Transcutaneous Electrical Nerve Stimulation for Pain Management for Women in Labor.

PURPOSE: To determine effectiveness of a transcutaneous electrical nerve stimulation (TENS) unit to improve labor pain management and patient satisfaction with overall labor experience among women in labor at term. STUDY DESIGN: Prospective, exploratory design using convenience sampling. METHODS: Pregnant women at term, anticipating a vaginal birth at our tertiary care hospital, were invited to participate in the TENS study to help manage early labor pain. Pain level was assessed on entry into the study and 2 hours post-TENS application using the Wong-Baker FACES® Pain Rating Scale. A TENS satisfaction survey was conducted during postpartum. Pain scores were analyzed using a matched Wilcoxon signed-rank test. RESULTS: There were 272 women enrolled in the study; 255 completed the patient satisfaction survey and 263 had measured pain assessments pre- and post-TENS application. There was a significant reduction in pain scores after application of TENS, (7.09 vs. 6.74, p = 0.02). Most women 78% (199/255) agreed that TENS helped manage early labor pain, 80% (203/255) would recommend TENS for management of early labor pain, and 72% (183/255) would use TENS again. CLINICAL IMPLICATIONS: TENS therapy provides nurses with an opportunity to offer women a low-cost, low-intervention treatment for managing early labor. TENS provides a distraction from contractions and generates a sense of control to help women manage the discomforts of labor and possibly remain home longer.

Effect of Blood Transfusions on Intermittent Hypoxic Episodes in a Prospective Study of Very Low Birth Weight Infants.

OBJECTIVES: To compare the number of intermittent hypoxia events before and after packed red blood cell (pRBC) and non-pRBC transfusions in very low birth weight infants, and to compare the time spent with saturations of ≤85% before and after transfusions in the same population. STUDY DESIGN: This prospective observational study was conducted from April 2014 to August 2017. It included 92 transfusions (81 pRBC, 11 non-pRBC) from 41 very low birth weight infants between 230/7 and 286/7 weeks of gestation. The primary outcome was number of intermittent hypoxia events. Secondary outcomes included the percent time of Peripheral capillary oxygen saturation (SpO2)of ≤85%, ≤80%, and ≤75%. A mixed ANOVA model was used to examine the relationship between event rate and covariates. RESULTS: The mean number of intermittent hypoxia events per hour decreased from 5.27 ± 5.02 events per hour before pRBC transfusion to 3.61 ± 3.17 per hour after pRBC transfusions (P < .01) and intermittent hypoxia did not change after non-RBC transfusions (before, 4.45 ± 3.19 vs after, 4.47 ± 2.78; P = NS). The percent time with saturations of ≤80% and ≤75% significantly decreased after pRBC transfusions (P = .01). The time with saturations of ≤85% did not significantly change after non-pRBC transfusion. CONCLUSIONS: In very low birth weight infants with a hematocrit of 20%-42%, pRBC transfusions are associated with decreased frequency of intermittent hypoxia. No such diminution of intermittent hypoxia events was observed in infants who had received a non-pRBC transfusion. This finding suggests that the observed beneficial effects of RBC transfusions on apnea and its clinical manifestations of intermittent hypoxia are mediated through an enhanced oxygen carrying capacity.

Microsimulation Model Using Christiana Care Early Warning System (CEWS) to Evaluate Physiological Deterioration.

While physiological warning signs prior to deterioration events during hospitalization have been widely studied, evaluating clinical interventions, such as rapid response team (RRT) activations, based on scoring systems remains an understudied area. Simulation of physiological deterioration patterns represented by scoring systems can facilitate testing different RRT policies without disturbing care processes. Christiana Care Early Warning System (CEWS) is a scoring system developed at the study hospital to detect the physiological warning signs and inform RRT activations. The objective of this study is to evaluate CEWS-triggered RRT policies based on patient demographics and policy structures. Using retrospective data derived from a subset of electronic health records between December 2015 and December 2016 (6000 patients), we developed a microsimulation model with integrated regression analysis to compare RRT policies on subpopulations defined by age, gender, and comorbidities to find score thresholds that result in the lowest percent of time spent above critical CEWS values. Policies that rely on average scores were more sensitive to threshold changes compared to policies that rely on current value and change in the CEWS. Policy using score threshold 10 provided the lowest percentage of time under the critical condition for majority of subpopulations. The proposed model is a novel framework to simulate individual deterioration patterns and systematically evaluate RRT policies based on their impact on health conditions. Our work highlights the importance of integration of data-driven models into personalized care and represents a significant opportunity to inform biomedical and health informatics research on designing and evaluating EWS-based clinical interventions.

Not all organ dysfunctions are created equal - Prevalence and mortality in sepsis.

PURPOSE: While organ dysfunctions within sepsis have been widely studied, interaction between measures of organ dysfunction remains an understudied area. The objective of this study is to quantify the impact of organ dysfunction on in-hospital mortality in infected population. MATERIALS AND METHODS: Descriptive and multivariate analyses of retrospective data including patients (age ≥ 18 years) hospitalized at the study hospital from July 2013 to April 2016 who met the criteria for an infection visit (62,057 unique visits). RESULTS: The multivariate logistic regression model had an area under the curve of 0.9. Highest odds ratio (OR) associated with increased mortality risk was identified as fraction of inspired oxygen (FiO2) > 21% (OR = 5.8 and 95% Confidence Interval (CI) 1.8-35.6), and elevated lactate >2.0 mmol/L (OR = 2.45 (95% CI = 2.1-2.8)). Most commonly observed measures of organ dysfunction within mortality visits included elevated lactate (> 2.0 mmol/L), mechanical ventilation, and oxygen saturation (SpO2)/FiO2 ratio (< 421) at least once within 48 h prior to or 24 h after anti-infective administration. CONCLUSION: There exist differences in measures of organ dysfunction occurrence and their association with mortality. These findings support increased clinical efforts to identify sepsis patients to inform diagnostic decisions.

Data-driven approach to Early Warning Score-based alert management.

BACKGROUND: Increasing adoption of electronic health records (EHRs) with integrated alerting systems is a key initiative for improving patient safety. Considering the variety of dynamically changing clinical information, it remains a challenge to design EHR-driven alerting systems that notify the right providers for the right patient at the right time while managing alert burden. The objective of this study is to proactively develop and evaluate a systematic alert-generating approach as part of the implementation of an Early Warning Score (EWS) at the study hospitals. METHODS: We quantified the impact of an EWS-based clinical alert system on quantity and frequency of alerts using three different alert algorithms consisting of a set of criteria for triggering and muting alerts when certain criteria are satisfied. We used retrospectively collected EHRs data from December 2015 to July 2016 in three units at the study hospitals including general medical, acute care for the elderly and patients with heart failure. RESULTS: We compared the alert-generating algorithms by opportunity of early recognition of clinical deterioration while proactively estimating alert burden at a unit and patient level. Results highlighted the dependency of the number and frequency of alerts generated on the care location severity and patient characteristics. CONCLUSION: EWS-based alert algorithms have the potential to facilitate appropriate alert management prior to integration into clinical practice. By comparing different algorithms with regard to the alert frequency and potential early detection of physiological deterioration as key patient safety opportunities, findings from this study highlight the need for alert systems tailored to patient and care location needs, and inform alternative EWS-based alert deployment strategies to enhance patient safety.

Time Series Analysis for Forecasting Hospital Census: Application to the Neonatal Intensive Care Unit.

BACKGROUND: Accurate prediction of future patient census in hospital units is essential for patient safety, health outcomes, and resource planning. Forecasting census in the Neonatal Intensive Care Unit (NICU) is particularly challenging due to limited ability to control the census and clinical trajectories. The fixed average census approach, using average census from previous year, is a forecasting alternative used in clinical practice, but has limitations due to census variations. OBJECTIVE: Our objectives are to: (i) analyze the daily NICU census at a single health care facility and develop census forecasting models, (ii) explore models with and without patient data characteristics obtained at the time of admission, and (iii) evaluate accuracy of the models compared with the fixed average census approach. METHODS: We used five years of retrospective daily NICU census data for model development (January 2008 - December 2012, N=1827 observations) and one year of data for validation (January - December 2013, N=365 observations). Best-fitting models of ARIMA and linear regression were applied to various 7-day prediction periods and compared using error statistics. RESULTS: The census showed a slightly increasing linear trend. Best fitting models included a non-seasonal model, ARIMA(1,0,0), seasonal ARIMA models, ARIMA(1,0,0)x(1,1,2)7 and ARIMA(2,1,4)x(1,1,2)14, as well as a seasonal linear regression model. Proposed forecasting models resulted on average in 36.49% improvement in forecasting accuracy compared with the fixed average census approach. CONCLUSIONS: Time series models provide higher prediction accuracy under different census conditions compared with the fixed average census approach. Presented methodology is easily applicable in clinical practice, can be generalized to other care settings, support short- and long-term census forecasting, and inform staff resource planning.

Biomechanical analysis of a double-loaded glenoid anchor configuration: can fewer anchors provide equivalent fixation?

BACKGROUND: Bankart repair with multiple anchor holes concentrated in the anterior-inferior glenoid may contribute to glenoid weakening and potentially may induce glenoid failure. PURPOSE: To compare the biomechanical strength of a Bankart repair construct that used 3 single-loaded suture anchors versus a repair construct that used 2 double-loaded suture anchors. STUDY DESIGN: Comparative laboratory study. METHODS: A standard Bankart lesion was created in 18 human cadaveric shoulders (9 matched pairs). Within each matched pair, 1 repair construct used 3 single-loaded anchors, whereas the other used 2 double-loaded suture anchors. Measured outcomes (load, stiffness, and energy absorbed) were recorded at failure and at 2 mm of labral displacement. Constructs were loaded to failure with a materials testing device that had differential variable reluctance transducers for displacement measurements. RESULTS: The double-loaded anchor construct had a significantly higher ultimate tensile load (944 ± 231 vs 784 ± 287 N; P = .03). For the other measures (load at 2 mm of displacement, energy absorbed at failure and at 2 mm of displacement and stiffness), there were no significant differences between tested constructs. CONCLUSION: A Bankart repair construct that used 2 double-loaded anchors was either superior to or equal to a repair construct that used 3 single-loaded anchors in all measured outcomes. CLINICAL RELEVANCE: Using 2 double-loaded suture anchors for a Bankart repair may limit anchor holes in the glenoid and reduce the risk of postsurgical glenoid fracture while providing a stable repair construct.

Repair of lesser tuberosity osteotomy for shoulder arthroplasty: biomechanical evaluation of the Backpack and Dual Row techniques.

BACKGROUND: Subscapularis dysfunction following total shoulder arthroplasty can result in permanent loss of function. The lesser tuberosity osteotomy (LTO) has been proposed as a method which utilizes bone-to-bone healing to improve subscapularis function. This study evaluates the biomechanical properties of two described techniques for LTO repair. We hypothesized that a Dual Row repair would be stronger and demonstrate less cyclic displacement than a Backpack repair. MATERIALS AND METHODS: Ten matched pairs of cadaveric humeri were dissected, leaving the subscapularis intact, and a lesser tuberosity osteotomy was performed. Matched shoulders were randomized to either a Backpack repair or a Dual Row repair. Repairs were subjected to cyclic loading to 180 N for 500 cycles, followed by ramp-up loading to ultimate failure. Clinical failure was defined as displacement >5 mm after 500 cycles. RESULTS: Displacement after 500 cycles was significantly greater for the Backpack repair (6.9 mm) than for the Dual Row repair (4.6 mm) (P = .007). Most displacement occurred on the first cycle (Backpack, 4.6 mm; Dual Row, 2.1 mm) (P < .001). There was a trend toward a higher clinical failure rate for the Backpack repair (8/10) than the Dual Row repair (3/10). Ultimate tensile strength was significantly greater for the Dual Row repair (632.3 N) than for the Backpack repair (510.9 N) (P = .01). CONCLUSION: The Dual Row technique is significantly stronger and demonstrates less cyclic displacement than the Backpack technique. Clinical studies are needed to determine the impact of LTO repair technique on subscapularis function following shoulder arthroplasty.

Use of an independent skeletal distractor in hip arthroscopy.

Distraction of the hip joint plays an important role in hip arthroscopy by improving visualization of and access to intra-articular structures. Distraction is usually performed by use of a standard traction table and foot plate, with the patient in either the supine or lateral position. Between 1996 and 2005 at our institution, we have used an inexpensive, independent, sterile radiolucent skeletal distractor device to perform hip arthroscopy in the lateral position successfully in 156 cases for a variety of indications and procedures. The device consists of a perineal post, a longitudinal distraction beam, and a telescoping distraction carriage fitted with a screw drive for attachment to a distal femoral K-wire. Skeletal traction is applied against the perineal post through the K-wire via the action of the distraction carriage and fine-tuned with the screw drive, affording excellent visualization of intra-articular structures. The use of this device during hip arthroscopy negates the need for a fracture table, enables the surgeon to remain sterile and still manipulate the traction apparatus intraoperatively, and provides for simultaneous hip and knee flexion to relax the sciatic nerve. Its modular design and small size make hip arthroscopy possible in almost all settings, including outpatient operating rooms.