Treatment of coronary artery perforations complicating percutaneous coronary intervention with a polytetrafluoroethylene-covered stent graft

Coronary artery perforation is a rare, but dreaded, complication of percutaneous coronary intervention. Conventional treatment, including reversal of anticoagulation and prolonged balloon inflation, is associated with a high incidence of death, Q-wave myocardial infarction, and emergency coronary bypass surgery. Although a number of case reports have demonstrated the feasibility of sealing coronary perforations with synthetic material-covered stent grafts, the efficacy of this treatment has not been reported in a large, multicenter series. We used a retrospective international registry to examine the outcomes of the polytetrafluoroethylene-coated JOSTENT coronary stent graft (CSG) in 41 cases of coronary perforations. Perforations were relatively severe: 16.7% Ellis grade 1, 54.2% grade 2, and 29.1% grade 3. Of the 41 patients, > 1/3 (n = 14) experienced life-threatening complications before stent graft implantation, including pericardial tamponade (12.2%), cardiogenic shock (9.8%), and cardiac arrest (2.4%). A total of 52 CSGs were used to treat the 41 perforations (mean 1.3 per lesion). All CSGs were placed successfully, with 92.9% of the perforations sealed completely and 7.1% partially. One patient developed abrupt vessel closure after CSG deployment, resulting in an overall procedure success rate of 96.4%. No in-hospital Q-wave myocardial infarctions, emergency coronary bypass surgeries, or deaths resulted. The CSG may be a reliable and highly effective treatment option for sealing coronary perforations complicating percutaneous coronary interventions.     

When is "good enough"? The role and responsibility of physicians to improve patient safety.

In September 2001, the Agency for Healthcare Research and Quality (AHRQ) and the ABIM Foundation jointly sponsored an invitational conference entitled "The Role and Responsibility of Physicians to Improve Patient Safety." The goal of the conference was to begin a national conversation focusing on the individual clinician's role and strategies physicians might employ to advance patient safety. The authors summarize the main themes and issues that emerged at the conference. The authors draw from work by the Institute of Medicine (IOM) to support the need for greater emphasis on quality improvement. To date, most of the work in this area has involved a systems-level approach, and physicians are often viewed as obstacles to improvement programs. By contrast, physicians may view population- or systems-based approaches to health care as interfering with the delivery of care to specific patients. The authors argue that physicians, individually and collectively, have a key role in quality improvement efforts, albeit a role that is yet fully defined. After reviewing successful examples involving physicians, the authors explore the major levers to achieve change-removing barriers, creating incentives, emphasizing collaboration, increasing education, and promulgating regulation-and summarize ten recurring themes, including both current and near-term opportunities, for physicians to exercise leadership in quality improvement and patient safety. Finally, they assert that even modest change can lead to substantial improvements, particularly if medical societies and the profession's standard-setting bodies work together.     

Peer evaluation of the professional behaviors of emergency medical technicians

INTRODUCTION: Professional behavior is one of the cornerstones of effective emergency medical services (EMS) practice and is a required part of the National Standard Curricula for advanced levels of EMS education. However, peer rating of emergency medical technicians with respect to the 11 categories of professional behavior never has been quantified. This study uses a peer evaluation methodology to assess the affective competencies of practicing EMS providers. METHODS: A professional behavior evaluation form was included as part of a survey that was sent to 2,443 randomly selected, nationally registered emergency medical technicians (EMTs). Participants were asked to rate the EMT partner with whom they worked most closely in the past year using 11 different categories of professional behavior using a Likert scale. RESULTS: One thousand, five hundred, ten (61.8%) surveys were returned and analyzed. Both nationally registered EMTs at the Basic and Paramedic levels rated their partners with respect to 11 categories of professional behavior. The overall average score was 0.68 on a 0-1 scale, with one being the highest. The rating of each of the categories was: (1) integrity (0.77); (2) appearance/personal hygiene (0.74); (3) patient advocacy (0.73); (4) empathy (0.72); (5) self-confidence (0.70); (6) careful delivery of service (0.70); (7) respect (0.65); (8) communication skills (0.64); (9) time management skills (0.63); (10) teamwork/diplomacy skills (0.62); and (11) self-motivation (0.61). Overall, the NREMT-Paramedics rated their partners significantly lower than did the NREMT-Basics (p = 0.0156) and experienced EMT-Basics rated their partners significantly lower than did the newer EMT-Basics (p = 0.0002). Those EMTs who indicated high satisfaction with their current EMS assignment rated their partner more highly on professional behaviors than did those EMTs who were not as satisfied. CONCLUSION: Overall, EMTs peer evaluation of professional behavior was "good." The behaviors most highly rated were integrity and appearance/personal hygiene. The behaviors rated lowest were self-motivation and team work/diplomacy. It appears that paramedics are more critical of their colleagues than are EMT-Basics, that experienced EMT-Basics are harsher critics than are newer EMT-Basics, and that there is a relationship between job satisfaction and peer evaluation.