A Simple Low-Cost Method to Integrate Telehealth Interprofessional Team Members During In Situ Simulation.

INTRODUCTION: With the growth of telehealth, simulation personnel will be called upon to support training that integrates these new technologies and processes. We sought to integrate remote telehealth electronic intensive care unit (eICU) personnel into in situ simulations with rural emergency department (ED) care teams. We describe how we overcame technical challenges of creating shared awareness of the patient's condition and the care team's progress among those executing the simulation, the care team, and the eICU. METHODS: The objective of the simulations was to introduce telehealth technology and new processes of engaging the eICU via telehealth during sepsis care in 2 rural EDs. Scenario development included experts in sepsis, telehealth, and emergency medicine. We describe the operational systems challenges, alternatives considered, and solutions used. Participants completed surveys on self-confidence presimulation/postsimulation in using telehealth and in managing patients with sepsis (1-10 Likert scale, with 10 "completely confident"). Pre-post responses were compared by two-tailed paired t test. RESULTS: We successfully engaged the staff of two EDs: 42 nurses, 9 physicians or advanced practice providers, and 9 technicians (N = 60). We used a shared in situ simulation clinical actions observational checklist, created within an off-the-shelf survey software program, completed during the simulations by an on-site observer, and shared with the eICU team via teleconferencing software, to message and cue eICU nurse engagement. The eICU nurse also participated in debriefing via the telehealth video system with successful simulation engagement. These solutions avoided interfering with real ED or eICU operations. The postsimulation mean ± SD ratings of confidence using telehealth increased from 5.3 ± 2.9 to 8.9 ± 1.1 (Δ3.5, P < 0.05) and in managing patients with sepsis increased from 7.1 ± 2.5 to 8.9 ± 1.1 (Δ1.8, P < 0.05). CONCLUSIONS: We created shared awareness between remote eICU personnel and in situ simulations in rural EDs via a low-cost method using survey software combined with teleconferencing methods.

Association between asthma/chronic obstructive pulmonary disease overlap syndrome and healthcare utilization among the US adult population.

Objectives: Asthma/chronic obstructive pulmonary disease (COPD) overlap (ACO) is a recently described phenomenon defined as the coexistence of both asthma and COPD. Both asthma and COPD are known to result in increased emergency department (ED) visits and hospitalizations, but it is unclear how the ACO population utilizes these same healthcare resources. The objective of this study was to compare healthcare utilization in the ACO population versus the general population, the asthma population and the COPD population. Methods: We conducted a pooled cross-sectional statistical analysis using the 2012-2015 National Health Interview Survey (NHIS) data. We focused on adults 18 years of age and older and excluded pregnant women. We employed an adjusted logit regression model, where the primary outcomes were dichotomous indicators on healthcare utilizations including ED visits and hospital stays. A key covariate was a four-category variable: 1) no asthma or COPD; 2) asthma only; 3) COPD only; and 4) ACO. Other covariates included age, sex, race, education level, marital status, household income level, medical insurance status, smoking status, body mass index (BMI) category, region, year and comorbidities (cancer, diabetes, hypertension, coronary heart disease and ulcer). Results: Adults with ACO were 134%, 53% and 21% more likely to have ED visits than the general population, asthma group and COPD group, respectively. For hospital stay, the ACO group was 120% and 86% more likely to be hospitalized than the general population and the asthma group respectively. In addition, adults with ACO were 61% and 130% more likely to have asthma exacerbations and asthma-related ED visits than the asthma group. Conclusions: ACO is a considerable risk factor for healthcare utilization versus the general population, the asthma population and the COPD population. Future focus should be placed on the ACO population to identify ways to reduce their healthcare utilization.

Implementation of Activity Sensor Equipment in the Homes of Chronic Obstructive Pulmonary Disease Patients.

INTRODUCTION: Telemedicine care models for managing advanced chronic obstructive pulmonary disease (COPD) may benefit from the addition of motion sensing, spirometry, and tablet-based symptom diary tracking. METHODS: We conducted a feasibility study of telemedicine in the home setting using multiple activity sensor monitoring equipment. Deployment and monitoring were supported by home health nurses with technical advice from the equipment makers as needed. Data analytics for motion sensing was provided by the research sponsor, but was not used for care decisions. On study intake, a health risk assessment, Quality of Life (SF-36) survey, and the St. George Respiratory Questionnaire were administered to assess patients' self-perception of quality of life, activities of daily life function, and difficulty living with COPD. RESULTS: Twenty-eight patients were enrolled and data were gathered for a minimum of 6 months and maximum of 9 months. The researchers demonstrated that augmentation of traditional telemedicine methods with motion sensing, spirometry, and symptom diaries appears feasible. The technical, process, logistics barriers, and solutions required for system deployment are described. The researchers demonstrated that augmentation of traditional telemedicine methods with motion sensing, spirometry, and symptom diaries appears feasible. CONCLUSIONS: Further exploration will be needed to determine the value of this information in preventing outcomes relevant to patients.

Association between availability of care providers and healthcare utilizations among adults with asthma.

BACKGROUND: Limited accessibility to providers may delay appropriate control of asthma exacerbations. The objective of our study is to estimate the contributors to the hospital/emergency department (ED) visits among adults with asthma focusing on the availability of healthcare providers. METHODS: We conducted a pooled cross-sectional analysis using the 2011-2013 Asthma Call-Back Survey linked with 2012-2016 Area Health Resource Files. We employed multivariable logistic regression with dichotomous outcomes of hospitalization and ED visits. Key covariates were the availability of county-level healthcare provider variables per 100,000 persons such as the number of lung disease specialists (including pulmonary care specialists, and allergy and immunology specialists), the number of hospitals, the number of safety-net facilities including rural health centers (RHCs) and federally qualified health centers (FQHCs), and the number of primary care physicians (PCPs). RESULTS: Among 25,621 adults, proportions of hospital visits and ED visits were 3.3% and 13.2%, respectively. An additional RHC reduced by 3% the odds of having an ED visit (odds ratio [OR] = 0.97, p = .004). Patients with cost barriers to seeing a PCP were 60% (OR = 1.60, p = .028) more likely to have a hospital visit than those without. In addition, patients with cost barriers to seeing a specialist were 90% (OR = 1.90, p = .007) and 111% (OR = 2.11, p = .001) more likely to have a hospital visit and ED visit, respectively, than those without. CONCLUSIONS: Hospital and ED visits among adults with asthma are partially related to the availability of providers, and more related to financial barriers. Therefore, financial support for the vulnerable asthma population might be a target for policy makers interested in reducing hospitalizations and ED visits.

An uncommon complication of a common clinical scenario: exploring reexpansion pulmonary edema with a case report and literature review.

Reexpansion pulmonary edema (RPE) is a rare complication that can occur after rapid reinflation of the lung following thoracentesis of a pleural effusion or chest tube drainage of pneumothorax. The severity in clinical presentation can be widely varied from radiographic changes only to rapidly progressive respiratory failure requiring mechanical ventilation. The quick nature of onset and potential for serious decline in a previously stable patient makes it important to prepare, recognize, diagnose, and appropriately manage patients who develop RPE. The standard treatment for RPE consists of supportive care, and there are certain measures that may be taken to reduce the risk, including limiting the amount drained and avoiding excessive negative pleural pressure. Exactly how to prevent RPE remains unclear, however, and varying recommendations exist. This is a case report of RPE after thoracentesis for a pleural effusion and a brief review of literature to date, including potential preventative strategies.

Effect of Endobronchial Coils vs Usual Care on Exercise Tolerance in Patients With Severe Emphysema: The RENEW Randomized Clinical Trial.

IMPORTANCE: Preliminary clinical trials have demonstrated that endobronchial coils compress emphysematous lung tissue and may improve lung function, exercise tolerance, and symptoms in patients with emphysema and severe lung hyperinflation. OBJECTIVE: To determine the effectiveness and safety of endobronchial coil treatment. DESIGN, SETTING, AND PARTICIPANTS: Randomized clinical trial conducted among 315 patients with emphysema and severe air trapping recruited from 21 North American and 5 European sites from December 2012 through November 2015. INTERVENTIONS: Participants were randomly assigned to continue usual care alone (guideline based, including pulmonary rehabilitation and bronchodilators; n = 157) vs usual care plus bilateral coil treatment (n = 158) involving 2 sequential procedures 4 months apart in which 10 to 14 coils were bronchoscopically placed in a single lobe of each lung. MAIN OUTCOMES AND MEASURES: The primary effectiveness outcome was difference in absolute change in 6-minute-walk distance between baseline and 12 months (minimal clinically important difference [MCID], 25 m). Secondary end points included the difference between groups in 6-minute walk distance responder rate, absolute change in quality of life using the St George's Respiratory Questionnaire (MCID, 4) and change in forced expiratory volume in the first second (FEV1; MCID, 10%). The primary safety analysis compared the proportion of participants experiencing at least 1 of 7 prespecified major complications. RESULTS: Among 315 participants (mean age, 64 years; 52% women), 90% completed the 12-month follow-up. Median change in 6-minute walk distance at 12 months was 10.3 m with coil treatment vs -7.6 m with usual care, with a between-group difference of 14.6 m (Hodges-Lehmann 97.5% CI, 0.4 m to ∞; 1-sided P = .02). Improvement of at least 25 m occurred in 40.0% of patients in the coil group vs 26.9% with usual care (odds ratio, 1.8 [97.5% CI, 1.1 to ∞]; unadjusted between-group difference, 11.8% [97.5% CI, 1.0% to ∞]; 1-sided P = .01). The between-group difference in median change in FEV1 was 7.0% (97.5% CI, 3.4% to ∞; 1-sided P < .001), and the between-group St George's Respiratory Questionnaire score improved -8.9 points (97.5% CI, -∞ to -6.3 points; 1-sided P < .001), each favoring the coil group. Major complications (including pneumonia requiring hospitalization and other potentially life-threatening or fatal events) occurred in 34.8% of coil participants vs 19.1% of usual care (P = .002). Other serious adverse events including pneumonia (20% coil vs 4.5% usual care) and pneumothorax (9.7% vs 0.6%, respectively) occurred more frequently in the coil group. CONCLUSIONS AND RELEVANCE: Among patients with emphysema and severe hyperinflation treated for 12 months, the use of endobronchial coils compared with usual care resulted in an improvement in median exercise tolerance that was modest and of uncertain clinical importance, with a higher likelihood of major complications. Further follow-up is needed to assess long-term effects on health outcomes. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01608490.

Explaining the link between access-to-care factors and health care resource utilization among individuals with COPD.

BACKGROUND: Limited accessibility to health care may be a barrier to obtaining good care. Few studies have investigated the association between access-to-care factors and COPD hospitalizations. The objective of this study is to estimate the association between access-to-care factors and health care utilization including hospital/emergency department (ED) visits and primary care physician (PCP) office visits among adults with COPD utilizing a nationally representative survey data. METHODS: We conducted a pooled cross-sectional analysis based upon a bivariate probit model, utilizing datasets from the 2011-2012 Behavioral Risk Factor Surveillance System linked with the 2014 Area Health Resource Files among adults with COPD. Dichotomous outcomes were hospital/ED visits and PCP office visits. Key covariates were county-level access-to-care factors, including the population-weighted numbers of pulmonary care specialists, PCPs, hospitals, rural health centers, and federally qualified health centers. RESULTS: Among a total of 9,332 observations, proportions of hospital/ED visits and PCP office visits were 16.2% and 44.2%, respectively. Results demonstrated that access-to-care factors were closely associated with hospital/ED visits. An additional pulmonary care specialist per 100,000 persons serves to reduce the likelihood of a hospital/ED visit by 0.4 percentage points (pp) (P=0.028). In contrast, an additional hospital per 100,000 persons increases the likelihood of hospital/ED visit by 0.8 pp (P=0.008). However, safety net facilities were not related to hospital utilizations. PCP office visits were not related to access-to-care factors. CONCLUSION: Pulmonary care specialist availability was a key factor in reducing hospital utilization among adults with COPD. The findings of our study implied that an increase in the availability of pulmonary care specialists may reduce hospital utilizations in counties with little or no access to pulmonary care specialists and that since availability of hospitals increases hospital utilization, directing patients with COPD to pulmonary care specialists may decrease hospital utilizations.

Phase 2 trial of eritoran tetrasodium (E5564), a toll-like receptor 4 antagonist, in patients with severe sepsis.

OBJECTIVES: Endotoxin is a potent stimulus of proinflammatory response and systemic coagulation in patients with severe sepsis. Endotoxin is a component of Gram-negative bacteria that triggers an innate immune response through Toll-like receptor 4 signaling pathways in myeloid cells. We evaluated safety and tolerability of two dose regimens of eritoran tetrasodium (E5564), a synthetic Toll-like receptor 4 antagonist, and explored whether it decreases 28-day mortality rate in subjects with severe sepsis. DESIGN: Prospective, randomized, double-blind, placebo-controlled, multicenter, ascending-dose phase II trial. SETTING: Adult intensive care units in the United States and Canada. PATIENTS: Three hundred adults within 12 hrs of recognition of severe sepsis, with Acute Physiology and Chronic Health Evaluation (APACHE) II-predicted risk of mortality between 20% and 80%. INTERVENTIONS: Intravenous eritoran tetrasodium (total dose of either 45 mg or 105 mg) or placebo administered every 12 hrs for 6 days. MEASUREMENTS AND MAIN RESULTS: Prevalence of adverse events was similar among subjects treated with 45 mg or 105 mg of eritoran tetrasodium or with placebo. For modified intent-to-treat subjects, 28-day all-cause mortality rates were 26.6% (eritoran tetrasodium 105 mg), 32.0% (eritoran tetrasodium 45 mg), and 33.3% in the placebo group. Mortality rate in the eritoran tetrasodium 105-mg group was not significantly different from placebo (p = .335). In prespecified subgroups, subjects at highest risk of mortality by APACHE II score quartile had a trend toward lower mortality rate in the eritoran tetrasodium 105-mg group (33.3% vs. 56.3% placebo group, p = .105). A trend toward a higher mortality rate was observed in subjects in the lowest APACHE II score quartile for the eritoran 105-mg group (12.0% vs. 0.0% placebo group, p = .083). CONCLUSIONS: Eritoran tetrasodium treatment appears well tolerated. The observed trend toward a lower mortality rate at the 105-mg dose, in subjects with severe sepsis and high predicted risk of mortality, should be further investigated.

Delayed closure of persistent postpneumonectomy bronchopleural fistula.

A 73-year-old man with a history of postpneumonectomy empyema and a long-term chest tube since 1979 presented with fever, chills, leukocytosis, and purulent fluid from the left tube thoracostomy. CT scan and bronchoscopy demonstrated a right lower lobe pneumonia and a left mainstem dehiscence with direct communication to the left tube thoracostomy. He underwent primary closure of the bronchopleural fistula with latissimus dorsi muscle flap coverage after antibiotic therapy for right lower lobe pneumonia.