Clinical pathway care improves outcomes among patients hospitalized for community-acquired pneumonia

PURPOSE: To examine the impact of a unique evidence-based clinical pathway on six outcomes of care in patients hospitalized for community-acquired pneumonia (CAP). METHODS: A retrospective cohort study of CAP patients discharged between January 1999 and December 2001, from 31 Adventist Health System institutions nationwide. A total of 22,196 records were available for multivariate analyses. Odds ratios (OR) for the outcomes were calculated and stratified by a unique severity score. The severity score ranged from 1 to 5, where 5 indicated the most severe condition. RESULTS: Pathway patients were significantly less likely to die in-hospital compared with non-pathway patients in four of the five severity strata (OR in severity level 1=0.37; 95% confidence interval [CI], 0.20-0.70). In all severity strata, pathway patients were approximately twice as likely as non-pathway patients to receive blood cultures and appropriate antibiotic therapy. Among patients who were classified as severity level 1, pathway patients experienced an 80% reduction in the odds of respiratory failure requiring mechanical ventilation (OR=0.20; 95% CI, 0.12-0.33). CONCLUSIONS: Patients who were placed on pneumonia clinical pathway care were much more likely than non-pathway patients to have favorable outcomes of care.     

Population pharmacokinetics of theophylline during paediatric extracorporeal membrane oxygenation

AIMS: To determine the population pharmacokinetics of theophylline during extracorporeal membrane oxygenation (ECMO) from routine monitoring data. METHODS: Retrospective data were collected from 75 term neonates and children (age range 2 days to 17 years) receiving continuous infusions of aminophylline (mean rate 9.2 +/- 2.6 micro g kg-1 min-1) during ECMO. A total of 160 plasma concentrations (range 1-8 per patient), sampled at time intervals ranging from 10 h to 432 h, were included. Population PK analysis and model building were carried out using WinNonMix Professional (Version 2.0.1). Cross-validation was used to evaluate the validity and predictive accuracy of the model. RESULTS: A one-compartment model with first order elimination combined with an additive error model was found to best describe the data. Of the covariables tested, bodyweight significantly influenced clearance and volume of distribution, whereas age was an important determinant of clearance, as adjudged by the differences in the -2 x log likelihood (P < 0.005) and the residual error value. The final model parameters were estimated as: clearance (l h-1) = 0.023 x bodyweight (kg) + 0.000057 x age (days) and volume of distribution (l) = 0.57 x bodyweight (kg). The interindividual variability in clearance and volume of distribution was 38% and 40%, respectively. The residual error corresponded to a standard deviation of 3.6 mg l-1. Cross-validation revealed a median (95% confidence interval) model bias of 9.4% (2.9, 16.5%) and precision of 29.5% (24.8, 36.0%). CONCLUSIONS: The estimated clearance is significantly lower, and volume of distribution higher, than previously reported in non-ECMO patients of similar age. These differences are probably a result of the expanded circulating volume during ECMO and altered renal and hepatic physiology in this critically ill group. Large interindividual variability reflects the heterogeneous nature of patients treated on ECMO.     

Evaluation of vascular and interventional procedures with time-action analysis: a pilot study

PURPOSE: To provide an objective method to measure the efficiency of vascular and interventional procedures. MATERIALS AND METHODS: The time-action analysis method is defined for peripheral vascular and interventional procedures. A taxonomy of actions is defined, geared specifically toward these procedures. The actions are: start-up/wrap-up, exchange, navigate, image, diagnose, treat, handle material, wait, compress puncture site, and unclassified. The recording method and analysis techniques are described. To show the type of data that can be obtained, the time-action analysis of 30 procedures is presented. RESULTS: The results provide a detailed picture of the time spent on various actions. Of all actions, the most time is spent on compressing the puncture site (18.5%), whereas the highest frequency of actions are for exchange of catheters, guide wires, and sheaths (20.4 times per procedure). Radiation exposure can be analyzed in detail, which can yield directions for possible reduction. For instance, 5.2%-8.3% of the total radiation exposure occurs during preparation of imaging to adjust the position of the patient table and set the image intensifier diaphragm. CONCLUSION: Time-action analysis provides an objective measurement method to monitor and evaluate vascular and interventional procedures. Potential applications and limitations of the technique are discussed.     

Postanaesthetic shivering--a new look at tramadol

We studied whether tramadol administered at the time of wound closure can prevent postanaesthetic shivering. One hundred and fifty patients scheduled for general anaesthesia and surgery were randomly allocated and tramadol was administered intravenously at a dose of 2 mg.kg(-1) in the high-dose group, 1 mg.kg- in the low-dose group and 0.9% saline in the control group. In the high-dose group, 2% of patients had postanaesthetic shivering, compared to 4% in the low-dose group and 48% in the control group (p < 0.001 vs. tramadol groups). There was no delay in tracheal extubation after reversal of neuromuscular blockade. The incidence of adverse side-effects such as sedation and vomiting did not differ statistically and were clinically not significant. This study strongly supports the use of tramadol at wound closure for prevention of postanaesthetic shivering.     

Valve perforation and balloon pulmonary valvuloplasty in an infant with tetralogy of Fallot and pulmonary atresia

We report an infant who had tetralogy of Fallot, hypoplastic pulmonary arteries, and membranous pulmonary atresia who underwent successful perforation of the atretic valve and subsequent balloon pulmonary valvuplasty. Because of the inability to access the pulmonary arteries via a patent ductus arteriosus, two-dimensional echocardiography was used to confirm wire position prior to perforation. The branch pulmonary arteries initially measured 1.5 mm in diameter and enlarged to 2.8 mm immediately after valvuloplasty. Four months postprocedure, the patient underwent a successful repeat balloon pulmonary valvuloplasty. The pulmonary arteries had grown to approximately 6 mm in diameter. Although it is a rare occurrence, patients with tetralogy of Fallot and membranous pulmonary atresia can be dilated with successful growth of the pulmonary arteries. Cathet. Cardiovasc. Diagn. 40:403–406, 1997. © 1997 Wiley-Liss, Inc.     

Numeracy Predicts Risk of Pre-Hospital Decision Delay: a Retrospective Study of Acute Coronary Syndrome Survival

Background

Many patients delay seeking medical attention during acute coronary syndromes (ACS), profoundly increasing their risk for death and major disability. Although research has identified several risk factors, efforts to improve patient decision making have generally been unsuccessful, prompting a call for more research into psychological factors.

Purpose

The purpose of this study is to estimate the relationship between ACS decision delay and numeracy, a factor closely related to general decision making skill and risk literacy.

Methods

About 5 days after experiencing ACS, 102 survivors (mean age = 58, 32–74) completed a questionnaire including measures of numeracy, decision delay, and other relevant factors (e.g., anxiety, depression, symptom severity, knowledge, demographics).

Results

Low patient numeracy was related to longer decision delay, OR = 0.64 [95 % confidence interval (CI) 0.44, 0.92], which was in turn related to higher odds of positive troponin on arrival at the hospital, OR = 1.37 [95 % CI 1.01, 2.01]. Independent of the influence of all other assessed factors, a patient with high (vs. low) numeracy was about four times more likely to seek medical attention within the critical first hour after symptom onset (i.e., OR_high-low = 3.84 [1.127, 11.65]).

Conclusions

Numeracy may be one of the largest decision delay risk factors identified to date. Results accord with theories emphasizing potentially pivotal roles of patient deliberation, denial, and outcome understanding during decision making. Findings suggest that brief numeracy assessments may predict which patients are at greater risk for life-threatening decision delay and may also facilitate the design of risk communications that are appropriate for diverse patients who vary in risk literacy.