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Easterday T, Byerly S, Magnotti L, Fischer P, Shah K, Croce M, Kerwin A, Howley I. Performance Improvement Program Review of Institutional Massive Transfusion Protocol Adherence: An Opportunity for Improvement. Am Surg 2024; 90:1082-1088. [PMID: 38297889 DOI: 10.1177/00031348221114036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
Abstract
BACKGROUND Given the acuity of patients who receive MTPs and the resources they require, MTPs are a compelling target for performance improvement. This study evaluated adherence with our MTP's plasma:red blood cell ratio (FFPR) of 1:2 and platelet:red blood cell ratio (PLTR) of 1:12, to test the hypothesis that ratio adherence is associated with lower inpatient mortality. MATERIALS AND METHODS The registry of an urban level I trauma center was queried for adult patients who received at least 6 units of packed red blood cells within 4 hours of presentation. Patients were excluded for interfacility transfer, cardiac arrest during the prehospital phase or within one hour of arrival, or for head AIS ≥5. Univariate analysis and multiple logistic regressions were performed to identify variables associated with early transfusion protocol noncompliance and the effect on inpatient mortality. RESULTS Three hundred and eighty-three patients were included, with mean ISS of 25.9 ± 13.3 and inpatient mortality of 28.5%. Increasing age, ISS, INR, and total units of blood product transfused were associated with increased odds of mortality, while an increase in revised trauma score was associated with a decreased odds ratio of mortality. Achieving our goal ratios were protective against mortality, with OR of .451 (P = .013) and .402 (P=.003), respectively. DISCUSSION Large proportions of critically injured patients were transfused fewer units of plasma and platelets than our MTP dictated; failure to achieve intended ratios at 4 hours was strongly associated with inpatient mortality. MTP processes and outcomes should be critically assessed on a regular basis as part of a mature performance improvement program to ensure protocol adherence and optimal patient outcome.
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Affiliation(s)
- Thomas Easterday
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Saskya Byerly
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Louis Magnotti
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Peter Fischer
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Kinjal Shah
- Department of Pathology, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Martin Croce
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Andrew Kerwin
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Isaac Howley
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
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Wilkins D, Lane AS, Orde SR. Audit of low tidal volume ventilation in patients with hypoxic respiratory failure in a tertiary Australian intensive care unit. Anaesth Intensive Care 2021; 49:301-308. [PMID: 34324389 DOI: 10.1177/0310057x21993132] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A low tidal volume ventilation (LTVV) strategy improves outcomes in patients with acute respiratory distress syndrome (ARDS). Subsequently, a LTVV strategy has become the standard of care for patients receiving mechanical ventilation. This strategy is poorly adhered to within intensive care units (ICUs). A retrospective analysis was conducted of prescribed tidal volumes in mechanically ventilated patients with hypoxic respiratory failure between April 2013 and March 2017. Data collection included the establishment of a new data-entry box for patient height in March 2016, aimed at assisting the calculation of LTVV. We reviewed 836 ICU admissions, comprising 19,884 hours of ventilation. A total of 92% of admissions lacked patient height recording. When height was recorded, 54% of hours of ventilation were LTVV adherent. Non-LTVV hours for both groups involved higher tidal volumes (38%) rather than lower tidal volumes (8%). Non-LTVV-adherent hours were significantly (P<0.001) more likely to be associated with patient mortality than LTVV-adherent hours were. For all hours of ventilation, mean tidal volume before March 2016 was significantly higher (496 (standard deviation (SD) 101) ml, compared to after March 2016 (451 (SD 107) ml, P<0.001, 95% confidence interval for true difference in means 42 to 48 ml). However, this trend gradually reversed over time. There was a clinician preference for multiples of 50 ml. There was poor adherence to LTVV strategy in patients with hypoxic respiratory failure, which was associated with an increase in patient mortality. An electronic medical record intervention was successful in producing change, but this was not sustainable over time. Clinician ventilation prescribing habits were based on numerical simplicity rather than evidence-based practice.
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Affiliation(s)
- David Wilkins
- Sydney Medical School, The University of Sydney, Sydney, Australia
| | - Andrew S Lane
- Sydney Medical School, The University of Sydney, Sydney, Australia.,Intensive Care Unit, Nepean Hospital, Penrith, Australia
| | - Sam R Orde
- Intensive Care Unit, Nepean Hospital, Penrith, Australia
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Bamat NA, Ekhaguere OA, Zhang L, Flannery DD, Handley SC, Herrick HM, Ellenberg SS. Protocol adherence rates in superiority and noninferiority randomized clinical trials published in high impact medical journals. Clin Trials 2020; 17:552-559. [PMID: 32666826 DOI: 10.1177/1740774520941428] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND/AIMS Noninferiority clinical trials are susceptible to false confirmation of noninferiority when the intention-to-treat principle is applied in the setting of incomplete trial protocol adherence. The risk increases as protocol adherence rates decrease. The objective of this study was to compare protocol adherence and hypothesis confirmation between superiority and noninferiority randomized clinical trials published in three high impact medical journals. We hypothesized that noninferiority trials have lower protocol adherence and greater hypothesis confirmation. METHODS We conducted an observational study using published clinical trial data. We searched PubMed for active control, two-arm parallel group randomized clinical trials published in JAMA: The Journal of the American Medical Association, The New England Journal of Medicine, and The Lancet between 2007 and 2017. The primary exposure was trial type, superiority versus noninferiority, as determined by the hypothesis testing framework of the primary trial outcome. The primary outcome was trial protocol adherence rate, defined as the number of randomized subjects receiving the allocated intervention as described by the trial protocol and followed to primary outcome ascertainment (numerator), over the total number of subjects randomized (denominator). Hypothesis confirmation was defined as affirmation of noninferiority or the alternative hypothesis for noninferiority and superiority trials, respectively. RESULTS Among 120 superiority and 120 noninferiority trials, median and interquartile protocol adherence rates were 91.5 [81.4-96.7] and 89.8 [83.6-95.2], respectively; P = 0.47. Hypothesis confirmation was observed in 107/120 (89.2%) of noninferiority and 64/120 (53.3%) of superiority trials, risk difference (95% confidence interval): 35.8 (25.3-46.3), P < 0.001. CONCLUSION Protocol adherence rates are similar between superiority and noninferiority trials published in three high impact medical journals. Despite this, we observed greater hypothesis confirmation among noninferiority trials. We speculate that publication bias, lenient noninferiority margins and other sources of bias may contribute to this finding. Further study is needed to identify the reasons for this observed difference.
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Affiliation(s)
- Nicolas A Bamat
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Osayame A Ekhaguere
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Indiana University, Indianapolis, IN, USA
| | - Lingqiao Zhang
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Biosense Webster, Inc., Irvine, CA, USA
| | - Dustin D Flannery
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Sara C Handley
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Heidi M Herrick
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Susan S Ellenberg
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Stonko DP, O Neill DC, Dennis BM, Smith M, Gray J, Guillamondegui OD. Trauma Quality Improvement: Reducing Triage Errors by Automating the Level Assignment Process. J Surg Educ 2018; 75:1551-1557. [PMID: 29656835 DOI: 10.1016/j.jsurg.2018.03.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 01/31/2018] [Accepted: 03/26/2018] [Indexed: 06/08/2023]
Abstract
BACKGROUND Trauma patients are triaged by the severity of their injury or need for intervention while en route to the trauma center according to trauma activation protocols that are institution specific. Significant research has been aimed at improving these protocols in order to optimize patient outcomes while striving for efficiency in care. However, it is known that patients are often undertriaged or overtriaged because protocol adherence remains imperfect. The goal of this quality improvement (QI) project was to improve this adherence, and thereby reduce the triage error. It was conducted as part of the formal undergraduate medical education curriculum at this institution. STUDY DESIGN A QI team was assembled and baseline data were collected, then 2 Plan-Do-Study-Act (PDSA) cycles were implemented sequentially. During the first cycle, a novel web tool was developed and implemented in order to automate the level assignment process (it takes EMS-provided data and automatically determines the level); the tool was based on the existing trauma activation protocol. The second PDSA cycle focused on improving triage accuracy in isolated, less than 10% total body surface area burns, which we identified to be a point of common error. Traumas were reviewed and tabulated at the end of each PDSA cycle, and triage accuracy was followed with a run chart. SETTING This study was performed at Vanderbilt University Medical Center and Medical School, which has a large level 1 trauma center covering over 75,000 square miles, and which sees urban, suburban, and rural trauma. PARTICIPANTS The baseline assessment period and each PDSA cycle lasted 2 weeks. During this time, all activated, adult, direct traumas were reviewed. There were 180 patients during the baseline period, 189 after the first test of change, and 150 after the second test of change. All were included in analysis. RESULTS Of 180 patients, 30 were inappropriately triaged during baseline analysis (3 undertriaged and 27 overtriaged) versus 16 of 189 (3 undertriaged and 13 overtriaged) following implementation of the web tool (p = 0.017 for combined errors). Overtriage dropped further from baseline to 10/150 after the second test of change (p = 0.005). The total number of triaged patients dropped from 92.3/week to 75.5/week after the second test of change. There was no statistically significant change in the undertriage rate. CONCLUSION The combination of web tool implementation and protocol refinement decreased the combined triage error rate by over 50% (from 16.7%-7.9%). We developed and tested a web tool that improved triage accuracy, and provided a sustainable method to enact future quality improvement. This web tool and QI framework would be easily expandable to other hospitals.
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Affiliation(s)
- David P Stonko
- Vanderbilt University School of Medicine, Nashville, Tennessee
| | | | - Bradley M Dennis
- Vanderbilt Division of Trauma and Surgical Critical Care, Nashville, Tennessee
| | - Melissa Smith
- Vanderbilt Division of Trauma and Surgical Critical Care, Nashville, Tennessee
| | - Jeffrey Gray
- Vanderbilt LifeFlight, Vanderbilt University Medical Center, Nashville, Tennessee
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Laxy M, Wilson ECF, Boothby CE, Griffin SJ. How good are GPs at adhering to a pragmatic trial protocol in primary care? Results from the ADDITION-Cambridge cluster-randomised pragmatic trial. BMJ Open 2018; 8:e015295. [PMID: 29903781 PMCID: PMC6009504 DOI: 10.1136/bmjopen-2016-015295] [Citation(s) in RCA: 3] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE To assess the fidelity of general practitioners' (GPs) adherence to a long-term pragmatic trial protocol. DESIGN Retrospective analyses of electronic primary care records of participants in the pragmatic cluster-randomised ADDITION (Anglo-Danish-Dutch Study of Intensive Treatment In People with Screen Detected Diabetes in Primary Care)-Cambridge trial, comparing intensive multifactorial treatment (IT) versus routine care (RC). Data were collected from the date of diagnosis until December 2010. SETTING Primary care surgeries in the East of England. STUDY SAMPLE/PARTICIPANTS A subsample (n=189, RC arm: n=99, IT arm: n=90) of patients from the ADDITION-Cambridge cohort (867 patients), consisting of patients 40-69 years old with screen-detected diabetes mellitus. INTERVENTIONS In the RC arm treatment was delivered according to concurrent treatment guidelines. Surgeries in the IT arm received funding for additional contacts between GPs/nurses and patients, and GPs were advised to follow more intensive treatment algorithms for the management of glucose, lipids and blood pressure and aspirin therapy than in the RC arm. OUTCOME MEASURES The number of annual contacts between patients and GPs/nurses, the proportion of patients receiving prescriptions for cardiometabolic medication in years 1-5 after diabetes diagnosis and the adherence to prescription algorithms. RESULTS The difference in the number of annual GP contacts (β=0.65) and nurse contacts (β=-0.15) between the study arms was small and insignificant. Patients in the IT arm were more likely to receive glucose-lowering (OR=3.27), ACE-inhibiting (OR=2.03) and lipid-lowering drugs (OR=2.42, all p values <0.01) than patients in the RC arm. The prescription adherence varied between medication classes, but improved in both trial arms over the 5-year follow-up. CONCLUSIONS The adherence of GPs to different aspects of the trial protocol was mixed. Background changes in healthcare policy need to be considered as they have the potential to dilute differences in treatment intensity and hence incremental effects. TRIAL REGISTRATION NUMBER ISRCTN86769081.
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Affiliation(s)
- Michael Laxy
- Institute of Health Economics, Helmholtz Zentrum München, Neuherberg, Germany
- German Center for Diabetes Research, Neuherberg, Germany
- MRC Epidemiology Unit, University of Cambridge, Cambridge, UK
| | - Edward C F Wilson
- Cambridge Centre for Health Services Research, University of Cambridge, Cambridge, UK
| | - Clare E Boothby
- MRC Epidemiology Unit, University of Cambridge, Cambridge, UK
| | - Simon J Griffin
- MRC Epidemiology Unit, University of Cambridge, Cambridge, UK
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van der Kolk M, van den Boogaard M, Ter Brugge-Speelman C, Hol J, Noyez L, van Laarhoven K, van der Hoeven H, Pickkers P. Development and implementation of a clinical pathway for cardiac surgery in the intensive care unit: Effects on protocol adherence. J Eval Clin Pract 2017; 23:1289-1298. [PMID: 28719134 DOI: 10.1111/jep.12778] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 05/08/2017] [Accepted: 05/09/2017] [Indexed: 01/13/2023]
Abstract
RATIONALE, AIMS AND OBJECTIVES Cardiac surgery (CS) is facilitated by multiple perioperative guidelines and protocols. Use of a clinical pathway (CP) may facilitate the care of these patients. METHODS This is a pre-post design study in the ICU of a tertiary referral centre. A CP for CS patients in the ICU was developed by ICU-nurses and enabled them to execute proactively predefined actions in accordance with and within the preset boundaries which were part of a variance report. A tailored implementation strategy was used. Primary outcome measure was protocol adherence above 80% on the domains of blood pressure control, action on chest tube blood loss and electrolyte control within the CP. RESULTS In a 4-month period, 84 consecutive CP patients were included and compared with 162 matched control patients admitted in the year before implementation; 3 patients were excluded. Propensity score was used as matching parameter. CP patients were more likely to receive early adequate treatment for derangements in electrolytes (96% vs 47%, P < .001), blood pressure (90% vs 49%, P < .001) and adequate treatment for chest tube blood loss (90% vs 10%, P < .001). We found no differences in hospital and ICU LOS, ICU readmission or mortality. CONCLUSION Use of the CP improved postoperative ICU treatment for cardiac surgical patients. Implementation of a CP and the use of a special variance report could be a blueprint for the implementation and use of a CP in low-volume high complex surgery.
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Affiliation(s)
- Marion van der Kolk
- Department of Surgery, Radboud University Medical Centre, Radboud Institute for Health Science, Nijmegen, The Netherlands.,Department of Intensive Care Medicine, Radboud University Medical Centre, Radboud Institute for Health Science, Nijmegen, The Netherlands
| | - Mark van den Boogaard
- Department of Intensive Care Medicine, Radboud University Medical Centre, Radboud Institute for Health Science, Nijmegen, The Netherlands
| | - Corine Ter Brugge-Speelman
- Department of Intensive Care Medicine, Radboud University Medical Centre, Radboud Institute for Health Science, Nijmegen, The Netherlands
| | - Jeroen Hol
- Department of Intensive Care Medicine, Radboud University Medical Centre, Radboud Institute for Health Science, Nijmegen, The Netherlands
| | - Luc Noyez
- Department of Cardiothoracic Surgery, Radboud University Medical Centre, Radboud Institute for Health Science, Nijmegen, The Netherlands
| | - Kees van Laarhoven
- Department of Surgery, Radboud University Medical Centre, Radboud Institute for Health Science, Nijmegen, The Netherlands
| | - Hans van der Hoeven
- Department of Intensive Care Medicine, Radboud University Medical Centre, Radboud Institute for Health Science, Nijmegen, The Netherlands
| | - Peter Pickkers
- Department of Intensive Care Medicine, Radboud University Medical Centre, Radboud Institute for Health Science, Nijmegen, The Netherlands
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McCoy C, Paredes M, Allen S, Blackey J, Nielsen C, Paluzzi A, Jonas B, Radovich P. Catheter-Associated Urinary Tract Infections: Implementing a Protocol to Decrease Incidence in Oncology Populations
. Clin J Oncol Nurs 2017; 21:460-465. [PMID: 28738041 DOI: 10.1188/17.cjon.460-465] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The impact of catheter-associated urinary tract infections (CAUTIs) on immunocompromised patients with cancer requires preventive intervention from bedside nurses.
. OBJECTIVES This protocol aims to prevent CAUTIs in the inpatient oncology population by implementing an evidence-based, nurse-driven protocol for discontinuing indwelling urinary catheters (IUCs).
. METHODS Following a literature review of 34 articles, a nurse-driven CAUTI prevention protocol was developed and implemented on two 26-bed oncology units. Unit staff were educated on the protocol and use of the audit tool.
. FINDINGS Although CAUTI rates remained unchanged, infections per 1,000 IUC days decreased, and adherence among oncology nurses rose 66%-90% within the first two months. The protocol encouraged preventive intervention from RNs to protect patients with cancer from CAUTIs.
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Mehrara M, Tavakoli N, Fathi M, Mahshidfar B, Zare MA, Asadi A, Hosseinzadeh S, Safdarian M. Protocol Adherence in Prehospital Medical Care Provided for Patients with Chest Pain and Loss of Consciousness; a Brief Report. Emerg (Tehran) 2017; 5:e40. [PMID: 28286847 PMCID: PMC5325911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Although many protocols are available in the field of the prehospital medical care (PMC), there is still a notable gap between protocol based directions and applied clinical practice. This study measures the rate of protocol adherence in PMC provided for patients with chest pain and loss of consciousness (LOC). METHOD In this cross-sectional study, 10 educated research assistants audited the situation of provided PMC for non-traumatic chest pain and LOC patients, presenting to the emergency department of a tertiary level teaching hospital, compare to national recommendations in these regards. RESULTS 101 cases with the mean age of 56.7 ± 12.3 years (30-78) were audited (55.4% male). 61 (60.3%) patients had chest pain and 40 (39.7%) cases had LOC. Protocol adherence rates for cardiac monitoring (62.3%), O2 therapy (32.8%), nitroglycerin administration (60.7%), and aspirin administration (52.5%) in prehospital care of patients with chest pain were fair to poor. Protocol adherence rates for correct patient positioning (25%), O2 therapy (75%), cardiac monitoring (25%), pupils examination (25%), bedside glucometery (50%), and assessing for naloxone administration (55%) in prehospital care of patients with LOC were fair to poor. CONCLUSION There were more than 20% protocol violation regarding prehospital care of chest pain patients regarding cardiac monitoring, O2 therapy, and nitroglycerin and aspirin administration. There were same situation regarding O2 therapy, positioning, cardiac monitoring, pupils examination, bedside glucometery, and assessing for naloxone administration of LOC patients in prehospital setting.
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Affiliation(s)
- Mostafa Mehrara
- Department of Emergency Medicine, Hazrat-e-Rasoul Akram Medical Centre, Iran University of Medical Sciences, Tehran, Iran
| | - Nader Tavakoli
- Department of Emergency Medicine, Hazrat-e-Rasoul Akram Medical Centre, Iran University of Medical Sciences, Tehran, Iran
| | - Marzieh Fathi
- Department of Emergency Medicine, Hazrat-e-Rasoul Akram Medical Centre, Iran University of Medical Sciences, Tehran, Iran.,Corresponding author: Marzieh Fathi; Emergency Department, Hazrat-e-Rasoul Akram Hospital, Satarkhan St., Niyayesh St., Tehran, Iran.
| | - Babak Mahshidfar
- Department of Emergency Medicine, Hazrat-e-Rasoul Akram Medical Centre, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad Amin Zare
- Department of Emergency Medicine, Hazrat-e-Rasoul Akram Medical Centre, Iran University of Medical Sciences, Tehran, Iran
| | - Azita Asadi
- Department of Emergency Medicine, Hazrat-e-Rasoul Akram Medical Centre, Iran University of Medical Sciences, Tehran, Iran
| | - Saeedeh Hosseinzadeh
- Department of Emergency Medicine, Hazrat-e-Rasoul Akram Medical Centre, Iran University of Medical Sciences, Tehran, Iran
| | - Mehdi Safdarian
- Department of Emergency Medicine, Hazrat-e-Rasoul Akram Medical Centre, Iran University of Medical Sciences, Tehran, Iran
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Kakebeeke D, Vis A, de Deckere ERJT, Sandel MH, de Groot B. Lack of clinically evident signs of organ failure affects ED treatment of patients with severe sepsis. Int J Emerg Med 2013; 6:4. [PMID: 23445761 PMCID: PMC3599042 DOI: 10.1186/1865-1380-6-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [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: 09/30/2012] [Accepted: 02/10/2013] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND It is not known whether lack of recognition of organ failure explains the low compliance with the "Surviving Sepsis Campaign" (SSC) guidelines. We evaluated whether compliance was higher in emergency department (ED) sepsis patients with clinically recognizable signs of organ failure compared to patients with only laboratory signs of organ failure. METHODS Three hundred twenty-three ED patients with severe sepsis and septic shock were prospectively included. Multivariable binary logistic regression was used to assess if clinical and biochemical signs of organ failure were associated with compliance to a SSC-based resuscitation bundle. In addition, two-way analysis of variance was used to investigate the relation between the predisposition, infection, response and organ failure (PIRO) score (3 groups: 1-7, 8-14, 15-24) as a measure of illness severity and time to antibiotics with disposition to ward or ICU as effect modifier. RESULTS One hundred twenty-five of 323 included sepsis patients with new-onset organ failure were admitted to the ICU, and in all these patients the SSC resuscitation bundle was started. Respiratory difficulty, hypotension and altered mental status as clinically recognizable signs of organ failure were independent predictors of 100% compliance and not illness severity per se. Corrected ORs (95% CI) were 3.38 (1.08-10.64), 2.37 (1.07-5.23) and 4.18 (1.92-9.09), respectively. Septic ED patients with clinically evident organ failure were more often admitted to the ICU compared to a ward (125 ICU admissions, P < 0.05), which was associated with shorter time to antibiotics [ward: 127 (113-141) min; ICU 94 (80-108) min (P = 0.005)]. CONCLUSIONS The presence of clinically evident compared to biochemical signs of organ failure was associated with increased compliance with a SSC-based resuscitation bundle and admission to the ICU, suggesting that recognition of severe sepsis is an important barrier for successful implementation of quality improvement programs for septic patients. In septic ED patients admitted to the ICU, the time to antibiotics was shorter compared to patients admitted to a normal ward.
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Affiliation(s)
| | - Alice Vis
- Medical Centre Haaglanden, The Hague, The Netherlands
| | | | | | - Bas de Groot
- Leiden University Medical Centre, Leiden, The Netherlands
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Halpern CT, Whitsel EA, Wagner B, Harris KM. Challenges of measuring diurnal cortisol concentrations in a large population-based field study. Psychoneuroendocrinology 2012; 37:499-508. [PMID: 21862225 PMCID: PMC3245839 DOI: 10.1016/j.psyneuen.2011.07.019] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2010] [Revised: 05/25/2011] [Accepted: 07/29/2011] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Longitudinal examinations of associations between daily stress, diurnal cortisol concentrations, and physiological parameters in population-based studies are needed. This study evaluates issues related to consent, collection, and protocol adherence for a low-burden saliva collection protocol. METHODS In the 2007 pretest (n=193) for Wave IV of the National Longitudinal Study of Adolescent Health (Add Health) a three-sample, one-day, unsupervised saliva collection protocol was pilot tested. Embedded experiments allowed for examination of adherence and effects of monetary incentives. RESULTS Although most (97%) study participants consented to collection, only about 80% actually mailed back samples. Use of a time-stamping TrackCap allowed comparison of self-reported and stamp-recorded collection times. Of returned samples, self-report of collection time was missing for about a quarter, and only about one in three respondents (of those for whom adherence was calculable) fully adhered to the collection protocol, indicating significant potential for bias. Consent, return, and protocol adherence were unrelated to key sociodemographic characteristics, and did not improve with higher monetary incentives or knowledge of being monitored. CONCLUSIONS Despite the relatively low-burden collection protocol and use of multiple strategies thought to improve collection and protocol adherence, response and adherence were poor, leading to a decision to drop cortisol measurement from the Wave IV Add Health protocol. Large field studies should carefully evaluate the feasibility of collection and protocol adherence for unsupervised collection protocols before implementing costly, and potentially unusable, biological measurements.
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Affiliation(s)
- Carolyn Tucker Halpern
- Department of Maternal and Child Health, University of North Carolina at Chapel Hill (UNC-CH), Chapel Hill, NC, USA.
| | | | - Brandon Wagner
- Department of Sociology, UNC-CH,Carolina Population Center, UNC-CH
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