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Anderson TM, Secrest K, Krein SL, Schildhouse R, Guetterman TC, Harrod M, Trumpower B, Kronick SL, Pribble J, Chan PS, Nallamothu BK. Best Practices for Education and Training of Resuscitation Teams for In-Hospital Cardiac Arrest. Circ Cardiovasc Qual Outcomes 2021; 14:e008587. [PMID: 34779653 PMCID: PMC8759032 DOI: 10.1161/circoutcomes.121.008587] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 11/16/2022]
Abstract
Background: Survival outcomes following in-hospital cardiac arrest (IHCA) vary significantly across hospitals. Research suggests clinician education and training may play a role. We sought to identify best practices related to the education and training of resuscitation teams. Methods: We conducted a descriptive qualitative analysis of semi-structured interview data obtained from in-depth site visits conducted from 2016-2017 at 9 diverse hospitals within the American Heart Association "Get With The Guidelines" registry, selected based on IHCA survival performance (5 top-, 1 middle-, 3 low-performing). We assessed coded data related to education and training including systems learning, informal feedback and debrief, and formal learning through ACLS and mock codes. Thematic analysis was used to identify best practices. Results: In total, 129 interviews were conducted with a variety of hospital staff including nurses, chaplains, security guards, respiratory therapists, physicians, pharmacists, and administrators, yielding 78 hours and 29 minutes of interview time. Four themes related to training and education were identified: engagement, clear communication, consistency, and responsive leadership. Top-performing hospitals encouraged employee engagement with creative marketing of new programs and prioritizing hands-on learning over passive didactics. Clear communication was accomplished with debriefing, structured institutional review, and continual, frequent education for departments. Consistency was a cornerstone to culture change and was achieved with uniform policies for simulation practice as well as reinforced, routine practice (weekly, monthly, quarterly). Finally, top-performing hospitals had responsive leadership teams across multiple disciplines (nursing, respiratory therapy, pharmacy and medicine), who listened and adapted programs to fit the needs of their staff. Conclusions: Among top-performing hospitals excelling in IHCA survival, we identified core elements for education and training of resuscitation teams. Developing tools to expand these areas for hospitals may improve IHCA outcomes.
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Affiliation(s)
- Theresa M Anderson
- Department of Internal Medicine (T.M.A., K.S., S.L. Krein, B.K.N., B.T.), University of Michigan Medical School, Ann Arbor
| | - Kayla Secrest
- Department of Internal Medicine (T.M.A., K.S., S.L. Krein, B.K.N., B.T.), University of Michigan Medical School, Ann Arbor
| | - Sarah L Krein
- Department of Internal Medicine (T.M.A., K.S., S.L. Krein, B.K.N., B.T.), University of Michigan Medical School, Ann Arbor
| | - Richard Schildhouse
- Department of Internal Medicine, Veteran Affairs Ann Arbor Healthcare System, MI (R.S.)
| | - Timothy C Guetterman
- Department of Family Medicine (T.C.G.), University of Michigan Medical School, Ann Arbor
| | - Molly Harrod
- Department of Internal Medicine, Veteran Affairs Ann Arbor Healthcare System, MI (R.S.)
| | - Brad Trumpower
- Department of Internal Medicine (T.M.A., K.S., S.L. Krein, B.K.N., B.T.), University of Michigan Medical School, Ann Arbor
| | - Steven L Kronick
- Department of Emergency Medicine (S.L. Kronick, J.P.), University of Michigan Medical School, Ann Arbor
| | - James Pribble
- Department of Emergency Medicine (S.L. Kronick, J.P.), University of Michigan Medical School, Ann Arbor
| | - Paul S Chan
- Department of Internal Medicine, Saint Luke's Health System, Kansas City, MO (P.S.C.)
| | - Brahmajee K Nallamothu
- Department of Internal Medicine (T.M.A., K.S., S.L. Krein, B.K.N., B.T.), University of Michigan Medical School, Ann Arbor
- Veterans Affairs Ann Arbor Center for Clinical Management Research, MI (S.L. Krein, M.H., B.K.N.)
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2
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Schroeder LF, Bachman MA, Idoni A, Gegenheimer-Holmes J, Kronick SL, Valdez R, Lephart PR. Predicting Direct-Specimen SARS-CoV-2 Assay Performance Using Residual Patient Samples. J Appl Lab Med 2021; 7:661-673. [PMID: 34755849 PMCID: PMC8767897 DOI: 10.1093/jalm/jfab159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 10/21/2021] [Indexed: 11/14/2022]
Abstract
Background Diagnostic sensitivities of point-of-care SARS-CoV-2 assays depend on specimen type and population-specific viral loads. Evaluation of these assays require ‘direct’ specimens from paired-swab studies rather than more accessible residual specimens in viral transport media (VTM). Methods Residual VTM and limit-of-detection studies were conducted on Abbott ID NOW™ COVID-19, Quidel Sofia 2™ SARS Antigen FIA, and DiaSorin Simplexa™ COVID-19 Direct assays, with cycle threshold (CT) adjustments to approximate direct-specimen testing based on gene-target doubling each PCR cycle. Logistic regression was used to model assay performance by specimen CT. These models were applied to CT distributions of symptomatic and asymptomatic populations presenting to emergency services to predict the percent of specimens that would be detected by each assay. A 96-sample paired-swab study was conducted to confirm model results. Results When using direct nasopharyngeal samples and fit with either VTM or limit-of-detection data, percent positivities for ID NOW (symptomatic 94.9%/97.4%; asymptomatic 88.4.0%/89.6%) and Simplexa (symptomatic 97.8%/97.2%; asymptomatic 91.1%/90.8%) were predicted to be similar. Likewise, fit with VTM data, percent positivities for ID NOW with direct nasal specimens (symptomatic 77.8%; asymptomatic 64.5%) and Sofia 2 with direct nasopharyngeal specimens (symptomatic 76.6%, asymptomatic 60.3%) were similar. The paired-swab study comparing direct nasopharyngeal specimens on ID NOW and nasopharyngeal VTM specimens on Simplexa showed 99% concordance. Conclusions Assay performance can be modeled as dependent on viral load, fit using laboratory bench study results, and adjusted to account for direct-specimen testing. When using nasopharyngeal specimens, direct testing on Abbott ID NOW and VTM testing on DiaSorin Simplexa have similar performance.
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Affiliation(s)
- Lee F Schroeder
- University of Michigan, Michigan Medicine, Department of Pathology, Ann Arbor, Michigan, USA
| | - Michael A Bachman
- University of Michigan, Michigan Medicine, Department of Pathology, Ann Arbor, Michigan, USA
| | - Allison Idoni
- University of Michigan, Michigan Medicine, Department of Pathology, Ann Arbor, Michigan, USA
| | | | - Steven L Kronick
- University of Michigan, Michigan Medicine, Department of Emergency Services, Ann Arbor, Michigan, USA
| | - Riccardo Valdez
- University of Michigan, Michigan Medicine, Department of Pathology, Ann Arbor, Michigan, USA
| | - Paul R Lephart
- University of Michigan, Michigan Medicine, Department of Pathology, Ann Arbor, Michigan, USA
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3
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Franklin BJ, Li KY, Somand DM, Kocher KE, Kronick SL, Parekh VI, Goralnick E, Nix AT, Haas NL. Emergency department provider in triage: assessing site-specific rationale, operational feasibility, and financial impact. J Am Coll Emerg Physicians Open 2021; 2:e12450. [PMID: 34085053 PMCID: PMC8144283 DOI: 10.1002/emp2.12450] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 04/09/2021] [Accepted: 04/22/2021] [Indexed: 11/18/2022] Open
Abstract
Emergency department (ED) crowding is recognized as a critical threat to patient safety, while sub-optimal ED patient flow also contributes to reduced patient satisfaction and efficiency of care. Provider in triage (PIT) programs-which typically involve, at a minimum, a physician or advanced practice provider conducting an initial screening exam and potentially initiating treatment and diagnostic testing at the time of triage-are frequently endorsed as a mechanism to reduce ED length of stay (LOS) and therefore mitigate crowding, improve patient satisfaction, and improve ED operational and financial performance. However, the peer-reviewed evidence regarding the impact of PIT programs on measures including ED LOS, wait times, and costs (as variously defined) is mixed. Mechanistically, PIT programs exert their effects by initiating diagnostic work-ups earlier and, sometimes, by equipping triage providers to directly disposition patients. However, depending on local contextual factors-including the co-existence of other front-end interventions and delays in ED throughput not addressed by PIT-we demonstrate how these features may or may not ultimately translate into reduced ED LOS in different settings. Consequently, site-specific analysis of the root causes of excessive ED LOS, along with mechanistic assessment of potential countermeasures, is essential for appropriate deployment and successful design of PIT programs at individual EDs. Additional motivations for implementing PIT programs may include their potential to enhance patient safety, patient satisfaction, and team dynamics. In this conceptual article, we address a gap in the literature by demonstrating the mechanisms underlying PIT program results and providing a framework for ED decision-makers to assess the local rationale for, operational feasibility of, and financial impact of PIT programs.
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Affiliation(s)
| | - Kathleen Y. Li
- Institute for Healthcare Policy and InnovationUniversity of MichiganAnn ArborMichiganUSA
- Department of Emergency MedicineMichigan MedicineAnn ArborMichiganUSA
- Department of Emergency MedicineIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - David M. Somand
- Department of Emergency MedicineMichigan MedicineAnn ArborMichiganUSA
- Division of Emergency Critical CareMichigan MedicineAnn ArborMichiganUSA
| | - Keith E. Kocher
- Institute for Healthcare Policy and InnovationUniversity of MichiganAnn ArborMichiganUSA
- Department of Emergency MedicineMichigan MedicineAnn ArborMichiganUSA
| | - Steven L. Kronick
- Department of Emergency MedicineMichigan MedicineAnn ArborMichiganUSA
| | - Vikas I. Parekh
- Department of Internal MedicineMichigan MedicineAnn ArborMichiganUSA
| | - Eric Goralnick
- Department of Emergency MedicineBrigham and Women's HospitalBostonMassachusettsUSA
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | - A. Tyler Nix
- Taubman Health Sciences LibraryUniversity of MichiganAnn ArborMichiganUSA
| | - Nathan L. Haas
- Department of Emergency MedicineMichigan MedicineAnn ArborMichiganUSA
- Division of Emergency Critical CareMichigan MedicineAnn ArborMichiganUSA
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4
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Cummings BC, Ansari S, Motyka JR, Wang G, Medlin RP, Kronick SL, Singh K, Park PK, Napolitano LM, Dickson RP, Mathis MR, Sjoding MW, Admon AJ, Blank R, McSparron JI, Ward KR, Gillies CE. Predicting Intensive Care Transfers and Other Unforeseen Events: Analytic Model Validation Study and Comparison to Existing Methods. JMIR Med Inform 2021; 9:e25066. [PMID: 33818393 PMCID: PMC8061893 DOI: 10.2196/25066] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 01/15/2021] [Accepted: 04/03/2021] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND COVID-19 has led to an unprecedented strain on health care facilities across the United States. Accurately identifying patients at an increased risk of deterioration may help hospitals manage their resources while improving the quality of patient care. Here, we present the results of an analytical model, Predicting Intensive Care Transfers and Other Unforeseen Events (PICTURE), to identify patients at high risk for imminent intensive care unit transfer, respiratory failure, or death, with the intention to improve the prediction of deterioration due to COVID-19. OBJECTIVE This study aims to validate the PICTURE model's ability to predict unexpected deterioration in general ward and COVID-19 patients, and to compare its performance with the Epic Deterioration Index (EDI), an existing model that has recently been assessed for use in patients with COVID-19. METHODS The PICTURE model was trained and validated on a cohort of hospitalized non-COVID-19 patients using electronic health record data from 2014 to 2018. It was then applied to two holdout test sets: non-COVID-19 patients from 2019 and patients testing positive for COVID-19 in 2020. PICTURE results were aligned to EDI and NEWS scores for head-to-head comparison via area under the receiver operating characteristic curve (AUROC) and area under the precision-recall curve. We compared the models' ability to predict an adverse event (defined as intensive care unit transfer, mechanical ventilation use, or death). Shapley values were used to provide explanations for PICTURE predictions. RESULTS In non-COVID-19 general ward patients, PICTURE achieved an AUROC of 0.819 (95% CI 0.805-0.834) per observation, compared to the EDI's AUROC of 0.763 (95% CI 0.746-0.781; n=21,740; P<.001). In patients testing positive for COVID-19, PICTURE again outperformed the EDI with an AUROC of 0.849 (95% CI 0.820-0.878) compared to the EDI's AUROC of 0.803 (95% CI 0.772-0.838; n=607; P<.001). The most important variables influencing PICTURE predictions in the COVID-19 cohort were a rapid respiratory rate, a high level of oxygen support, low oxygen saturation, and impaired mental status (Glasgow Coma Scale). CONCLUSIONS The PICTURE model is more accurate in predicting adverse patient outcomes for both general ward patients and COVID-19 positive patients in our cohorts compared to the EDI. The ability to consistently anticipate these events may be especially valuable when considering potential incipient waves of COVID-19 infections. The generalizability of the model will require testing in other health care systems for validation.
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Affiliation(s)
- Brandon C Cummings
- Michigan Center for Integrative Research in Critical Care, Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Sardar Ansari
- Michigan Center for Integrative Research in Critical Care, Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Jonathan R Motyka
- Michigan Center for Integrative Research in Critical Care, Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Guan Wang
- Michigan Center for Integrative Research in Critical Care, Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Richard P Medlin
- Michigan Center for Integrative Research in Critical Care, Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Steven L Kronick
- Michigan Center for Integrative Research in Critical Care, Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Karandeep Singh
- Michigan Center for Integrative Research in Critical Care, Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, United States.,Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States.,Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI, United States.,Michigan Institute for Data Science, University of Michigan, Ann Arbor, MI, United States
| | - Pauline K Park
- Michigan Center for Integrative Research in Critical Care, Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, United States.,Department of Surgery, University of Michigan, Ann Arbor, MI, United States
| | - Lena M Napolitano
- Michigan Center for Integrative Research in Critical Care, Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, United States.,Department of Surgery, University of Michigan, Ann Arbor, MI, United States
| | - Robert P Dickson
- Michigan Center for Integrative Research in Critical Care, Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, United States.,Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States.,Department of Microbiology & Immunology, University of Michigan, Ann Arbor, MI, United States
| | - Michael R Mathis
- Michigan Center for Integrative Research in Critical Care, Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, United States.,Department of Anesthesiology, University of Michigan, Ann Arbor, MI, United States
| | - Michael W Sjoding
- Michigan Center for Integrative Research in Critical Care, Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, United States.,Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Andrew J Admon
- Michigan Center for Integrative Research in Critical Care, Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, United States.,Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States.,Michigan Institute for Data Science, University of Michigan, Ann Arbor, MI, United States
| | - Ross Blank
- Michigan Center for Integrative Research in Critical Care, Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, United States.,Department of Anesthesiology, University of Michigan, Ann Arbor, MI, United States
| | - Jakob I McSparron
- Michigan Center for Integrative Research in Critical Care, Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, United States.,Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Kevin R Ward
- Michigan Center for Integrative Research in Critical Care, Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, United States.,Michigan Institute for Data Science, University of Michigan, Ann Arbor, MI, United States.,Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, United States
| | - Christopher E Gillies
- Michigan Center for Integrative Research in Critical Care, Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, United States.,Michigan Institute for Data Science, University of Michigan, Ann Arbor, MI, United States
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5
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Petty LA, Vaughn VM, Flanders SA, Patel T, Malani AN, Ratz D, Kaye KS, Pogue JM, Dumkow LE, Thyagarajan R, Hsaiky LM, Osterholzer D, Kronick SL, McLaughlin E, Gandhi TN. Assessment of Testing and Treatment of Asymptomatic Bacteriuria Initiated in the Emergency Department. Open Forum Infect Dis 2020; 7:ofaa537. [PMID: 33324723 PMCID: PMC7724506 DOI: 10.1093/ofid/ofaa537] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 10/29/2020] [Indexed: 02/04/2023] Open
Abstract
Background Reducing antibiotic use in patients with asymptomatic bacteriuria (ASB) has been inpatient focused. However, testing and treatment is often started in the emergency department (ED). Thus, for hospitalized patients with ASB, we sought to identify patterns of testing and treatment initiated by emergency medicine (EM) clinicians and the association of treatment with outcomes. Methods We conducted a 43-hospital, cohort study of adults admitted through the ED with ASB (February 2018-February 2020). Using generalized estimating equation models, we assessed for (1) factors associated with antibiotic treatment by EM clinicians and, after inverse probability of treatment weighting, (2) the effect of treatment on outcomes. Results Of 2461 patients with ASB, 74.4% (N = 1830) received antibiotics. The EM clinicians ordered urine cultures in 80.0% (N = 1970) of patients and initiated treatment in 68.5% (1253 of 1830). Predictors of EM clinician treatment of ASB versus no treatment included dementia, spinal cord injury, incontinence, urinary catheter, altered mental status, leukocytosis, and abnormal urinalysis. Once initiated by EM clinicians, 79% (993 of 1253) of patients remained on antibiotics for at least 3 days. Antibiotic treatment was associated with a longer length of hospitalization (mean 5.1 vs 4.2 days; relative risk = 1.16; 95% confidence interval, 1.08-1.23) and Clostridioides difficile infection (CDI) (0.9% [N = 11] vs 0% [N = 0]; P = .02). Conclusions Among hospitalized patients ultimately diagnosed with ASB, EM clinicians commonly initiated testing and treatment; most antibiotics were continued by inpatient clinicians. Antibiotic treatment was not associated with improved outcomes, whereas it was associated with prolonged hospitalization and CDI. For best impact, stewardship interventions must expand to the ED.
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Affiliation(s)
- Lindsay A Petty
- Internal Medicine, Division of Infectious Diseases, University of Michigan, Ann Arbor, Michigan, USA
| | - Valerie M Vaughn
- Internal Medicine, Division of General Internal Medicine, University of Utah Medical School, Salt Lake City, Utah, USA
| | - Scott A Flanders
- Internal Medicine, Division of Hospital Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Twisha Patel
- Department of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Anurag N Malani
- Internal Medicine, Division of Infectious Diseases, St. Joseph Mercy Health System, Ann Arbor, Michigan, USA
| | - David Ratz
- Internal Medicine, Division of Hospital Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Keith S Kaye
- Internal Medicine, Division of Infectious Diseases, University of Michigan, Ann Arbor, Michigan, USA
| | - Jason M Pogue
- Department of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Lisa E Dumkow
- Department of Pharmacy, Mercy Health Saint Mary's, Grand Rapids, Michigan, USA
| | | | - Lama M Hsaiky
- Department of Pharmacy, Beaumont Hospital, Dearborn, Michigan, USA
| | - Danielle Osterholzer
- Internal Medicine, Division of Infectious Diseases, Hurley Medical Center, Flint, Michigan, USA
| | - Steven L Kronick
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Elizabeth McLaughlin
- Internal Medicine, Division of Hospital Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Tejal N Gandhi
- Internal Medicine, Division of Infectious Diseases, University of Michigan, Ann Arbor, Michigan, USA
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6
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Gillies CE, Taylor DF, Cummings BC, Ansari S, Islim F, Kronick SL, Medlin RP, Ward KR. Demonstrating the consequences of learning missingness patterns in early warning systems for preventative health care: A novel simulation and solution. J Biomed Inform 2020; 110:103528. [PMID: 32795506 DOI: 10.1016/j.jbi.2020.103528] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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: 01/17/2020] [Revised: 05/20/2020] [Accepted: 08/03/2020] [Indexed: 01/04/2023]
Abstract
When using tree-based methods to develop predictive analytics and early warning systems for preventive healthcare, it is important to use an appropriate imputation method to prevent learning the missingness pattern. To demonstrate this, we developed a novel simulation that generated synthetic electronic health record data using a variational autoencoder with a custom loss function, which took into account the high missing rate of electronic health data. We showed that when tree-based methods learn missingness patterns (correlated with adverse events) in electronic health record data, this leads to decreased performance if the system is used in a new setting that has different missingness patterns. Performance is worst in this scenario when the missing rate between those with and without an adverse event is the greatest. We found that randomized and Bayesian regression imputation methods mitigate the issue of learning the missingness pattern for tree-based methods. We used this information to build a novel early warning system for predicting patient deterioration in general wards and telemetry units: PICTURE (Predicting Intensive Care Transfers and other UnfoReseen Events). To develop, tune, and test PICTURE, we used labs and vital signs from electronic health records of adult patients over four years (n = 133,089 encounters). We analyzed primary outcomes of unplanned intensive care unit transfer, emergency vasoactive medication administration, cardiac arrest, and death. We compared PICTURE with existing early warning systems and logistic regression at multiple levels of granularity. When analyzing PICTURE on the testing set using all observations within a hospital encounter (event rate = 3.4%), PICTURE had an area under the receiver operating characteristic curve (AUROC) of 0.83 and an adjusted (event rate = 4%) area under the precision-recall curve (AUPR) of 0.27, while the next best tested method-regularized logistic regression-had an AUROC of 0.80 and an adjusted AUPR of 0.22. To ensure system interpretability, we applied a state-of-the-art prediction explainer that provided a ranked list of features contributing most to the prediction. Though it is currently difficult to compare machine learning-based early warning systems, a rudimentary comparison with published scores demonstrated that PICTURE is on par with state-of-the-art machine learning systems. To facilitate more robust comparisons and development of early warning systems in the future, we have released our variational autoencoder's code and weights so researchers can (a) test their models on data similar to our institution and (b) make their own synthetic datasets.
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Affiliation(s)
- Christopher E Gillies
- Department of Emergency Medicine, United States; Michigan Center for Integrative Research in Critical Care (MCIRCC), United States; Michigan Institute for Data Science (MIDAS), University of Michigan, Ann Arbor, United States.
| | - Daniel F Taylor
- Department of Emergency Medicine, United States; Michigan Center for Integrative Research in Critical Care (MCIRCC), United States
| | - Brandon C Cummings
- Department of Emergency Medicine, United States; Michigan Center for Integrative Research in Critical Care (MCIRCC), United States
| | - Sardar Ansari
- Department of Emergency Medicine, United States; Michigan Center for Integrative Research in Critical Care (MCIRCC), United States
| | - Fadi Islim
- School of Nursing, United States; Michigan Dialysis Services, Canton, MI, United States; Michigan Center for Integrative Research in Critical Care (MCIRCC), United States
| | - Steven L Kronick
- Department of Emergency Medicine, United States; Michigan Center for Integrative Research in Critical Care (MCIRCC), United States
| | - Richard P Medlin
- Department of Emergency Medicine, United States; Michigan Center for Integrative Research in Critical Care (MCIRCC), United States
| | - Kevin R Ward
- Department of Emergency Medicine, United States; Department of Biomedical Engineering, United States; Michigan Center for Integrative Research in Critical Care (MCIRCC), United States; Michigan Institute for Data Science (MIDAS), University of Michigan, Ann Arbor, United States
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7
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Krein SL, Kronick SL, Chopra V, Shever LL, Weston LE, Gregory L, Harrod M. Comparing inpatient versus emergency department clinician perceptions of personal protective equipment for different isolation precautions. Am J Infect Control 2020; 48:224-226. [PMID: 31672320 DOI: 10.1016/j.ajic.2019.08.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 08/27/2019] [Accepted: 08/27/2019] [Indexed: 12/24/2022]
Abstract
Adherence to isolation precaution practices, including use of personal protective equipment (PPE), remains a challenge in most hospitals. We surveyed inpatient and emergency department clinicians about their experiences and opinions of various isolation policies, specifically those related to wearing PPE. Our findings show several differences between inpatient and emergency department clinicians involving perceptions related to safety, and the difficulty associated with using PPE for certain types of organisms.
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8
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Guetterman TC, Kellenberg JE, Krein SL, Harrod M, Lehrich JL, Iwashyna TJ, Kronick SL, Girotra S, Chan PS, Nallamothu BK. Nursing roles for in-hospital cardiac arrest response: higher versus lower performing hospitals. BMJ Qual Saf 2019; 28:916-924. [PMID: 31420410 DOI: 10.1136/bmjqs-2019-009487] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 08/01/2019] [Accepted: 08/06/2019] [Indexed: 11/04/2022]
Abstract
BACKGROUND Good outcomes for in-hospital cardiac arrest (IHCA) depend on a skilled resuscitation team, prompt initiation of high-quality cardiopulmonary resuscitation and defibrillation, and organisational structures to support IHCA response. We examined the role of nurses in resuscitation, contrasting higher versus lower performing hospitals in IHCA survival. METHODS We conducted a descriptive qualitative study at nine hospitals in the American Heart Association's Get With The Guidelines-Resuscitation registry, purposefully sampling hospitals that varied in geography, academic status, and risk-standardised IHCA survival. We conducted 158 semistructured interviews with nurses, physicians, respiratory therapists, pharmacists, quality improvement staff, and administrators. Qualitative thematic text analysis followed by type-building text analysis identified distinct nursing roles in IHCA care and support for roles. RESULTS Nurses played three major roles in IHCA response: bedside first responder, resuscitation team member, and clinical or administrative leader. We found distinctions between higher and lower performing hospitals in support for nurses. Higher performing hospitals emphasised training and competency of nurses at all levels; provided organisational flexibility and responsiveness with nursing roles; and empowered nurses to operate at a higher scope of clinical practice (eg, bedside defibrillation). Higher performing hospitals promoted nurses as leaders-administrators supporting nurses in resuscitation care at the institution, resuscitation team leaders during resuscitation and clinical champions for resuscitation care. Lower performing hospitals had more restrictive nurse roles with less emphasis on systematically identifying improvement needs. CONCLUSION Hospitals that excelled in IHCA survival emphasised mentoring and empowering front-line nurses and ensured clinical competency and adequate nursing training for IHCA care. Though not proof of causation, nurses appear to be critical to effective IHCA response, and how to support their role to optimise outcomes warrants further investigation.
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Affiliation(s)
- Timothy C Guetterman
- Interdisciplinary Studies, Creighton University, Omaha, Nebraska, USA
- Family Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Sarah L Krein
- Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Molly Harrod
- Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, Michigan, USA
| | - Jessica L Lehrich
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - Theodore J Iwashyna
- Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, Michigan, USA
| | | | - Saket Girotra
- Internal Medicine, University of Iowa Roy J and Lucille A Carver College of Medicine, Iowa City, Iowa, USA
| | - Paul S Chan
- Internal Medicine, Saint Luke's Health System, Kansas City, Missouri, USA
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Dukes K, Bunch JL, Chan PS, Guetterman TC, Lehrich JL, Trumpower B, Harrod M, Krein SL, Kellenberg JE, Reisinger HS, Kronick SL, Iwashyna TJ, Nallamothu BK, Girotra S. Assessment of Rapid Response Teams at Top-Performing Hospitals for In-Hospital Cardiac Arrest. JAMA Intern Med 2019; 179:1398-1405. [PMID: 31355875 PMCID: PMC6664378 DOI: 10.1001/jamainternmed.2019.2420] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Rapid response teams (RRTs) are foundational to hospital response to deteriorating conditions of patients. However, little is known about differences in RRT organization and function across top-performing and non-top-performing hospitals for in-hospital cardiac arrest (IHCA) care. OBJECTIVE To evaluate differences in design and implementation of RRTs at top-performing and non-top-performing sites for survival of IHCA, which is known to be associated with hospital performance on IHCA incidence. DESIGN, SETTING, AND PARTICIPANTS A qualitative analysis was performed of data from semistructured interviews of 158 hospital staff members (nurses, physicians, administrators, and staff) during site visits to 9 hospitals participating in the Get With The Guidelines-Resuscitation program and consistently ranked in the top, middle, and bottom quartiles for IHCA survival during 2012-2014. Site visits were conducted from April 19, 2016, to July 27, 2017. Data analysis was completed in January 2019. MAIN OUTCOMES AND MEASURES Semistructured in-depth interviews were performed and thematic analysis was conducted on strategies for IHCA prevention, including RRT roles and responsibilities. RESULTS Of the 158 participants, 72 were nurses (45.6%), 27 physicians (17.1%), 27 clinical staff (17.1%), and 32 administrators (20.3%). Between 12 and 30 people at each hospital participated in interviews. Differences in RRTs at top-performing and non-top-performing sites were found in the following 4 domains: team design and composition, RRT engagement in surveillance of at-risk patients, empowerment of bedside nurses to activate the RRT, and collaboration with bedside nurses during and after a rapid response. At top-performing hospitals, RRTs were typically staffed with dedicated team members without competing clinical responsibilities, who provided expertise to bedside nurses in managing patients who were at risk for deterioration, and collaborated with nurses during and after a rapid response. Bedside nurses were empowered to activate RRTs based on their judgment and experience without fear of reprisal from physicians or hospital staff. In contrast, RRT members at non-top-performing hospitals had competing clinical responsibilities and were generally less engaged with bedside nurses. Nurses at non-top-performing hospitals reported concerns about potential consequences from activating the RRT. CONCLUSIONS AND RELEVANCE This qualitative study's findings suggest that top-performing hospitals feature RRTs with dedicated staff without competing clinical responsibilities, that work collaboratively with bedside nurses, and that can be activated without fear of reprisal. These findings provide unique insights into RRTs at hospitals with better IHCA outcomes.
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Affiliation(s)
- Kimberly Dukes
- Institute of Clinical and Translational Science, University of Iowa, Iowa City
| | | | - Paul S Chan
- Department of Internal Medicine, University of Missouri-Kansas City.,Division of Cardiology, Department of Internal Medicine, University of Missouri-Kansas City and Saint Luke's Mid America Heart Institute, Kansas City
| | | | - Jessica L Lehrich
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | - Brad Trumpower
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | - Molly Harrod
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Sarah L Krein
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor.,Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Joan E Kellenberg
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | - Heather Schacht Reisinger
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City.,Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, Iowa
| | - Steven L Kronick
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor
| | - Theodore J Iwashyna
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor.,Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Brahmajee K Nallamothu
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor.,Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Saket Girotra
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, Iowa.,Division of Cardiovascular Diseases, Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City
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Davenport MS, Gaetke-Udager K, Kronick SL. Authors’ Reply. J Am Coll Radiol 2019; 16:274-275. [DOI: 10.1016/j.jacr.2018.12.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 12/19/2018] [Indexed: 10/27/2022]
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Nallamothu BK, Guetterman TC, Harrod M, Kellenberg JE, Lehrich JL, Kronick SL, Krein SL, Iwashyna TJ, Saint S, Chan PS. How Do Resuscitation Teams at Top-Performing Hospitals for In-Hospital Cardiac Arrest Succeed? A Qualitative Study. Circulation 2018; 138:154-163. [PMID: 29986959 PMCID: PMC6245659 DOI: 10.1161/circulationaha.118.033674] [Citation(s) in RCA: 107] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 04/12/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND In-hospital cardiac arrest (IHCA) is common, and outcomes vary substantially across US hospitals, but reasons for these differences are largely unknown. We set out to better understand how top-performing hospitals organize their resuscitation teams to achieve high survival rates for IHCA. METHODS We calculated risk-standardized IHCA survival to discharge rates across American Heart Association Get With The Guidelines-Resuscitation registry hospitals between 2012 and 2014. We identified geographically and academically diverse hospitals in the top, middle, and bottom quartiles of survival for IHCA and performed a qualitative study that included site visits with in-depth interviews of clinical and administrative staff at 9 hospitals. With the use of thematic analysis, data were analyzed to identify salient themes of perceived performance by informants. RESULTS Across 9 hospitals, we interviewed 158 individuals from multiple disciplines including physicians (17.1%), nurses (45.6%), other clinical staff (17.1%), and administration (20.3%). We identified 4 broad themes related to resuscitation teams: (1) team design, (2) team composition and roles, (3) communication and leadership during IHCA, and (4) training and education. Resuscitation teams at top-performing hospitals demonstrated the following features: dedicated or designated resuscitation teams; participation of diverse disciplines as team members during IHCA; clear roles and responsibilities of team members; better communication and leadership during IHCA; and in-depth mock codes. CONCLUSIONS Resuscitation teams at hospitals with high IHCA survival differ from non-top-performing hospitals. Our findings suggest core elements of successful resuscitation teams that are associated with better outcomes and form the basis for future work to improve IHCA.
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Affiliation(s)
- Brahmajee K Nallamothu
- Departments of Internal Medicine (B.K.N., J.E.K., J.L.L., S.L. Krein, T.J.I., S.S.)
- University of Michigan Medical School, Ann Arbor. Veterans Affairs Ann Arbor Center for Clinical Management Research, MI (B.K.N., S.L. Krein, T.J.I., S.S.)
| | | | | | - Joan E Kellenberg
- Departments of Internal Medicine (B.K.N., J.E.K., J.L.L., S.L. Krein, T.J.I., S.S.)
| | - Jessica L Lehrich
- Departments of Internal Medicine (B.K.N., J.E.K., J.L.L., S.L. Krein, T.J.I., S.S.)
| | | | - Sarah L Krein
- Departments of Internal Medicine (B.K.N., J.E.K., J.L.L., S.L. Krein, T.J.I., S.S.)
- University of Michigan Medical School, Ann Arbor. Veterans Affairs Ann Arbor Center for Clinical Management Research, MI (B.K.N., S.L. Krein, T.J.I., S.S.)
| | - Theodore J Iwashyna
- Departments of Internal Medicine (B.K.N., J.E.K., J.L.L., S.L. Krein, T.J.I., S.S.)
- University of Michigan Medical School, Ann Arbor. Veterans Affairs Ann Arbor Center for Clinical Management Research, MI (B.K.N., S.L. Krein, T.J.I., S.S.)
| | - Sanjay Saint
- Departments of Internal Medicine (B.K.N., J.E.K., J.L.L., S.L. Krein, T.J.I., S.S.)
- University of Michigan Medical School, Ann Arbor. Veterans Affairs Ann Arbor Center for Clinical Management Research, MI (B.K.N., S.L. Krein, T.J.I., S.S.)
| | - Paul S Chan
- Department of Internal Medicine, Saint Luke's Health System, Kansas City, MO (P.S.C.)
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Girotra S, Dukes K, Bunch J, Guetterman T, Harrod M, Krein S, Kellenberg J, Lehrich J, Reisinger H, Kronick SL, Chan PS, Nallamothu BK. Abstract 223: Rapid Response Teams at Top-performing Hospitals for In-hospital Cardiac Arrest: A Qualitative Study. Circ Cardiovasc Qual Outcomes 2018. [DOI: 10.1161/circoutcomes.11.suppl_1.223] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Prior studies have shown that hospitals with exceptional survival for in-hospital cardiac arrest (IHCA) also excel at preventing IHCA—a key function of rapid response team (RRT). However, little is known about how RRTs differ across sites. We used qualitative methods to evaluate organizational and contextual factors of RRTs that may be linked to hospital performance on IHCA survival.
Methods:
We selected 9 academically and geographically diverse hospitals in the AHA Get With The Guidelines Resuscitation registry based on risk standardized IHCA survival during 2012-2014 (top quartile: 5 hospitals; middle quartiles: 1 hospital; bottom quartile: 3 hospitals). During site visits, we conducted semi-structured interviews with key stakeholders regarding resuscitation care at their site. We conducted a directed content analysis focused on RRT roles and activities related to preventing IHCA.
Results:
A total of 158 interviews were conducted that included physicians (17.1%), nurses (45.6%), other clinical (17.1%), and administrative staff (20.3%). Differences in RRTs at top and bottom performing sites were noted in the following domains: team design and composition, engagement of RRT in surveillance of at-risk patients, empowerment of bedside nurses to activate RRT, and collaboration of RRT members with bedside nurses during and after a rapid response. Differences within each domain and representative quotes are included in the Table. Top performing hospitals tended to have RRTs staffed with members without other clinical responsibilities, often served as a resource for bedside nurses in preventing patient decline, and collaborated with them during and after a rapid response. Bedside nurses were empowered to activate RRTs based on their judgement and experience. In contrast, RRTs at bottom performing hospitals were staffed with members with competing clinical responsibilities, and were generally less engaged with bedside nurses. Moreover, nurses were concerned about potential consequences (e.g. fear of reprisal from physicians) in calling a rapid response.
Conclusions:
The design and implementation of RRTs differ markedly between top and bottom performing hospitals with regard to IHCA survival. Our findings provide unique insights into RRTs at hospitals with better IHCA outcomes.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Paul S Chan
- Mid America Heart Institute, Kansas City, MO
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Kronick SL, Kurz MC, Lin S, Edelson DP, Berg RA, Billi JE, Cabanas JG, Cone DC, Diercks DB, Foster J(J, Meeks RA, Travers AH, Welsford M. Part 4: Systems of Care and Continuous Quality Improvement. Circulation 2015; 132:S397-413. [DOI: 10.1161/cir.0000000000000258] [Citation(s) in RCA: 191] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Neumar RW, Shuster M, Callaway CW, Gent LM, Atkins DL, Bhanji F, Brooks SC, de Caen AR, Donnino MW, Ferrer JME, Kleinman ME, Kronick SL, Lavonas EJ, Link MS, Mancini ME, Morrison LJ, O'Connor RE, Samson RA, Schexnayder SM, Singletary EM, Sinz EH, Travers AH, Wyckoff MH, Hazinski MF. Part 1: Executive Summary: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2015; 132:S315-67. [PMID: 26472989 DOI: 10.1161/cir.0000000000000252] [Citation(s) in RCA: 490] [Impact Index Per Article: 54.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Barnes GD, Katz A, Desmond JS, Kronick SL, Beach J, Chetcuti SJ, Bates ER, Gurm HS. False activation of the cardiac catheterization laboratory for primary PCI. Am J Manag Care 2013; 19:671-675. [PMID: 24304215] [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] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
OBJECTIVES We sought to evaluate trends in door-to-balloon (D2B) times and false activation rates for the cardiac catheterization laboratory (CCL) in patients presenting to the emergency department (ED) with acute ST-elevation myocardial infarction (STEMI). In patients with STEMI, national efforts have focused on reducing D2B times for primary percutaneous coronary intervention (P-PCI). This emphasis on time-to-treatment may increase the rate of false CCL activations and unnecessary healthcare utilization. STUDY DESIGN Retrospective quality improvement chart review. METHODS We examined all emergent CCL activations for P-PCI between 2007 and 2011 at the University of Michigan Hospital. False activation was defined as emergent CCL activation when the patient did not require CCL care or emergent cardiology evaluation in the ED. Pre-hospital or ED false activation rates and mean D2B time were retrospectively determined by chart review. RESULTS The CCL was activated 717 times for suspected STEMI. The number of CCL activations increased from 96 in 2007 to 190 in 2011. False CCL activations accounted for 28% of all prehospital and 29% of all ED activations. The false activation rate increased from 15% of all cases in 2007 to 40% of all cases in 2011. The median D2B time decreased from 67 minutes in 2007 to 55 minutes in 2011. CONCLUSIONS Over a 5-year period with a strong emphasis on reducing D2B times, there has been an increased CCL false activation rate for P-PCI.
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Affiliation(s)
- Geoffery D Barnes
- CVC Cardiovascular Medicine, 1500 E Medical Center Dr, Ann Arbor, MI 48109-5853. E-mail:
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Goldberger ZD, Chan PS, Berg RA, Kronick SL, Cooke CR, Lu M, Banerjee M, Hayward RA, Krumholz HM, Nallamothu BK. Duration of resuscitation efforts and survival after in-hospital cardiac arrest: an observational study. Lancet 2012; 380:1473-81. [PMID: 22958912 PMCID: PMC3535188 DOI: 10.1016/s0140-6736(12)60862-9] [Citation(s) in RCA: 278] [Impact Index Per Article: 23.2] [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: 11/23/2022]
Abstract
BACKGROUND During in-hospital cardiac arrests, how long resuscitation attempts should be continued before termination of efforts is unknown. We investigated whether duration of resuscitation attempts varies between hospitals and whether patients at hospitals that attempt resuscitation for longer have higher survival rates than do those at hospitals with shorter durations of resuscitation efforts. METHODS Between 2000 and 2008, we identified 64,339 patients with cardiac arrests at 435 US hospitals within the Get With The Guidelines—Resuscitation registry. For each hospital, we calculated the median duration of resuscitation before termination of efforts in non-survivors as a measure of the hospital's overall tendency for longer attempts. We used multilevel regression models to assess the association between the length of resuscitation attempts and risk-adjusted survival. Our primary endpoints were immediate survival with return of spontaneous circulation during cardiac arrest and survival to hospital discharge. FINDINGS 31,198 of 64,339 (48·5%) patients achieved return of spontaneous circulation and 9912 (15·4%) survived to discharge. For patients achieving return of spontaneous circulation, the median duration of resuscitation was 12 min (IQR 6-21) compared with 20 min (14-30) for non-survivors. Compared with patients at hospitals in the quartile with the shortest median resuscitation attempts in non-survivors (16 min [IQR 15-17]), those at hospitals in the quartile with the longest attempts (25 min [25-28]) had a higher likelihood of return of spontaneous circulation (adjusted risk ratio 1·12, 95% CI 1·06-1·18; p<0·0001) and survival to discharge (1·12, 1·02-1·23; 0·021). INTERPRETATION Duration of resuscitation attempts varies between hospitals. Although we cannot define an optimum duration for resuscitation attempts on the basis of these observational data, our findings suggest that efforts to systematically increase the duration of resuscitation could improve survival in this high-risk population. FUNDING American Heart Association, Robert Wood Johnson Foundation Clinical Scholars Program, and the National Institutes of Health.
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Affiliation(s)
- Zachary D Goldberger
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI 48109-5869, USA
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Deakin CD, Morrison LJ, Morley PT, Callaway CW, Kerber RE, Kronick SL, Lavonas EJ, Link MS, Neumar RW, Otto CW, Parr M, Shuster M, Sunde K, Peberdy MA, Tang W, Hoek TLV, Böttiger BW, Drajer S, Lim SH, Nolan JP. Part 8: Advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation 2011; 81 Suppl 1:e93-e174. [PMID: 20956032 DOI: 10.1016/j.resuscitation.2010.08.027] [Citation(s) in RCA: 149] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Jain R, Kuhn L, Repaskey W, Chan PS, Kronick SL, Flanders S, Nallamothu BK. Physician implicit review to identify preventable errors during in-hospital cardiac arrest. ACTA ACUST UNITED AC 2011; 171:89-90. [PMID: 21220666 DOI: 10.1001/archinternmed.2010.475] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Neumar RW, Otto CW, Link MS, Kronick SL, Shuster M, Callaway CW, Kudenchuk PJ, Ornato JP, McNally B, Silvers SM, Passman RS, White RD, Hess EP, Tang W, Davis D, Sinz E, Morrison LJ. Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010; 122:S729-67. [PMID: 20956224 DOI: 10.1161/circulationaha.110.970988] [Citation(s) in RCA: 880] [Impact Index Per Article: 62.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The goal of therapy for bradycardia or tachycardia is to rapidly identify and treat patients who are hemodynamically unstable or symptomatic due to the arrhythmia. Drugs or, when appropriate, pacing may be used to control unstable or symptomatic bradycardia. Cardioversion or drugs or both may be used to control unstable or symptomatic tachycardia. ACLS providers should closely monitor stable patients pending expert consultation and should be prepared to aggressively treat those with evidence of decompensation.
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Peberdy MA, Callaway CW, Neumar RW, Geocadin RG, Zimmerman JL, Donnino M, Gabrielli A, Silvers SM, Zaritsky AL, Merchant R, Vanden Hoek TL, Kronick SL. Part 9: Post–Cardiac Arrest Care. Circulation 2010; 122:S768-86. [DOI: 10.1161/circulationaha.110.971002] [Citation(s) in RCA: 1034] [Impact Index Per Article: 73.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Morrison LJ, Deakin CD, Morley PT, Callaway CW, Kerber RE, Kronick SL, Lavonas EJ, Link MS, Neumar RW, Otto CW, Parr M, Shuster M, Sunde K, Peberdy MA, Tang W, Hoek TLV, Böttiger BW, Drajer S, Lim SH, Nolan JP, Adrie C, Alhelail M, Battu P, Behringer W, Berkow L, Bernstein RA, Bhayani SS, Bigham B, Boyd J, Brenner B, Bruder E, Brugger H, Cash IL, Castrén M, Cocchi M, Comadira G, Crewdson K, Czekajlo MS, Davies SR, Dhindsa H, Diercks D, Dine CJ, Dioszeghy C, Donnino M, Dunning J, El Sanadi N, Farley H, Fenici P, Feeser VR, Foster JA, Friberg H, Fries M, Garcia-Vega FJ, Geocadin RG, Georgiou M, Ghuman J, Givens M, Graham C, Greer DM, Halperin HR, Hanson A, Holzer M, Hunt EA, Ishikawa M, Ioannides M, Jeejeebhoy FM, Jennings PA, Kano H, Kern KB, Kette F, Kudenchuk PJ, Kupas D, La Torre G, Larabee TM, Leary M, Litell J, Little CM, Lobel D, Mader TJ, McCarthy JJ, McCrory MC, Menegazzi JJ, Meurer WJ, Middleton PM, Mottram AR, Navarese EP, Nguyen T, Ong M, Padkin A, Ferreira de Paiva E, Passman RS, Pellis T, Picard JJ, Prout R, Pytte M, Reid RD, Rittenberger J, Ross W, Rubertsson S, Rundgren M, Russo SG, Sakamoto T, Sandroni C, Sanna T, Sato T, Sattur S, Scapigliati A, Schilling R, Seppelt I, Severyn FA, Shepherd G, Shih RD, Skrifvars M, Soar J, Tada K, Tararan S, Torbey M, Weinstock J, Wenzel V, Wiese CH, Wu D, Zelop CM, Zideman D, Zimmerman JL. Part 8: Advanced Life Support. Circulation 2010; 122:S345-421. [DOI: 10.1161/circulationaha.110.971051] [Citation(s) in RCA: 250] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Meurer WJ, Kronick SL, Lowell MJ, Desmond JS, Mudgal CS. Complex metacarpophalangeal dislocation. Int J Emerg Med 2008; 1:227-8. [PMID: 19384525 PMCID: PMC2657271 DOI: 10.1007/s12245-008-0058-7] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2008] [Accepted: 07/30/2008] [Indexed: 11/28/2022] Open
Affiliation(s)
- William J Meurer
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI 48109-5303, USA.
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Peberdy MA, Cretikos M, Abella BS, Devita M, Goldhill D, Kloeck W, Kronick SL, Morrison LJ, Nadkarni VM, Nichol G, Nolan JP, Parr M, Tibballs J, van der Jagt EW, Young L. Recommended guidelines for monitoring, reporting, and conducting research on medical emergency team, outreach, and rapid response systems: an Utstein-style scientific statement. A Scientific Statement from the International Liaison Committee on Resuscitation; the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiopulmonary, Perioperative, and Critical Care; and the Interdisciplinary Working Group on Quality of Care and Outcomes Research. Resuscitation 2008; 75:412-33. [PMID: 17993369 DOI: 10.1016/j.resuscitation.2007.09.009] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2007] [Accepted: 09/24/2007] [Indexed: 11/30/2022]
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Abstract
OBJECTIVES To determine whether performance decrements at night actually translate into worsened measures of quality of patient care in the emergency department (ED). Emergency physicians and healthcare workers are sleepier and less cognitively proficient at night than during the day. Despite a lack of data, medical errors have been attributed to these deficits, and pharmacologic solutions recently have been suggested. METHODS The authors studied 36 months of emergency care and measured quality indicators, including early mortality (deaths occurring after arrival in the ED or within 48 hours of hospital admission), frequency of return after ED discharge, time to thrombolysis in acute myocardial infarction (AMI), frequency of aspirin use in AMI, and performance of endotracheal intubation. Comparisons were by time of day in eight-hour epochs. RESULTS There were 345,000 patient encounters in the study period. The distribution in time was determined for 25,079 sampled ED visits, 3,666 admissions, and 507 early deaths. Estimated early mortality was 0.5% (95% CI = 0.0 to 1.0%) greater at night compared with during the day. There was no effect of time of day on 1,828 returns with admission after ED discharge. In 257 patients who received thrombolytics for AMI, mean time-to-treatment and frequency of aspirin use were not worse at night. In 443 emergent endotracheal intubations, there was no difference at night in the duration or number of attempts required, or in protocol adherence. CONCLUSIONS Quality indicators used in this study do not demonstrate marked deficits in patient care occurring at night. A very small, but measurable, increase in early mortality was identified. Improved measures to counter circadian disruption warrant study but may result in minimal improvements in patient care.
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Affiliation(s)
- Robert Silbergleit
- Department of Emergency Medicine and Survival Flight, University of Michigan, Ann Arbor, MI 48109-0303, USA.
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