Critical Illness Outcomes in General Versus Specialty Intensive Care Units 5.14.08

This study compared outcomes of patients admitted to general intensive care units (ICUs) versus specialty ICUs for specific conditions like heart attacks or pneumonia. The study analyzed data on over 84,000 patients from 124 ICUs. It found that admission to an "ideal" specialty ICU matched to a patient's condition did not generally provide a survival benefit compared to general ICU care. However, admission to a "non-ideal" specialty ICU, or boarding, was associated with higher risk-adjusted mortality. The results suggest specialty ICUs may not necessarily improve survival outcomes.

Table. Risk-adjusted Odds Ratios of ICU Type a on Hospital Mortality for Select Diagnoses Diagnosis OR (95% CI) b Acute Coronary Syndrome Ideal Specialty ICU (n=9,967) 1.17 (0.95,1.45) Non-ideal Specialty ICU (n=1,161) 1.41 (1.01,1.96) † Ischemic Stroke Ideal Specialty ICU (n=1,457) 1.35 (0.96,1.89) Non-ideal Specialty ICU (n=752) 1.41 (1.03,1.94) † Intracranial Hemorrhage Ideal Specialty ICU (n=6,023) 1.00 (0.79,1.28) Non-ideal Specialty ICU (n=2,126) 1.31 (1.03,1.66) † Pneumonia Ideal Specialty ICU (n=3,925) 1.20 (1.02,1.40) † Non-ideal Specialty ICU (n=314) 1.02 (0.74,1.40) Abdominal Surgery Ideal Specialty ICU (n=3,915) 1.06 (0.83,1.36) Non-ideal Specialty ICU (n=2,373) 1.29 (1.04,1.61) † Cardiothoracic Surgery Ideal Specialty ICU (n=22,634) 0.60 (0.32,1.13) Non-ideal Specialty ICU (n=75) NC NC=Not calculated; a Reference group is general ICU; b Values adjusted for age, race, gender, diagnosis, source of admission, acute physiology score, pre-hospital length of stay, ventilation status (yes/no), hospital location (by region), and hospital teaching status; † Designates significance at p<0.05. ,[object Object],Objectives ,[object Object],[object Object],[object Object],[object Object],[object Object],Methods ,[object Object],[object Object],[object Object],Limitations ,[object Object],[object Object],Policy Implications ,[object Object],[object Object],[object Object],Background ,[object Object],[object Object],Conclusions ,[object Object],[object Object],[object Object],Results ,[object Object],[object Object],[object Object],Critical illness outcomes in general versus specialty intensive care units Jason P. Lott MA 3 , Theodore J. Iwashyna MD PhD 1-3 , Jason D. Christie MD MSCE 1-3 , David A. Asch MD MBA 1-3 Andrew A. Kramer PhD 4 and Jeremy M. Kahn MD MS 1-3 1 Division of Pulmonary, Allergy & Critical Care, 2 Leonard Davis Institute of Health Economics, 3 University of Pennsylvania School of Medicine, Philadelphia PA; 4 Cerner Corporation, Vienna VA

- The study examined outcomes of 84,182 patients admitted to general intensive care units (ICUs) versus specialty ICUs for conditions like heart attacks, strokes, pneumonia and surgery. - Risk-adjusted mortality was similar for general ICUs and "ideal" specialty ICUs that matched a patient's condition. However, admission to a "non-ideal" specialty ICU was associated with higher odds of death. - The results suggest creating more specialty ICU beds may not necessarily improve survival outcomes compared to general ICUs, and patients may face higher risks if admitted to specialty units that do not match their condition.

Deborah Stein - Trauma is Risky Business

SMACC Conference

Deborah Stein SMACC Chicago talk Trauma is Risky Business - delves into the risk patients and physicians undergo when treating or being treated for Trauma. Stein’s speaks of the Risk Benefit Determination that physicians make daily and how this is used to best answer on going questions such as; can a patient have?, how do we care for this patient? and how do we best make all the these decisions?. Stein’s suggests a thorough Risk Benefit Determination will include: Analysis of best available data Use of best available judgement Gathering of different opinions An understanding that you won’t always make the right decision To document the 'crap' out of it! And to remember you’ll never know what you prevented from not occurring. Stein’s also focuses on the risk to patients due to missed injuries and the processes physicians can take to help ensure that a patient injuries are not missed. Stating that 1.3-39% of injuries in trauma are missed (a majority of which present as orthopaedic cases). Touching on the processes designed to prevent missed injuries such as; Territory Trauma Survey Roles of clinical decision rules To scan the living ‘crap’ out of them - whole body CT scans (can decrease mortality but comes attached with its own risks). Stein’s then delves into the risks trauma providers (physicians) face on a daily bases. Stating that in the USA trauma providers are one of the highest categories of physicians to be sued, have higher indemnity payment awarded against them and achieve a higher risk score in studies for being sued. While, lawsuits are more likely to increase the chance of physician burnout, career burnout, depression and are emotionally and physically exhausting. Steins sights recent studies that suggest the more open, honest and forthright a physician is with their error with their peers and their hospital the likelihood of being sued reduces. Stein’s also notes that needle stick injuries in most departments have decreased in recent years due to universal precautions, yet have increased in trauma care due to the nature of the ER environment and proper precautions not being taken. Violence is of risk to attending ER nurses, physicians and paramedics, sighting an Australian study that 79% of triage nurses have experienced physical violence from patients. And, the emotional harm the trauma environment can have on trauma providers. Steins suggests that trauma providers must be aware and learn how to manage risk better to ensure patient and provider safety.

May 25, 2021 Perioperative Geriatrics

Manual of Geriatric Anesthesia

Springer

The document discusses important considerations for anesthetic choice in elderly patients undergoing surgery. Older patients are at higher risk of complications and mortality compared to younger patients. Even minor physiologic disturbances during surgery can have serious consequences for frail elderly patients with limited reserve. The choice of anesthetic regimen and agents can help minimize risks. For example, etomidate is preferred over propofol for induction due to lower risk of hypotension in older patients. Careful preoperative evaluation and avoidance of complications is important for optimizing outcomes in elderly surgical patients.

Imogen Mitchell - Morphing the Recalcitrant Clinician

SMACC Conference

Imogen Mitchell’s SMACC Chicago talk 'Morphing the Recalcitrant Clinician’ talks us through the steps to engage the reluctant physician when implementing change. Imogen initally touches on the stages of physician engagement from aversion, to apathy, to engaged and then outlines the steps to morphing the reluctant physician. 1. Seek out a clinical champion 2. Establish a common purpose/vision 3. Standardise what is standardisable 4. Communication, communication, communication 5. Work out barriers and overcome them 6. Deal with the ‘Whats in it for me?’WIFM

Geriatric Cardio-Oncology

This document discusses special considerations for cardiac dysfunction in older adults living with cancer. It begins with objectives to apply a framework for multimorbidity and review cardiovascular physiology of aging and considerations in cardio-oncology for older adults. It then discusses how chronic diseases increase with age, including cancer and heart disease. Older adults are underrepresented in oncology trials despite having high rates of cancer. A comprehensive geriatric assessment is recommended to identify vulnerabilities beyond standard oncology assessments. Certain chemotherapy agents have increased cardiotoxicity risks in older patients. A multimorbidity framework is presented to guide management of multiple chronic conditions. Strategies are discussed to minimize cardiac complications in older cancer patients, including risk stratification, cardioprotective therapies

An approach to mulitmorbidity in frail older adults

Ms. A is a 72-year-old woman with multiple chronic conditions including COPD, CAD, CHF, diabetes, and CKD. She has multimorbidity, with some conditions being concordant due to similar pathophysiology and management plans. Her diabetes may be considered the dominant condition. Over 10 years, her condition progresses with the addition of colon cancer and mild dementia. In her last year of life, she is frail and in the terminal phase of her multimorbidity. Interventions shift to advanced care planning, symptom management, and liaison with palliative care.

Perioperative delirium

This document outlines the elements and benefits of a proactive geriatric trauma consultation service. It discusses how such a service was established at St. Michael's Hospital in Toronto through collaboration between geriatrics and trauma specialists. The service utilizes comprehensive geriatric assessments and focuses on common geriatric issues for injured older patients. Evaluation of the service found benefits including reduced delirium, nursing home discharges, other consultations, and length of stay. The 10 essential elements of collaborative care models are presented, which were followed to achieve measured improved outcomes. The service has expanded to other hospitals and continues to demonstrate sustained volumes and adherence to guidelines.

Geriatric oncology 2019

Chayakrit (Charles) Krittanawong

1) Geriatric assessment is important for elderly cancer patients to evaluate multiple health domains beyond just cancer and avoid under or overtreatment. 2) Assessments can identify issues like frailty, nutrition, mood, functionality that require management to optimize outcomes and quality of life during cancer treatment. 3) A multidisciplinary approach including nutrition support, exercise interventions, and comprehensive management of geriatric conditions can improve survival and reduce complications in elderly cancer patients.

AHA 2015 by Krittanawong et al from SCAD Mayo Clinic - All Rights Reserved

- The study compared 412 patients with spontaneous coronary artery dissection (SCAD) who participated in cardiac rehabilitation (CR) versus those who did not. - 76% of participants attended at least one CR session, with attendees averaging 18 sessions. CR participants reported physical and emotional benefits. - CR participants had higher anxiety scores and were more likely to increase exercise amounts than non-participants. The primary reason for non-participation was lack of provider recommendation. - Participation in CR was associated with improved physical and mental health outcomes as well as increased exercise. Increased CR referral by providers may help more SCAD patients benefit from rehabilitation.

20150300.0 00007

samirsharshar

The document discusses patient-centered outcomes for perioperative research. It proposes "disability-free survival" as a new outcome measure that is meaningful to patients. Disability-free survival combines survival rates with a validated patient-reported assessment of disability. The authors validate a short version of the World Health Organization Disability Assessment Schedule (WHODAS) for use in surgical patients. Widespread use of disability-free survival could improve shared decision making, quality metrics, and benchmarking by focusing on outcomes that matter to patients rather than surrogate outcomes or doctor perceptions of success.

Geriatric Oncology

Outcomes of Carotid Stent Systems Versus Endarterectomy 4.29.08

Ingrid Abrahamsen, MS, CCRP

Patients who received carotid stent systems (CSS) had slightly higher mortality and major adverse clinical event rates compared to patients receiving carotid endarterectomy (CE). These differences were more pronounced when comparing CSS patients to contemporary CE patients. While CSS is an approved alternative to CE for carotid artery stenosis, concerns remain about its outcomes compared to CE, particularly in non-experimental settings. This study used propensity score matching to compare outcomes of Medicare patients receiving CSS or CE after the 2005 Medicare coverage decision for CSS.

Clinical Decision Support Systems and their Impact on Cardiovascular Disease ...

Xiaoming Zeng

This document summarizes research on the use of clinical decision support systems (CDSS) to improve care for cardiovascular disease. It finds that CDSS can reduce mortality for congestive heart failure patients and improve guideline adherence for hypertension, but do not necessarily lower blood pressure. CDSS also improve management of dyslipidemia and medication prescription post-myocardial infarction. However, more rigorous randomized studies are still needed to fully understand the costs and long-term impacts of implementing CDSS for cardiovascular disease.

CLEVER Final Manuscript_JACC_17Mar2015

This study compared the long-term (18-month) outcomes of supervised exercise (SE), stent revascularization (ST), and optimal medical therapy (OMT) for patients with claudication due to aortoiliac peripheral artery disease. 79 patients completed the 18-month follow-up assessment. The study found that both SE and ST resulted in significantly greater improvements in peak walking time and claudication onset time compared to OMT. SE and ST also provided durable improvements in quality of life measures up to 18 months. Both SE and ST had better long-term outcomes than OMT alone for treating claudication, demonstrating the durability of exercise interventions for peripheral artery disease.

Wiedermann isicem 2013 where are we now

Claudiana Landesfachhochschule für Gesundheitsberufe

1) Large clinical trials and meta-analyses in 2013 provided new evidence about the safety of hydroxyethyl starch (HES) solutions and albumin in critical illness. 2) Meta-analyses found HES solutions were associated with increased mortality, renal replacement therapy, and red blood cell transfusions compared to crystalloids. 3) HES 130/0.4-0.42 was found to increase mortality and renal replacement therapy even at doses far below approved maximums.

NEJM - Year in review 2013

Jaime dehais

This document summarizes two studies that raised questions about the risks and benefits of testosterone therapy: 1. A retrospective study found that male veterans with low testosterone who received testosterone therapy had a higher risk of heart attack, stroke, or death compared to those not receiving therapy, even after adjusting for potential confounding factors. 2. A randomized trial found that adding testosterone to optimized sildenafil therapy for erectile dysfunction provided no additional improvement in erectile function compared to sildenafil alone. Together these studies highlight the need for more research on the long-term risks and benefits of testosterone therapy, as current understanding is limited despite its increasing use.

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This study evaluated shock index (SI), defined as heart rate divided by systolic blood pressure, as a predictor of morbidity and mortality in pediatric trauma patients. The study used data from the 2010 National Trauma Data Bank and found that an elevated age-adjusted SI was strongly associated with mortality, need for blood transfusion, ventilation, procedures, and ICU stay. Compared to hypotension alone, elevated SI had improved sensitivity for predicting negative outcomes while maintaining high specificity. The findings support using SI as a simple tool to identify pediatric trauma patients at risk of shock-related complications.

Anesthesia and geriatrics 2021 no recording

This document discusses anesthesia and surgery risks in older patients. It defines postoperative cognitive dysfunction (POCD) and reviews risk factors. Neuroinflammation from surgery and anesthesia may cause POCD through breakdown of the blood-brain barrier and neurotoxic effects. Risk factors for POCD include age, preexisting cognitive impairment, diabetes, hypertension and sleep disorders. A comprehensive geriatric assessment evaluates medical, functional and social risks. Prevention prioritizes optimization of risk factors through treatment of medical conditions and good perioperative care. Most POCD cases resolve within months without direct treatment.

Jc eurotherm3235 ppt

University of Michigan Department of Emergency Medicine

This randomized controlled trial compared outcomes for patients with traumatic brain injury (TBI) and intracranial hypertension who received therapeutic hypothermia (32-35°C) plus standard care versus standard care alone. The trial was stopped early due to higher mortality in the hypothermia group. At 6 months, functional outcomes as measured by the GOSE were worse in the hypothermia group. While hypothermia successfully controlled intracranial pressure, it did not result in improved outcomes compared to standard care alone and was associated with higher mortality.

International Study of Comparative Health Effectiveness with Medical and Inva...

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Bhargav Kiran

This document summarizes the results of the ASCEND trial, which investigated the effects of low-dose aspirin (100 mg daily) for primary prevention of cardiovascular events in 15,480 adults with diabetes but no history of cardiovascular disease. Over a mean follow-up of 7.4 years: - Serious vascular events were lower in the aspirin group (8.5%) compared to placebo (9.6%), but major bleeding events were higher with aspirin (4.1% vs 3.2%). - There was no significant difference in gastrointestinal cancer rates between groups. - Aspirin prevented some vascular events but increased bleeding, largely offsetting the benefits. The absolute risks and benefits were closely balanced

Effect of zolendronic acid journal club

Ard Nepid

- This study evaluated 120 elderly patients with intertrochanteric hip fractures who were randomized to receive either zoledronic acid or a placebo after surgical treatment. - Outcome measures including functional scores and bone mineral density were higher in the treatment group who received zoledronic acid compared to the placebo group. - Mortality rates at 12 months were lower in the treatment group at 24.5% compared to the placebo group. - The study concluded that the use of zoledronic acid after surgical treatment of intertrochanteric hip fractures in osteoporotic elderly patients over 65 years old is a safe treatment modality.

Ueda 2016 dm & cad-amr el hadidy

ueda2015

This document discusses screening for coronary artery disease (CAD) in asymptomatic patients with diabetes. It notes that while CAD risk is elevated in diabetic patients, widespread screening is not currently recommended due to a lack of evidence that it improves outcomes. Some key points made in the document: - The risk of CAD is higher and often silent in diabetic patients. However, screening the large number of diabetic patients is very costly, and it is unclear if treating silent CAD found on screening would actually help patients. - Two studies found that screening stress SPECT imaging found abnormal results in only 16-17% of asymptomatic diabetic patients. - More data is still needed to determine if screening can identify a high-risk group of diabetic patients

Presentation by Michele Nypaver

Cavernoma JC

Health Informatics New Zealand

This study compared outcomes of patients with cerebral cavernous malformations (CCMs) and new-onset seizures who received either initial surgical treatment, initial conservative treatment, or delayed surgical treatment after failed conservative treatment. Results showed that patients who received initial surgical treatment or delayed surgery had better seizure control and were more likely to discontinue antiepileptic drugs than those who received only conservative treatment. However, operative morbidity was low and comparable between surgical groups and conservative treatment. The presence of residual hemosiderin on postoperative imaging was associated with continued seizures after surgery. Overall, the study provides observational evidence that early surgical treatment may improve seizure outcomes for CCM patients with new-onset seizures compared to initial conservative management.

Psychological determinants-of-problematic-outcomes-following-total-knee-arthr...

Paul Coelho, MD

This study examined psychological factors that may predict problematic outcomes following total knee arthroplasty (TKA). 75 patients completed measures of pain catastrophizing, pain-related fears, depression, and pain/function before and 6 weeks after TKA surgery. Results showed that pre-surgical pain and pain catastrophizing uniquely predicted greater post-surgical pain severity. Pre-surgical pain-related fears predicted worse function at follow-up in initial analyses but not when accounting for other medical factors. The findings suggest different psychological factors may influence post-surgical pain versus function. Targeting psychological risk factors could potentially improve outcomes after TKA.

The value of information

The document discusses the value of information in healthcare and analyzing temporal patterns in patient care and health services. It provides examples of studies that analyzed patterns in test follow-up rates and mortality rates for weekend hospital admissions. While the studies found issues like high rates of unreviewed tests and higher mortality for weekend admissions, further analysis of temporal patterns provided insights into potential causative factors and opportunities for intervention. The value of information is realized when it leads to changes in decisions and care processes that improve outcomes.

BLOOD TRANSFUSIONS ARE ASSOCIATED WITH MORTALITY IN PEDIATRIC PATIENTS WITH S...

Texas Children's Hospital

Restrictive thresholds for red blood cell (RBC) transfusion have not been shown to be inferior to liberal transfusion thresholds after cardiac surgery in pediatric or adult patients.1,2 RBC transfusions are associated with readmission due to heart failure (HF) in adults after aortic valve replacements, and with increased risk of right ventricle-pulmonary artery conduit failure in pediatric patients.3,4 Data are limited about RBC transfusions in pediatric patients with HF.

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International Study of Comparative Health Effectiveness with Medical and Inva...

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Cardiovascular Diagnosis and Therapy (CDT)

PROSPER trial journal club

Govind Madhaw

The study compared outcomes of ischemic stroke patients prescribed direct oral anticoagulants (DOACs) versus warfarin at discharge. Patients prescribed DOACs had more days at home within one year of discharge, fewer major adverse cardiovascular events, and lower rates of death, readmissions, hemorrhagic strokes, and bleedings compared to warfarin. However, DOACs were associated with a higher risk of gastrointestinal bleeding. The retrospective study was limited by potential selection biases from its exclusion criteria and inability to account for differences in warfarin dosage adjustments compared to DOACs.

Is clinician gestalt undervalued in chest pain assessment in ED

kellyam18

1-s2.0-S0002914913019292-main

Brian Vendel

1. Recurrent myocardial infarction (MI) after primary percutaneous coronary intervention (PPCI) for ST-segment elevation myocardial infarction (STEMI) occurs in about 21% of patients and is associated with worse clinical outcomes. 2. Recurrent MI significantly increases the risks of subsequent cardiac mortality, noncardiac mortality, stroke, and bleeding. 3. Early recurrent MIs within 1 day of the initial PPCI are associated with higher unadjusted cardiac mortality compared to later recurrent MIs, but after adjustment, recurrent MIs occurring more than 1 year after PPCI carry the highest risk of cardiac death.

Curb 65 thorax-2003-lim-377-82

José Manuel Valencia Gallardo

This document describes a study that derived and validated a new severity assessment model called CURB-65 for stratifying patients with community acquired pneumonia (CAP) into different risk groups upon hospital admission. The study combined data from previous CAP studies involving over 1000 patients. Using logistic regression, factors independently associated with 30-day mortality were identified as age over 65, albumin level under 30 g/dl, and CURB score over 2 (which evaluates confusion, urea, respiratory rate, blood pressure). These factors were used to create the CURB-65 score, which stratifies patients into risk groups from 0.7% to 57% 30-day mortality risk based on their score. The validation cohort confirmed similar mortality risks based on

Early mobilisation in ICU

Shikha Panwar

1) Early mobilization of critically ill patients in the ICU can reduce ICU-acquired weakness, improve functional recovery during hospitalization, and reduce hospital length of stay. However, many ICUs are still conservative in mobilizing mechanically ventilated patients. 2) A study found that combining daily interruption of sedation with physical and occupational therapy led to more patients returning to independent function at discharge and fewer ICU delirium days compared to interruption of sedation alone. 3) While early mobilization studies have shown it to be safe, some physicians still report patient safety as a barrier; interdisciplinary communication and leadership may help reduce avoidable barriers to early mobilization.

Classification and Regression Tree Analysis in Biomedical Research

Salford Systems

This document discusses using classification and regression tree (CART) analysis to develop clinical decision rules for three clinical settings: 1) emergency department triage of HIV-infected patients, 2) survival prediction of patients with colon and rectal cancer, and 3) prediction of neurologic survival in patients following out-of-hospital cardiac arrest. For each setting, the document describes developing CART models using various clinical variables to classify patients into risk groups and reports validation results for predicting outcomes like medical urgency and survival.

Mdct2

guest8e029d

1) This study investigated whether using 64-slice MDCT as part of the initial diagnostic strategy for patients presenting with acute chest pain could reduce emergency department and hospital length of stay, admissions, and 30-day major adverse cardiac events. 2) 267 patients were randomized to either a conventional diagnostic strategy or a MDCT-based strategy. The MDCT-based strategy reduced unnecessary admissions in patients at intermediate risk and decreased hospital length of stay overall and in high-risk patients specifically. 3) Emergency department length of stay was not different between the strategies. No patients in the MDCT group experienced events at the one-month follow-up.

PCI vs OMT vs CABG in Stable CAD

Vivek Rana

This document summarizes recent evidence on medical treatments, percutaneous coronary intervention (PCI), and coronary artery bypass grafting (CABG) for stable coronary artery disease. Key findings include: 1) Large clinical trials found no significant difference in outcomes between PCI and optimal medical therapy for stable CAD patients. 2) CABG was shown to reduce mortality, myocardial infarction, and repeat revascularization compared to medical therapy or PCI for multi-vessel disease. 3) For left main coronary artery disease, CABG may be preferable to PCI for patients with high anatomical complexity scores. 4) Ongoing trials like ISCHEMIA are further evaluating optimal revascularization strategies for stable CAD patients with ischemia.

The art of the possible ideas

howardcooper

The document discusses quality improvement initiatives in several countries aimed at reducing patient harm and mortality in healthcare. It outlines specific interventions and goals for the UK, Scotland, Denmark, Canada, Wales, and the US including reducing surgical complications, preventing central line infections, reducing harm from high-risk medicines, and preventing MRSA infections. Evidence is presented on the impact of certain interventions like proper use of antibiotics, beta blockers, and venous thromboembolism prophylaxis in surgery.

The Changing Face of Trauma Care

CICM 2019 Annual Scientific Meeting

Which Chest Pain Can Be Safely Discharged From Ed

Rashidi Ahmad

This document discusses strategies for evaluating and safely discharging chest pain patients from the emergency department (ED). It notes that over 30% of medical admissions are for chest pain, but only 50% actually have acute coronary syndrome (ACS). The diagnostic challenges include non-specific symptoms, limitations of electrocardiograms and cardiac markers in the early stages of ACS. Risk prediction tools like the TIMI score can help determine which low-risk patients may be safely discharged. Younger patients with no cardiac risk factors and normal initial tests have a very low 0.14% risk of ACS. Stress tests and echocardiography have limitations in the ED setting but may help rule out problems in some patients. The goal is to

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tyfngnc

This document discusses unplanned extubations in the intensive care unit (ICU). It provides data on ICU admissions and mortality in the United States. It then focuses on safety issues in ICUs, including classifications of incidents like unplanned extubations. Risk factors for unplanned extubation are examined, like agitation, delirium, and the night shift. Outcomes of unplanned extubation are poorer and include higher rates of reintubation. The document then discusses efforts at one hospital to reduce unplanned extubations through staff education, monitoring high-risk patients, and implementing a care bundle to manage pain, agitation, and delirium.

Post cardiac arrest care in ED

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Patients Of Size Nti

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Treating patients of size in the ICU presents many challenges including difficulties with positioning, skin integrity, respiratory function, and safety concerns for both patients and caregivers. Obesity does not independently increase mortality in the ICU but is associated with longer ICU and hospital stays as well as increased need for mechanical ventilation. A multidisciplinary approach is needed utilizing special equipment, techniques to prevent complications, and a culture of sensitivity.

Resuscitation update by Professor Peter Morley

The good news in resuscitation is that there have not been any new advances that mandate a change in practice since the 2016 ANZCOR Guidelines. The bad news is that despite our best intent, the ever-increasing research appears unable to demonstrate improved outcomes with any particular approach. Two of the most exciting areas (eCPR and post-resuscitation care) are being covered in detail at separate talks at this meeting. This presentation will focus on updating the audience on the more continuous approach to evidence evaluation, and the key recent publications that have made us at least re-evaluate our practices in BLS (including ventilation), ALS (including anti-arrhythmics) and peri-resuscitation care.

Sternal Fractures & Dislocations - EMGuidewire Radiology Reading Room

Sean M. Fox

The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Sternal Fractures and Dislocations and is brought to you by Carrie Bissell, MD, Aaron Fox, MD, Kendrick Lim, MD, Stephanie Jensen, MD, and Olivia Rice, MD. It is has special guest editor: Sean Dieffenbaugher, MD and Laurence Kempton, MD

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This study analyzed insurance claims data from before and after the implementation of the Federal Mental Health Parity and Addiction Equity Act to examine the effects of parity on substance use disorder treatment. The results showed: 1) There was no change in the use of substance use disorder services or the total annual spending per enrollee on these services (which increased by only $10 per enrollee). 2) There was also no change in out-of-pocket spending for substance use disorder treatment users or several HEDIS quality measures related to identification and initiation of treatment. 3) This suggests that concerns about parity greatly increasing health care costs related to substance use disorder treatment were unfounded.

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This study conducted a telephone survey of labor and delivery units at U.S. hospitals to determine the prevalence of hospital policies addressing non-medically indicated deliveries prior to 39 weeks gestation. They found that 66.5% of responding hospitals reported having such a policy. Hospitals in states with initiatives to reduce early deliveries were more likely to have a policy, with 67.8% of hospitals in initiative states reporting a policy compared to 62.1% in non-initiative states. The majority (68.8%) of policies were coded as having a "hard stop" against early deliveries. The study concludes that state initiatives can effectively encourage more hospitals to adopt restrictive policies on non-medically indicated early deliver

A Qualitative Study of Adverse Childhood Experiences of Low-Income Youth in P...

This study explored a broader range of adverse childhood experiences reported by low-income adults from Philadelphia compared to those measured in previous research. The researchers conducted focus groups with 119 participants who generated a list of childhood stressors across 10 domains. The most commonly reported experiences were issues within family relationships, community safety threats, personal victimization, and economic hardship. The study concludes that considering a wider range of adversities is important for understanding health impacts on low-income urban populations.

The Intersection of Attitudes and Organizational Factors by Provider Type in ...

This document summarizes a mixed-methods study examining the relationship between mental health therapists' attitudes towards evidence-based practices (EBPs), perceptions of organizational factors, and degree status. The study found that doctoral-level therapists with positive attitudes reported more autonomy, while those with less positive attitudes reported requirements to use CBT and lack of time. Non-doctoral therapists reported lack of resources, space, funding, and regular client access as barriers. Managerial support was a facilitator for all therapists. The study provides insight into implementation challenges faced in community clinics from front-line perspectives.

Doulas to fill the gap: a proposed model of doula delivery of cognitive-behav...

This document proposes a model where doulas receive training in cognitive behavioral therapy (CBT) principles from staff at an integrated maternal wellness clinic. The objectives are to incorporate doulas into standard practice while providing training, and to utilize doulas to increase implementation of evidence-based CBT for common mental health issues in the perinatal period like anxiety and depression. Limitations include challenges of implementing a novel intervention and ensuring standardized training, protected staff time, and adherence to practice guidelines.

A Glorious Mess: Implementing Evidence-Based Social Skills Interventions in P...

This study piloted a modified social skills intervention for children with ASD implemented by school personnel in public school settings. The intervention focused on facilitating peer engagement during lunch and recess. Results showed improvements in social network centrality and joint engagement for children who received the immediate treatment compared to those in the waitlist control. However, barriers like unclear staff roles, lack of support, and loss of recess time prevented long-term sustainability. Future work is needed to address school-level barriers to implementation and adapt interventions to fit individual school contexts.

Healthcare System Supports for Internists Caring for Young Adult Patients wit...

This study examined the healthcare system supports for internists caring for young adult patients with chronic illnesses that began in pediatric care. Semi-structured interviews were conducted with 21 internists across 4 states. The interviews identified 5 major themes of healthcare system burdens experienced by internists, including difficulty identifying patients' medical teams, inadequate time for complex patients, significant administrative burden, lack of social/case management support, and financial constraints. The interviews also identified 3 potential strategies to improve supports, such as formalizing transfer processes, maximizing electronic records/communication, and leveraging patient-centered medical homes and bundled payments.

Elderly Adults with Dementia and Young Adults with Developmental Disabilities...

Most internists found more similarities than differences in caring for young adults with intellectual and developmental disabilities (I/DD) and elderly adults with dementia. Both populations require longer office visits and more staffing resources due to complex health histories. Obtaining records and coordinating care can be difficult for both. Reliance on advocates, community services for transportation and supervision, and vulnerability to insurance changes are also similarities. While specific diseases differ, models for geriatric care could potentially address supervision and caretaking needs for adults with I/DD. Strengthening safety net services would help low-income families and elderly patients with dementia or I/DD.

Is the quality of case management in a medical home associated with patient s...

This study examines the association between patient perceptions of case manager performance and satisfaction with care, as well as the relationship between perceptions of case managers and primary care providers (PCPs) and subsequent healthcare utilization. The study analyzed survey and claims data from over 2,000 patients receiving primary care from a medical home model with embedded case managers. The results found that higher ratings of both case manager and PCP performance were independently associated with greater patient satisfaction. The study concludes by noting that perceptions of case management may impact health outcomes and behaviors, warranting further analysis of utilization patterns.

Comparison of HIV Testing with other Markers of Chronic Disease Screening 4_...

This document analyzes survey data from 2002-2010 on HIV testing rates and chronic disease screening in Southeastern Pennsylvania. It finds that HIV testing rates are lower than screening for other chronic diseases. Populations receiving care at community health clinics, emergency rooms, or with no primary care are more likely to get HIV testing than those at private clinics. While community health clinics perform similar to private clinics on chronic disease screening, those using emergency rooms or with no primary care are less likely to receive routine chronic disease screening. Primary care physicians adhere to guidelines for screening of conditions like blood pressure and cancer but may neglect appropriately screening for HIV.

Comparison of HIV Testing with other Markers of Chronic Disease Screening

This study analyzed survey data from 50,698 individuals in Southeastern Pennsylvania between 2002-2010 to compare HIV testing rates to other routine health screenings. It found that HIV testing rates were lower than for other conditions. Those receiving care at community health clinics, emergency rooms, or with no primary care had higher odds of receiving an HIV test compared to private clinics. While community health clinics performed similarly to private clinics on other screenings, emergency rooms and no primary care had lower rates. The study suggests primary care physicians may neglect appropriate HIV screening of patients despite adhering to other screening guidelines.

High Value Cost Conscious Care: Is it Rationing or Rational Care? 1_11_13

1. The document discusses high value cost conscious care and whether it constitutes rationing or rational care. 2. It notes that health care costs in the US continue to rise significantly each year, with diagnostic imaging being a major driver of increasing costs. 3. Data from 6 large health systems showed large variations in diagnostic imaging rates between different regions without clear clinical benefits, indicating opportunities for more rational use of imaging to improve quality and reduce costs.

LDI Research Seminar with Art Kellermann, MD, MPH 11_28_12

This document summarizes key findings from RAND research on health care spending in the United States. It finds that between 1999-2009, health care costs grew substantially for a median-income American family, consuming money that could have otherwise been used to pay down debt, save for retirement, or pay for education. While Americans received more medical services, the quality of care was still suboptimal, with recommended care received only about 55% of the time. The document also examines different approaches to reducing health care costs, finding that high-deductible health plans with deductibles over $1,000 were effective in reducing spending.

CMHPSR/LDI Research Seminar_New Models for Childrens Mental Health Services D...

The document outlines Marc Atkins' presentation goals which include reviewing concerns with the current U.S. children's mental health care system, justifying a focus on schooling using ecological principles and a public health framework, presenting an experimental intervention model and preliminary results, and discussing future directions. It then lists the collaborators involved in the research from various universities.

LDI Research Seminar 9_7_12 Effects of Federal Policy to Insure Young Adults...

The document summarizes a study that analyzes the effects of the 2010 Affordable Care Act's dependent coverage mandate on young adults' health insurance coverage and labor market behavior using data from the 2008 panel of the Survey of Income and Program Participation. The study finds that the policy led to a 3.3 percentage point reduction in uninsurance among young adults ages 19-25, a 6.2 percentage point increase in dependent coverage through a parent's employer-sponsored insurance, and evidence of increased labor market flexibility for young adults.

LDI Poster Template

This document provides a template for creating scientific posters. It includes suggestions for formatting, design principles, and sections like the title, abstract, methods, results, and conclusions. The template is meant to simplify poster creation and emphasize key points for viewers through techniques like italics, boldface, and effective use of space. Proper formatting of images, tables, and graphs is also discussed. The goal is to design posters that are easy to understand and focused on the needs of the audience.

LDI Charles Leighton Memorial Lecture with Mark Chassin, MD 5_4_12