Teaching prioritization skills: a preceptor forum.

The Medical Specialty Preceptor Council of a large tertiary medical center selected prioritization as a theme to address with medical specialty registered nurse preceptors. Activities included exploration of the literature, personal reflection on preceptor experiences, and creation of a project that culminated in a preceptor forum. The forum included interactive poster stations staged for a drop-in session for preceptors. The stations were developed and staffed by Council members using research and ideas from colleagues.

Time to death of hospitalized injured patients as a measure of quality of care.

BACKGROUND: In population-based studies, the quality of care delivered to injured patients is commonly judged by hospital survival rates. Evidence suggests injured patients surviving hospitalization remain at risk for death from their injuries after discharge. Patient characteristics associated with higher risk of late death are not completely defined. METHODS: The National Death Index is a government-maintained database composed of death certificate records from all decedents in the United States. Patients in a trauma registry were cross-linked to decedents in National Death Index on the basis of Social Security number or other unique identifiers. Decedents' time from injury to death was calculated. Logistic regression models were fit to those who died at hospital discharge and those who died in the first year after injury. RESULTS: Among 4293 hospitalized injured patients recorded in a trauma registry, 157 died during hospitalization. Among the 4136 discharged alive, 91 patients were linked to death certificate records filed in the 365 days after discharge. Patients over the age of 65 had a 15-fold greater odds of death than younger patients. CONCLUSION: Trauma registry data cross-linked to vital statistics records is practicable. Patients who die in the year after injury differ from the traditional population used to evaluate quality of trauma care, and new standards are needed that evaluate long-term survival.

Postoperative duplex scan surveillance of axillofemoral bypass grafts.

OBJECTIVE: Duplex scan surveillance (DS) for axillofemoral bypass grafts (AxFBGs) has not been extensively studied. The intent of this study was twofold: 1, to characterize the flow velocities within AxFBGs; and 2, to determine whether postoperative DS is useful in assessment of future patency of AxFBGs. METHODS: We identified all patients who underwent AxFBG procedures between January 1996 and January 2001 at our combined university and Veterans Affairs hospital vascular surgical service. All grafts were performed with ringed 8-mm polytetrafluoroethylene with the distal limb of the axillofemoral component anastomosed to the hood of the femoral-femoral graft. DS was every 3 months for 1 year and every 6 months thereafter. Duplex scan results were compared in primarily patent grafts with grafts that thrombosed. Graft failures from infection were excluded. Influences of ankle-brachial index, blood pressure, outflow patency, operative indication, and comorbidities on graft patency were analyzed. RESULTS: One hundred twenty patients underwent AxFBG procedures. Twenty-eight were excluded because of infection or death before surveillance examination. Fourteen were lost to follow-up, 23 had failed grafts from occlusion, and 55 had grafts that remained patent. In the 78 patients evaluated during long-term follow-up period, the mean peak systolic velocities (PSVs) at the proximal (axillary) anastomosis during the first postoperative year ranged from 153 to 194 cm/s. Mean PSVs at the mid portion of the axillofemoral graft during the first postoperative year ranged from 100 to 125 cm/s, whereas those for the distal axillofemoral anastomosis ranged from 93 to 129 cm/s. Mean midgraft and distal anastomotic velocities obtained before thrombosis were significantly lower in the thrombosed grafts compared with the last recorded velocities at the same sites in the patent grafts (mean PSV, 84 versus 112 cm/s; P =.015; mean PSV, 89 versus 127 cm/s; P =.024, respectively). Forty-eight percent of occluded grafts had a mean midgraft PSV at last observation of less than 80 cm/s. Blood pressure correlated with midgraft velocity (r = 0.415; P <.05). With multivariate logistic regression analysis, a mean midgraft velocity less than 80 cm/s was the sole independent factor associated with graft failure (P <.01). No patients with midgraft velocities greater than 155 cm/s had occlusion. CONCLUSION: Flow velocity varies widely within and among AxFBGs. Patency of AxFBGs is associated with higher midgraft PSV, and thrombosis with midgraft velocities less than 80 cm/s.

Repeat axillofemoral grafting as treatment for axillofemoral graft occlusion.

BACKGROUND: Patency of failed axillofemoral (ax-fem) grafts following thrombectomy is so poor, aortofemoral grafts are recommended as treatment for ax-fem graft thrombosis. In patients who are not candidates for aortic grafting, repeat ax-fem grafting is an alternative to thrombectomy. This report compares our experience treating ax-fem graft thrombosis with replacement or revision vs thrombectomy. METHODS: Patients treated with ax-fem grafts from October 1985 to April 2001 were identified, and those who underwent reoperation for thrombosis were reviewed. Limb salvage and patency of revision procedures (thrombectomy vs repeat ax-fem grafting) were determined using Kaplan-Meier curves. RESULTS: Three hundred thirty-five patients underwent ax-fem grafting, and 39 (11.6%) of the 335 required reoperation for graft failure. Twenty-five of these 39 patients had 51 operations for graft thrombosis: 42 graft replacements and/or anastomotic revision(s), and 9 thrombectomies. At 18 months, mean +/- SD patency following thrombectomy was 11% +/- 10%, while that for graft replacement or anastomotic revision was 54% +/- 8% (P<.001). Limb salvage at 18 months following revision for thrombosis was 88% +/- 5%. CONCLUSIONS: The large majority of ax-fem grafts do not require reoperation. For failure due to thrombosis, repeat ax-fem grafting provides excellent limb salvage. Axillofemoral graft replacement and/or anastomotic revision has superior patency to thrombectomy.

Survival of seriously injured patients first treated in rural hospitals.

BACKGROUND: Patients injured in rural counties are hypothesized to have improved survival if local hospitals are categorized as Level III, Level IV, and Level V trauma centers. METHODS: Data were abstracted on patients with brain, liver, or spleen injuries who were first treated in 16 rural hospitals in Oregon (with categorized trauma centers) and 16 hospitals in Washington (without categorized trauma centers). Logistic regression models evaluated survival up to 30 days after hospital discharge. RESULTS: Among Oregon's 642 study patients, 63% were transferred to another hospital. Among Washington's 624 patients, a higher proportion, 70%, were transferred. Risk-adjusted odds of death for Washington patients (reference odds, 1) were the same as for Oregon patients (odds ratio, 0.82; 95% confidence interval, 0.53-1.28). Most patients died after transfer to another hospital. CONCLUSION: In states with a prevailing practice of promptly transferring brain-injured patients, survival of these patients may not be enhanced by categorization of hospitals as rural trauma centers. To further improve the outcome of these patients, policy makers should adjust statewide trauma system guidelines to enhance integration and to perfect coordination among sequential decision makers.