Faculty Bibliography

BACKGROUND: Delays in patient transfers are associated with worse outcomes for some neurosurgical conditions. One of the primary causes of transfer delay is lack of neurosurgery ICU bed availability. In this study, we characterize the results of implementing an interhospital transfer protocol to reduce unnecessary transfers and improve bed availability. METHODS: A transfer protocol was implemented in July 2012 at the Bellevue Hospital Department of Neurosurgery that screened for and prevented transfer of low-risk patients that were unlikely to require specialized inpatient neurosurgical care. The impact of this protocol was assessed with prospectively recorded data on all potential interhospital transfers from May 2011 through June 2016. RESULTS: Of the 1978 calls (regarding 1886 individual patients), 402 occurred prior to the implementation of the transfer protocol and 1576 occurred after. Prior to the protocol, 84.1% of transfer requests were accepted but 15.2% were subsequently denied for bed unavailability. After the protocol, a smaller share of transfer requests were accepted after protocol screening (71.8%, p<.001), but only 1.9% (p<.001) were subsequently denied because of bed unavailability. The diagnosis demographics changed significantly (p<.001), with a larger share of arriving transfers suffering from aneurysms or tumors after the protocol and a smaller share suffering from stenosis/disc disease without neurological symptoms. CONCLUSIONS: The transfer protocol implemented in this study allowed transfer determination based on the need for specialized neurosurgical care rather than chance unavailability of beds. Developing interhospital transfer protocols may be an effective strategy to efficiently allocate limited hospital resources and improve transfer systems.

BACKGROUND: Few data is available on triage of critically ill patients. Because the demand for ICU beds often exceeds their availability, frequently intensivists need to triage these patients in order to equally and efficiently distribute the available resources based on the concept of potential benefit and reasonable chance of recovery. The objective of this study is to evaluate factors influencing triage decisions among patients referred for ICU admission and to assess its impact in outcome. METHODS: A single-center, prospective, observational study of 165 consecutive triage evaluations was conducted in patients referred for ICU admission that were either accepted, or refused and treated on the medical or surgical wards as well as the step-down and telemetry units. RESULTS: Seventy-one patients (43.0%) were accepted for ICU admission. Mean Acute Physiology and Chronic Health Evaluation (APACHE)-II score was 15.3 (0 - 36) and 13.9 (0 - 30) for accepted and refused patients, respectively. Three patients (4.2%) had active advance directives on admission to ICU. Age, gender, and number of ICU beds available at the time of evaluation were not associated with triage decisions. Thirteen patients (18.3%) died in ICU, while the in-hospital mortality for refused patients was 12.8%. CONCLUSION: Refusal of admission to ICU is common, although patients in which ICU admission is granted have higher mortality. Presence of active advance directives seems to play an important role in the triage decision process. Further efforts are needed to define which patients are most likely to benefit from ICU admission. Triage protocols or guidelines to promote efficient critical care beds use are warranted.

Background. Although access to HAART has prolonged survival and improved quality of life, HIV-infected patients with severe immunosuppression or comorbidities may develop complications that require critical care support. Our objective is to evaluate the etiology of respiratory failure in patients with HIV infection admitted to the ICU, its relationship with the T-lymphocytes cell count as well as the use of HAART, and its impact on outcome. Methods. A single-center, prospective, and observational study among all patients with HIV-infection and respiratory failure admitted to the ICU from December 1, 2011, to February 28, 2013, was conducted. Results. A total of 42 patients were admitted during the study period. Their median CD4 cell count was 123 cells/ mu L (mean 205.7, range 2.0-694.0), with a median HIV viral load of 203.5 copies/mL (mean 58,676, range <20-367,649). At the time of admission, 23 patients (54.8%) were receiving HAART. Use of antiretroviral therapy at ICU admission was not associated with survival, but it was associated with higher CD4 cell counts and lower HIV viral loads. Twenty-five patients (59.5%) had respiratory failure secondary to non-HIV-related diseases. Mechanical ventilation was required in 36 patients (85.1%). Thirteen patients (31.0%) died. Conclusions. Noninfectious etiologies of respiratory failure account for majority of HIV-infected patients admitted to ICU. Increased mortality was observed among patients with sepsis as etiology of respiratory failure (HIV related and non-AIDS related), in those receiving mechanical ventilation, and in patients with decreased CD4 cell count. Survival was not associated with the use of HAART. Complementary studies are warranted to address the impact of HAART on outcomes of HIV-infected patients with respiratory failure admitted to ICU.

Background/Case Studies: >25% of the 15 million RBC transfusions (TXN) in the US are probably medically unnecessary. Many studies have demonstrated the safety of using lower hemoglobin (Hgb) TXN thresholds. In 2010 the 11 acute care hospitals in our system adopted a common set of RBC TXN triggers to standardize practice and improve patient care. The adult triggers were A) Hgb <7 g/dl and symptomatic anemia, B) Hgb <9 g/dl with significant cardiac, neurological, or respiratory disease, C) Blood loss >20% refractory to fluid resuscitation, and D) Pre-op for major surgery with anticipated blood loss >1000 ml and Hgb <7 g/dl. Education was part of the roll-out of the new triggers. In 2011 we sought to evaluate the adherence to the triggers. Study Design/Methods: The pre-TXN Hgb result just prior to each RBC order was pulled from the EMR into a data warehouse where it could be manipulated. The number of RBC orders placed at pre-TXN Hgb values were sorted and grouped. Because of the way the messages come from the blood bank computer system into the EMR, it is not possible to electronically extract the Hgb just prior to RBC issuance. Thus we were forced to look at the Hgb just prior to RBC order as a surrogate for adherence to the RBC TXN triggers Results/Findings: From 1/1/11 to 10/31/11, 16,375 RBC orders were placed of which 13077 had a preceding Hgb level. 34,891 RBCs were transfused. 4474 orders were placed with a pre-TXN Hgb >/= 9 g/dl. 3481 orders were placed with a pre-TXN Hgb <7 g/dl. 5695 orders were placed with a pre-TXN Hgb 7- <9 g/dl. 9.6% of RBCs were ordered at a Hgb >10 g/dl. A portion ordered at higher Hgb levels were for pre-operative patients. 10% of RBCs issued were returned to the blood bank. 3% of RBCs were issued using emergency release, presumably for trauma and other rapidly bleeding patients, and thus may explain a portion of the RBC units ordered at Hgb >10 g/dl Conclusion: 27% of RBCs are being ordered and transfused to patients with Hgb >9 g/dl. The more restrictive RBC TXN triggers adopted have not eliminated unnecessary transfusions. While computers are able to sort blood orders based on the use of lab data and the physician selected TXN triggers, smarter computers which are able to assess lab values and supporting clinical documentation are needed. The blood bank needs to play a proactive role in ensuring that RBCs are not issued to patients who do not satisfy the specific TXN trigger selected by the ordering physician. Until such clinical support exists from the EMR, auditing must continue to ensure adherence to the RBC TXN triggers and prevent clinically unnecessary TXN. (Table presented)

OBJECTIVES: To test the efficacy of an electronic asthma monitoring system (AMS) to reduce pediatric emergency department (ED) visits and hospitalizations for asthma. STUDY DESIGN: Randomized clinical trial. METHODS: Families of pediatric patients with asthma aged 8 to 17 years were recruited at 6 medical centers. Children were randomly assigned to the American Medical Alert Corporation pediatric AMS or a paper diary. The numbers of and costs associated with ED visits and hospitalizations for the 2 groups in the year following randomization were compared using t tests of statistical significance. RESULTS: Of 59 children recruited to the trial, 29 were randomized to the AMS and 30 to the diary. The 2 groups were similar in demographic and clinical characteristics. During their study year, 24 AMS group members logged on a mean (SD) of 211.0 (117.3) days; 13 diary group members provided data on a mean (SD) of 136.6 (128.0) days. During the 32 months that the study was in progress, the case managers logged on a mean (SD) of 171.0 (97.2) days. Overall, 35 children had at least 1 ED visit, but only 7 children were hospitalized. The 2 groups had no statistically significant differences in the numbers of or charges associated with ED visits or hospitalizations. CONCLUSION: Electronic devices are being developed to make chronic disease management easier for patients and their families, but they should not be adopted without careful study, including randomized trials, to ascertain their use, costs, and benefits