Heart Failure With Preserved Ejection Fraction: Will Cardiac Magnetic Imaging Impact on Diagnosis, Treatment, and Outcomes?: Explaining the Need for Advanced Imaging to Clinical Stakeholders.

Clinicians frequently equate symptoms of volume overload to heart failure (HF) but such generalization may preclude diagnostic or etiologic precision essential to optimizing outcomes. HF itself must be specified as the disparate types of cardiac pathology have been traditionally surmised by examination of left ventricular (LV) ejection fraction (EF) as either HF with preserved LVEF (HFpEF-LVEF >50%) or reduced LVEF of (HFrEF-LVEF <40%). More recent data support a third, potentially transitional HF subtype, but therapy, assessment, and prognosis have been historically dictated within the corresponding LV metrics determined by echocardiography. The present effort asks whether this historically dominant role of echocardiography is now shifting slightly, becoming instead a shared if not complimentary test. Will there be a gradual increasing profile for cardiac magnetic resonance as the attempt to further refine our understanding, diagnostic accuracy, and outcomes for HFpEF is attempted?

A trigger tool to identify adverse events in the intensive care unit.

BACKGROUND: The Institute for Healthcare Improvement has tested and taught use of a variety of trigger tools, including those for adverse medication events, neonatal intensive care events, and a global trigger tool for measuring all event categories in a hospital. The trigger tools have evolved as a complimentary adjunct to voluntary reporting. The Trigger Tool technique was used to identify the rate of occurrence of adverse events in the intensive care unit (ICU), and a subset of ICUs described those events in detail. METHODS: Sixty-two ICUs in 54 hospitals (both academic and community) engaged in IHI critical care collaboratives between 2001 and late 2004. Charts were selected using a random sampling technique and reviewed using a two-stage process. RESULTS: The prevalence of adverse events observed on 12,074 ICU admissions was 11.3 adverse events/100 patient days. For a subset of 1,294 charts from 13 ICUs which were reviewed in detail, 1,450 adverse events were identified, for a prevalence of 16.4 events/100 ICU days. Fifty-five percent of the charts in this subset contained at least one adverse event. DISCUSSION: The Trigger Tool methodology is a practical approach to enhance detection of adverse events in ICU patients. Evaluation of these adverse events can be used to direct resource use for improvement work. The measurement of these sampled chart reviews can also be used to follow the impact of the change strategies on the occurrence of adverse events within a local ICU.

Shifting care of chronic ventilator-dependent patients from the intensive care unit to the nursing home.

BACKGROUND: Among the most resource intensive and challenging of medical needs is the treatment of patients requiring long-term or chronic mechanical ventilation. Expenditures are significant, and definitions of "successful weaning," are often inconsistent. A weaning program was initiated for patients referred to a stand-alone nursing home ventilator unit. METHODS: Weaning entailed standardized weaning protocols, enhanced socialization, a multidisciplinary approach to care, empowerment of staff to initiate weaning, and aggressive utilization of noninvasive positive pressure ventilation (NPPV) in selected patients. RESULTS: Sixty-eight (67%) of 102 patients were successfully weaned during a six-year period. NPPV facilitated successful weaning in 27 (26%) of 102 patients. Of the 28 chronic ventilator-dependent patients admitted with a neuromuscular etiology for respiratory failure, NPPV was utilized in 73% (8/11) of the successfully weaned patients. Total variable costs per ventilator per patient per day for the years 1998-2000 were $319.79, $302.75, and $297.59. Six-year cost savings for referring hospitals were estimated at $18.5 million. DISCUSSION: Incentives were aligned between the hospital, nursing home, and physicians to develop a financially stable model. Developing an off-site nursing home ventilator unit resulted in significant cost savings to the referring hospitals and positively affected patient flow.

Standardization as a mechanism to improve safety in health care.

BACKGROUND: A growing body of literature shows that when patterns of care are widely divergent, clinical outcomes suffer and, as a result, safety may be compromised. A multispecialty group at Luther Midelfort, Mayo Health System (LM, MHS) initiated efforts to reduce variance in the clinical practice patterns of providers. The pilot initiative, which entailed standardization of a sliding-scale insulin protocol, served as a template throughout the LM, MHS for reducing variance and enhancing safety. STANDARDIZING INSULIN ADMINISTRATION: A single sliding-scale insulin protocol for regular insulin use in appropriate patients was intended to decrease the number of hypoglycemic events. A six-week comparison revealed that in the protocol-driven standardized sliding-scale insulin group, two episodes of hypoglycemia occurred in 134 dosages administered versus 20 hypoglycemic events in 519 dosages administered in the traditional group (1.49 versus 3.85%, p < .04). Subsequent 30-month data months revealed a reduction in hypoglycemic episodes from 2.95% to 1.1%. MEDICATION USE PROBLEM: A reconciliation of medications initiative focused on clarifying, correcting, and specifying the medications patients were consuming at different intervals of their hospitalization and then amending the data in the medical record. In a seven-month chart audit, errors per 100 admissions decreased from 213 to fewer than 50 errors. DISCUSSION: Standardization efforts to increase uniformity of practice are worth considering in other practice areas to increase safety and possibly reduce costs.

Mechanical prosthetic valve-associated strands: Pathologic correlates to transesophageal echocardiography.

Echocardiographic detection of prosthetic valve-associated strands has previously been reported, but their clinical relevance is unclear. Limited data are available regarding the cause, composition, and natural history of these strands. This report presents the gross and histopathologic findings of an explanted mechanical prosthetic valve shown by transesophageal echocardiography to have several strands. The patient had not experienced prior neurologic symptoms. Potential causes of strand formation in various clinical settings are also discussed.

Using a unit assessment tool to optimize patient flow and staffing in a community hospital.

BACKGROUND: Hospital environments are too often characterized by delays for patients receiving diagnostic testing and prolonged waiting times to complete needed therapy. Frequently there is confusion in scheduling, related at least in part to the complex interplay of clinical acuity and highly individualized care. Luther Midelfort recently began to change the process of patient flow to improve access to care, optimize outcomes by enabling timely intervention, and decrease the wasting of resources. UNIT ASSESSMENT TOOL: The hospital developed a unit assessment tool based on the traffic light concept, which consisted of an assessment of current capacity and a graded, color-coded "workload tolerance" for each hospital unit. Each unit can instantly update its own status and query those of other work environments in the hospital. EXPERIENCE WITH THE UNIT ASSESSMENT TOOL: For most of the January-July 2001 period, there was generally a progressive decrease in the percentage of time that the units were coded as red (unit closed to new admissions), with concurrent increases in the percentage of time that the units were coded as green (unit open). Use of the tool appears to have contributed to a dramatic increase in staff satisfaction. SUMMARY AND CONCLUSIONS: The key to regulating patient flow has been to adopt a nursing-initiated capping trust policy whereby nurses are given the authority to limit new admissions. Initiatives are now under way to provide different units with novel models of resource sharing, ranging from flexible housekeeping to "flying nurse squads" to assist units that have become red.

NextStitch: double-stranded suture chain, a tool to optimize approximation of sutures in valve surgery with echocardiographic correlation.

Suture technique for valve replacement surgery has often focused on decreasing the soft tissue injury that leads to pseudoaneurysm formation and associated latent infection. There is universal recognition that precise suture placement is essential for avoiding adverse sequelae while allowing flexibility during the implantation of the prosthesis. The use of a continuous chain of linked horizontal mattress sutures (NextStitch) has allowed maximal precision in the approximation of sutures within the valve annulus. The product was used in a series of consecutive mitral and aortic valve replacements, and typical echocardiographic images from each type of implantation are presented. Postoperative echocardiography images revealed that no perivalvular leaks occurred and that NextStitch did not obscure detailed interrogation or assessment of the valve prosthesis.