Quality Improvement: Arterial Grafting Redux, 2010:2019.

BACKGROUND: The evidence base favoring utilization of multiple arterial conduits in coronary artery bypass grafting has strengthened in recent years. Nevertheless, utilization of arterial conduits in the US lags behind that of many European peers. We describe a statewide collaborative based approach to improving utilization. METHODS: Four metrics of arterial revascularization were devised. These were displayed and discussed at quarterly statewide quality collaborative meetings from January 2016 onwards, integrated with an educational program regarding attendant benefits. We undertook retrospective review of isolated coronary artery bypass grafting statewide from 2012-2019 to assess impact. RESULTS: A total of 38,523 cases met inclusion/exclusion criteria. Statewide incidence of multiple arterial grafting increased from 7.4% at baseline to 21.7% in 2019 (P < .001), implementation across hospitals varied widely, ranging from 67.6% to 0.0%. Utilization of total arterial revascularization increased 1.9% to 4.4% (P < .001) between time frames. Utilization of both radial artery and bilateral internal thoracic artery conduit increased significantly from 5.3% to 13.2% (P < .001) and 2.1% to 8.5% (P < .001), respectively; radial artery utilization was significantly higher than bilateral internal thoracic artery for each year (P < .001 for all comparisons). CONCLUSIONS: Our statewide quality improvement initiative improved rates of utilization of multiple arterial grafting by all metrics. Barriers to current utilization were identified to guide future quality improvement efforts. This reproducible approach is readily transferable to improve quality of care in other domains and geographical areas.

The Role of Regional Collaboratives in Quality Improvement: Time to Organize, and How?

Over the last 12 years, surgeon representatives from the 33 participating hospitals of the Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative (MSTCVS-QC), along with data specialists, surgical and quality improvement (QI) teams, have met at least 4 times a year to improve health-care quality and outcomes of cardiac and general thoracic surgery patients. The MSTCVS-QC nature of interactive learning has allowed all members to examine current data from each site in an unblinded manner for benchmarking, learn from their findings, institute clinically meaningful changes in survival and health-related quality of life, and carefully follow the effects. These meetings have resulted in agreement on various interventions to improve patient selection, periprocedural strategies, and adherence with evidence-based directed medication regimens, Factors contributing to the quality movement across hospitals include statewide-recognized clinicians who are eager to involve themselves in QI initiatives, dedicated health-care professionals at the hospital level, trusting environments in which failure is only a temporary step on the way toward achieving QI goals, real-time analytics of accurate data, and payers who strongly support QI efforts designed to improve outcomes.

Respiratory health effects associated with restoration work in post-Hurricane Katrina New Orleans.

BACKGROUND: This study examines prevalence of respiratory conditions in New Orleans-area restoration workers after Hurricane Katrina. METHODS: Between 2007 and 2010, spirometry and respiratory health and occupational questionnaire were administered to 791 New Orleans-area adults who mostly worked in the building construction and maintenance trades or custodial services. The associations between restoration work hours and lung function and prevalence of respiratory symptoms were examined by multiple linear regression, χ², or multiple logistic regression. RESULTS: 74% of participants performed post-Katrina restoration work (median time: 620 hours). Symptoms reported include episodes of transient fever/cough (29%), sinus symptoms (48%), pneumonia (3.7%), and new onset asthma (4.5%). Prevalence rate ratios for post-Katrina sinus symptoms (PRR = 1.3; CI: 1.1, 1.7) and fever and cough (PRR = 1.7; CI: 1.3, 2.4) were significantly elevated overall for those who did restoration work and prevalence increased with restoration work hours. Prevalence rate ratios with restoration work were also elevated for new onset asthma (PRR = 2.2; CI: 0.8, 6.2) and pneumonia (PRR = 1.3; CI: 0.5, 3.2) but were not statistically significant. Overall, lung function was slightly depressed but was not significantly different between those with and without restoration work exposure. CONCLUSIONS: Post-Katrina restoration work is associated with moderate adverse effects on respiratory health, including sinusitis and toxic pneumonitis.

Longitudinal respiratory health study of the wood processing industry.

BACKGROUND: A 5-year longitudinal study examined nonmalignant respiratory effects of wood processing dust exposure. METHODS: Ten study plants, investigator selected from 447 candidate plants, included 1 sawmill-planing-plywood, 1 plywood, 1 milling, 3 cabinet and 4 furniture facilities. Personal dust samples (2363) were divided into three size fractions (extrathoracic, tracheobronchial, and respirable) which were apportioned into wood solids (WS) and residual particulate matter (RPM), and used to compute each individuals TWA exposure for the 6 exposure types. Serial spirometric tests and medical, smoking and occupational questionnaires were collected with 1,164 subjects having adequate follow-up (minimum 3 datapoints over at least 2.5 years) for analyses. Forward selection regression was used to evaluate the effect of exposure on annual change in FEV(1), FVC, FEF(25-75), and FEV(1)/FVC. RESULTS: There were no significant adverse effects of WS exposures (overall means were 0.66, 0.32, and 0.05 mg/m(3), for extrathoracic, tracheobronchial, and respirable fractions, respectively). Statistically significant effects were only to respirable RPM in the milling facility (mean exposures of 0.147 mg/m(3) associated with changes in FEV(1) = -32 ml/year, FEV(1)/FVC = -0.48%/year, and FEF(25-75) = -0.11 l/s/year) and in the sawmill-planing-plywood facility (mean exposures of 0.255 mg/m(3) associated with changes in FEV(1) = -59 ml/year and FVC = -103 ml/year). CONCLUSION: Exposure to WS was not associated with significant adverse effects. Respirable RPM was associated with an obstructive effect in the milling facility, and respirable RPM was also associated with a restrictive effect in the sawmill-planing plywood facility. Finally, this study does not exclude the possibility that other exposures common to this industry can cause respiratory effects, only that none were noted in this population for wood solids for the exposure levels and durations studied.

Can a falling bullet be lethal at terminal velocity? Cardiac injury caused by a celebratory bullet.

This is a case report of rare cardiac and abdominal organ injuries sustained by an innocent bystander from a New Year's Eve celebratory gun shooting. The force and velocity of a projectile fired into the air as it ascends and returns to earth, along with its potential for bodily injury will be reviewed.

Spray-painting and chronic airways obstruction.

BACKGROUND: The aim was to investigate the respiratory response of HDI-based paint aerosol within the context of the protection afforded by current exposure guidelines. METHODS: A cross-sectional study of 240 painters spraying polyurethane enamels was undertaken at four aircraft maintenance plants. Questionnaire and spirometric data were related to gravimetric measures of cumulative total and respirable paint aerosol (TPA and RPA) and estimated isocyanate in total and respirable aerosols (TIA and RIA). RESULTS: Average cumulative exposures in mg/m(3)-years +/- SD were 159.0 +/- 115.2 TPA, 19.1 +/- 13.8 RPA, 15.8 +/- 11.5 TIA, and 1.9 +/- 1.4 RIA. After adjusting for smoking and asthma symptoms, higher exposures were associated with statistically significant reduction in expiratory flowrates. Significant smoking-related reductions were also observed, without exposure interactions. CONCLUSIONS: These results suggest important respiratory effects from exposures to spray paint aerosols at levels generally in compliance with existing standards for otherwise unregulated particulates and for the isocyanate component of the paint.