Faculty Bibliography

There is robust evidence to support the concept that critical pathways, derived from evidence-based guidelines, are an effective strategy for bridging the gap between published guidelines and clinical practice. It was with this idea in mind that in 2004 we developed an innovative novel program at our institution, that is, the "Advanced Cardiac Admission Program." The Advanced Cardiac Admission program consists of tools and strategies for implementing American College of Cardiology or American Heart Association guidelines into daily clinical practice. The program is composed of 8 novel critical pathways for the management of cardiac patients. In this article, we describe our experience in successfully implementing this program at our institutions.

BACKGROUND: Loop diuretics are considered first-line therapy for patients with acute decompensated heart failure (ADHF). Adding nitroglycerin (NTG) to diuretic therapy for alleviation of acute shortness of breath has been advocated in our institution. We evaluated the benefits of adding NTG to diuretics in the emergency department for patients with ADHF and chronic kidney disease (CKD). METHODS: 430 consecutive patients with ADHF who were admitted with a chief complaint of dyspnea were included in this retrospective study. Patients were divided into 3 groups. Group A patients were treated with neither diuretics nor NTG; Group B patients were treated with diuretics only; and Group C patients were treated with both diuretics and NTG. Estimated glomerular filtration rate (GFR) was calculated according to the Cockcroft-Gault formula. Follow-up was 36 +/- 9 (mean +/- standard deviation [SD]) months. Primary endpoints were readmission rate at 30 days and mortality at 24 months. RESULTS: 430 patients were included in this study (42% men; age, 69 +/- 14 [mean +/- SD] years); mean New York Heart Association class was 2.4 +/- 0.7 (mean +/- SD) and mean ejection fraction was 28% +/- 17% (mean +/- SD). Group A included 257 (59%) patients, Group B had 127 (29%) patients, and Group C had 46 (11%) patients. Group C patients were older (mean age, 72 +/- 13 years) with lower body mass index (26 +/- 7 kg/m2), lower estimated GFR (55.8 +/- 38 mL/min per 1.73 m2), higher B-type natriuretic peptide levels (1112 +/- 876 pg/mL; P = nonsignificant [NS]), and higher systolic and diastolic blood pressures on admission (P = 0.001). The primary endpoint was assessed as a composite of all-cause mortality and ADHF readmission seen in 143 (56%) Group A patients, 68 (53%) Group B patients, and 22 (48%) Group C patients (P = NS). At 30 days there were 53 (12%) readmissions--26 in Group A, 20 in Group B, and 7 in Group C (P = NS). However, survival at 24 months was higher in Group C (87%) compared with Groups A (79%) and B (82%) (P = 0.002). Using the Cox proportional-hazards regression module, early administration of NTG and Lasix (95% confidence interval [CI], 1.06-1.62; P = 0.01) followed by CKD stage (95% CI, 1.00-1.35; P = 0.04) were the only predictors for survival. CONCLUSION: There is a role for early administration of NTG in addition to diuretic therapy in patients admitted to the emergency department with ADHF, with resultant decreased length of stay and a trend toward a decrease in the composite endpoint of all-cause mortality and ADHF readmission. The mortality benefit at 2 years reported in our study is thought-provoking and raises a premise to be proven in randomized clinical trials.

About 65 million Americans, one fourth of the adult population in the United States, and over 1 billion people worldwide have hypertension (HTN). HTN therefore is present in 1 of every 4 patients admitted to any US hospital. Surprisingly, no guidelines are available for the management of inpatient HTN. Based on a comprehensive search of the literature we are proposing a pathway for the management of HTN in nonpregnant hospitalized patients. The pathway provides a definition and clinical assessment of HTN for patients admitted to the hospital. The assessment is followed by an organ/system based therapeutic approach specifying timing, blood pressure goals, recommended antihypertensive drug therapy and the sequence of add-on drugs. The pathway specifically discusses assessment and management of HTN in patients with (1) acute aortic syndrome, (2) acute neurologic syndrome, (3) acute coronary syndrome, (4) congestive heart failure, (5) renal failure, and (6) secondary forms. Finally, the pathway provides a step by step recommendation for the management of in hospital HTN and of hypertensive emergencies

Inhospital morbidity and mortality are increased in hyperglycemia. Normalization of blood glucose levels using intensive insulin infusion protocols improves clinical outcomes. Insulin infusion algorithms have been shown to be safe and effective; however, a major obstacle in their implementation is their complexity. We have developed a novel pathway for the management of hyperglycemia, which introduces the "wheel" concept for insulin dosing complemented by "catchup" insulin dosing. The "wheel" serves as a treatment guide. It is made up of 4 concentric circles. The inner circle features blood glucose ranges and the 3 outer circles correspond to increasing rates of insulin infusion. Simple guidelines are provided to facilitate conversion from insulin infusion to a subcutaneous insulin-delivery regimen in preparation for transfer from the critical care unit setting. Our protocols eliminate reliance on the familiar "sliding scale" insulin administration schemes with the introduction of "catchup" insulin dosing to supplement the basic regimen. This pathway is comprehensive yet simple and provides guidelines for treatment of hyperglycemia for all patients screened to a critical care unit or to a stepdown unit.