Faculty Bibliography

Objective: Pulmonary embolism response teams (PERTs)have become increasingly popular at institutions around the country, although only anecdotal evidence is available to support their efficacy. PERTs are mechanisms for rapid involvement of a multidisciplinary team in the management of a time-sensitive condition with many treatment options spanning multiple specialties. We aimed to evaluate time to management of pulmonary embolisms and outcomes since 2016 under our institution's PERT. Method(s): We retrospectively reviewed 151 patients with PERT activations since inception, collecting data on demographics, time to treatment, treatment modality, and in-hospital outcomes. Result(s): The average age was 62.4 years (range, 30-95 years), and 54% of patients were male; 39.4% of patients had normal echocardiographic recordings, with 27% showing right ventricular (RV)hypokinesis, 9.1% showing elevated pulmonary artery pressures, and 6.1% showing RV enlargement. Anticoagulation alone was received by 91.4% of patients; 4.5% had catheter-directed therapy (CDL), and 3.0% had systemic administration of tissue plasminogen activator (tPA). The average time to invasive intervention was 665 minutes (95% confidence interval [CI], 249-1080 minutes)for CDL and 22 minutes (95% CI, 0-456 minutes)for systemic tPA. Average time to anticoagulation was 3 minutes (95% CI, 154-160 minutes). For patients with echocardiographic findings suggestive of RV strain, 21.4% (95% CI, 0.04-0.51)had tPA or an invasive intervention. Of patients with echocardiographic findings consistent with RV strain who underwent conservative management, 80% were discharged home after an average length of stay of 6.0 days (95% CI, 4.5-7.5). Twenty (14.1%; 95% CI, 5.5-22.5)patients receiving anticoagulation alone had bleeding events, whereas none of the patients undergoing CDL or tPA had bleeding. Sixteen (11.2%; 95% CI, 5.7-16.3)patients who had anticoagulation died in the hospital or were discharged to hospice, and none of the patients receiving CDL or tPA died or were discharged to hospice. The odds of in-hospital death were lower for patients receiving anticoagulation than for those without (odds ratio, 0.29), suggesting appropriate identification of high-risk patients. Average hospital stay was 6.5 days (95% CI, 4.9-8.5)for patients who received anticoagulation, 5.3 days for CDL (95% CI, 0-11.2), and 8 days for tPA (95% CI, 2.6-13.4). Conclusion(s): We found that a dedicated PERT team leads to efficient delivery of care and excellent outcomes. The majority of pulmonary embolisms can be managed with anticoagulation alone. CDT and systemic tPA are safe adjunctive treatments for select patients.

Purpose: The opioid epidemic has expanded the cardiac donor pool, but the concern for primary graft dysfunction (PGD) remains a barrier to wider utilization of these hearts. We analyzed donor characteristics in transplanted and discarded cardiac allografts from overdosed donors (ODD) to determine if viable ODD hearts are being unnecessarily discarded due to inappropriate bias. Method(s): Data on adult cardiac transplantation from 2010-2017 were provided by the SRTR. Eight donor characteristics associated with PGD were analyzed: age, gender, hypertension, high creatinine, cocaine abuse, inotropic support, LVEF, and cardiac arrest. Donor characteristics of transplanted and discarded hearts were compared between ODD and non-ODD. Result(s): ODD comprised 11% (1710/15904) of transplanted hearts and 7% (2600/32678) of discarded hearts. Among transplanted hearts, ODD more frequently were younger than 50 (98% vs 90%), did not have hypertension (86% vs 83%), and did not require inotropic support (62% vs 55%) compared to non-ODD; ODD less frequently were male (63% vs 70%), had no history of cocaine abuse (57% vs 84%), or had creatinine <=1.5 (62% vs 81%). Among discarded hearts, ODD more frequently were younger than 50 (87% vs 46%), had no history of hypertension (78% vs 49%), and did not require inotropic support (51% vs 41%); ODD less often had no history of cocaine abuse (50% vs 86%) or creatinine <=1.5 (61% vs 69%) (Table). Donors known to have at least 6 of 8 favorable qualities comprised 36% (942/2600) of discarded ODD hearts, compared to 28% (9152/32678) of discarded non-ODD hearts (p<0.001). The most common reasons given for discard of ODD hearts with favorable qualities were poor organ function (18%), refusal by all programs (16%), and lack of recipient (11%). Conclusion(s): ODD hearts with favorable qualities are being discarded at disproportionally higher rates than non-ODD hearts. Further studies and better documentation are needed to understand current discard practices and if further expansion into this donor pool is appropriate.

Purpose: Controversy remains over the mortality benefit of single (SLT) versus double lung transplantation (DLT) in idiopathic pulmonary fibrosis (IPF). Independent of this controversy, hesitancy to perform SLT in this population exists on the basis of unclear one year functional status. We compared functional status at one year between IPF patients listed for both who ultimately received SLT or DLT. Method(s): All consecutive adult lung transplants for IPF provided by the Scientific Registry of Transplant Recipients were retrospectively reviewed (2007-2017). Isolated lobar transplants (n=4), patients listed only for SLT (n=1834) or DLT (n=2372), and patients with missing functional status data (n=715) were excluded. Group stratification was based on the ultimate procedure (SLT or DLT). Group propensity matching was performed based on 25 recipient/donor characteristics. We compared 'good functional status' defined as >70%, at one year. Result(s): During the study period, 45% (660/1464) and 55% (804/1464) of patients listed for both procedures ultimately received SLT and DLT, respectively. After propensity matching, 341 matched patients remained in each group. Donor and recipient characteristics were similar (Table). There was no statistically significant difference in 'good functional status' at one year between SLT (77%, 264/341) and DLT (81%, 275/341) (p=0.301). The same trend is present for patients younger than 50 who receive SLT (82%, 23/28) versus DLT (94%, 34/36) (p=0.225), and patients between 50 and 60 who receive SLT (78%, 86/110) versus DLT (84%, 97/115) (p=0.305). The opposite trend is noted in patients older than 70 who receive SLT (72%, 13/18) versus DLT (61%, 11/18) (p=0.725). Conclusion(s): In this cohort of lung transplant recipients listed for both SLT and DLT, functional status was statistically similar between groups, even in younger recipients. This data suggests that SLT should not be precluded in IPF patients on the basis of expected functional status at one year.

Introduction/Aim: Caring for critically ill patients is labor intensive and challenging for bedside nurses. Utilization of extracorporeal life support (ECLS) for these patients adds an additional layer of complexity. This requires supplemental education and increased diligence and compassion at the bedside to provide excellent patient care. As our institution's Adult ECMO Program grew, we developed a program to formalize the resources available to support the nursing staff caring for this patient population. Material and Methods: Our institution's first adult ECMO patient was in December 2014. In early 2016 with the addition of an ECMO Coordinator, we began to formalize the Adult ECMO Program. Our first initiative was a formal education program in June 2016. A comprehensive initial ECMO course, geared towards the critical care nurse's role and responsibility in caring for an ECMO patient was developed. Programmatic processes, clinical practice guidelines, and protocols were created and made easily accessible to the nursing staff. The second initiative was our ECMO Team's collaboration with Palliative Care Services in October 2016. The collaboration established Palliative Care's role in ECMO, including an automatic consult to their service upon every ECMO initiation. Our third initiative was development of unit-based multidisciplinary ECMO debriefs. The debriefs were held within a few days of each patient coming off of ECMO support and were led by the ECMO Surgical Director, ECMO Coordinator, and ICU Nursing Leadership. The first debrief was in May 2017. Our last initiative included collaboration with Integrative Health Services. From July 2017 to October 2017, their service provided biweekly wellness sessions for the nurses. While the service provided support to the nurses, it was also utilized to support their patients and family members. A mixed method evaluation of these initiatives supporting critical care nurses caring for ECMO patients was conducted. Quantitative data was collected to assess ECMO nursing competency and Palliative Care's role in ECMO. For ECMO competency, we evaluated the percentage of nurses who were ECMO educated pre-and post-implementation of a structured education plan. For the ECMO Team's collaboration with Palliative Care Services, pre-and post-initiative data was collected upon retrospective chart review. Qualitative data collection was conducted through focus groups with the Cardiovascular Surgical Intensive Care Unit (CVICU) nursing staff. Each focus group included a semi-structured interview with a series of open-ended questions related to implemented initiatives and resources. Themes were identified for participation in ECMO debriefs and utilization of Integrative Health Services. Results: Quantitative data showed an increase in ECMO competent nurses and an increase in the use of Palliative Care Services. Pre-education initiative, 5 out of 26 (19%) CVICU nurses were educated on ECMO. Postinitiative, 26 out of 26 (100%) CVICU nurses were educated with the first roll out of a structured ECMO course. Since then, the CVICU nursing staff remains 100% compliant in both initial and annual ECMO educational requirements, allowing our ECMO Program to transition to a Perfusionrounding model. For the ECMO Team's collaboration with Palliative Care Services, pre-and post-initiative data was collected by retrospective chart review. Both groups totaled 13 patients. The pre-initiative group (10/2015-10/2016) showed 4 out of 13 patients (31%) had consults within the first 48 hours of ECMO initiation, while the post-initiative (10/2016-10/2017) group showed 10 out of 13 (77%) patients had consults within this timeframe. The timeliness of consults in the post-initiative group also showed an average time of < 24 hours to consult placement. Qualitative assessment of the focus group evaluation of ECMO debriefs identified two themes of "teamwork" and "reassurance." Per the focus groups, the ECMO debriefs proved to be beneficial, allowing for acknowledgement of the teamwork needed to care for ECMO patients and reassurance that the team provided optimum care to the patient regardless of the outcome. The theme "self-care" was identified for Integrative Health Services. The nurses emphasized that they utilized the service for themselves, their patients, and the family members and found their services useful in decreasing stress and anxiety. Conclusions: Establishment of structured education, consistent supportive services, and recurring multidisciplinary team discussions promote self-confidence and continuing education in the critical care nursing staff caring for adult ECMO patients