Palliative Care Exposure Relative to Predicted Risk of Six-Month Mortality in Hospitalized Adults.

CONTEXT: The optimal strategy for implementing mortality-predicting algorithms to facilitate clinical care, prognostic discussions, and palliative care interventions remains unknown. OBJECTIVES: To develop and validate a real-time predictive model for 180 day mortality using routinely available clinical and laboratory admission data and determine if palliative care exposure varies with predicted mortality risk. METHODS: Adult admissions between October 1, 2013 and October.1, 2017 were included for the model derivation. A separate cohort was collected between January 1, 2018 and July 31, 2020 for validation. Patients were followed for 180 days from discharge, and logistic regression with selected variables was used to estimate patients' risk for mortality. RESULTS: In the model derivation cohort, 7963 events of 180 day mortality (4.5% event rate) were observed. Median age was 53.0 (IQR 24.0-66.0) with 92,734 females (52.5%). Variables with strongest association with 180 day mortality included: Braden Score (OR 0.83; 95% CI 0.82-0.84); admission Do Not Resuscitate orders (OR 2.61; 95% CI 2.43-2.79); admission service and admission status. The model yielded excellent discriminatory ability in both the derivation (c-statistic 0.873; 95% CI 0.870-0.877; Brier score 0.04) and validation cohorts (c-statistic 0.844; 95% CI 0.840-0.847; Brier score 0.072). Inpatient palliative care consultations increased from 3% of minimal-risk encounters to 41% of high-risk encounters (P < 0.01). CONCLUSION: We developed and temporally validated a predictive mortality model for adults from a large retrospective cohort, which helps quantify the potential need for palliative care referrals based on risk strata. Machine learning algorithms for mortality require clinical interpretation, and additional studies are needed to design patient-centered and risk-specific interventions.

Improving Mortality Attribution in Otolaryngology - Head and Neck Surgery.

OBJECTIVE/HYPOTHESIS: Mortality attribution can have significant implications for reimbursement, hospital/department rankings, and perceptions of safety. This work seeks to compare the accuracy of externally assigned diagnosis-related group (DRG)-based service line mortality attribution in otolaryngology to an internal review process that assigns mortality to the teams that cared for a patient during hospitalization. STUDY DESIGN: Retrospective case series. METHODS: Mortality events at Vanderbilt University Medical Center (VUMC) from 2012 to 2018 were compared. Included events were assigned to the otolaryngology service line (OSL) via the following methods: an external agency (Vizient) using DRG, utilization management assignment based on the service that provided care at admission (admission service), discharge (discharge service), or throughout hospitalization (major service line), or through the internal VUMC mortality review committee. Internal review was considered the standard for comparison. RESULTS: Of the 28 mortality events assigned to OSL by the DRG-based external method, nine (32%) were actually attributable to OSL. Of the 23 total mortality events attributable to OSL at our institution, external DRG-based review captured nine (39%). The designation of major service during hospitalization was correct 95% of the time and captured 87% of mortality events. Differences between external and internal attribution methods were statistically significant (P < .001). CONCLUSIONS: DRG-based models are frequently utilized but can be inaccurate when attributing mortality for an individual otolaryngology department. Otolaryngology mortalities appear to be captured and assigned more accurately by assigning deaths to the service that renders the majority of care during hospitalization. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E1805-E1810, 2021.

Reducing intraoperative red blood cell unit wastage in a large academic medical center.

BACKGROUND: The wastage of red blood cell (RBC) units within the operative setting results in significant direct costs to health care organizations. Previous education-based efforts to reduce wastage were unsuccessful at our institution. We hypothesized that a quality and process improvement approach would result in sustained reductions in intraoperative RBC wastage in a large academic medical center. STUDY DESIGN AND METHODS: Utilizing a failure mode and effects analysis supplemented with time and temperature data, key drivers of perioperative RBC wastage were identified and targeted for process improvement. RESULTS: Multiple contributing factors, including improper storage and transport and lack of accurate, locally relevant RBC wastage event data were identified as significant contributors to ongoing intraoperative RBC unit wastage. Testing and implementation of improvements to the process of transport and storage of RBC units occurred in liver transplant and adult cardiac surgical areas due to their history of disproportionately high RBC wastage rates. Process interventions targeting local drivers of RBC wastage resulted in a significant reduction in RBC wastage (p < 0.0001; adjusted odds ratio, 0.24; 95% confidence interval, 0.15-0.39), despite an increase in operative case volume over the period of the study. Studied process interventions were then introduced incrementally in the remainder of the perioperative areas. CONCLUSIONS: These results show that a multidisciplinary team focused on the process of blood product ordering, transport, and storage was able to significantly reduce operative RBC wastage and its associated costs using quality and process improvement methods.

Transfusion reactions in pediatric compared with adult patients: a look at rate, reaction type, and associated products.

BACKGROUND: The majority of reports on transfusion reactions address adult patients. Less is known about the types, incidence, and other clinical details of transfusion reactions in pediatric populations. Furthermore, to our knowledge, there have been no previous reports directly comparing these aspects between adults and pediatric patient populations to assess if there are differences. STUDY DESIGN AND METHODS: Between the period of January 1, 2011, and February 1, 2013, all reported adult and pediatric transfusion reactions at Vanderbilt University Medical Center (VUMC) were evaluated by transfusion medicine clinical service. The information was subsequently shared with the hemovigilance database. Data provided to hemovigilance included age, sex, blood product associated with the reaction, severity of the reaction, and the type of transfusion reactions. These were collated with hospital and blood bank information system-acquired data on overall admission and product transfusion. RESULTS: A total of 133,671 transfusions were performed at VUMC during the study period including 20,179 platelet (PLT) transfusions, 31,605 plasma transfusions, 79,933 red blood cell (RBC) transfusions, and 2154 cryoprecipitate transfusions. Over the same period, 108 pediatric and 277 adult transfusion reactions were recorded. This corresponds to an incidence of 6.2 reactions per 1000 transfusions within the pediatric (age < 21) population and an incidence of 2.4 reactions per 1000 transfusions within the adult population. In both adult and pediatric populations, transfusion reactions were most commonly associated with PLT, followed by RBC, and then plasma transfusions. Within the pediatric population, subset analysis identified multiple differences when compared to the adult population, including an increased incidence of allergic transfusion reactions (2.7/1000 vs. 1.1/1000, p < 0.001), febrile nonhemolytic transfusion reactions (1.9/1000 vs. 0.47/1000, p < 0.001), and hypotensive transfusion reactions (0.29/1000 vs. 0.078/1000, p < 0.05). Interestingly, while the reaction incidence was the same between sexes in adults, in pediatric patients, reactions were more common in male patients (7.9/1000 pediatric males vs. 4.3/1000 pediatric females, p < 0.01). CONCLUSION: To our knowledge this is the first study to provide detailed comparisons of acute transfusion reactions to all blood products between pediatric and adult populations at a single institution and supported by a single transfusion service and culture. Collectively these data provide insight into pediatric transfusion reactions and demonstrate a general increase in the incidence of transfusion reactions within the pediatric compared to adult population.

Diastolic field stimulation: the role of shock duration in epicardial activation and propagation.

Detailed knowledge of tissue response to both systolic and diastolic shock is critical for understanding defibrillation. Diastolic field stimulation has been much less studied than systolic stimulation, particularly regarding transient virtual anodes. Here we investigated high-voltage-induced polarization and activation patterns in response to strong diastolic shocks of various durations and of both polarities, and tested the hypothesis that the activation versus shock duration curve contains a local minimum for moderate shock durations, and it grows for short and long durations. We found that 0.1-0.2-ms shocks produced slow and heterogeneous activation. During 0.8-1 ms shocks, the activation was very fast and homogeneous. Further shock extension to 8 ms delayed activation from 1.55 ± 0.27 ms and 1.63 ± 0.21 ms at 0.8 ms shock to 2.32 ± 0.41 ms and 2.37 ± 0.3 ms (N = 7) for normal and opposite polarities, respectively. The traces from hyperpolarized regions during 3-8 ms shocks exhibited four different phases: beginning negative polarization, fast depolarization, slow depolarization, and after-shock increase in upstroke velocity. Thus, the shocks of >3 ms in duration created strong hyperpolarization associated with significant delay (P < 0.05) in activation compared with moderate shocks of 0.8 and 1 ms. This effect appears as a dip in the activation-versus-shock-duration curve.

Implementation of a transfusion algorithm to reduce blood product utilization in pediatric cardiac surgery.

AIM: The goal of this project is to measure the impact of standardization of transfusion practice on blood product utilization and postoperative bleeding in pediatric cardiac surgery patients. BACKGROUND: Transfusion is common following cardiopulmonary bypass (CPB) in children and is associated with increased mortality, infection, and duration of mechanical ventilation. Transfusion in pediatric cardiac surgery is often based on clinical judgment rather than objective data. Although objective transfusion algorithms have demonstrated efficacy for reducing transfusion in adult cardiac surgery, such algorithms have not been applied in the pediatric setting. METHODS: This quality improvement effort was designed to reduce blood product utilization in pediatric cardiac surgery using a blood product transfusion algorithm. We implemented an evidence-based transfusion protocol in January 2011 and monitored the impact of this algorithm on blood product utilization, chest tube output during the first 12 h of intensive care unit (ICU) admission, and predischarge mortality. RESULTS: When compared with the 12 months preceding implementation, blood utilization per case in the operating room odds ratio (OR) for the 11 months following implementation decreased by 66% for red cells (P = 0.001) and 86% for cryoprecipitate (P < 0.001). Blood utilization during the first 12 h of ICU did not increase during this time and actually decreased 56% for plasma (P = 0.006) and 41% for red cells (P = 0.031), indicating that the decrease in OR transfusion did not shift the transfusion burden to the ICU. Postoperative bleeding, as measured by chest tube output in the first 12 ICU hours, did not increase following implementation of the algorithm. Monthly surgical volume did not change significantly following implementation of the algorithm (P = 0.477). In a logistic regression model for predischarge mortality among the nontransplant patients, after accounting for surgical severity and duration of CPB, use of the transfusion algorithm was associated with a 0.247 relative risk of mortality (P = 0.013). CONCLUSIONS: These results indicate that introduction of an objective transfusion algorithm in pediatric cardiac surgery significantly reduces perioperative blood product utilization and mortality, without increasing postoperative chest tube losses.

Blood product positive patient identification: comparative simulation-based usability test of two commercial products.

BACKGROUND: The blood product administration process has been subject to various quality improvement initiatives aimed at reducing errors, including blood product labels that are missing, inaccessible, unreadable, or mismatched to orders and/or patients. This article reports the results of a formal simulation-based usability test of two comparable technologies designed to reduce blood product administration errors. STUDY DESIGN AND METHODS: Nineteen nurses and three anesthesia providers evaluated one of the two products during simulated use in realistic scenarios during 90-minute test sessions. Both products required additional learning despite 15 minutes of dedicated vendor-provided pretest training. RESULTS: There were significant effectiveness differences between the two products, but use of both devices was less efficient than manual checking. Usability issues included poor access to subtasks, lack of process feedback, inadequate error messaging, and confusing device interactions. CONCLUSION: While clinicians' subjective ratings of both devices were similarly high, both products had significant usability issues likely to lead to clinician frustration and workarounds during actual use. This study suggests that usability testing is a valuable and more effective method than preference surveys of determining the ability of blood administration products to meet clinicians' needs in the complex world of patient care.

The potential of dual camera systems for multimodal imaging of cardiac electrophysiology and metabolism.

Fluorescence imaging has become a common modality in cardiac electrodynamics. A single fluorescent parameter is typically measured. Given the growing emphasis on simultaneous imaging of more than one cardiac variable, we present an analysis of the potential of dual camera imaging, using as an example our straightforward dual camera system that allows simultaneous measurement of two dynamic quantities from the same region of the heart. The advantages of our system over others include an optional software camera calibration routine that eliminates the need for precise camera alignment. The system allows for rapid setup, dichroic image separation, dual-rate imaging, and high spatial resolution, and it is generally applicable to any two-camera measurement. This type of imaging system offers the potential for recording simultaneously not only transmembrane potential and intracellular calcium, two frequently measured quantities, but also other signals more directly related to myocardial metabolism, such as [K(+)](e), NADH, and reactive oxygen species, leading to the possibility of correlative multimodal cardiac imaging. We provide a compilation of dye and camera information critical to the design of dual camera systems and experiments.

Effects of unipolar stimulation on voltage and calcium distributions in the isolated rabbit heart.

BACKGROUND: The effect of electric stimulation on the polarization of cardiac tissue (virtual electrode effect) is well known; the corresponding response of intracellular calcium concentration ([Ca(2+)](i)) and its dependence on coupling interval between conditioning stimulus (S1) and test stimulus (S2) has yet to be elucidated. OBJECTIVE: Because uncovering the transmembrane potential (V(m))-[Ca(2+)](i) relationship during an electric shock is imperative for understanding arrhythmia induction and defibrillation, we aimed to study simultaneous V(m) and [Ca(2+)](i) responses to strong unipolar stimulation. METHODS: We used a dual-camera optical system to image concurrently V (m) and [Ca(2+)](i) responses to unipolar stimulation (20 ms +/- 20 mA) in Langendorff-perfused rabbit hearts. RH-237 and Rhod-2 fluorescent dyes were used to measure V(m) and [Ca(2+)](i), respectively. The S1-S2 interval ranged from 10 to 170 ms to examine stimulation during the action potential. RESULTS: The [Ca(2+)](i) deflections were less pronounced than changes in V(m) for all S1-S2 intervals. For cathodal stimulation, [Ca(2+)](i) at the central virtual cathode region increased with prolongation of S1-S2 interval. For anodal stimulation, [Ca(2+)](i) at the central virtual anode area decreased with shortening of the S1-S2 interval. At very short S1-S2 intervals (10-20 ms), when S2 polarization was superimposed on the S1 action potential upstroke, the [Ca(2+)](i) distribution did not follow V(m) and produced a more complex pattern. After S2 termination [Ca(2+)](i) exhibited three outcomes in a manner similar to V(m): non-propagating response, break stimulation, and make stimulation. CONCLUSIONS: Changes in the [Ca(2+)](i) distribution correlate with the behavior of the V (m) distribution for S1-S2 coupling intervals longer than 20 ms; at shorter intervals S2 creates more heterogeneous [Ca(2+)](i) distribution in comparison with V(m). Stimulation in diastole and at very short coupling intervals caused V(m)-[Ca(2+)](i) uncoupling at the regions of positive polarization (virtual cathode).

High-resolution high-speed panoramic cardiac imaging system.

A panoramic cardiac imaging system consisting of three high-speed CCD cameras has been developed to image the surface electrophysiology of a rabbit heart via fluorescence imaging using a voltage-sensitive fluorescent dye. A robust, unique mechanical system was designed to accommodate the three cameras and to adapt to the requirements of future experiments. A unified computer interface was created for this application - a single workstation controls all three CCD cameras, illumination, stimulation, and a stepping motor that rotates the heart. The geometric reconstruction algorithms were adapted from a previous cardiac imaging system. We demonstrate the system by imaging a polymorphic cardiac tachycardia.