four patients following surgery for DRF were randomized into a focused sensorimotor postoperative protocol and the standard of care protocol. Exclusion criteria included inability to attend therapy or comply with the home therapy protocol and patients with preceding injuries and deficits in the wrist and hand. Patients were evaluated initially in the first days after the operation, at 6 weeks, and at 4 months postsurgery. Results: All patients following surgery for DRF demonstrated similar initial significant deficits in proprioception (72%), stereognosis (36%), and the Moberg pick-up test (30 seconds vs 10.8 seconds). There was documented sensorimotor and functional improvement in both groups with treatment in range of motion (ROM), strength, and sensorimotor testing. The Disabilities of the Arm, Shoulder and Hand (DASH) score was 10.8 (14.2) in the trial group at 3 months and 29.2 (9.6) in the control group P = .05. Wrist ROM at 3 months was significantly better in the trial group ( P = .003). We had no cases of chronic regional pain syndrome (CRPS). Conclusions: (1) Patients after surgery for DRF demonstrate significant sensorimotor deficits that should be evaluated and addressed in therapy. (2) These deficits and function seem to improve more at 3 months when utilizing a comprehensive sensorimotor treatment protocol. (3) Further study is ongoing to evaluate the value of the treatment protocol and to provide sensorimotor therapeutic guidelines following surgery for DRF.

Effectiveness of Intraoral Chlorhexidine Protocols in the Prevention of Ventilator-Associated Pneumonia: Meta-Analysis and Systematic Review.

Ventilator-associated pneumonia (VAP) is common in critical patients and related with increased morbidity and mortality. We conducted a systematic review and meta-analysis, with intention-to-treat analysis, of randomized controlled clinical trials that assessed the effectiveness of different intraoral chlorhexidine protocols for the prevention of VAP. Search strategies were developed for the MEDLINE, EMBASE, and LILACS databases. MeSH terms were combined with Boolean operators and used to search the databases. Eligible studies were randomized controlled trials of mechanically ventilated subjects receiving oral care with chlorhexidine or standard oral care protocols consisting of or associated with the use of a placebo or no chemicals. Pooled estimates of the relative risk and corresponding 95% CIs were calculated with random effects models, and heterogeneity was assessed with the Cochran Q statistic and I(2). The 13 included studies provided data on 1,640 subjects that were randomly allocated to chlorhexidine (n = 834) or control (n = 806) treatments. A preliminary analysis revealed that oral application of chlorhexidine fails to promote a significant reduction in VAP incidence (relative risk 0.80, 95% CI 0.59-1.07, I(2) = 45%). However, subgroup analyses showed that chlorhexidine prevents VAP development when used at 2% concentration (relative risk 0.53, 95% CI 0.31-0.91, I(2) = 0%) or 4 times/d (relative risk 0.56, 95% CI 0.38-0.81, I(2) = 0%). We found that oral care with chlorhexidine is effective in reducing VAP incidence in the adult population if administered at 2% concentration or 4 times/d.

Presentation Number 07 - Preventing Non-Device Related Pneumonia with Comprehensive Oral Care

BACKGROUND: Non-ventilator (i.e., non-device related) hospital acquired pneumonia (NV-HAP) is an understudied disease, with substantial fiscal impacts and potential for reduction of morbidity and mortality. Because it is not required by regulatory agencies, most hospitals do not monitor NV-HAP. In 2014, the US Centers for Disease Control and Prevention's reported that NV-HAP now represents 60% of the HAP with mortality similar to VAP. Due to the association between the oral microbiome and pneumonia, we sought to utilize transdisciplinary partnerships to determine the incidence and implement a standardized oral care protocol to reduce NV-HAP.

Presentation Number 08 - Electronic Hand Hygiene Monitoring with a Complementary Improvement Program Significantly Increases Hand Hygiene Rates

BACKGROUND: Non-ventilator (i.e., non-device related) hospital acquired pneumonia (NV-HAP) is an understudied disease, with substantial fiscal impacts and potential for reduction of morbidity andmortality. Because it is not required by regulatory agencies, most hospitals do notmonitor NV-HAP. In 2014, the US Centers for Disease Control and Prevention’s reported that NV-HAP now represents 60% of the HAP with mortality similar to VAP. Due to the association between the oral microbiome and pneumonia, we sought to utilize transdisciplinary partnerships to determine the incidence and implement a standardized oral care protocol to reduce NV-HAP. METHODS:We used a descriptive, retrospective comparative study to determine changes in oral care delivery and incidence of NV-HAP. We implemented a universal (all adult units and all perioperative patients) standardized oral care protocol from May 1, 2012 to December 31, 2014 at a 550 bed urban hospital. We computed percent of oral care delivered, NV-HAP cases/total discharges, and odds ratio of NV-HAP during the intervention period compared to the reference period. RESULTS: Implementation of a universal oral care protocol resulted in a 70% decrease in NV-HAP in the year 2014, with a 75% decrease in post-operative patients (P < .0001:OR = 0.51; 95% CI = 0.38, 0.70). Since 2012, we avoided 170 cases of NV-HAP and prevented 32 patient deaths. In addition, we saved $6.8M in costs, minus $320K for therapeutic equipment and supplies, which resulted in a return on investment of $6.48M. CONCLUSIONS: Comprehensive oral care is correlated with prevention of NV-HAP in the acute care setting. NV-HAP should be elevated to the same level of concern, attention, and effort as prevention of VAP. Infection Preventionists using a team-based, transdisciplinary approach, can take the lead in their hospital system to monitor and implement effective programs to protect their patients from NV-HAP, saving lives and dollars.

Association of itraconazole and potassium iodide in the treatment of feline sporotrichosis: a prospective study.

Feline sporotrichosis is an endemic disease in Rio de Janeiro, Brazil, where zoonotic transmission of Sporothrix spp. has been reported since 1998. Itraconazole (ITZ) remains the first choice for treating this disease in cats. However, there have been reports of therapeutic failure and a long-term endeavor. Potassium iodide (KI), considered in the past as a drug with variable effectiveness in cats with sporotrichosis, arises as an important option in the treatment of cats from the endemic area of Rio de Janeiro. In order to evaluate the effectiveness of the association of ITZ and KI in naive cats with sporotrichosis, a prospective cohort study was conducted on 30 cats receiving ITZ 100mg/day and KI 2.5 mg-20mg/kg/day. Clinical and laboratory adverse effects were assessed once a month according to the standard care protocol. The cure rate was 96.15% within a median of 14 weeks of treatment. Adverse effects were observed in 50% of cats and were managed with a temporary drug suspension and/or a hepatoprotective therapy. The association of ITZ and KI emerges as an effective option for the treatment of feline sporotrichosis.

Fascial Manipulation Associated With Standard Care Compared to Only Standard Postsurgical Care for Total Hip Arthroplasty: A Randomized Controlled Trial

BackgroundPostsurgical physiotherapy programs after total hip arthroplasty (THA) show important differences between types and numbers of treatment sessions. To increase functional recovery in postsurgical patients, manual therapy can be added to traditional physiotherapy programs. Fascial manipulation (FM) has been demonstrated to be effective in decreasing pain and increasing muscular capacity. ObjectiveTo compare the effectiveness of FM when added to a standard protocol of care. DesignRandomized controlled trial. SettingRehabilitation center. PatientsA total of 51 patients were recruited after total hip arthroplasty. Inclusion criteria were first THA surgery, posterior-lateral access, and onset of pain within a maximum 2 years. Exclusion criteria were previous hip or knee prosthesis, congenital hip dysplasia, elective THA secondary to trauma, real leg-length discrepancy (≥1.5 cm), cognitive impairment, concomitant rheumatic pathology in acute phase, and serious comorbidities such as cardiac, respiratory, and/or neuromuscular pathologies. MethodsPatients were randomized into 2 groups; both followed a standard protocol based on 2 daily sessions of active exercises for 45 minutes. In the study group, 2 sessions were replaced by FM. The clinical trial was registered at clinicaltrials.gov (NCT02576028). Main Outcome MeasuresFunctional outcome measures were collected before and after treatment and at the end of the rehabilitation program. The measures included the Harris Hip Score; Timed Up-and-Go test; articular range of motion in abduction, flexion, extension, and bilateral external rotation with heels together; and verbal numerical scale. ResultsStatistically significant differences were observed in degrees of flexion between the study and control group with 25.4 (±11.3) and 18.7 (±9.5), respectively (P = .04); for abduction with 16.8 (±7.0) and 11.1 (±6.1), respectively (P = .005); for extension with 16.2 (±4.9) and 9.3 (±3.8), respectively (P = .001); for bilateral external rotation with heels together with 8.3 (±4.3) and 5.5 (±4.6), respectively (P = .04); for the Harris Hip Score 23.3 (±8.9) and 14.5 (±8.5), respectively (P = .002); and for verbal numerical scale score 1.1 (±2.1) and 0.5 (±1.1), respectively. ConclusionsThis study demonstrates that 2 FM sessions are able to significantly improve several functional outcomes in patients compared to usual treatment after THA. Level of EvidenceII

Anastomotic leak predicts diminished long-term survival after resection for gastric and esophageal cancer

Previous studies have reported on the association between perioperative morbidity and diminished oncologic outcomes in patients undergoing resection for colorectal or pancreatic cancer. However, the effect of anastomotic leak (AL) on the survival of patients with gastric or esophageal cancer remains unclear. Clinicopathologic data of patients who underwent resection for gastric or esophageal cancer between 2005 and 2012 were assessed, and predictors for overall survival and disease-free survival were identified. In addition, we evaluated the impact of AL on oncologic outcomes. Curative resection for gastric or esophageal cancer was performed in 471 patients. The primary tumor was located in the stomach and esophagus in 53% and 47% of the patients, respectively. Forty-one patients (8.7%) suffered an AL. The AL rate was significantly higher following resection for esophageal cancer compared with the resection for gastric cancer (12.9% vs 5.3%, P=.001). Postoperative mortality (4%) was not significantly associated with the occurrence of AL (4% without AL vs 7% with AL, P=.2). After a median follow-up time of 35months, the median overall survival and disease-free survival were 101 and 93months, respectively. Factors associated with worse overall survival in multivariate analysis included AL (P=.001), American Society of Anesthesiologists physical status (P<.0001), advanced Union for International Cancer Control (UICC) stage (P<.0001), and poorly differentiated carcinoma (G3; P=.04). In the multivariate analysis for predictors of disease-free survival, AL (P=.037), advanced UICC stage (P<.0001), poorly differentiated carcinoma (G3; P=.044), and lymphangiosis carcinomatosa (P=.004) were independently associated with a high risk for recurrence. AL following resection for gastric and esophageal cancer has a negative prognostic impact on long-term survival, independent from tumor stage and biology. Further investigation of the interactions between AL and the development of tumor recurrence as well as the establishment of standardized perioperative care protocols are necessary for the improvement of outcomes after gastric and esophageal resection.

Clinical safety and effectiveness evaluation of a new antimicrobial wound dressing designed to manage exudate, infection and biofilm.

The objective of this work was to evaluate the safety and effectiveness of a next-generation antimicrobial wound dressing (NGAD; AQUACEL® Ag+ Extra™ dressing) designed to manage exudate, infection and biofilm. Clinicians were requested to evaluate the NGAD within their standard protocol of care for up to 4 weeks, or as long as deemed clinically appropriate, in challenging wounds that were considered to be impeded by suspected biofilm or infection. Baseline information and post-evaluation dressing safety and effectiveness data were recorded using standardised evaluation forms. This data included wound exudate levels, wound bed appearance including suspected biofilm, wound progression, skin health and dressing usage. A total of 112 wounds from 111 patients were included in the evaluations, with a median duration of 12 months, and biofilm was suspected in over half of all wounds (54%). After the introduction of the NGAD, exudate levels had shifted from predominantly high or moderate to low or moderate levels, while biofilm suspicion fell from 54% to 27% of wounds. Wound bed coverage by tissue type was generally shifted from sloughy or suspected biofilm towards predominantly granulation tissue after the inclusion of the NGAD. Stagnant (65%) and deteriorating wounds (27%) were shifted to improved (65%) or healed wounds (13%), while skin health was also reported to have improved in 63% of wounds. High levels of clinician satisfaction with the dressing effectiveness and change frequency were accompanied by a low number of dressing-related adverse events (n = 3; 2·7%) and other negative observations or comments. This clinical user evaluation supports the growing body of evidence that the anti-biofilm technology in the NGAD results in a safe and effective dressing for the management of a variety of challenging wound types.

THE POSSIBILITY OF CONSERVATIVE MANAGEMENT OF BLUNT AND PENETRATING LIVER TRAUMA OF VARIOUS SEVERITY

Until now, surgery is a standard treatment strategy in liver trauma. However, continuous evolution and improvement of imaging and interventional techniques open a wide perspective for conservative management of liver trauma patients. In the recent years, this method is getting more and more widely used and becomes a component of the standard care protocols for patients with liver trauma in tertiary centers.

Implementation of an Interdisciplinary, Team-Based Complex Care Support Health Care Model at an Academic Medical Center: Impact on Health Care Utilization and Quality of Life.

IntroductionThe Geriatric Resources for the Assessment and Care of Elders (GRACE) program has been shown to decrease acute care utilization and increase patient self-rated health in low-income seniors at community-based health centers.AimsTo describe adaptation of the GRACE model to include adults of all ages (named Care Support) and to evaluate the process and impact of Care Support implementation at an urban academic medical center.Setting152 high-risk patients (≥5 ED visits or ≥2 hospitalizations in the past 12 months) enrolled from four medical clinics from 4/29/2013 to 5/31/2014.Program DescriptionPatients received a comprehensive in-home assessment by a nurse practitioner/social worker (NP/SW) team, who then met with a larger interdisciplinary team to develop an individualized care plan. In consultation with the primary care team, standardized care protocols were activated to address relevant key issues as needed.Program EvaluationA process evaluation based on the Consolidated Framework for Implementation Research identified key adaptations of the original model, which included streamlining of standardized protocols, augmenting mental health interventions and performing some assessments in the clinic. A summative evaluation found a significant decline in the median number of ED visits (5.5 to 0, p = 0.015) and hospitalizations (5.5 to 0, p<0.001) 6 months before enrollment in Care Support compared to 6 months after enrollment. In addition, the percent of patients reporting better self-rated health increased from 31% at enrollment to 64% at 9 months (p = 0.002). Semi-structured interviews with Care Support team members identified patients with multiple, complex conditions; little community support; and mild anxiety as those who appeared to benefit the most from the program.DiscussionIt was feasible to implement GRACE/Care Support at an academic medical center by making adaptations based on local needs. Care Support patients experienced significant reductions in acute care utilization and significant improvements in self-rated health.

Evaluation of the effect on patient parameters of not monitoring gastric residual volume in intensive care patients on a mechanical ventilator receiving enteral feeding: A randomized clinical trial

PurposeThis study aimed to evaluate the effects of not measuring gastric residual volume (GRV) in intensive care patients on a mechanical ventilator and receiving enteral feeding on the feeding intolerance, gastroesophageal reflux (GER) risk, and nutritional adequacy. MethodsThis randomized clinical study was performed in 2 medical intensive care units of 2 university hospitals in Ankara, Turkey. The patients were randomized into 2 groups. In the group with GRV monitoring, GRV was measured 3 times a day, and the GRV threshold was accepted as 250 mL. In addition, 24-hour pH monitoring was used in this group to assess the risk of GER. In the group without GRV monitoring, GRV was not measured. The patients were followed-up for 5 days. ResultsThe feeding targets were reached more quickly in the group without GRV monitoring (n = 26) with no increase in the complication rate (P < .05). No significant relationship was found between GRV and GER in the group with GRV monitoring (n = 25) (P > .05). ConclusionThe discrepancies in GRV measurement make it unreliable for monitoring feeding intolerance and GER. The use of GRV measurements may therefore be discontinued as part of the standard care protocol in medical intensive care units.

Saving Time Under Pressure: Effectiveness of Standardizing Pediatric Resuscitation Carts.

Resuscitation situations are high risk and high stress, and delays in care can have significant influences on outcomes. Standardization of care protocols and equipment is postulated to decrease some of the stress and risk. The objective of this study was to document increased efficiency in finding resuscitation equipment in a standardized resuscitation cart. A new standardized resuscitation cart design was created, and a multimedia education program addressing the new design was launched. A goal was set to find required equipment in <15 seconds. Five cohorts of 10 nurses were timed at finding randomly chosen items 1, 12, 49, 152, and 351 days after new cart launch. t tests were used to compare estimated acquisition times of requested items using the new cart system to the old cart system (baseline), and a separate regression analysis was used to model skill degradation. All pairwise comparisons showed significant decreases in mean acquisition time compared with baseline. One day after launch, the mean time to find items was reduced by 46%. Mean time to find requested items was below the goal of 15 seconds 12, 49, and 152 days after launch. This effect was lost by 351 days from launch. Regression analysis predicted the time to find items would exceed 15 seconds 287 days after launch. Standardizing the resuscitation cart design greatly reduced time to find items and was accomplished with reduced financial cost. Skill degradation did occur over time, and refresher training was required.

A Qualitative Study Exploring Factors Associated with Provider Adherence to Severe Pediatric Traumatic Brain Injury Guidelines.

Despite demonstrated improvement in patient outcomes with use of the Pediatric Traumatic Brain Injury (TBI) Guidelines (Guidelines), there are differential rates of adherence. Provider perspectives on barriers and facilitators to adherence have not been elucidated. This study aimed to identify and explore in depth the provider perspective on factors associated with adherence to the Guidelines using 19 focus groups with nurses and physicians who provided acute management for pediatric patients with TBI at five university-affiliated Level 1 trauma centers. Data were examined using deductive and inductive content analysis. Results indicated that three inter-related domains were associated with clinical adherence: 1) perceived guideline credibility and applicability to individual patients, 2) implementation, dissemination, and enforcement strategies, and 3) provider culture, communication styles, and attitudes towards protocols. Specifically, Guideline usefulness was determined by the perceived relevance to the individual patient given age, injury etiology, and severity and the strength of the evidence. Institutional methods to formally endorse, codify, and implement the Guidelines into the local culture were important. Providers wanted local protocols developed using interdisciplinary consensus. Finally, a culture of collaboration, including consistent, respectful communication and interdisciplinary cooperation, facilitated adherence. Provider training and experience, as well as attitudes towards other standardized care protocols, mirror the use and attitudes towards the Guidelines. Adherence was determined by the interaction of each of these guideline, institutional, and provider factors acting in concert. Incorporating provider perspectives on barriers and facilitators to adherence into hospital and team protocols is an important step toward improving adherence and ultimately patient outcomes.

PREVENTION OF NON-SURGICAL COMPLICATIONS AFTER HEPATIC RESECTIONS IN THE ELDERLY PATIENTS

Elderly patients constitute a significant part of patients undergoing liver resection. Non-specific cardio-vascular and pulmonary complications as well as postoperative delirium are common in this group of patients. We analyzed the impact of a standardized perioperative care protocol on the rate of such complications after resections of the liver in patients younger and older than 70 years. Material and methods We analyzed the results of elective liver resections, performed in the Department of Surgical Oncology of the Medical and Rehabilitation Center under the Ministry of Health from 2013 to 2016. There were 122 resection in 99 patients less than 70 years old and 30 procedures in 29 elderly patients. Patients in the elderly group had significantly more cardio-vascular co-morbidities whereas younger patients have had preoperative chemotherapy more often. Results.There were no differences regading the extent of liver resection, bloodloss, operating time. Severe morbidity (Clavien-Dindo III–IV grade) developed in 22 and 20% among patients younger and older 70, respectively, mortality was 6 and 7%. Elderly patients developed liver failure more often (13 vs 7%). There were 3 nonspecific complications: pneumonia and heart failure in patients younger than 70 years and atrial fibrillation in an elderly patient. Conclusion Standardized protocol of perioperative care in patients undergoing hepatectomy leads to a very low rate of non-specific postoperative complications.