1
|
Manson DK, Shen S, Lavelle MP, Lumish HS, Chong DH, De Miguel MH, Christianer K, Burnett EJ, Nickerson KG, Chandra S. Reorganizing a Medicine Residency Program in Response to the COVID-19 Pandemic in New York. Acad Med 2020; 95:1670-1673. [PMID: 32544102 PMCID: PMC7309644 DOI: 10.1097/acm.0000000000003548] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
The COVID-19 pandemic has been particularly severe in New York City, resulting in a rapid influx of patients into New York-Presbyterian Hospital/Columbia University Irving Medical Center. The challenges precipitated by this pandemic have required urgent changes to existing models of care. Internal medicine residents are at the forefront of caring for patients with COVID-19, including the critically ill. This article describes the exigent restructuring of the New York-Presbyterian Hospital/Columbia University Internal Medicine Residency Program. Patient care and educational models were fundamentally reconceptualized, which required a transition away from traditional hierarchical team structures and a significant expansion in the program's capacity and flexibility to care for large numbers of patients with disproportionately high levels of critical illness. These changes were made while the residency program maintained the priorities of patient care and safety, resident safety and well-being, open communication, and education. The process of adapting the residency program to the demands of the pandemic was iterative given the unprecedented nature of this crisis. The goal of this article is to share the experiences and lessons learned from this crisis, communicate the solutions that were designed, and inform others who may be facing the prospect of creating similar disaster response measures.
Collapse
Affiliation(s)
- Daniel K. Manson
- D.K. Manson is chief resident, Internal Medicine Residency Program, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Sherry Shen
- S. Shen is chief resident, Internal Medicine Residency Program, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Michael P. Lavelle
- M.P. Lavelle is chief resident, Internal Medicine Residency Program, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Heidi S. Lumish
- H.S. Lumish is chief resident, Internal Medicine Residency Program, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - David H. Chong
- D.H. Chong is former program director, Internal Medicine Residency Program, and associate professor of medicine, Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Maria H. De Miguel
- M.H. De Miguel is associate program director, Internal Medicine Residency Program, and assistant professor of medicine, Division of General Internal Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Kaylan Christianer
- K. Christianer is associate program director, Internal Medicine Residency Program, and assistant professor of medicine, Division of General Internal Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Eric J. Burnett
- E.J. Burnett is associate program director, Internal Medicine Residency Program, and instructor of medicine, Division of General Internal Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Katherine G. Nickerson
- K.G. Nickerson is vice chair of education, Department of Medicine, and professor of medicine, Division of Rheumatology, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Subani Chandra
- S. Chandra is program director, Internal Medicine Residency Program, associate vice chair of education, Department of Medicine, and associate professor of medicine, Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| |
Collapse
|
2
|
Munck C, Sheth RU, Cuaresma E, Weidler J, Stump SL, Zachariah P, Chong DH, Uhlemann AC, Abrams JA, Wang HH, Freedberg DE. The effect of short-course antibiotics on the resistance profile of colonizing gut bacteria in the ICU: a prospective cohort study. Crit Care 2020; 24:404. [PMID: 32646458 PMCID: PMC7350675 DOI: 10.1186/s13054-020-03061-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 06/04/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The need for early antibiotics in the intensive care unit (ICU) is often balanced against the goal of antibiotic stewardship. Long-course antibiotics increase the burden of antimicrobial resistance within colonizing gut bacteria, but the dynamics of this process are not fully understood. We sought to determine how short-course antibiotics affect the antimicrobial resistance phenotype and genotype of colonizing gut bacteria in the ICU by performing a prospective cohort study with assessments of resistance at ICU admission and exactly 72 h later. METHODS Deep rectal swabs were performed on 48 adults at the time of ICU admission and exactly 72 h later, including patients who did and did not receive antibiotics. To determine resistance phenotype, rectal swabs were cultured for methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE). In addition, Gram-negative bacterial isolates were cultured against relevant antibiotics. To determine resistance genotype, quantitative PCR (qPCR) was performed from rectal swabs for 87 established resistance genes. Within-individual changes in antimicrobial resistance were calculated based on culture and qPCR results and correlated with exposure to relevant antibiotics (e.g., did β-lactam antibiotic exposure associate with a detectable change in β-lactam resistance over this 72-h period?). RESULTS Of 48 ICU patients, 41 (85%) received antibiotics. Overall, there was no increase in the antimicrobial resistance profile of colonizing gut bacteria during the 72-h study period. There was also no increase in antimicrobial resistance after stratification by receipt of antibiotics (i.e., no detectable increase in β-lactam, vancomycin, or macrolide resistance regardless of whether patients received those same antibiotics). This was true for both culture and PCR. Antimicrobial resistance pattern at ICU admission strongly predicted resistance pattern after 72 h. CONCLUSIONS Short-course ICU antibiotics made little detectable difference in the antimicrobial resistance pattern of colonizing gut bacteria over 72 h in the ICU. This provides an improved understanding of the dynamics of antimicrobial resistance in the ICU and some reassurance that short-course antibiotics may not adversely impact the stewardship goal of reducing antimicrobial resistance.
Collapse
Affiliation(s)
- Christian Munck
- Department of Systems Biology, Columbia University Irving Medical Center, 3960 Broadway, New York, NY, 10032, USA.
| | - Ravi U Sheth
- Department of Systems Biology, Columbia University Irving Medical Center, 3960 Broadway, New York, NY, 10032, USA
| | - Edward Cuaresma
- Department of Medicine, Columbia University Irving Medical Center, New York, USA
| | - Jessica Weidler
- Division of Infectious Diseases, Columbia University Irving Medical Center, New York, USA
| | - Stephania L Stump
- Division of Infectious Diseases, Columbia University Irving Medical Center, New York, USA
| | - Philip Zachariah
- Division of Pediatric Infectious Diseases, Columbia University Irving Medical Center, New York, USA
| | - David H Chong
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center, New York, USA
| | - Anne-Catrin Uhlemann
- Division of Infectious Diseases, Columbia University Irving Medical Center, New York, USA
| | - Julian A Abrams
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, 630 West 168th Street, P&S 3-401, New York, NY, 10032, USA
| | - Harris H Wang
- Department of Systems Biology, Columbia University Irving Medical Center, 3960 Broadway, New York, NY, 10032, USA
| | - Daniel E Freedberg
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, 630 West 168th Street, P&S 3-401, New York, NY, 10032, USA.
| |
Collapse
|
3
|
Fu Y, Moscoso DI, Porter J, Krishnareddy S, Abrams JA, Seres D, Chong DH, Freedberg DE. Relationship Between Dietary Fiber Intake and Short-Chain Fatty Acid-Producing Bacteria During Critical Illness: A Prospective Cohort Study. JPEN J Parenter Enteral Nutr 2019; 44:463-471. [PMID: 31385326 DOI: 10.1002/jpen.1682] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 06/25/2019] [Accepted: 06/28/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Dietary fiber increases short-chain fatty acid (SCFA)-producing bacteria yet is often withheld in the intensive care unit (ICU). This study evaluated the safety and effect of fiber in ICU patients with gut microbiome sampling. METHODS This was a retrospective study nested within a prospective cohort. Adults were included if newly admitted to the ICU and could receive oral nutrition, enteral feedings, or no nutrition. Rectal swabs were performed at admission and 72 hours later. The primary exposure was fiber intake over 72 hours, classified in tertiles and adjusted for energy intake. The primary outcome was the relative abundance (RA) of SCFA producers via 16S RNA sequencing and the tolerability of fiber. RESULTS In 129 patients, median fiber intake was 13.4 g (interquartile range 0-35.4 g) over 72 hours. The high-fiber group had less abdominal distension (11% high fiber vs 28% no fiber, P < .01) and no increase in diarrhea (15% high fiber vs 13% no fiber, P = .94) or other adverse events. The median RA of SCFA producers after 72 hours was 0.40%, 0.50%, and 1.8% for the no-, low-, and high-fiber groups (P = .05 for trend). After correcting for energy intake, the median RA of SCFA producers was 0.41%, 0.32%, and 2.35% in the no-, low-, and high-corrected-fiber categories (P < .01). These associations remained significant after adjusting for clinical factors including antibiotics. CONCLUSIONS During the 72 hours after ICU admission, fiber was well tolerated, and higher fiber intake was associated with more SCFA-producers.
Collapse
Affiliation(s)
- Yichun Fu
- Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | | | - Joyce Porter
- Irving Medical Center, Columbia University, New York, New York, USA
| | - Suneeta Krishnareddy
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, New York, New York, USA
| | - Julian A Abrams
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, New York, New York, USA
| | - David Seres
- Department of Medicine, Division of Preventive Medicine and Nutrition and Institute of Human Nutrition, Columbia University Irving Medical Center, New York, New York, USA
| | - David H Chong
- Division of Allergy, Pulmonary and Critical Care, Columbia University Irving Medical Center, New York, New York, USA
| | - Daniel E Freedberg
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, New York, New York, USA.,Mailman School of Public Health, New York, New York, USA
| |
Collapse
|
4
|
Kahn JM, Davis BS, Yabes JG, Chang CCH, Chong DH, Hershey TB, Martsolf GR, Angus DC. Association Between State-Mandated Protocolized Sepsis Care and In-hospital Mortality Among Adults With Sepsis. JAMA 2019; 322:240-250. [PMID: 31310298 PMCID: PMC6635905 DOI: 10.1001/jama.2019.9021] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
IMPORTANCE Beginning in 2013, New York State implemented regulations mandating that hospitals implement evidence-based protocols for sepsis management, as well as report data on protocol adherence and clinical outcomes to the state government. The association between these mandates and sepsis outcomes is unknown. OBJECTIVE To evaluate the association between New York State sepsis regulations and the outcomes of patients hospitalized with sepsis. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of adult patients hospitalized with sepsis in New York State and in 4 control states (Florida, Maryland, Massachusetts, and New Jersey) using all-payer hospital discharge data (January 1, 2011-September 30, 2015) and a comparative interrupted time series analytic approach. EXPOSURES Hospitalization for sepsis before (January 1, 2011-March 31, 2013) vs after (April 1, 2013-September 30, 2015) implementation of the 2013 New York State sepsis regulations. MAIN OUTCOMES AND MEASURES The primary outcome was 30-day in-hospital mortality. Secondary outcomes were intensive care unit admission rates, central venous catheter use, Clostridium difficile infection rates, and hospital length of stay. RESULTS The final analysis included 1 012 410 sepsis admissions to 509 hospitals. The mean age was 69.5 years (SD, 16.4 years) and 47.9% were female. In New York State and in the control states, 139 019 and 289 225 patients, respectively, were admitted before implementation of the sepsis regulations and 186 767 and 397 399 patients, respectively, were admitted after implementation of the sepsis regulations. Unadjusted 30-day in-hospital mortality was 26.3% in New York State and 22.0% in the control states before the regulations, and was 22.0% in New York State and 19.1% in the control states after the regulations. Adjusting for patient and hospital characteristics as well as preregulation temporal trends and season, mortality after implementation of the regulations decreased significantly in New York State relative to the control states (P = .02 for the joint test of the comparative interrupted time series estimates). For example, by the 10th quarter after implementation of the regulations, adjusted absolute mortality was 3.2% (95% CI, 1.0% to 5.4%) lower than expected in New York State relative to the control states (P = .004). The regulations were associated with no significant differences in intensive care unit admission rates (P = .09) (10th quarter adjusted difference, 2.8% [95% CI, -1.7% to 7.2%], P = .22), a significant relative decrease in hospital length of stay (P = .04) (10th quarter adjusted difference, 0.50 days [95% CI, -0.47 to 1.47 days], P = .31), a significant relative decrease in the C difficile infection rate (P < .001) (10th quarter adjusted difference, -1.8% [95% CI, -2.6% to -1.0%], P < .001), and a significant relative increase in central venous catheter use (P = .02) (10th quarter adjusted difference, 4.8% [95% CI, 2.3% to 7.4%], P < .001). CONCLUSIONS AND RELEVANCE In New York State, mandated protocolized sepsis care was associated with a greater decrease in sepsis mortality compared with sepsis mortality in control states that did not implement sepsis regulations. Because baseline mortality rates differed between New York and comparison states, it is uncertain whether these findings are generalizable to other states.
Collapse
Affiliation(s)
- Jeremy M. Kahn
- CRISMA Center, Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Billie S. Davis
- CRISMA Center, Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jonathan G. Yabes
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Chung-Chou H. Chang
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - David H. Chong
- Division of Pulmonary, Allergy and Critical Care Medicine, Columbia University Medical Center, New York, New York
| | - Tina Batra Hershey
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Grant R. Martsolf
- Department of Acute and Tertiary Care, School of Nursing, University of Pittsburgh, Pittsburgh, Pennsylvania
- RAND Corporation, Pittsburgh, Pennsylvania
| | - Derek C. Angus
- CRISMA Center, Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| |
Collapse
|
5
|
Livanos AE, Snider EJ, Whittier S, Chong DH, Wang TC, Abrams JA, Freedberg DE. Rapid gastrointestinal loss of Clostridial Clusters IV and XIVa in the ICU associates with an expansion of gut pathogens. PLoS One 2018; 13:e0200322. [PMID: 30067768 PMCID: PMC6070193 DOI: 10.1371/journal.pone.0200322] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 06/23/2018] [Indexed: 12/15/2022] Open
Abstract
Commensal gastrointestinal bacteria resist the expansion of pathogens and are lost during critical illness, facilitating pathogen colonization and infection. We performed a prospective, ICU-based study to determine risk factors for loss of gut colonization resistance during the initial period of critical illness. Rectal swabs were taken from adult ICU patients within 4 hours of admission and 72 hours later, and analyzed using 16S rRNA gene sequencing and selective culture for vancomycin-resistant Enterococcus (VRE). Microbiome data was visualized using principal coordinate analyses (PCoA) and assessed using a linear discriminant analysis algorithm and logistic regression modeling. 93 ICU patients were analyzed. At 72 hours following ICU admission, there was a significant decrease in the proportion of Clostridial Clusters IV/XIVa, taxa that produce short chain fatty acids (SCFAs). At the same time, there was a significant expansion in Enterococcus. Decreases in Cluster IV/XIVa Clostridia were associated with loss of gut microbiome colonization resistance (reduced diversity and community stability over time). In multivariable analysis, both decreased Cluster IV/XIVa Clostridia and increased Enterococcus after 72 hours were associated with receipt of antibiotics. Cluster IV/XIVa Clostridia, although a small fraction of the overall gastrointestinal microbiome, drove distinct clustering on PCoA. During initial treatment for critical illness, there was a loss of Cluster IV/XIVa Clostridia within the distal gut microbiome which associated with an expansion of VRE and with a loss of gut microbiome colonization resistance. Receipt of broad-spectrum antibiotics was associated with these changes.
Collapse
Affiliation(s)
- Alexandra E. Livanos
- Division of General Medicine, Columbia University Medical Center, New York, NY, United States of America
| | - Erik J. Snider
- Division of General Medicine, Columbia University Medical Center, New York, NY, United States of America
| | - Susan Whittier
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, NY, United States of America
| | - David H. Chong
- Division of Allergy, Pulmonary, and Critical Care Medicine, Columbia University Medical Center, New York, NY, United States of America
| | - Timothy C. Wang
- Division of Digestive and Liver Diseases, Columbia University Medical Center, New York, NY, United States of America
| | - Julian A. Abrams
- Division of Digestive and Liver Diseases, Columbia University Medical Center, New York, NY, United States of America
| | - Daniel E. Freedberg
- Division of Digestive and Liver Diseases, Columbia University Medical Center, New York, NY, United States of America
- * E-mail:
| |
Collapse
|
6
|
Postelnicu R, Pastores SM, Chong DH, Evans L. Sepsis early warning scoring systems: The ideal tool remains elusive! J Crit Care 2018; 52:251-253. [PMID: 30017205 DOI: 10.1016/j.jcrc.2018.07.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 06/03/2018] [Accepted: 07/05/2018] [Indexed: 01/19/2023]
Affiliation(s)
- Radu Postelnicu
- Division of Pulmonary, Critical Care, and Sleep Medicine, New York University School of Medicine, Bellevue Hospital, New York, NY, USA
| | - Stephen M Pastores
- Critical Care Center, Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - David H Chong
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, New York, NY, USA
| | - Laura Evans
- Division of Pulmonary, Critical Care, and Sleep Medicine, New York University School of Medicine, Bellevue Hospital, New York, NY, USA.
| |
Collapse
|
7
|
Freedberg DE, Zhou MJ, Cohen ME, Annavajhala MK, Khan S, Moscoso DI, Brooks C, Whittier S, Chong DH, Uhlemann AC, Abrams JA. Pathogen colonization of the gastrointestinal microbiome at intensive care unit admission and risk for subsequent death or infection. Intensive Care Med 2018; 44:1203-1211. [PMID: 29936583 DOI: 10.1007/s00134-018-5268-8] [Citation(s) in RCA: 91] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 06/05/2018] [Indexed: 02/07/2023]
Abstract
PURPOSE Loss of colonization resistance within the gastrointestinal microbiome facilitates the expansion of pathogens and has been associated with death and infection in select populations. We tested whether gut microbiome features at the time of intensive care unit (ICU) admission predict death or infection. METHODS This was a prospective cohort study of medical ICU adults. Rectal surveillance swabs were performed at admission, selectively cultured for vancomycin-resistant Enterococcus (VRE), and assessed using 16S rRNA gene sequencing. Patients were followed for 30 days for death or culture-proven bacterial infection. RESULTS Of 301 patients, 123 (41%) developed culture-proven infections and 76 (25%) died. Fecal biodiversity (Shannon index) did not differ based on death or infection (p = 0.49). The presence of specific pathogens at ICU admission was associated with subsequent infection with the same organism for Escherichia coli, Pseudomonas spp., Klebsiella spp., and Clostridium difficile, and VRE at admission was associated with subsequent Enterococcus infection. In a multivariable model adjusting for severity of illness, VRE colonization and Enterococcus domination (≥ 30% 16S reads) were both associated with death or all-cause infection (aHR 1.46, 95% CI 1.06-2.00 and aHR 1.47, 95% CI 1.00-2.19, respectively); among patients without VRE colonization, Enterococcus domination was associated with excess risk of death or infection (aHR 2.13, 95% CI 1.06-4.29). CONCLUSIONS Enterococcus status at ICU admission was associated with risk for death or all-cause infection, and rectal carriage of common ICU pathogens predicted specific infections. The gastrointestinal microbiome may have a role in risk stratification and early diagnosis of ICU infections.
Collapse
Affiliation(s)
- Daniel E Freedberg
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Medical Center, 630 West 168th Street, New York, NY, 10032, USA.
| | - Margaret J Zhou
- Department of Medicine, Columbia University Medical Center, New York, USA
| | - Margot E Cohen
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - Medini K Annavajhala
- Microbiome and Pathogen Genomics Core, Department of Medicine, Columbia University Medical Center, New York, USA
| | - Sabrina Khan
- Microbiome and Pathogen Genomics Core, Department of Medicine, Columbia University Medical Center, New York, USA
| | - Dagmara I Moscoso
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Medical Center, 630 West 168th Street, New York, NY, 10032, USA
| | - Christian Brooks
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Medical Center, 630 West 168th Street, New York, NY, 10032, USA
| | - Susan Whittier
- Division of Laboratory Medicine, Department of Pathology and Cell Biology, Columbia University Medical Center, New York, USA
| | - David H Chong
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University Medical Center, New York, USA
| | - Anne-Catrin Uhlemann
- Microbiome and Pathogen Genomics Core, Department of Medicine, Columbia University Medical Center, New York, USA.,Division of Infectious Diseases, Department of Medicine, Columbia University Medical Center, New York, USA
| | - Julian A Abrams
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Medical Center, 630 West 168th Street, New York, NY, 10032, USA.,Mailman School of Public Health, New York, USA
| |
Collapse
|
8
|
Boverman G, Isaacson D, Newell JC, Saulnier GJ, Kao TJ, Amm BC, Wang X, Davenport DM, Chong DH, Sahni R, Ashe JM. Efficient Simultaneous Reconstruction of Time-Varying Images and Electrode Contact Impedances in Electrical Impedance Tomography. IEEE Trans Biomed Eng 2016; 64:795-806. [PMID: 27295649 DOI: 10.1109/tbme.2016.2578646] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE In electrical impedance tomography (EIT), we apply patterns of currents on a set of electrodes at the external boundary of an object, measure the resulting potentials at the electrodes, and, given the aggregate dataset, reconstruct the complex conductivity and permittivity within the object. It is possible to maximize sensitivity to internal conductivity changes by simultaneously applying currents and measuring potentials on all electrodes but this approach also maximizes sensitivity to changes in impedance at the interface. METHODS We have, therefore, developed algorithms to assess contact impedance changes at the interface as well as to efficiently and simultaneously reconstruct internal conductivity/permittivity changes within the body. We use simple linear algebraic manipulations, the generalized singular value decomposition, and a dual-mesh finite-element-based framework to reconstruct images in real time. We are also able to efficiently compute the linearized reconstruction for a wide range of regularization parameters and to compute both the generalized cross-validation parameter as well as the L-curve, objective approaches to determining the optimal regularization parameter, in a similarly efficient manner. RESULTS Results are shown using data from a normal subject and from a clinical intensive care unit patient, both acquired with the GE GENESIS prototype EIT system, demonstrating significantly reduced boundary artifacts due to electrode drift and motion artifact.
Collapse
|
9
|
Abstract
Recent studies have shown a dramatic increase in the number of intensive care unit (ICU) beds in recent decades. As technologies have become more complex, ICUs continue to grow in size and in specialization. The driving forces behind ICU bed expansion include not only the incorporation of advanced technologies but also other factors such as the increased utilization of ICU beds for patients who previously were not offered ICU care--those who may be terminally ill and those who are not critically ill. This expansion of ICU care in the United States sets it apart from other industrialized nations with comparably fewer ICU beds in relation to other hospital beds. The consequences of this expansion are now being felt in the form of unused beds, workforce shortages, and overuse of ICUs for patients who previously were not cared for in ICUs. ICUs are also now commonly used in the care of dying patients. In coming decades it is likely that changes will need to take place to forestall exorbitant costs and labor shortages. In addition to bringing in new forms of medical staff such as hospitalists and physician assistants, recent opinion papers have suggested that a de-escalation of ICU growth and a new tiered system of ICU care will be necessary in the United States.
Collapse
Affiliation(s)
- Nicholas S Ward
- Division of Pulmonary, Critical Care and Sleep Medicine, Alpert/Brown Medical School, Providence, Rhode Island
| | - David H Chong
- Division of Critical Care, New York Presbyterian Hospital/Columbia University Medical Center, New York, New York
| |
Collapse
|
10
|
Chandra S, Chong DH. New cost-effective treatment strategies for acute emergency situations. Annu Rev Med 2013; 65:459-69. [PMID: 24160941 DOI: 10.1146/annurev-med-060112-095857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
In an era of ever-increasing healthcare costs, new treatments must not only improve outcomes and quality of care but also be cost-effective. This is most challenging for emergency and critical care. Bigger and better has been the mantra of Western medical care for decades, leading to costlier but not necessarily better care. Recent advances focused on new implementation processes for evidence-based best practices such as checklists and bundles have transformed medical care. We outline recent advances in medical practice that have positively affected both the quality of care and its cost-effectiveness. Future medical care must be smarter and more effective if we are to meet the increasing demands of an aging patient population in the context of ever more limited resources.
Collapse
Affiliation(s)
- Subani Chandra
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care, Columbia University College of Physicians and Surgeons, New York, New York 10032; ,
| | | |
Collapse
|
11
|
Avarbock AB, Gill KZ, Lauren CT, Chong DH, Silvers DN, Grossman ME. Serpentine supravenous hyperpigmentation secondary to superficial venous thrombosis in autoimmune hemolytic anemia. Int J Dermatol 2013; 53:e96-7. [PMID: 23330569 DOI: 10.1111/j.1365-4632.2012.05721.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Andrew B Avarbock
- Department of Dermatology, Columbia-Presbyterian Medical Center, New York, NY, USA.
| | | | | | | | | | | |
Collapse
|
12
|
Beitler JR, Link N, Bails DB, Hurdle K, Chong DH. Reduction in hospital-wide mortality after implementation of a rapid response team: a long-term cohort study. Crit Care 2011; 15:R269. [PMID: 22085785 PMCID: PMC3388666 DOI: 10.1186/cc10547] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/21/2011] [Revised: 10/18/2011] [Accepted: 11/15/2011] [Indexed: 11/10/2022]
Abstract
Introduction Rapid response teams (RRTs) have been shown to reduce cardiopulmonary arrests outside the intensive care unit (ICU). Yet the utility of RRTs remains in question, as most large studies have failed to demonstrate a significant reduction in hospital-wide mortality after RRT implementation. Methods A cohort design with historical controls was used to determine the effect on hospital-wide mortality of an RRT in which clinical judgment, in addition to vital-signs criteria, was widely promoted as a key trigger for activation. All nonprisoner patients admitted to a tertiary referral public teaching hospital from 2003 through 2008 were included. In total, 77, 021 admissions before RRT implementation (2003 through 2005) and 79, 013 admissions after RRT implementation (2006 through 2008) were evaluated. The a priori primary outcome was unadjusted hospital-wide mortality. A Poisson regression model was then used to adjust for hospital-wide mortality trends over time. Secondary outcomes defined a priori were unadjusted out-of-ICU mortality and out-of-ICU cardiopulmonary-arrest codes. Results In total, 855 inpatient RRTs (10.8 per 1, 000 hospital-wide discharges) were activated during the 3-year postintervention period. Forty-seven percent of RRTs were activated for reasons of clinical judgment. Hospital-wide mortality decreased from 15.50 to 13.74 deaths per 1, 000 discharges after RRT implementation (relative risk, 0.887; 95% confidence interval (CI), 0.817 to 0.963; P = 0.004). After adjusting for inpatient mortality trends over time, the reduction in hospital-wide mortality remained statistically significant (relative risk, 0.825; 95% CI, 0.694 to 0.981; P = 0.029). Out-of-ICU mortality decreased from 7.08 to 4.61 deaths per 1, 000 discharges (relative risk, 0.651; 95% CI, 0.570 to 0.743; P < 0.001). Out-of-ICU cardiopulmonary-arrest codes decreased from 3.28 to 1.62 codes per 1, 000 discharges (relative risk, 0.493; 95% CI, 0.399 to 0.610; P < 0.001). Conclusions Implementation of an RRT in which clinical judgment, in addition to vital-signs criteria, was widely cited as a rationale for activation, was associated with a significant reduction in hospital-wide mortality, out-of-ICU mortality, and out-of-ICU cardiopulmonary-arrest codes. The frequent use of clinical judgment as a criterion for RRT activation was associated with high RRT utilization.
Collapse
Affiliation(s)
- Jeremy R Beitler
- Pulmonary and Critical Care Unit, Massachusetts General Hospital, 55 Fruit Street, BUL-148, Boston, Massachusetts 02114, USA.
| | | | | | | | | |
Collapse
|
13
|
Owen MC, Chang NM, Chong DH, Vawdrey DK. Evaluation of medication list completeness, safety, and annotations. AMIA Annu Symp Proc 2011; 2011:1055-1061. [PMID: 22195166 PMCID: PMC3243276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Clinical documents frequently contain a list of a patient's medications. Missing information about the dosage, route, or frequency of a medication impairs clinical communication and may harm patients. We examined 253 medication lists. There were 181 lists (72%) with at least one medication missing a dose, route, or frequency. Missing information was judged to be potentially harmful in 47 of the lists (19% of 253) by three physician reviewers (kappa=0.69). We also observed that many lists contained additional information included as annotations, prompting a secondary thematic analysis of the annotations. Fifty-five of the 253 lists (22%) contained one or more annotations. The most frequent types of annotations were comments about the patient's medical history, the clinician's treatment plan changes, and the patient's adherence to a medication. Future development of electronic medication reconciliation tools to improve medication list completeness should also support annotating the medication list in a flexible manner.
Collapse
|
14
|
Abstract
BACKGROUND AND OBJECTIVE 5-aminolaevulinic acid (ALA) is a new, promising photosensitizer for PDT of cancer. Subcellular toxicity induced by ALA and light exposure in single cells was studied to elucidate the mechanism of cell damage. STUDY DESIGN/MATERIALS AND METHODS CPAE, PTK2, and rat neonatal myocardial cells treated with ALA were examined for localization using fluorescence microscopy and for subcellular phototoxicity using 630 nm laser microbeam irradiation of specific subcellular regions. RESULTS In CPAE and PTK2 cells, a large amount of fluorescence was detected in the peri-nuclear cytoplasm. In rat neonatal myocardial cells, the sensitizer selectively localized in the large mitochondria. In both cell types, there was little phototoxicity when the peripheral cytoplasmic region was exposed, as compared to considerable phototoxicity with exposure of either the perinuclear or nuclear regions. CONCLUSION Both the CPAE and PTK2 cells demonstrated that the nucleus followed by the perinuclear cytoplasm are the most sensitive cell areas with no sensitivity in the peripheral cytoplasm.
Collapse
Affiliation(s)
- H Liang
- Beckman Laser Institute and Medical Clinic, University of California, Irvine 92612, USA
| | | | | | | | | | | | | | | | | |
Collapse
|