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1.
PM R ; 8(9S): S302-S303, 2016 Sep.
Article in English | MEDLINE | ID: mdl-27673182
2.
Am J Med ; 129(8): 866-871.e1, 2016 08.
Article in English | MEDLINE | ID: mdl-27107920

ABSTRACT

BACKGROUND: Pressure ulcer formation continues to be problematic in acute care settings, especially intensive care units (ICUs). Our institution developed a program for early mobility in the ICU using specially trained nursing aides. The goal was to impact hospital-acquired pressure ulcers incidence as well as factors associated with ICU deconditioning by using specially trained personnel to perform the acute early mobility interventions. METHODS: A 5-point mobility scale was developed and used to establish a patients' highest level of activity achievable during evaluation. A mobility team was created consisting of skin-care prevention/mobility nurses and a new category of worker called a patient mobility assistant. Each level has a corresponding plan of care (intervention) that was followed and adjusted according to the patient's progress and nursing evaluation. Data collection included the type of interventions at each encounter, mobility and skin assessments, new hospital-acquired pressure ulcer, the current mobility level, Braden score, rate of ventilator-associated pneumonia, ICU length of stay, and hospital readmission. Staff was also surveyed about their attitudes toward mobilization and perception of mobility barriers; a prepilot and a postpilot survey were planned. RESULTS: During the 1-year study interval, 3233 patients were enrolled from the medical intensive care unit (MICU). The 2011 preimplementation MICU hospital-acquired pressure ulcer rate was 9.2%. After 1 year of employing the mobility team, there was a statistically significant decrease in the MICU hospital-acquired pressure ulcer rate to 6.1% (P = .0405). Hospital readmission of MICU patients also significantly decreased from 17.1% to 11.5% (P = .0010). The mean MICU length of stay decreased by 1 day. There were no safety issues directly or indirectly associated with these interventions. CONCLUSIONS: Use of this mobility program resulted in a 3% decrease in the most recalcitrant patients in the MICU. This corresponds to a decrease of 1.2 per 1000 patient days. It is definitely both statistically and clinically significant. We believe this lays the groundwork for further work in this area. We have shown that properly trained nonlicensed professionals can safely and effectively mobilize patients in the ICU setting. This can represent a cost-effective way to introduce early mobility in the ICU setting.


Subject(s)
Early Ambulation , Intensive Care Units , Nursing Assistants , Pressure Ulcer/prevention & control , Adolescent , Adult , Aged , Female , Humans , Incidence , Male , Middle Aged , Nursing Assessment , Outcome Assessment, Health Care , Pilot Projects , Pressure Ulcer/epidemiology
3.
Arch Osteoporos ; 9: 194, 2014.
Article in English | MEDLINE | ID: mdl-25234658

ABSTRACT

UNLABELLED: The term insufficiency fracture implies inadequate bone and is applied to some subchondral knee magnetic resonance images. We reviewed bone mineral density, body mass index, meniscal extrusion, comorbidities, and demographics in 32 knee insufficiency fracture patients. Only five were osteoporotic. Meniscal extrusion was predominant. PURPOSE: The literature supports systemic osteoporosis as a risk fracture for spontaneous osteonecrosis of the knee (SONK). SONK is also called a subchondral insufficiency fracture. Recognizing that insufficiency fracture and SONK are related, we designed this retrospective study to determine if knee subchondral insufficiency fractures were associated with osteoporosis based on bone mineral density. METHODS: Based on magnetic resonance imaging findings, 32 patients were diagnosed as having an insufficiency fracture by an orthopaedic surgeon with magnetic resonance imaging confirmation by a musculoskeletal radiologist. We reviewed body mass index, age, sex, comorbidities, demographics, and bone mineral density using both T-scores and Z-scores. RESULTS: The average age was 70, and only five patients were osteoporotic. Twenty-six of the 32 patients were female. The average age-related Z-score was 1 standard deviation above normal. CONCLUSIONS: We conclude that osteoporosis is not the underlying cause of this disorder in the majority of patients.


Subject(s)
Fractures, Stress/etiology , Knee Injuries/etiology , Osteonecrosis/etiology , Osteoporosis/complications , Aged , Aged, 80 and over , Body Mass Index , Bone Density , Female , Humans , Male , Middle Aged , Retrospective Studies , Tibial Meniscus Injuries
4.
J Trauma Acute Care Surg ; 72(4): 878-83, 2012 Apr.
Article in English | MEDLINE | ID: mdl-22491599

ABSTRACT

BACKGROUND: Colectomy patients experience a broad set of adverse outcomes. Complications requiring critical care support are common in this group. We hypothesized that as frailty increases, the risk of Clavien class IV and V complications will increase in colectomy patients. METHODS: Using the National Surgical Quality Improvement Program (NSQIP) participant use files for 2005-2009, we identified patients who underwent laparoscopic and open colectomies by Current Procedural Terminology code. Using the Clavien classification for postoperative complications, we identified NSQIP data points most consistent with Clavien class IV requiring intensive care unit (ICU) care or class V complications (death). We used a modified frailty index with 11 variables based on mapping the Canadian Study of Health and Aging Frailty Index and existing NSQIP variables. Logistic regression was performed to acuity adjust the findings. RESULTS: A total of 58,448 colectomies were identified. As frailty index increased from 0 to 0.55, the proportion of those experiencing Clavien class IV or V complications increased from 3.2% at baseline to 56.3%. Variables found to be significant by logistic regression (odds ratio) were frailty index (14.4; p = 0.001), open procedure (2.35; p < 0.001), and American Society of Anesthesiologists class 4 (3.2; p = 0.038) or 5 (7.1; p = 0.001) while emergency operation and wound classification 3 or 4 were not. CONCLUSIONS: Complications requiring ICU care represent a significant morbidity in the colectomy patient population. Frailty index seems to be an important predictor of ICU-level complications and death, and laparoscopy seems to be protective.


Subject(s)
Colectomy/adverse effects , Critical Care , Laparoscopy/adverse effects , Postoperative Complications/etiology , Aged , Aged, 80 and over , Colectomy/methods , Colectomy/mortality , Critical Care/standards , Critical Care/statistics & numerical data , Female , Frail Elderly/statistics & numerical data , Humans , Laparoscopy/statistics & numerical data , Logistic Models , Male , Middle Aged , Odds Ratio , Postoperative Complications/epidemiology , Postoperative Complications/mortality , Quality Improvement/statistics & numerical data , Retrospective Studies , Severity of Illness Index , United States/epidemiology
5.
Am J Surg ; 203(3): 388-91; discussion 391, 2012 Mar.
Article in English | MEDLINE | ID: mdl-22364905

ABSTRACT

BACKGROUND: We sought to pilot and initiate validation of a surgical drainage model. METHODS: We designed a laboratory model to compare Jackson-Pratt surgical drains using 3 soups to emulate body fluids of serous, purulent, and necrotic debris. Each drain was trialed with each of the 3 fluids. Time and completeness of drainage were recorded. A survey of surgical residents and faculty was performed for convenience sampling. RESULTS: Under serous conditions, the round Jackson-Pratt drained the cavity quicker, but left a larger residual volume of fluid. Under purulent conditions, the round Jackson-Pratt was slower and drained less fluid. With debris fluid, the round Jackson-Pratt was quicker with less residual fluid whereas the flat type clogged each time. Survey results showed adequate concordance with surgeons in agreement on soup choice. CONCLUSIONS: The Jackson-Pratt drains perform differently depending on the drainage situation. The surgical community requires improved drain data to drive practice patterns.


Subject(s)
Drainage/instrumentation , Models, Biological , Abdominal Cavity , Attitude of Health Personnel , Body Fluids , Humans , Pilot Projects , Surveys and Questionnaires , Time Factors
6.
Am J Surg ; 199(3): 336-40; discussion 340-1, 2010 Mar.
Article in English | MEDLINE | ID: mdl-20226906

ABSTRACT

OBJECTIVE: Technology currently exists for the application of remote guidance in the laparoscopic operating suite. However, these solutions are costly and require extensive preparation and reconfiguration of current hardware. We propose a solution from existing technology, to send video of laparoscopic cholecystectomy to the Blackberry Pearl device (RIM Waterloo, ON, Canada) for remote guidance purposes. This technology is time- and cost-efficient, as well as reliable. METHODS: After identification of the critical maneuver during a laparoscopic cholecystectomy as the division of the cystic duct, we captured a segment of video before it's transection. Video was captured using the laparoscopic camera input sent via DVI2USB Solo Frame Grabber (Epiphan Ottawa, Canada) to a video recording application on a laptop. Seven- to 40-second video clips were recorded. The video clip was then converted to an .mp4 file and was uploaded to our server and a link was then sent to the consultant via e-mail. The consultant accessed the file via Blackberry for viewing. After reviewing the video, the consultant was able to confidently comment on the operation. RESULTS: Approximately 7 to 40 seconds of 10 laparoscopic cholecystectomies were recorded and transferred to the consultant using our method. All 10 video clips were reviewed and deemed adequate for decision making. CONCLUSION: Remote guidance for laparoscopic cholecystectomy with existing technology can be accomplished with relatively low cost and minimal setup. Additional evaluation of our methods will aim to identify reliability, validity, and accuracy. Using our method, other forms of remote guidance may be feasible, such as other laparoscopic procedures, diagnostic ultrasonography, and remote intensive care unit monitoring. In addition, this method of remote guidance may be extended to centers with smaller budgets, allowing ubiquitous use of neighboring consultants and improved safety for our patients.


Subject(s)
Cell Phone , Cholecystectomy, Laparoscopic , Telemedicine , Video-Assisted Surgery , Cholecystectomy, Laparoscopic/standards , Humans , Safety
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