University Of Michigan Health System Research Articles

A Validation Study of a Retrospective Venous Thromboembolism Risk Scoring Method

Validate a retrospective venous thromboembolism (VTE) risk scoring method, which was developed at the University of Michigan Health System and based on the Caprini risk assessment model, and assess the confounding effects of VTE prophylaxis. Assessing patients for risk of VTE is essential to initiating appropriate prophylaxis and reducing the mortality and morbidity associated with deep vein thrombosis and pulmonary embolism. VTE risk factors were identified for 8216 inpatients from the National Surgical Quality Improvement Program using the retrospective scoring method. Logistic regression was used to calculate odds ratios (OR) for VTE within 30 days after surgery for risk factors and risk level. A bivariate probit model estimated the effects of risk while controlling for adherence to prophylaxis guidelines. Distribution of the study population by risk level was highest, 52.1%; high, 36.5%; moderate, 10.4%; and low, 0.9%. Incidence of VTE within 30 days was overall 1.4%; by risk level: highest, 1.94%; high, 0.97%; moderate, 0.70%; low, 0%. Controlling for length of hospitalization (>2 d) and fiscal year, pregnancy or postpartum (OR = 8.3; 1.0-68, P < 0.05), recent sepsis (4.0; 1.4-10.9, P < 0.01), malignancy (2.3; 1.5-3.3, P < 0.01), history of VTE (2.1; 1.1-4.1, P < 0.05), and central venous access (1.8; 1.1-3.0, P < 0.05) were significantly associated with VTE. Risk level was significantly associated with VTE (1.9; 1.3-2.6, P < 0.01). The bivariate probit demonstrated significant correlation between the probability of VTE and lack of adherence to prophylaxis guidelines (rho = 0.299, P = 0.013). The retrospective risk scoring method is valid and supports use of individual patient assessment of risk for VTE within 30 days after surgery.

Staphylococcus aureus Bloodstream Infections in Older Adults: Clinical Outcomes and Risk Factors for In‐Hospital Mortality

To assess clinical outcomes and identify risk factors for mortality in older adults with Staphylococcus aureus bloodstream infection (SAB). Retrospective review. University of Michigan Health System, Ann Arbor. All patients aged 80 and older with SAB between January 2004 and July 2008. Clinical data, including comorbid conditions, SAB source, echocardiography results, Charlson Comorbidity Index, mortality (in-hospital and 6-month), and need for rehospitalization or chronic care after discharge. Seventy-six patients aged 80 and older (mean 85.5 +/- 4.2) with SAB were identified. Infection sources included 14 (18.4%) vascular catheter associated, 16 (21.1%) wound related, seven (9.2%) endocarditis, five (6.6%) intravascular, and 19 (25%) with unknown source; 46 (60.5%) patients had methicillin-resistant strains. Twenty-two (28.9%) patients underwent surgery or device placement within 30 days of developing SAB; 10 of these 22 had SAB associated with surgical site infection (SSI). Twenty two (28.9%) patients died in the hospital or were discharged to hospice care; at least 43 (56.6%) patients died within 6 months of presentation, and eight were lost to follow-up. Unknown source of bacteremia (odds ratio=5.2, P=.008) was independently associated with in-hospital death. Echocardiography was not pursued in 45% of patients. Of surviving patients, 40 (74.1%) required skilled care after discharge; eight (20%) required rehospitalization. SAB was associated with high mortality rates in patients aged 80 and older. The observed association between SAB and SSI may direct preventive strategies such as perioperative decolonization or antimicrobial prophylaxis. Interventions to optimize clinical care practices in elderly patients with SAB are essential given the associated morbidity and mortality.

Glycemic Control in the Intensive Care Unit

Letters5 January 2010Glycemic Control in the Intensive Care UnitCesar Alaniz, PharmD and Robert C. Hyzy, MDCesar Alaniz, PharmDFrom University of Michigan Health System, Ann Arbor, MI 48109.Search for more papers by this author and Robert C. Hyzy, MDFrom University of Michigan Health System, Ann Arbor, MI 48109.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-152-1-201001050-00023 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail TO THE EDITOR:We would like to clarify one aspect of Comi's (1) commentary on glucose control in the intensive care unit and amplify another. First, although the NICE-SUGAR (Normoglycaemia in Intensive Care Evaluation and Survival Using Glucose Algorithm Regulation) (2) control group was stated to have a target glucose level less than 10.0 mmol/L (<180 mg/dL), it was actually much less than that, because insulin infusions were continued until the blood glucose level reached 8.0 mmol/L (144 mg/dL). Indeed, the time-weighted mean blood glucose level in the control group was 8.0 mmol/L (144 mg/dL). Data on the mean glucose ...

Model for End-Stage Liver Disease Score Predicts Left Ventricular Assist Device Operative Transfusion Requirements, Morbidity, and Mortality

The Model for End-Stage Liver Disease (MELD) predicts events in cirrhotic subjects undergoing major surgery and may offer similar prognostication in left ventricular assist device candidates with comparable degrees of multisystem dysfunction. Preoperative MELD scores were calculated for subjects enrolled in the University of Michigan Health System (UMHS) mechanical circulatory support database. Univariate and multiple regression analyses were performed to investigate the ability of patient characteristics, laboratory data (including MELD scores), and hemodynamic measurements to predict total perioperative blood product exposure and operative mortality. The ability of preoperative MELD scores to predict operative mortality was evaluated in subjects enrolled in the Interagency Registry of Mechanically Assisted Circulatory Support (INTERMACS), and results were compared with those from the UMHS cohort. The mean+/-SD MELD scores for the UMHS (n=211) and INTERMACS (n=324) cohorts were 13.7+/-6.1 and 15.2+/-5.8, respectively, with 29 (14%) and 19 (6%) perioperative deaths. In the UMHS cohort, median total perioperative blood product exposure was 74 units (25th and 75th percentiles, 44 and 120 units). Each 5-unit MELD score increase was associated with 15.1+/-3.8 units (beta+/-SE) of total perioperative blood product exposure. Each 10-unit increase in total perioperative blood product exposure increased the odds of operative death (odds ratio, 1.05; 95% confidence interval, 1.01 to 1.10). Odds ratios, measuring the ability of MELD scores to predict perioperative mortality, were 1.5 (95% confidence interval, 1.1 to 2.0) and 1.5 (95% confidence interval, 1.1 to 2.1) per 5 MELD units for the UMHS and INTERMACS cohorts, respectively. When MELD scores were dichotomized as >or=17 and <17, risk-adjusted Cox proportional-hazard ratios for 6-month mortality were 2.5 (95% confidence interval, 1.2 to 5.3) and 2.5 (95% confidence interval, 1.1 to 5.4) for the UMHS and INTERMACS cohorts, respectively. The MELD score identified left ventricular assist device candidates at high risk for perioperative bleeding and mortality.

Does a Policy of Disclosing Medical Errors and Offering Compensation Affect Malpractice Claims

Since 2001, all malpractice claims at the University of Michigan Health System (UMHS) have been assigned to an expert committee for review; UMHS admits fault and offers compensation when the committee determines that an error has occurred and defends cases when no error is …

Cardiovascular Supply Cost Negotiations

As a major expense driver to cardiovascular programs, supply costs related to electrophysiology and cardiac catheterization procedures directly link to the overall financial health of organizations associated with those programs. Because of this, it is important that institutions establish a logical and resolute approach to obtaining supply pricing that maximizes cost-saving opportunities, buffers their organizations from escalating costs related to the advances in available technologies, defines supply chain expectations while preserving clinicians' access to high-quality cardiovascular supplies, and maintains the availability of the full spectrum of products to our physicians, referring physicians, and patients. In a joint effort with physicians, administration, and suppliers, and in the spirit of partnership, the University of Michigan Health System has developed and implemented such a model that illustrates the opportunities to be gained.

Antimicrobial Use Among Patients Receiving Palliative Care Consultation

We sought to characterize antimicrobial use among patients receiving palliative care consultation. Retrospective review of patients seen by the Palliative Care Service at the University of Michigan Health System from January 2008 to May 2008. Of 131 patients seen in consultation, 70 received antimicrobials. We identified 92 infections among these 70 patients; therapy for 54 (58.7%) was empiric. Empiric therapy was most commonly prescribed for respiratory infection and urinary tract infection. Piperacillin/tazobactam (P/T) was the most frequently used agent, with 26 patients receiving P/T (37.1%); 22 of 26 received this agent empirically (84.6%, P = .005). Vancomycin was prescribed to 23 patients (32.9%). Sixteen patients (22.9%) died in hospital; another 31 were enrolled in hospice care. Our results suggest significant use of empiric, broad-spectrum antimicrobial therapy among hospitalized patients near the end of life. We advocate for careful assessment of potential benefits and treatment burdens of antimicrobial therapy, especially when palliation is the goal.

Improving the Provision of Language Services at an Academic Medical Center: Ensuring High-Quality Health Communication for Limited-English-Proficient Patients

To evaluate and improve the provision of language services at an academic medicine center caring for a diverse population including many limited-English-proficient (LEP) patients. The authors performed a prospective observational study between November 2006 and December 2008 evaluating the provision of language services at the University of Michigan Health System. The primary performance measures were (1) screening patients for their preferred language for health care, (2) assessing the proportion of LEP patients receiving language services from a qualified language services provider, and (3) assessing whether there were any disparities in diabetes care for LEP patients compared with English-speaking patients. The proportion of patients screened for preferred language increased from 59% to 96% with targeted inventions, such as training staff to capture preferred language for health care and correcting prior inaccurate primary language data entry. The proportion of LEP outpatients with a qualified language services provider increased from 19% to 83% through the use of staff and contract interpreters, over-the-phone interpreting and bilingual providers. There were no systematic differences in diabetes quality performance measures between LEP and English-proficient patients. Academic medical centers should measure their provision of language services and compare quality and safety data (e.g., performance measures and adverse events) between LEP and English-speaking patients to identify disparities in care. Leadership support and ongoing training are needed to ensure language-specific services are embedded into clinical care to meet the needs of our diverse patient populations.

Variations in Surveillance Imaging for Patients with Treated Diffuse Large B-Cell Lymphoma in the National Comprehensive Cancer Network (NCCN) Lymphoma Database.

Abstract 1387Poster Board I-409 BACKGROUND:Utility and optimal timing of surveillance imaging for patients with treated diffuse large B-cell lymphoma (DLBCL) remains uncertain, especially in the era of positron emission tomography. METHODS:Data were obtained from the NCCN Non-Hodgkin's Lymphoma Outcomes Database, a prospective cohort study collecting comprehensive clinical, treatment, and outcome data for patients seen at 7 participating NCCN centers. Patients who presented between January 1, 2001 and June 30, 2007 with a new diagnosis of DLBCL in remission for at least three months after the completion of initial therapy were eligible for this study. For those patients with at least two years of follow-up, we assessed overall number and modality of imaging studies performed starting 90 days after the end date of their first-line therapy until documented relapse or end of two-year follow-up window. We then created three subcategories depending upon surveillance strategy: “PET” = positron emission tomography scans or combined positron emission tomography/limited computed tomography scans only; “CT”= computed tomography scans only; or “BOTH PET AND CT” = combination of both “PET” and “CT” at different times. For those who relapsed after being in primary remission for at least 90 days, we assessed the nature of the visit where relapse was first documented, recent accompanying imaging, and the presence of a confirmatory biopsy within one month before or after that relapse. RESULTS:As of July 1, 2009, 433 newly-diagnosed DLBCL patients had at least two years of follow-up from 6 of the 7 participating NCCN centers; median age was 56 and 57% were male. Initial stage and International Prognostic Index (IPI) were as follows: I = 24%; II= 24%; III= 16%; IV=36%; and low= 47%; low-intermediate= 26%; high-intermediate= 19% and high= 8%. For surveillance imaging as defined above, 14% received PET, 48% received CT, and 38% received BOTH PET AND CT. Range of median frequencies across NCCN centers are reported below, both overall and by test type. Overall median number of tests received per year differed significantly across NCCN centers (p for Kruskal-Wallis < 0.0001).Surveillance StrategyMedian tests/year across all NCCN centersMedian tests/year, NCCN center rangeMean tests/year across all NCCN centersAll tests2.81.5 – 3.52.8PET2.01.5 – 2.752.2CT2.51.5 – 3.52.6BOTH PET AND CT3.01.5 – 4.03.3Of 990 patients in primary remission for at least 90 days, there were 108 (11%) documented relapses. Of those, 20% were found at non-routine visits with symptoms, 41% at routine visits with symptoms, 37% at routine visits without symptoms and 2% were unclear. Of those found at routine visits without symptoms, 73% had undergone imaging within one month before and up to the date of relapse. Finally, 77% of those with relapse underwent confirmatory biopsy within one month before or after relapse. CONCLUSIONS:The frequency of surveillance imaging for patients with treated DLBCL is highly variable, even within the context of tertiary care academic centers. Despite controversy surrounding its use, a high proportion of DLBCL patients in remission are followed with PET modalities. Those being followed exclusively with PET modalities tend to have less frequent imaging, which may have implications for comparative effectiveness. Routine imaging likely identifies relapse in about a quarter of patients with DLBCL; the impact on ultimate outcome remains to be further evaluated. Disclosures:Friedberg: Genentech: Membership on an entity's Board of Directors or advisory committees. Blayney: American Society of Clinical Oncology: Membership on an entity's Board of Directors or advisory committees; BlueCross Blue Shield of Michigan: Research Funding; NCCN: Honoraria; University of Michigan Health System: Employment.

R-CHOP, Followed by High Dose Therapy and Autologous Stem Cell Rescue (HDT/ASCR), and R-Hypercvad Have Equivalent Progression-Free Survival and Are Superior to R-CHOP Alone in Younger Patients with Mantle Cell Lymphoma: a Comparative Effectiveness Analysis From the National Comprehensive Cancer Network (NCCN) Non-Hodgkin's Lymphoma Outcomes Database Project.

Abstract 403 Background:Mantle Cell Lymphoma (MCL) is an uncommon histology of non-Hodgkin's lymphoma (NHL) with an unfavorable prognosis for which optimal initial therapy has not been clearly defined. Despite a number of single center studies and uncontrolled trials examining first-line therapy options in MCL, no randomized clinical trials or observational studies have directly compared initial therapeutic options in a single cohort of patients. The role of aggressive induction therapy versus sequential standard chemotherapy remains uncertain, particularly in younger patients. We therefore used the NCCN NHL Outcomes Database to compare R-HyperCVAD, R-CHOP followed by HDT/ASCR and R-CHOP alone as first-line therapy. Our endpoints were progression-free survival (PFS) and overall survival (OS). Methods:The NCCN Non-Hodgkin's Lymphoma Outcomes Database is a prospective cohort study collecting comprehensive clinical, treatment, and outcome data for patients seen at 7 participating NCCN centers. Overall, 229 patients <65 years old with newly diagnosed MCL presented at NCCN institutions between August 2000 and February 2009. Patients were excluded if they (1) were enrolled in clinical trial (n=27), (2) did not receive Rituximab therapy (n=27), (3) did not receive either R-HyperCVAD or R-CHOP induction therapy (n=10), or (4) received both R-CHOP and R-HyperCVAD as induction (n=9). Induction therapy was determined as the initial chemo-immunotherapy received within 180 days of diagnosis. HDT/ASCR consolidation was defined as a transplant after achieving remission. In the R-CHOP+ HDT/ASCR group, ASCR was initiated within 100 days of induction therapy for 90% of patients. The maximum time from induction to ASCR was 172 days. In total, 156 patients were included in the final analysis. Median follow-up was 30 months. Results:Overall, 28 (18%) patients received R-CHOP alone, 29 (19%) received R-CHOP+HDT/ASCR, and 99 (63%) received R-HyperCVAD. No significant differences were observed between therapy groups with regards to co-morbidity (p=0.419), ECOG performance status (p=0.216), B symptoms (p=0.685), bulky disease (p=0.647), IPI risk group (p=0.247), or bone marrow involvement (p=0.651). No difference in PFS (p=0.546) was observed between the R-HyperCVAD and R-CHOP+HDT/ASCR arm (figure 1a). R-CHOP without consolidation had significantly poorer PFS than both R-HyperCVAD (p=0.001) and R-CHOP+HDT/ASCR (p=0.001). No significant differences in OS were observed between the three groups. However, there was a strong trend favoring R-HyperCVAD over R-CHOP (p=0.082, figure 1b). Conclusion:R-CHOP was inferior to both R-HyperCVAD and R-CHOP+HDT/ASCR, which had equal PFS and OS in patients with de novo mantle cell lymphoma. Even with these aggressive induction regimens in younger patient populations, the median PFS in these cohorts was only 3 years. Future trials should focus on incorporating novel agents rather than comparing efficacy of current suboptimal regimens. [Display omitted] Disclosures:Czuczman:NCCN: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding. Nademanee:Genzyme Corporation: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding. Blayney:American Society of Clinical Oncology: Membership on an entity's Board of Directors or advisory committees; BlueCross Blue Shield of Michigan: Research Funding; NCCN: Honoraria; University of Michigan Health System: Employment. Friedberg:Genentech: Membership on an entity's Board of Directors or advisory committees.

Discussion

Ann Arbor, Mich. From the Section of Plastic Surgery, University of Michigan Health System. Received for publication May 28, 2009; accepted June 1, 2009. Disclosure:Neither of the author has any financial interests to declare in relation to the content of this Discussion or the associated article. Kevin C. Chung, M.D., M.S., Section of Plastic Surgery, University of Michigan Health System, 2130 Taubman Center, 1500 East Medical Center Drive, Ann Arbor, Mich. 48109-0340, [email protected]

Why Certification You Ask?

Editor's Note: Why should you become certified? It's a question frequently asked in the biomed field, so we asked recently certified biomeds why they embarked on studying for the exam. Here are some of their responses. (We also asked for their tips on studying for the exam, which they have provided in the Inside Certification article in this edition of BI&amp;T.)I took the exam because I wanted to provide the best that I can to my colleagues, to clinicians, and to patients and families who interface with the medical devices that we inspect and maintain.Getting certified is simply making a personal commitment to achieve a minimum standard of professionalism and knowledge in the field of biomedical technology. The use of technology in healthcare is becoming more complex. As a result, errors are bound to happen which extend beyond the capabilities of the traditional role of the biomed support person. Today's biomedical equipment technician should be able to understand this change.Salim Kai, CBET, University of Michigan Health System, Ann Arbor, MIBecoming a certified biomedical equipment technician (CBET) has affected my position due to the simple fact of respect. Before, when I wasn't certified, I felt that sometimes my words were taken lightly as a manager, and perhaps I lacked some confidence about fixing medical equipment. Having your certification proves to everyone that being certified is being able to competently complete all jobs and that you are serious about your career. In today's society, a demonstration of ability or knowledge is required by professionals, and above all we are all professionals.Christopher J. Correll, USAF, CBET, Pope Air Force Base, NCThis certification experience has been a valuable refresher for forgotten information, as well as an opportunity to look into newer technology. The certification has helped in the tough economic times to be confident in my knowledge and to be marketable across the country.Jeff Goldstein, CBET, Hill-Rom, Pennsauken, NJBefore becoming certified, my main goal for taking the exam was the opportunity for advancement. Upon passing the certification, we are given three extra years of experience toward promotion from Tech II to Tech III.Since becoming certified, not only will I get the benefit of the promotion, but I have become a much better tech. My interaction with doctors and nurses relating to more physical aspects of troubleshooting has greatly improved. My knowledge of different pieces of medical devices, and how important safety is in the medical field, has increased dramatically.Barry Kise, Cox Medical Centers, Springfield, MOBecoming certified will not transform a career overnight. I did not receive an instant pay raise or promotion. However, it is essential to a biomedical career to continually learn. Most directors and regional managers whom I have met have passed the certification exams. Also, many states have already tried, although not successfully, to make some kind of certification mandatory. I believe certification will be mandatory at some point. Taking the test did not make me a better biomed, but studying for it did.Matthew Frank, CBET, Providence Medford Medical Center, Medford, OR

How Can You Pass the Exam? Listen to Those Who Know…

How Can You Pass the Exam? Listen to Those Who Know…

Fungemia Associated with Left Ventricular Assist Device Support

Infections remain an important complication of left ventricular assist device (LVAD) support. While relatively uncommon, fungal infections present a serious concern given a high association with adverse events including death. We sought to further characterize the epidemiology of fungemias during LVAD support. Retrospective review of 292 patients receiving LVAD support from October 1996 to April 2009 at the University of Michigan Health System was done. Seven cases of LVAD-associated fungemia were observed during the study period (0.1 infections/1000 days of device support). Five patients had infection with Candida species and two with Aspergillus species. The two patients with Aspergillus infection presented with disseminated disease, quickly dying of multiorgan failure, and sepsis. All five patients with Candida infections were successfully treated with systemic antifungal therapy along with transplantation in four of five patients. The fifth patient is receiving mechanical support as destination therapy. He remains on long-term suppression with high-dose fluconazole. Fungal infections appear to be a rare but serious complication of LVAD support. Future studies should aim to improve our understanding of risk factors for fungal infection during mechanical support, especially disseminated Aspergillus. Short-term perioperative antifungal prophylaxis with fluconazole appears to be an effective and reasonable approach to prevention.

Did we learn anything from Humpty Dumpty?*

Critical Care Support Services,; University of Michigan HealthSystem; Ann Arbor, MI The author has not disclosed any potential conflicts of interest. *See also p. 2753.

Did we learn anything from Humpty Dumpty?*

Critical Care Support Services,; University of Michigan HealthSystem; Ann Arbor, MI The author has not disclosed any potential conflicts of interest. *See also p. 2753.

Bacterial Pneumonias during an Influenza Pandemic: How Will We Allocate Antibiotics?

We are currently in the midst of the 2009 H1N1 pandemic, and a second wave of flu in the fall and winter could lead to more hospitalizations for pneumonia. Recent pathologic and historic data from the 1918 influenza pandemic confirms that many, if not most, of the deaths in that pandemic were a result of secondary bacterial pneumonias. This means that a second wave of 2009 H1N1 pandemic influenza could result in a widespread shortage of antibiotics, making these medications a scarce resource. Recently, our University of Michigan Health System (UMHS) Scarce Resource Allocation Committee (SRAC) added antibiotics to a list of resources (including ventilators, antivirals, vaccines) that might become scarce during an influenza pandemic. In this article, we summarize the data on bacterial pneumonias during the 1918 influenza pandemic, discuss the possible impact of a pandemic on the University of Michigan Health System, and summarize our committee's guiding principles for allocating antibiotics during a pandemic.

Implementation of Lean Thinking: One Health System’s Journey

Lean Thinking is a management philosophy derived from the manufacturing industry, where Toyota has long been the gold standard. Health care organizations have started to apply this approach to patient care. After initial experimentation, the University of Michigan Health System (UMHS) has adopted Lean Thinking as its uniform approach to quality improvement and is striving to become a complete Lean organization. In 2005, the senior leadership selected an initial set of projects in areas that traced the patient's journey across different care settings within our health system. Four of the projects were as follows: orthopedic surgery clinic scheduling, radiation oncology therapy, peripherally inserted central catheter (PICC) services, and coordination of care to the outpatient setting. Lean Thinking encourages service providers to focus on value as defined by the customer and the relentless elimination of waste that impedes the flow of value. A series of learning projects were conducted to test whether Lean methods would work at UMHS. The following factors were found to be key to LEAN PROJECT SUCCESS: expert guidance for initial efforts, leadership in the form of clinical champions and senior management support of the improvement work, frontline worker engagement in mapping out "current state" processes, identifying waste and designing an improved "future state," using metrics to develop and track interventions, and defining realistic project scope. As UMHS's experience applying Lean Thinking to our patient care processes has grown, so have support, enthusiasm, and expertise within the organization. UMHS's Lean Thinking system, now known as the Michigan Quality System, has emerged as the core improvement strategy.

Discussion

Ann Arbor, Mich. From the Section of Plastic Surgery, The University of Michigan Medical School. Received for publication March 2, 2009; accepted March 5, 2009. Disclosure: The author has no financial interest to declare in relation to the content of this Discussion or the associated article. Kevin C. Chung, M.D., M.S.; Section of Plastic Surgery; University of Michigan Health System; 2130 Taubman Center, SPC 5340; 1500 E. Medical Center Drive; Ann Arbor, Mich. 48109-5340; [email protected]

Is Faculty Presence during Emergent Tracheal Intubations Justified?

We read with interest the prospective trial by Schmidt et al .1and the accompanying editorial,2which suggest that faculty supervision during emergency endotracheal intubations decreases the rate of airway complications. However, as with any observational study, confounders must be considered.First, several variables suggest that the set of intubations supervised by faculty anesthesiologists may have been slightly less emergent than those accomplished without faculty supervision. The reasons for intubation in the supervised group were more commonly airway protection and “other.” The supervised group was more likely to use neuromuscular blockade to accomplish tracheal intubation. The supervised group performed a higher proportion of intubations in the intensive care unit, a setting in which decompensating patients are more likely to be recognized before complete physiologic deterioration. Moreover, unlike some floor settings, intensive care unit beds are uniformly equipped with functioning suction, oxygen, and devices to deliver positive pressure mask ventilation and staffed by support personnel who are more experienced in identifying, mobilizing and participating in emergent clinical scenarios. Regardless of location, urgent and semiemergent intubations are more likely to allow time to assemble a full complement of personnel and equipment, to optimize patient position, and to consider aspiration prophylaxis, all of which should minimize risk of various complications.Second, as the authors suggest, the presence of a second anesthesia provider, irrespective of the level of training or experience, may facilitate safer tracheal intubation. Based on a multivariate logistic regression analysis of data collected in a prospective multicenter study,3tracheal intubation managed by an anesthesia team (including a junior and a senior provider) as opposed to a single senior provider, was shown to protect against airway complications. Our institution's experience and data support the conclusion that a second anesthesia provider, as opposed to a faculty anesthesiologist, is the process characteristic responsible for improved outcomes. The emergency intubation team at our institution includes a junior (CA-1 or CA-2) and senior anesthesiology resident (CA-3 with at least 24 months of laryngoscopic experience). Typically, a faculty member is present when difficult intubation is anticipated. Preliminary analysis of the electronic medical records for 2,460 emergent intubations over a 4-yr period revealed a 2.3% composite complication rate, with no differences based on faculty presence. Operator-reported complications included aspiration (n = 37), dental injury (n = 4), and esophageal intubation (n = 15). Of note, 8.4% of tracheal intubations were accomplished with the aid of a bougie introducer. The availability of this adjunct or providers' experience in its use was not presented by Schmidt et al . This may be responsible for the rate of frequent esophageal intubation in their studied population.Finally, time of day has been shown to affect survival to discharge after cardiopulmonary arrest.4The data collection sheet used by Schmidt et al ., which was presented in previous work,5includes the date and time of intubation. An analysis to evaluate the effect of nighttime or weekend intubations would be helpful. If nighttime intubations, or weekend intubations, or both, result in more complications, the explanation may be decreased faculty presence, but may also be a result of decreased nursing vigilance delaying the recognition of a need for emergency intubation, increased time from code activation to presence of the anesthesiology team, or circadian biologic factors in both patients and staff attempting the intubation.Faculty presence is the standard of care for intubations in the operating room. Extending this standard to emergency intubations would be desirable if it were to improve patient safety. However, undesirable effects on perioperative patient safety and healthcare costs must also be considered. During nights, weekends, and other periods of limited staffing, emergency intubations may pull on-call faculty away from the operating room or intensive care unit. Dedicated faculty to cover emergent intubations will entail increased on-call commitments and economic costs in many centers. These concerns justify a prospective study in either the intensive care unit or the floor with systematic or even randomized allocation of faculty presence to clarify the contribution of faculty anesthesiologists, urgency, location, time of day, and other confounders on significant patient airway outcomes.*University of Michigan Health System, Ann Arbor, Michigan. jmmhyre@umich.edu