Telemetry Beds Research Articles

Abstract 13262: A Self-Administered Home Inotrope Program for Unfunded Patients With End-Stage Heart Failure

Introduction: Uninsured patients with inotrope-dependent end-stage heart failure (HF) pose a formidable challenge to the healthcare system and innovative solutions are required. We created a health system funded home program for palliative and bridge-to-funding inotrope strategies for unfunded patients. Herein, we report our updated experiences. Methods: We reviewed records of all patients enrolled in the home inotrope program since inception in 2019. Patients must have demonstrated a low cardiac index that was stabilized on a single inotrope. Advanced HF and palliative care consultations are mandatory. Next, a multidisciplinary team educates the patient via a teach-teach back method on how to self-administer intravenous inotropes via a provided continuous infusion pump. After discharge, patients attended weekly clinic appointments for assessment and dressing changes. Clinic appointments, supplies, and medications are provided by the health system at minimal cost to the patient. This project was deemed IRB exempt as a quality improvement project. Results: Thus far the program has enrolled 15 uninsured patients through April 24, 2023 (table). The median duration of inotropic support was 70 (32-143) days. Patients remained at home for 90% of the 1500 total supported days. To date, one patient has received a heart transplant and three patients have received LVAD surgery after obtaining health insurance. Three (20%) patients experienced a catheter-associated infection, with two developing bacteremia. All patients endorsed satisfaction with increased time spent outside of the hospital. This was estimated to have saved >$2,363,000 in self-pay discounted charges for a general care telemetry bed and >$586,000 in professional charges (CPT 99233, estimates via price transparency act). Conclusion: A self-administered home inotrope program for select patients is feasible, safe, and cost-effective. It may also serve as a bridge to funding for advanced therapies.

Abstract 065: Advancing Stroke Care Services through Collaborative Efforts: Mission Thrombectomy Surveys of Slovenia

Introduction Acute stroke care must always be improved because stroke is still a leading cause of mortality and adult‐onset disability. The Mission Thrombectomy Slovenia Regional Committee (RC) has established a forward‐thinking initiative to improve stroke treatment services in response to this challenge. With a focus on showcasing the complete picture of stroke systems and identifying areas for improvement to achieve better patient outcomes and increase accessibility to mechanical thrombectomy (MT) treatments in Slovenia, this partnership aims to conduct extensive surveys, analyses, and propose a roadmap to overcome obstacles and optimize the stroke care ecosystem. The SVIN Mission Thrombectomy Slovenia Regional committee (RC) comprises distinguished experts, including Zoran Miloševič as Neurointerventional co‐chair, and Senta Frol and Janja Pretnar Oblak as stroke co‐chairs, respectively, and Igor Rigler as ER co‐chair, whose expertise and collaborative efforts form the backbone of this initiative. Methods As an initial step, we have commenced surveys with UMC Ljubljana, Slovenia. UMC Ljubljana, as a Mechanical Thrombectomy Center, has demonstrated consistent growth in the number of procedures conducted. There is a projection of 180 procedures in 2023, an increase from 135 in 2021 and 109 in 2022. The increased projected procedure volume indicates the hospital's proactive approach in delivering cutting‐edge stroke treatments. A pivotal aspect of UMC Ljubljana's stroke care model lies in its advanced imaging capabilities, including CTA/CTP and MRI/MRP, enabling precise and swift diagnoses, fostering better treatment planning, and optimizing patient outcomes. Furthermore, the presence of a well‐equipped Angio suite, staffed with competent MT operators, ensures seamless execution of interventional procedures. Results The collaboration's future vision involves conducting surveys and analyzing data to identify barriers to MT access, streamlining the patient journey, and improving overall stroke care efficiency. The ongoing efforts of building a Stroke Registry at UMC Ljubljana will enable in‐depth analysis, fostering continuous evolution in stroke care practices. Additionally, investments in Intermediate/Step down care and Telemetry beds will play a vital role in strengthening the continuum of care, enabling smooth patient transitions, and reducing potential delays in treatment. Healthcare practitioners' awareness for stroke triage and Physician Training emerge as the most impactful Thrombectomy Patient Health Initiatives. By prioritizing these initiatives, UMC Ljubljana and Mission Thrombectomy aim to foster early recognition, prompt treatment, and streamlined care for stroke patients. Conclusion In conclusion, the collaborative efforts of UMC Ljubljana and Mission Thrombectomy Slovenia RC are poised to elevate stroke care and MT services through data‐driven analysis and the proposed roadmap. By incorporating future surveys and continuous improvement strategies, the collaboration aims to create a paradigm shift in stroke care, ensuring accessible, efficient, and optimized services to patients in need. Moving forward, we will continue to conduct surveys within the current EVT and stroke centers examining the calculated MT Operator availability (MTOA), MT Center availability (MTCA), and MT Access Rate (MTAR) scores to identify the current barriers to increase access to mechanical thrombectomy.

Assessing the Usability of a Novel Wearable Remote Patient Monitoring Device for the Early Detection of In-Hospital Patient Deterioration: Observational Study.

BackgroundPatients admitted to general wards are inherently at risk of deterioration. Thus, tools that can provide early detection of deterioration may be lifesaving. Frequent remote patient monitoring (RPM) has the potential to allow such early detection, leading to a timely intervention by health care providers.ObjectiveThis study aimed to assess the potential of a novel wearable RPM device to provide timely alerts in patients at high risk for deterioration.MethodsThis prospective observational study was conducted in two general wards of a large tertiary medical center. Patients determined to be at high risk to deteriorate upon admission and assigned to a telemetry bed were included. On top of the standard monitoring equipment, a wearable monitor was attached to each patient, and monitoring was conducted in parallel. The data gathered by the wearable monitors were analyzed retrospectively, with the medical staff being blinded to them in real time. Several early warning scores of the risk for deterioration were used, all calculated from frequent data collected by the wearable RPM device: these included (1) the National Early Warning Score (NEWS), (2) Airway, Breathing, Circulation, Neurology, and Other (ABCNO) score, and (3) deterioration criteria defined by the clinical team as a “wish list” score. In all three systems, the risk scores were calculated every 5 minutes using the data frequently collected by the wearable RPM device. Data generated by the early warning scores were compared with those obtained from the clinical records of actual deterioration among these patients.ResultsIn total, 410 patients were recruited and 217 were included in the final analysis. The median age was 71 (IQR 62-78) years and 130 (59.9%) of them were male. Actual clinical deterioration occurred in 24 patients. The NEWS indicated high alert in 16 of these 24 (67%) patients, preceding actual clinical deterioration by 29 hours on average. The ABCNO score indicated high alert in 18 (75%) of these patients, preceding actual clinical deterioration by 38 hours on average. Early warning based on wish list scoring criteria was observed for all 24 patients 40 hours on average before clinical deterioration was detected by the medical staff. Importantly, early warning based on the wish list scoring criteria was also observed among all other patients who did not deteriorate.ConclusionsFrequent remote patient monitoring has the potential for early detection of a high risk to deteriorate among hospitalized patients, using both grouped signal-based scores and algorithm-based prediction. In this study, we show the ability to formulate scores for early warning by using RPM. Nevertheless, early warning scores compiled on the basis of these data failed to deliver reasonable specificity. Further efforts should be directed at improving the specificity and sensitivity of such tools.Trial RegistrationClinicalTrials.gov NCT04220359; https://clinicaltrials.gov/ct2/show/NCT04220359

Hospitalist Co-Management of a Vascular Surgery Service Improves Quality Outcomes and Reduces Cost

Hospitalists can be instrumental in management of inpatients with multiple comorbidities requiring complex medical care such as vascular surgery patients, as well as an expertise in health care delivery. We instituted a unique hospitalist co-management program and assessed length of stay, 30-day readmission rates and mortality, and performed an overall cost-analysis. Hospitalist co-management of vascular surgery inpatients was implemented beginning April 2019, and data was studied until March 2020. We compared this data to an eight-month period prior to implementing co-management (7/2018 - 3/2019). Patient-related outcomes that were assessed include length of stay, re-admission index, mortality index, case-mix index. Cost-analysis was performed to look at indirect and direct cost of care. A total of 1,062 patients were included in the study 520 pre co-management and 542 patients were post-comanagement. Baseline case-mix index was 2.47, and post-comanagement was 2.46 (P >0.05). In terms of average length of stay (aLOS), the baseline aLOS was 5.16 days per patient, while after co-management it was significantly decreased by 1.25 days to 3.91 days (P <0.05). This improvement in length of stay opened an average of 2.4 telemetry beds per day. Similarly, excess days per patient which reflects the expected length of stay based on comorbidities, improved from -0.59 to -1.65, an improvement of -1.46. Hospitalist co-management improves outcomes for vascular surgery inpatients, decreases length of stay, re-admission and mortality while providing a significant cost-savings. The overall average variable direct cost decreased by $1,732 per patient.

Telemetry Bed Usage for Patients with Low-Risk Chest Pain: An Updated Review of the Literature for the Clinician.

Telemetry monitoring in patients with low-risk chest pain continues to be highly used despite a 2011 literature review and recommendations by the Clinical Practice Committee (CPC) of the American Academy of Emergency Medicine that did not find quality data to support its use. To update the medical literature review on the utility of telemetry monitoring in patients with low-risk chest pain and to offer evidence-based recommendations to emergency physicians. A PubMed literature search was performed for systematic reviews in English relevant to low-risk chest pain between 2011 and 2019 and then expanded to all citations by removing the systematic review criteria. Studies identified then underwent a structured review from which results could be evaluated in the context of the associated 2011 literature review and CPC recommendations. The initial search yielded 2 potentially relevant studies, although none directly addressed telemetry. The expanded search resulted in 76 abstracts that were screened. Two addressed telemetry, including the last CPC statement, which were reviewed and recommendations given. No further quality data were identified to support the use of telemetry monitoring in patients with low-risk chest pains. Telemetry monitoring is unlikely to benefit patients with low-risk chest pain with a low-risk HEART Score.

Abstract 12650: A Faster and Safe Way for Dose Escalation of Sotalol Therapy in Patients With Atrial Fibrillation or Flutter

Sotalol is frequently employed to prevent the recurrence of highly symptomatic atrial fibrillation or flutter, but recurrence is not unusual and may require dose escalation. Sotalol can cause QTc prolongation proportional to blood concentration and at times may cause Torsade de Pointes ventricular tachycardia (TdP). Because the risk of TdP, dose escalation of oral sotalol therapy is mandated by FDA to be in-hospital for a minimum of 3 days under ECG monitoring with facilities and personnel able to provide cardiac resuscitation. With oral administration (bid), 3 days are needed to reach the new maximal steady-state blood concentrations (Cmax ss) and thus maximal QTc . Three hospital days in a telemetry bed is costly of time and resources. IV sotalol makes it possible to reduce the escalation time from 3 days to 1 day. The IV to oral dose escalation has been developed by model informed drug development. Serum sotalol concentrations and corresponding QTc were obtained from a bioequivalence study in healthy volunteers who received a single dose of oral and IV sotalol. NONMEM software package was used for population pharmacokinetic modeling and simulation. First Order Conditional Estimation method with Interaction (FOCE-INTER) was used for computation. We chose to administer IV sotalol over 1 hour to obtain the new Cmax ss target in a timeframe convenient for medical staff to supervise. Simulation for dose escalation from 80 to 120 mg bid is shown in the Figure; 75 mg IV sotalol is administered over 1 hour followed by 120 mg oral sotalol at 5 hours from start of infusion, then a second oral dose of 120 mg at 12 hours. One can target escalation from 120 to 160 mg by loading 90 mg IV over 1 hr followed by 160 mg oral dosing. Sotalol concentration will peak in 2-4 hours following each oral administration, thus in 21 hour there will be 3 sotalol peak concentrations. This permits evaluation of QTc response and risk of TdP all within a 1 day admission.

Abstract 12649: A Faster and Safe Way to Initiate Sotalol Therapy for Patients With Atrial Fibrillation or Flutter

Sotalol drug therapy is frequently employed to prevent the recurrence of highly symptomatic atrial fibrillation or flutter (AF, AFb). Sotalol can cause QTc prolongation that is proportional to blood concentration. Excessive concentration can cause Torsade de Pointes ventricular tachycardia (TdP). Because the risk of TdP, initiation of oral sotalol therapy is mandated by FDA to be in-hospital for a minimum of three days under ECG monitoring with facilities and personnel able to provide cardiac resuscitation. With oral administration (bid), 3 days are needed to reach maximal steady-state blood concentrations (Cmax ss) and thus maximal QTc prolongation. Three hospital days in a telemetry bed is costly and considerable expenditure of time and resources. Availability of IV sotalol makes it possible to reduce the loading time from 3 days to 1 day. The IV to oral loading regimen has been developed by model informed drug development. Serum sotalol concentrations and corresponding QTc were obtained from a previously performed bioequivalence study in healthy volunteers who received a single dose of oral and IV sotalol. NONMEM software package was used for population pharmacokinetic modeling and simulation. First Order Conditional Estimation method with Interaction (FOCE-INTER) was used for computation. We chose to administer IV sotalol over 1 hour to obtain Cmax ss target in a timeframe convenient for medical staff to supervise. The simulation for loading to the Cmax target produced by 80 mg PO bid is shown in the Figure; 60 mg IV sotalol is administered over 1 hour followed by 80 mg oral sotalol at 5 hours from start of infusion end then a second oral dose of 80 mg at 12 hours. One can target 120 mg maintenance dose by loading 90 mg IV over 1 hr followed by 120 mg oral dosing. Sotalol concentration will peak in 2-4 hours following each oral administration, thus in 21 hour there will be 3 sotalol peak concentrations. This permits evaluation of QTc response and risk of TdP all within a 1 day admission.

Hospitalist Co-Management Improves Outcomes and Decreases Costs for an Inpatient Vascular Surgery Service

Vascular surgery patients often have multiple comorbidities with increased length of stay and readmission rates, thus leading to higher health care-related costs. Hospitalists can be instrumental in optimal management of chronic comorbidities and in timely recognition and management of acute medical issues. Our aim was to evaluate the outcomes and cost of a hospitalist co-management team for an inpatient vascular surgery service. We instituted co-management for vascular surgery inpatients from April 2019 to October 2019 with one hospitalist and five vascular surgeons. The hospitalist worked closely with the vascular surgery attendings and with the support staff, including house staff, physician assistants, consultants, social workers, and case managers. The hospitalist conducted rounds with the vascular team daily to discuss medical plans for the day and led interdisciplinary rounds with all disciplines involved in the care of the patient. We compared an 8-month period before initiation of co-management (July 2018-March 2019) with a 6-month period after initiation (April 2019-October 2019). We assessed outcomes in terms of length of stay, length of intensive care unit days, readmission, and mortality. We also performed a financial analysis of the direct variable care cost. The period before co-management included a total of 542 patients; after co-management, there were 285 patients. The case mix index was 2.40 at baseline and 2.44 after co-management, suggesting similar patient complexity. After institution of hospital co-management, there was a significant decrease in length of stay by 1.18 days (Table; P < .05), which opened 2.2 telemetry beds per day. Furthermore, there was a significant decrease in average intensive care unit days per 100 patients from 57% to 37% (P < .05). This was primarily due to reduced escalations in level of care. Excess days per patient improved from −0.59 to −1.65. Along with the decreased length of stay, we had a 7% reduction in our readmission index (Table). The mortality index decreased from 0.83 to 0.63. In terms of direct variable care cost, the ancillary and room and board costs per patient decreased by $577 and $1159, respectively, leading to a decrease in overall direct variable cost of $1736 per patient. As a result, there was an overall cost savings of $494,760 during the study period and an annualized cost savings of $1,329,776. Hospitalist co-management improves outcomes for vascular surgery inpatients and decreases length of stay, readmission, and mortality while providing a significant cost savings.TableComparison of quality outcomes with and without hospitalist Comanagement (a denotes statistical significance P < .05)OutcomePre-comanagementPost-comanagementLength of staya5.14 days3.96 daysReadmission index (observed/expected)1.541.45Mortality index (observed/expected).83.63Average cost (per patient)a$6501$5098 Open table in a new tab

Appropriate utilisation of cardiac telemetry monitoring: a quality improvement project

For hospitals located in the United States, appropriate use of cardiac telemetry monitoring can be achieved resulting in cost savings to healthcare systems. Our institution has a limited number of...

TELEMETRY: DO YOU HAVE THE HEART NOT TO ORDER IT

The overuse of telemetry produces a significant cost burden, facilitates inappropriate testing for rhythm artifacts, and contributes to a shortage of telemetry beds. Reducing the use of telemetry has not demonstrated a negative impact to overall patient outcomes. Our objective was to improve

VP25 HTA Enables Nurses To Discontinue Continuous ECG Monitoring

IntroductionProviders frequently issue orders for telemetry (continuous ECG monitoring) of hospital inpatients, but they rarely issue orders to discontinue telemetry. This can cause telemetry beds to be unavailable for patients who need them.MethodsOur hospital health technology assessment (HTA) center conducted a rapid systematic review of evidence on algorithms, guidelines, and other tools for nurses to identify patients who no longer need telemetry. Databases searched included Medline, CINAHL, the Cochrane Library, National Guideline Clearinghouse, and Joanna Briggs Institute.ResultsWe found no guidelines or existing systematic reviews of nurse-driven protocols for discontinuing telemetry. There were three published articles describing projects where protocols for discontinuing telemetry were tested. All three of these studies were of low methodologic quality. They all found that use of the protocol reduced the number of hours of telemetry monitoring that were used in the hospital. Two studies published in letter form reported adaptations of computerized order entry systems where nurses assess the patient's readiness for discontinuing telemetry and either discontinue telemetry or report to the ordering physician when the stated discontinuation criteria are met.ConclusionsOur hospitals are now implementing the HTA findings in our electronic ordering system.

Cardiology Admissions from Catheterization Laboratory – Time Series Forecasting

Emergent and unscheduled cardiology admissions from cardiac catheterization laboratory add complexity to the management of Cardiology and in-patient department. In this article, we sought to study the behavior of cardiology admissions from Catheterization laboratory using time series models. Our research involves retrospective cardiology admission data from March 1, 2012, to November 3, 2016, retrieved from a hospital in Iowa. Autoregressive integrated moving average (ARIMA), Holt’s method, mean method, naive method, seasonal naive, exponential smoothing, and drift method were implemented to forecast weekly cardiology admissions from Catheterization laboratory. ARIMA (2,0,2) (1,1,1) was selected as the best fit model with the minimum sum of error, Akaike information criterion, and Schwartz Bayesian criterion. The model failed to reject the null hypothesis of stationarity, it lacked the evidence of independence and rejected the null hypothesis of normality. The implication of this study will not only improve catheterization laboratory staff schedule, advocate efficient use of imaging equipment and inpatient telemetry beds but also equip management to proactively tackle inpatient overcrowding, plan for physical capacity expansion and so forth.

Received care compared to ADP-guided care of patients admitted to hospital with chest pain of possible cardiac origin.

PurposeTo assess the extent to which accelerated diagnostic protocols (ADPs), compared to traditional care, identify patients presenting to emergency departments (EDs) with chest pain who are at low cardiac risk and eligible for early ED discharge.Patients and methodsRetrospective study of 290 patients admitted to hospital for further evaluation of chest pain following negative ED workup (no acute ischemic electrocardiogram [ECG] changes or elevation of initial serum troponin assay). Demographic data, serial ECG and troponin results, Thrombolysis in Myocardial Infarction (TIMI) score, cardiac investigations, and outcomes (confirmed acute coronary syndrome [ACS] at discharge and major adverse cardiac events [MACEs]) over 6 months of follow-up were analyzed. A validated ADP (ADAPT-ADP) was retrospectively applied to the cohort, and processes and outcomes of ADP-guided care were compared with those of care actually received.ResultsPatients had mean (±SD) TIMI score of 1.8 (±1.7); six (2.0%) patients were diagnosed with ACS at discharge. At 6 months, one patient (0.3%) re-presented with ACS and two (0.6%) died of non-coronary causes. The ADAPT-ADP defined 97 (33.4%) patients as being at low risk and eligible for early ED discharge, but who instead incurred mean hospital stay of 1.5 days, with 40.2% in telemetry beds, and 21.6% subject to non-invasive testing with only one positive result for coronary artery disease. None had a discharge diagnosis of ACS or developed MACE at 6 months.ConclusionCompared to traditional care, application of the ADAPT-ADP would have allowed one-third of chest pain patients with initially negative investigations in ED to have been safely discharged from ED.

MP12: Emergency department boarding: predictors and outcomes

Introduction: Delays in transfer to an in-patient bed of admitted patients boarded in the ED has been identified as one of the chief drivers of ED overcrowding. Our study aims to replicate findings from a previous study in identifying patient characteristics associated with increased boarding time, and the impact of increased boarding time on in-patient length of stay (IPLOS). Methods: We conducted a retrospective single-centre observational study during the period between January 1, 2015 December 31, 2015 at a very high volume community hospital (~ 75,000 ED visits/year). All patients admitted from the ED to Medicine, Pediatrics, Surgery, and Critical Care were identified. The mean time to in-patient bed (TTB), as well as patient-specific and institutional factors that were associated with prolonged boarding times ( 12 hours) were identified. Mean IP LOS was calculated for those with prolonged boarding times and compared to those without prolonged boarding times. Results: There were 8,096 unique admissions during the study period. Patients admitted to the Medicine service exhibited significantly higher boarding times than those admitted to other services, with a mean boarding time of 17.4 hrs, as compared to 4.2 hrs, 5.7 hrs, and 4.0 hrs for those admitted to Surgery, Critical Care and Pediatrics respectively. Within Medicine patients, there was a statistically significant greater odds of prolonged boarding time for patients who were older, had a greater comorbidity burden, and required more specialized in-patient care (i.e. an isolation bed or telemetry bed). Medicine patients with prolonged boarding times also experienced 0.7 days longer IP LOS, even after correcting for age and comorbidity (mean adjusted IP LOS 10.6 days versus 11.3 days). Conclusion: Within our study period, older, sicker patients and those patients requiring more resource-intensive in-patient care have the longest ED boarding times. These prolonged ‘boarding’ times are associated with significantly increased IP LOS.

Abstract 5: Optimizing Emergency Room Throughput for Cardiac Telemetry Patients: A Queuing Theory Approach

Background: The capacity of telemetry monitoring in hospitalized patients is constrained due to limited equipment and personnel. Electing for telemetry monitoring may pose a bottleneck for patients admitted through the Emergency Department (ED). This can result in increased length of stays in the ED, a parameter that is correlated with decreased quality of care due to crowding and delay in treatment. Queuing theory is the mathematical study of waiting times. We opted to use queuing theory to analyze system performance before and after an expansion of telemetry capacity. Objective: To retrospectively analyze the impact of telemetry capacity on ED wait times using enterprise data warehouse (EDW) data and queuing theory. Methods: Unused telemetry boxes were used as a proxy metric for available cardiac telemetry monitoring. The number of telemetry boxes in use at a large urban academic medical center was determined by daily manual count. The number of telemetry admissions, average length of telemetry use, and length of stay in the ED were obtained from EDW data. Using queuing theory, system parameters including expected wait time and percent of patients who will wait were calculated for scenarios to simulate before and after the expansion of telemetry capacity. These modeled system behaviors were compared to observed data from before and after the intervention to understand the utility of the mathematical model. Results: Over the study period of 365 days, a total of 13,515 inpatient non-critical care hospital encounters had orders for telemetry monitoring. Prior to the increase in telemetry capacity, there were 144 telemetry boxes, which were utilized at 96.7% of capacity. Using these parameters, the model predicts a 5.8-hour average wait time and a 42.1% chance that a patient will have to wait for a telemetry box. Increasing telemetry capacity modestly by 10 boxes (144 to154 boxes) results in a dramatic system improvement, reducing utilization to 88.6%, average wait time for a telemetry bed to 34 minutes, and percent of patients waiting for a telemetry slot to 9.4%. These predicted results compared well to the observed data. After the intervention, there was a decrease in utilization to 86.9%, and a statistically significant reduction in time waiting in the ED for an inpatient bed by 1.24 (p&lt;0.05) hours per telemetry patient, representing a total savings of ED boarding time of 11.2 bed-days per week. Conclusions: Queuing theory allows for modeling of healthcare system behavior to predict needed clinical capacity for achieving system goals. Our simplified model demonstrates that a modest increase in capacity can drive significant system improvements. Utilizing queuing theory and understanding the behavior of the healthcare system can improve the predicted impact of interventions on cost-effectiveness and quality of care.

A multidisciplinary approach to reducing alarm fatigue and cost through appropriate use of cardiac telemetry

BackgroundAlarm fatigue (AF) is a distressing factor for staff and patients in the hospital. Using cardiac telemetry (CT) without clinical indications can create unnecessary alarms, and increase AF and cost...

Intercostal nerve cryoablation versus thoracic epidural catheters for postoperative analgesia following pectus excavatum repair: Preliminary outcomes in twenty-six cryoablation patients

BackgroundMultimodal pain management strategies are used for analgesia following pectus excavatum repair. However, the optimal regimen has not been identified. We describe our early experience with intercostal cryoablation for pain management in children undergoing the Nuss procedure and compare early cryoablation outcomes to our prior outcomes using thoracic epidural analgesia. MethodsA multi-institutional, retrospective review of fifty-two patients undergoing Nuss bar placement with either intercostal cryoablation (n=26) or thoracic epidural analgesia (n=26) from March 2013 to January 2016 was conducted. The primary outcome was hospital length of stay. Secondary outcomes included telemetry unit monitoring time, total intravenous narcotic use, duration of intravenous narcotic use, and postoperative complications. ResultsPatients who underwent intercostal cryoablation had a significant reduction in the mean hospital length of stay, time in a monitored telemetry bed, total use of intravenous narcotics, and the duration of intravenous narcotic administration when compared to thoracic epidural patients. Cryoablation patients had a slightly higher rate of postoperative complications. ConclusionIntercostal cryoablation is a promising technique for postoperative pain management in children undergoing repair of pectus excavatum. This therapy results in reduced time to hospital discharge, decreased intravenous narcotic utilization, and has eliminated epidurals from our practice. Level of evidenceRetrospective study – level III.

Hospitalist intervention for appropriate use of telemetry reduces length of stay and cost.

Telemetry monitoring is a widely used, labor-intensive, and often-limited resource. Little is known of the effectiveness of methods to guide appropriate use. Our intervention for appropriate use included: (1) a hospitalist-led, daily review of bed utilization, (2) hospitalist-driven education module for trainees, (3) quarterly feedback of telemetry usage, and (4) financial incentives. Hospitalists were encouraged to discuss daily telemetry utilization on rounds. A module on appropriate telemetry usage was taught by hospitalists during the intervention period (January 2013-August 2013) on medicine wards. Pre- and post-evaluations measured changes regarding telemetry use. We compared hospital bed-use data between the baseline period (January 2012-December 2012), intervention period, and extension period (September 2014-March 2015). During the intervention period, hospital bed-use data were sent to the hospitalist group quarterly. Financial incentives were provided after a decrease in hospitalist telemetry utilization. Stanford Hospital, a 444-bed, academic medical center in Stanford, California. Hospitalists saw reductions for both length of stay (LOS) (2.75 vs 2.13 days, P = 0.005) and total cost (22.5% reduction) for telemetry bed utilization in the intervention period. Nonhospitalists telemetry bed utilization remained unchanged. We saw significant improvements in trainee knowledge of the most cost-saving action (P = 0.002) and the least cost-saving action (P = 0.003) in the pre- and post-evaluation analyses. Results were sustained in the hospitalist group, with telemetry LOS of 1.93 days in the extension period. A multipronged, hospitalist-driven intervention to improve appropriate use of telemetry reduces LOS and cost, and increases knowledge of cost-saving actions among trainees.

Telemetry Monitoring: Are Admission Criteria Based on Evidence?

Telemetry Monitoring: Are Admission Criteria Based on Evidence?

Evaluation of Risk Factors Associated with Code Blue or Rapid Response Calls Within 12 hours of Admission to Medical, Surgical, Telemetry, or Floor Beds from the Emergency Department

The emergency department (ED) physician is responsible for stabilizing and identifying the appropriate level of inpatient care for each admitted patient. Patients sent to a non-intensive care unit (ICU) admitted from the ED may require a “code blue” (CB) or “rapid response” (RR) shortly after admission. Patients who experience these events outside of the ICU have a higher morbidity and mortality than those admitted directly to the ICU. Currently, no decision tool exists to assist ED physicians in recognizing patients who may not meet classic criteria of ICU admission but require such upgraded care within 12 hours of admission. We hypothesize there may be vital signs or laboratory values associated with non-ICU patients having a CB or RR called within 12 hours of admission.