Systems of Care Delivery and Optimization in the Postoperative Care Wards.

A third of all patients are at risk for a serious adverse event, including death, in the first month after undergoing a major surgery. Most of these events will occur within 24 hours of the operation but are unlikely to occur in the operating room or postanesthesia care unit. Most opioid-induced respiratory depression events in the postoperative period resulted in death (55%) or anoxic brain injury (22%).

Development and Validation of a Machine Learning Algorithm Using Clinical Pages to Predict Imminent Clinical Deterioration.

Background: Early detection of clinical deterioration among hospitalized patients is a clinical priority for patient safety and quality of care. Current automated approaches for identifying these patients perform poorly at identifying imminent events.

Objective: Develop a machine learning algorithm using pager messages sent between clinical team members to predict imminent clinical deterioration.

Etiology and Timing of Postoperative Rapid Response Team Activations.

In this retrospective cohort study we sought to evaluate the association between the etiology and timing of rapid response team (RRT) activations in postoperative patients at a tertiary care hospital in the southeastern United States. From 2010 to 2016, there were 2,390 adult surgical inpatients with RRT activations within seven days of surgery. Using multivariable linear regression, we modeled the correlation between etiology of RRT and timing of the RRT call, as measured from the conclusion of the surgical procedure.

Code status at time of rapid response activation - Impact on escalation of care?

Background: A code status documents the decision to receive or forgo cardiopulmonary resuscitation in the event of cardiac arrest. For patients who undergo a rapid response team activation (RRT) for possible escalation to an intensive care unit (ICU), the presence or absence of a code status represents a critical inflection point for guiding care decisions and resource utilization. This study characterizes the prevalence of code status at the time of RRT and how code status at RRT affects rates of intensive treatments in the ICU.

Incidence of Laryngotracheal Stenosis after Thermal Inhalation Airway Injury.

Inhalation injury is independently associated with burn mortality, yet little information is available on the incidence, risk factors, or functional outcomes of thermal injury to the airway. In patients with thermal inhalation injury, we sought to define the incidence of laryngotracheal stenosis (LTS), delineate risk factors associated with LTS development, and assess long-term tracheostomy dependence as a proxy for laryngeal function. Retrospective cohort study of adult patients treated for thermal inhalation injury at a single institution burn critical care unit from 2012 to 2017.

Nursing attitudes towards continuous capnographic monitoring of floor patients.

Introduction: Nurses' perceptions of the utility of capnography monitoring are inconsistent in previous studies. We sought to outline the limitations of a uniform education effort in bringing about consistent views of capnography among nurses.

Methods: A survey was administered to 22 nurses in three subacute care floors participating in a pragmatic clinical trial employing capnography monitoring in a large, urban tertiary care hospital.

Balanced Crystalloids versus Saline in Critically Ill Adults.

Background: Both balanced crystalloids and saline are used for intravenous fluid administration in critically ill adults, but it is not known which results in better clinical outcomes.

Methods: In a pragmatic, cluster-randomized, multiple-crossover trial conducted in five intensive care units at an academic center, we assigned 15,802 adults to receive saline (0.9% sodium chloride) or balanced crystalloids (lactated Ringer's solution or Plasma-Lyte A) according to the randomization of the unit to which they were admitted.

Intensive Care Unit Enhanced Recovery Pathway for Patients Undergoing Orthotopic Liver Transplants Recipients: A Prospective, Observational Study.

Background: Liver transplant recipients continue to have high perioperative resource utilization and prolonged length of stay despite improvements in perioperative care. Enhanced recovery pathways have been shown in other surgical populations to produce reductions in hospital resource utilization.

Methods: A prospective, observational study was performed to examine the effect of an enhanced recovery pathway for postoperative care after liver transplantation.

Creation and Execution of a Novel Anesthesia Perioperative Care Service at a Veterans Affairs Hospital.

Physician-led perioperative surgical home models are developing as a method for improving the American health care system. These models are novel, team-based approaches that help to provide continuity of care throughout the perioperative period. Another avenue for improving care for surgical patients is the use of enhanced recovery after surgery pathways.

Daily Lowest Hemoglobin and Risk of Organ Dysfunctions in Critically Ill Patients.

Objectives: To determine the association between hemoglobin levels and the daily risk of individual organ dysfunctions in critically ill patients.

Design: Post hoc analysis of prospectively collected data.

Setting: Vanderbilt University Medical Center and Saint Thomas Hospital Medical and Surgical ICUs.

An Electronic Tool for the Evaluation and Treatment of Sepsis in the ICU: A Randomized Controlled Trial.

Objectives: To determine whether addition of an electronic sepsis evaluation and management tool to electronic sepsis alerting improves compliance with treatment guidelines and clinical outcomes in septic ICU patients.

Design: A pragmatic randomized trial.

Setting: Medical and surgical ICUs of an academic, tertiary care medical center.

Cryoamputation as a temporizing measure in severe burn injury.

Cryoamputation, or physiologic amputation, is a well-described procedure typically used to amputate gangrenous lower extremities. In such cases the patient is too unstable for transport to the operating room, so cryoamputation using dry ice or other refrigerant allows for immediate bedside intervention and later operative amputation when the patient is more stable. In this study the authors describe the use of cryoamputation to stabilize a burn patient with a nonviable upper extremity considered to be contributing significantly to his metabolic acidosis.

The science and economics of improving clinical communication.

This article presents a complex clinical scenario based on actual communication breakdowns that led to a sentinel event. Basic communication theory that underlies clinical interactions and the tenets of health care economic evaluation are reviewed. The process of the handoff as it relates to clinical interactions is discussed and the weaknesses in communication arising from handoff failures in the operative and critical care environments are examined.

Workflow in intensive care unit remote monitoring: A time-and-motion study.

Objective: To investigate workflow in intensive care unit remote monitoring, a technology-driven practice that allows critical care specialists to perform proactive and continuous patient care from a remote site.

Design: A time-and-motion study.

Setting: Facility that remotely monitored 132 beds in nine intensive care units.

A time-motion study of registered nurses' workflow in intensive care unit remote monitoring.

Utilizing advanced information technology, Intensive Care Unit (ICU) remote monitoring allows highly trained specialists to oversee a large number of patients at multiple sites on a continuous basis. In the current research, we conducted a time-motion study of registered nurses' work in an ICU remote monitoring facility. Data were collected on seven nurses through 40 hours of observation.