Implementation of Virtual Interactive Cases for Pharmacy Education: A Single-Center Experience.

Patient case simulation software are described in pharmacy education literature as useful tools to improve skills in patient assessment (including medication history-taking and physical assessment), clinical reasoning and communication, and are typically well-received by students and instructors. The virtual interactive case (VIC) system is a web-based software developed to deliver deliberate practice opportunities in simulated patient encounters across a spectrum of clinical topics. This article describes the implementation and utilization of VIC in the undergraduate curriculum at one Canadian pharmacy school. Methods: At our facility, the use of VIC was integrated across the training spectrum in the curriculum, including core and elective didactic courses and practice labs, experiential learning, interprofessional education, and continuing education. Its use was evaluated through student and instructor surveys and qualitative student interviews). VIC is easy to navigate and created a positive and realistic learning environment. Students identified that it enhanced their ability to identify relevant patient information, accurately simulated hospital pharmacy practice and thereby helped them to prepare for their upcoming experiential courses. The use of VIC has expanded beyond its original intended purpose for individual student practice to become a valuable addition to pharmacy undergraduate education. Future plans include ongoing development of cases and exploration of further uses of VIC within the didactic curriculum, for remediation in experiential courses, and for pharmacist continuing education.

Effect of a national guideline on postoperative troponin surveillance: a retrospective cohort study.

PURPOSE: We aimed to evaluate the effect of the 2017 Canadian Cardiovascular Society (CCS) guidelines on troponin surveillance after noncardiac surgery. METHODS: This was a single-centre, retrospective, observational study. Patients aged 40 yr or older undergoing intermediate- to high-risk elective noncardiac surgery between 2016 and 2021 were included. We compared the number and percentage of troponin tests ordered before and after the guidelines were published and compared patient characteristics, specifically cardiovascular comorbidity, using odds ratio's (OR) with 95% confidence intervals (CIs). Outcomes were myocardial injury, myocardial infarction (MI), and in-hospital mortality. RESULTS: The cohort included 36,386 patients and the median age was 63 yr. Between 2016 and 2018, troponin surveillance was done in 2,461 (13%) of the 19,046 patients, compared with 2,398 (14%) of the 17,340 patients who had surgery between 2019 and 2021 (OR, 1.08; 95% CI, 1.02 to 1.15). Patients who had surgery in the second period had less cardiovascular comorbidity; the adjusted OR for troponin surveillance was 1.14 (95% CI, 1.07 to 1.21). In the two periods, troponin was elevated in 561 (2.9%) and 470 (2.7%) patients, an MI was documented in 54 (0.3%) and 36 (0.2%) patients, and 95 (0.5%) and 73 (0.4%) patients died, respectively. After adjustment for baseline differences in the two periods, the ORs for MI and mortality were 0.83 (95% CI, 0.54 to 1.27) and 0.88 (95% CI, 0.64 to 1.19), respectively. CONCLUSION: Although the odds of troponin ordering were slightly but significantly higher after publication of the CCS guidelines, the odds for detecting an MI and for mortality did not change.

RéSUMé: OBJECTIF: Notre objectif était d'évaluer l'effet des lignes directrices 2017 de la Société canadienne de cardiologie (SCC) sur le monitorage de la troponine après une chirurgie non cardiaque. MéTHODE: Il s'agissait d'une étude observationnelle rétrospective monocentrique. Les patient·es âgé·es de 40 ans ou plus bénéficiant d'une chirurgie non cardiaque non urgente à risque intermédiaire à élevé entre 2016 et 2021 ont été inclus·es. Nous avons comparé le nombre et le pourcentage de tests de troponine prescrits avant et après la publication des lignes directrices et comparé les caractéristiques des patient·es, en particulier la comorbidité cardiovasculaire, en utilisant le rapport de cotes (RC) avec des intervalles de confiance (IC) à 95 %. Les critères d'évaluation comprenaient les lésions myocardiques, l'infarctus du myocarde (IM) et la mortalité hospitalière. RéSULTATS: La cohorte comprenait 36 386 personnes et l'âge médian était de 63 ans. Entre 2016 et 2018, le monitorage de la troponine a été réalisé chez 2461 (13 %) des 19 046 patient·es, contre 2398 (14 %) des 17 340 patient·es opéré·es entre 2019 et 2021 (RC, 1,08; IC 95%, 1,02 à 1,15). Les patient·es qui ont bénéficié d'une intervention chirurgicale au cours de la deuxième période présentaient moins de comorbidité cardiovasculaire; le RC ajusté pour le monitorage de la troponine était de 1,14 (IC 95 %, 1,07 à 1,21). Au cours des deux périodes, la troponine était élevée chez 561 (2,9 %) et 470 (2,7 %) patient·es, un IM a été documenté chez 54 (0,3 %) et 36 (0,2 %) patient·es, et 95 (0,5 %) et 73 (0,4 %) patient·es sont décédé·es, respectivement. Après ajustement pour tenir compte des différences initiales au cours des deux périodes, les RC pour l'IM et la mortalité étaient de 0,83 (IC 95 %, 0,54 à 1,27) et de 0,88 (IC 95 %, 0,64 à 1,19), respectivement. CONCLUSION: Bien que les probabilités de commande de troponine aient été légèrement mais significativement plus élevées après la publication des lignes directrices de la SCC, les probabilités de détection d'un IM et de mortalité n'ont pas changé.

An online immunohematology educational resource for post-graduate hematology trainees: LearnSerology.ca.

BACKGROUND: Canadian hematology residents are required to demonstrate competencies in transfusion medicine by the end of their 2-year training. Prior evaluation of final year trainees revealed significant variation in knowledge. To address the lack of standardization in serology teaching, an online educational immunohematology resource was created and evaluated. STUDY DESIGN AND METHODS: All Canadian post-graduate trainees completing a residency program in adult hematology during the 2018/2019 academic year were invited to participate. Only trainees from one university were exposed to the program curriculum. A validated exam was administered to trainees at both exposed and unexposed sites at the start of the academic year as a pre-test and in the following year as a post-test. The effectiveness of the program was assessed by both comparing the degree of improvement from pre- to post-test, and by comparing performance on the post-test. RESULTS: 57 trainees from 13 universities completed the pre-test, and 45 trainees from 14 universities completed the post-test. A strong trend towards better performance in the exposed vs non-exposed trainees on the post-test was observed, and the difference was more pronounced, and statistically significant, when analysis was limited to two questions relating to interpretation of an antibody investigation panel. DISCUSSION: LearnSerology.ca is effective and may be potentially superior to traditional immunohematology teaching. The interactive capability of the platform can improve skills related to the resolution of red cell antibody panels.

Albumin use for fluid resuscitation in cardiac surgical patients: a survey of Canadian perioperative care providers.

PURPOSE: To evaluate the perceptions and practices of Canadian cardiovascular anesthesiologists and intensivists towards intravenous albumin as a resuscitation fluid in patients undergoing cardiac surgery. METHODS: We conducted a cross-sectional survey of cardiac anesthesiologists and intensivists involved in the care of cardiac surgical patients. The 22-item survey included seven open-ended questions and assessed practice patterns and attitudes towards albumin. Descriptive statistics were analyzed using counts and proportions. Qualitative data were analyzed to identify themes describing albumin use patterns in Canada. RESULTS: A total of 133 respondents from seven provinces participated, with 83 (62%) using albumin perioperatively. The majority of respondents (77%) felt a low fluid balance in cardiac surgical patients was important, and that supplementing crystalloids with albumin was helpful for this objective (67%). There was poor agreement among survey respondents regarding the role of albumin for faster vasopressor weaning or intensive care discharge, and ≥ 90% did not feel albumin reduced mortality, renal injury, or coagulopathy. Nevertheless, cardiac surgical patients were identified as a distinct population where albumin may help to minimize fluid balance. There was an acknowledged paucity of formal evidence supporting possible benefits. Fewer than 10% of respondents could identify institutional or national guidelines for albumin use. A lack of evidence supporting albumin use in cardiac surgical patients, especially those at highest risk of complications, was a frequently identified concern. CONCLUSIONS: The majority of Canadian anesthesiologists and intensivists (62%) use albumin in cardiac surgical patients. There is clinical equipoise regarding its utility, and an acknowledged need for higher quality evidence to guide practice.

RéSUMé: OBJECTIF: Évaluer les perceptions et les pratiques des anesthésiologistes et intensivistes cardiovasculaires canadiens à l'égard de l'albumine intraveineuse comme liquide de réanimation pour les patients bénéficiant d'une chirurgie cardiaque. MéTHODE: Nous avons mené un sondage transversal auprès d'anesthésiologistes et d'intensivistes cardiaques impliqués dans les soins aux patients de chirurgie cardiaque. Le sondage en 22 éléments comprenait sept questions ouvertes et évaluait les habitudes de pratique et les attitudes des praticiens à l'égard de l'albumine. Les statistiques descriptives ont été analysées à l'aide de dénombrements et de proportions. Des données qualitatives ont été analysées pour identifier des thèmes décrivant les tendances d'utilisation de l'albumine au Canada. RéSULTATS: Au total, 133 répondants de sept provinces ont participé, et 83 (62 %) utilisent l'albumine en périopératoire. La majorité des répondants (77 %) estimaient qu'un bilan liquidien négatif était important chez les patients en chirurgie cardiaque et que la supplémentation en cristalloïdes par de l'albumine était utile pour atteindre cet objectif (67 %). Il y avait un faible accord parmi les répondants concernant le rôle de l'albumine pour accélérer le sevrage des vasopresseurs ou la sortie de soins intensifs, et ≥ 90 % ne pensaient pas que l'albumine réduisait la mortalité, les lésions rénales ou la coagulopathie. Néanmoins, les patients en chirurgie cardiaque ont été identifiés comme une population distincte pour laquelle l'albumine pourrait contribuer à minimiser le bilan liquidien. Il y avait un manque reconnu de données probantes formelles à l'appui des avantages possibles. Moins de 10 % des répondants ont pu trouver des lignes directrices institutionnelles ou nationales portant sur l'utilisation de l'albumine. Le manque de données probantes à l'appui de l'utilisation de l'albumine chez les patients en chirurgie cardiaque, en particulier chez ceux présentant le risque le plus élevé de complications, était une préoccupation fréquemment identifiée. CONCLUSION: La majorité des anesthésiologistes et intensivistes canadiens (62 %) utilisent l'albumine chez les patients en chirurgie cardiaque. Il existe un équilibre clinique quant à son utilité et un besoin reconnu de données probantes de meilleure qualité pour guider la pratique.

Early Adopters of Apple Health Records at a Large Academic Medical Center: Cross-sectional Survey of Users.

BACKGROUND: Mobile applications offer a new approach to personal health records, which are internet-based tools for patients to consolidate and manage their health information. The University of Pennsylvania Health System (UPHS) was one of the first health systems to participate in Apple Health Records (AHR), a prominent example of this new generation of personal health records. OBJECTIVE: This study aimed to characterize early adoption of AHR among UPHS patients and understand user perspectives. METHODS: An email-based survey with fixed answer, Likert scale, and open-ended questions was administered to all UPHS patients using AHR in the first 10 months of enrollment. Survey data linked to the UPHS electronic health record system were used to analyze responses. Multivariable logistic regression modeled the association of patient characteristics with user ratings. Content analysis was used to analyze open-ended questions. RESULTS: At the time of the survey, a total of 1458 patients had used AHR at least once. Mean age of AHR users was 47.5 years, 66.3% (967/1458) were male, 70.9% (1033/1458) were white, and 80.8% (1178/1458) had private insurance. Response rate was 26.8% (391/1458); 46.3% (180/389) were very satisfied with AHR, and 67.7% (264/390) described it as very easy to use. The most commonly utilized features were lab results (324/391, 82.9%), clinical vitals (264/391, 67.5%), and medications (253/391, 64.7%). No patient characteristics were associated with reporting high satisfaction or ease of use. The most common reason for using AHR was convenience/ease of use, and 58.2% (160/275) of users reported allowing no other apps to access their health information, citing privacy as one consideration. CONCLUSIONS: Early adopters of AHR were demographically white, male, and privately insured. Convenience was an important facilitator, and users were selective in which apps they allowed to access their health information.

Managing Families' Expectations in the Coronial Jurisdiction: Barriers to Enacting an Ethic of Care.

The coronial jurisdiction is different in function, character and procedure to most other legal processes in Australia, being inquisitorial rather than adversarial. It is also, by virtue of its focus on the circumstances of death, situated at the intersection of trauma and grief on the one hand, and legal exploration and evidence-gathering, on the other. For families a coronial investigation offers the potential for resolution about a death, but it can also exacerbate grief and trauma, particularly in the public forum of an inquest. This article utilises interviews with legal professionals engaged in the coronial jurisdiction to explore their understanding of the issues that impact upon families during a death investigation. Our findings indicate that an ethics of care is evident in the court but that this remains contingent on adequate resourcing of the sector, and that this is increasingly the case as the jurisdiction becomes more specialised.

Assessing the utility of an IoS application in the perioperative care of spine surgery patients: the NeuroPath Pilot study.

BACKGROUND: In an attempt to improve care while decreasing costs and postoperative pain, we developed a novel IoS mobile health application, NeuroPath. The objective of this innovative app is to integrate enhanced recovery after surgery (ERAS) principles, patient education, and real-time pain and activity monitoring in a home setting with unencumbered two-way communication. METHODS: The NeuroPath application was built over 18 months, with support from Apple, Medable, the Department of Information-Technology and the Department of Neurosurgery. Target areas addressed by NeuroPath include patient prep for surgery, perioperative risk mitigation, activity monitoring, wound care, and opioid use management. These target areas are monitored through a provider app, which is downloaded to the care providers IPad Mini. The provider app permits real time viewing of wound healing (patient incision photographs), activity levels, pain levels, and narcotic usage. Participants are given a daily To-Do list, via the Care Card section of the interface. The To-Do list presents the patient with specific tasks for exercise, instructions to wash incision area, pre-operative instructions, directions for discussing medication with care team, among other patient specific recommendations. RESULTS: Of the 30 patients enrolled in the pilot study, there was a range of activity on the app. Patients with high involvement in the app logged in nearly every day from a week pre-op to >45 days post-op. Data for patients that utilized the app and uploaded regularly show trends of appropriately healing wounds, decreasing levels of pain, increasing step counts, and discontinuation of narcotics. CONCLUSIONS: This pilot study of the NeuroPath app demonstrates its potential utility for improving quality of patient care without increased costs. Participants who regularly used the app showed consistent improvement throughout the post-operative recovery period (increasing ambulation, decreasing pain and guided reduction in narcotic usage).

Descriptive Analysis of Pharmacy Students' Impressions on Virtual Interactive Case Software.

Objective. To assess students' impressions on whether Virtual Interactive Cases (VICs) contribute to their learning experience. Methods. Ten fourth- year pharmacy students each independently completed the same four VICs followed by a semi-structured interview conducted by VIC project team members. The interviews were audio-recorded, transcribed, and coded for themes using qualitative research methods. Results. All participating students completed all the cases. Overall, students' feedback on VIC was positive. Five main themes emerged from the transcripts: VIC facilitated their skills in information gathering; they learned from the built-in, real-time, formative feedback; they had a fun and positive learning experience; VICs were realistic; and VIC system was user-friendly. Students also recommended that VIC be incorporated into classroom learning. Some students required additional explanation on the concept of time and costs associated with each action they selected, and the associated performance score. Conclusion. Pharmacy students' positive experiences with VICs support its use to bridge classroom learning with clinical practice.

Online virtual cases to teach resource stewardship.

BACKGROUND: As health care costs rise, medical education must focus on high-value clinical decision making. To teach and assess efficient resource use in rheumatology, online virtual interactive cases (VICs) were developed to simulate real patient encounters to increase price transparency and reinforce cost consciousness. To teach and assess efficient resource use in rheumatology, online virtual interactive cases (VICs) were developed METHODS: The VIC modules were distributed to a sample of medical students and internal medicine residents, who were required to assess patients, order appropriate investigations, develop differential diagnoses and formulate management plans. Each action was associated with a time and price, with the totals compared against ideals. Trainees were evaluated not only on their diagnosis and patient management, but also on the total time, cost and value of their selected workup. Trainee responses were tracked anonymously, with opportunity to provide feedback at the end of each case. RESULTS: Seventeen medical trainees completed a total of 48 VIC modules. On average, trainees spent CAN $227.52 and 68 virtual minutes on each case, which was lower than expected. This may have been the result of a low management score of 52.4%, although on average 92.0% of participants in each case achieved the correct diagnosis. In addition, 85.7% felt more comfortable working up similar cases, and 57.1% believed that the modules increased their ability to appropriately order cost-conscious rheumatology investigations. DISCUSSION: Our initial assessment of the VIC rheumatology modules was positive, supporting their role as an effective tool in teaching an approach to rheumatology patients, with an emphasis on resource stewardship. Future directions include the expansion of cases, based on feedback, wider dissemination and an evaluation of learning retention.

Coronial Practice, Indigeneity and Suicide.

All available data suggest that, like many other Indigenous peoples, Australian Aborigines are significantly more likely to kill themselves than are non-Aboriginal Australians. This statistical disparity is normally positioned an objective, ontological and undeniable social fact, a fact best explained as a function of endemic community disadvantage and disenfranchisement. This research explores the possibility that higher-than-normal Aboriginal suicide rates may also be a function of coronial decision-making practices. Based upon in-depth interviews with 32 coroners from across Australia, the following conclusions emerged from the data. First, coroners have differing perceptions of Indigenous capacity, and are less likely to have concerns about intent when the suicide is committed by an Indigenous person. Second, coroners have identified divergent scripts of Indigenous suicide, particularly its spontaneity and public location, and this supports rather than challenges, a finding of suicide. Third, the coronial perception of Indigenous life is a factor which influences a suicide determination for Indigenous deaths. Finally, the low level of Indigenous engagement with the coronial system, and the unlikelihood of a challenge to the finding of suicide by Indigenous families, means that a coronial determination of suicide is more likely.

Depicting surgical anatomy of the porta hepatis in living donor liver transplantation.

Visualizing the complex anatomy of vascular and biliary structures of the liver on a case-by-case basis has been challenging. A living donor liver transplant (LDLT) right hepatectomy case, with focus on the porta hepatis, was used to demonstrate an innovative method to visualize anatomy with the purpose of refining preoperative planning and teaching of complex surgical procedures. The production of an animation-enhanced video consisted of many stages including the integration of pre-surgical planning; case-specific footage and 3D models of the liver and associated vasculature, reconstructed from contrast-enhanced CTs. Reconstructions of the biliary system were modeled from intraoperative cholangiograms. The distribution of the donor portal veins, hepatic arteries and bile ducts was defined from the porta hepatis intrahepatically to the point of surgical division. Each step of the surgery was enhanced with 3D animation to provide sequential and seamless visualization from pre-surgical planning to outcome. Use of visualization techniques such as transparency and overlays allows viewers not only to see the operative field, but also the origin and course of segmental branches and their spatial relationships. This novel educational approach enables integrating case-based operative footage with advanced editing techniques for visualizing not only the surgical procedure, but also complex anatomy such as vascular and biliary structures. The surgical team has found this approach to be beneficial for preoperative planning and clinical teaching, especially for complex cases. Each animation-enhanced video case is posted to the open-access Toronto Video Atlas of Surgery (TVASurg), an education resource with a global clinical and patient user base. The novel educational system described in this paper enables integrating operative footage with 3D animation and cinematic editing techniques for seamless sequential organization from pre-surgical planning to outcome.

Visualising a rare and complex case of advanced hilar cholangiocarcinoma.

The Toronto Video Atlas of Liver, Pancreas, Biliary, and Transplant Surgery (TVASurg) is a free online library of three-dimensional (3D) animation-enhanced surgical videos, designed to instruct surgical fellows in hepato-pancreato-biliary (HPB) and transplant procedures. The video 'Klatskin tumours: Extended left hepatectomy with complex portal vein reconstruction and in situ cold perfusion of the liver', which is available to watch at http://TVASurg.ca , is a unique and valuable visual resource for surgeons in training to assist them in learning this rare procedure. This paper describes the methodologies used in producing this 3D animation-enhanced surgical video.

Decision-making in a death investigation: Emotion, families and the coroner.

The role of the coroner in common law countries such as Australia, England, Canada and New Zealand is to preside over death investigations where there is uncertainty as to the manner of death, a need to identify the deceased, a death of unknown cause, or a violent or unnatural death. The vast majority of these deaths are not suspicious and thus require coroners to engage with grieving families who have been thrust into a legal process through the misfortune of a loved one's sudden or unexpected death. In this research, 10 experienced coroners discussed how they negotiated the grief and trauma evident in a death investigation. In doing so, they articulated two distinct ways in which legal officers engaged with emotions, which are also evident in the literature. The first engages the script of judicial dispassion, articulating a hierarchical relationship between reason and emotion, while the second introduces an ethic of care via the principles of therapeutic jurisprudence, and thus offers a challenge to the role of emotion in the personae of the professional judicial officer. By using Hochschild's work on the sociology of emotions, this article discusses the various ways in which coroners manage the emotion of a death investigation through emotion work. While emotional distance may be an understandable response by coroners to the grief and trauma experienced by families and directed at cleaner coronial decision-making, the article concludes that coroners may be better served by offering emotions such as sympathy, consideration and compassion directly to the family in those situations where families are struggling to accept, or are resistant to, coroners' decisions.

Creating an animation-enhanced video library of hepato-pancreato-biliary and transplantation surgical procedures.

The potential for integrating real-time surgical video and state-of-the art animation techniques has not been widely applied to surgical education. This paper describes the use of new technology for creating videos of liver, pancreas and transplant surgery, annotating them with 3D animations, resulting in a freely-accessible online resource: The Toronto Video Atlas of Liver, Pancreas and Transplant Surgery ( http://tvasurg.ca ). The atlas complements the teaching provided to trainees in the operating room, and the techniques described in this study can be readily adapted by other surgical training programmes.

Who Leaves Suicide Notes? An Exploration of Victim Characteristics and Suicide Method of Completed Suicides in Queensland.

The objective of this study is to address the question: are those who leave suicide notes representative of the larger population of those who commit suicide? The method involves an analysis of a full population of suicides by residents of Queensland, Australia for the full year of 2004, with the information drawn from Coronial files. Our overall results suggest that, and in support of previous research, the population who leaves suicide notes are remarkably similar to those who do not. Differences are identified in four areas: first, and in contrast to prior research, females are less likely to leave a suicide note; second, and in support of previous research, Aboriginal Australians are less likely to leave suicide notes; third, and in support of some previous research, those who use gas as a method of suicide are more likely to leave notes, while those who use a vehicle or a train are less likely to leave notes; finally, our findings lend support to research which finds that those with a diagnosed mental illness are less likely to leave notes. The discussion addresses some of the reasons these disparities may have occurred, and continues the debate over the degree to which suicide notes give insight into the larger suicide population.

Clinician Perception of the Effectiveness of an Automated Early Warning and Response System for Sepsis in an Academic Medical Center.

RATIONALE: We implemented an electronic early warning and response system (EWRS) to improve detection of and response to severe sepsis. Sustainability of such a system requires stakeholder acceptance. We hypothesized that clinicians receiving such alerts perceive them to be useful and effective. OBJECTIVES: To survey clinicians after EWRS notification about perceptions of the system. METHODS: For a 6-week study period 1 month after EWRS implementation in a large tertiary referral medical center, bedside clinicians, including providers (physicians, advanced practice providers) and registered nurses (RNs), were surveyed confidentially within 2 hours of an alert. MEASUREMENTS AND MAIN RESULTS: For the 247 alerts that triggered, 127 providers (51%) and 105 RNs (43%) completed the survey. Clinicians perceived most patients as stable before and after the alert. Approximately half (39% providers, 48% RNs) felt the alert provided new information, and about half (44% providers, 56% RNs) reported changes in management as a result of the alert, including closer monitoring and additional interventions. Over half (54% providers, 65% RNs) felt the alert was appropriately timed. Approximately one-third found the alert helpful (33% providers, 40% RNs) and fewer felt it improved patient care (24% providers, 35% RNs). CONCLUSIONS: A minority of responders perceived the EWRS to be useful, likely related to the perception that most patients identified were stable. However, management was altered half the time after an alert. These results suggest further improvements to the system are needed to enhance clinician perception of the system's utility.

Association of intraoperative hypotension with acute kidney injury after elective noncardiac surgery.

BACKGROUND: Intraoperative hypotension (IOH) may be associated with postoperative acute kidney injury (AKI), but the duration of hypotension for triggering harm is unclear. The authors investigated the association between varying periods of IOH with mean arterial pressure (MAP) less than 55, less than 60, and less than 65 mmHg with AKI. METHODS: The authors conducted a retrospective cohort study of 5,127 patients undergoing noncardiac surgery (2009 to 2012) with invasive MAP monitoring and length of stay of 1 or more days. Exclusion criteria were preoperative MAP less than 65 mmHg, dialysis dependence, urologic surgery, and surgical duration less than 30 min. The primary exposure was IOH. The primary outcome was AKI (50% or 0.3 mg/dl increase in creatinine) during the first 2 postoperative days. Multivariable logistic regression was used to model the exposure-outcome relationship. RESULTS: AKI occurred in 324 (6.3%) patients and was associated with MAP less than 60 mmHg for 11 to 20 min and MAP less than 55 mmHg for more than 10 min in a graded fashion. The adjusted odds ratio of AKI for MAP less than 55 mmHg was 2.34 (1.35 to 4.05) for 11- to 20-min exposure and 3.53 (1.51 to 8.25) for more than 20 min. For MAP less than 60 mmHg, the adjusted odds ratio for AKI was 1.84 (1.11 to 3.06) for 11- to 20-min exposure. CONCLUSIONS: In this analysis, postoperative AKI is associated with sustained intraoperative periods of MAP less than 55 and less than 60 mmHg. This study provides an impetus for clinical trials to determine whether interventions that promptly treat IOH and are tailored to individual patient physiology could help reduce the risk of AKI.

Development, implementation, and impact of an automated early warning and response system for sepsis.

BACKGROUND: Early recognition and timely intervention significantly reduce sepsis-related mortality. OBJECTIVE: Describe the development, implementation, and impact of an early warning and response system (EWRS) for sepsis. DESIGN: After tool derivation and validation, a preimplementation/postimplementation study with multivariable adjustment measured impact. SETTING: Urban academic healthcare system. PATIENTS: Adult non-ICU patients admitted to acute inpatient units from October 1, 2011 to October 31, 2011 for tool derivation, June 6, 2012 to July 5, 2012 for tool validation, and June 6, 2012 to September 4, 2012 and June 6, 2013 to September 4, 2013 for the preimplementation/postimplementation analysis. INTERVENTION: An EWRS in our electronic health record monitored laboratory values and vital signs in real time. If a patient had ≥4 predefined abnormalities at any single time, the provider, nurse, and rapid response coordinator were notified and performed an immediate bedside patient evaluation. MEASUREMENTS: Screen positive rates, test characteristics, predictive values, and likelihood ratios; system utilization; and resulting changes in processes and outcomes. RESULTS: The tool's screen positive, sensitivity, specificity, and positive and negative predictive values and likelihood ratios for our composite of intensive care unit (ICU) transfer, rapid response team call, or death in the derivation cohort was 6%, 16%, 97%, 26%, 94%, 5.3, and 0.9, respectively. Validation values were similar. The EWRS resulted in a statistically significant increase in early sepsis care, ICU transfer, and sepsis documentation, and decreased sepsis mortality and increased discharge to home, although neither of these latter 2 findings reached statistical significance. CONCLUSIONS: An automated prediction tool identified at-risk patients and prompted a bedside evaluation resulting in more timely sepsis care, improved documentation, and a suggestion of reduced mortality.