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Updated Stroke Prevention Guidelines

Updated Stroke Prevention Guidelines

The American Heart Association and American Stroke Association (AHA/ASA) have updated guidelines on primary stroke prevention based on comprehensive and timely evidence from clinical investigations and research trials. Recommendations are included for controlling risk factors, using interventional approaches to atherosclerotic disease, and antithrombotic treatments for preventing stroke. The guidelines were published in Stroke and are available for free online at http://stroke.ahajournals.org. “One of the most important changes in the AHA/ASA guidelines is that newer anticoagulants can be used as alternatives to warfarin to prevent stroke in patients with atrial fibrillation (AF),” says James F. Meschia, MD, FAHA, who chaired the AHA/ASA committee that developed the recommendations. The guidelines note that although some of the new AF drugs are more expensive, they require less ongoing monitoring and therefore represent reasonable options for patients. Another key recommendation from the guidelines is that clinicians are urged to use of statins, along with diet and exercise, to help lower the stroke risk in patients at high risk for experiencing a stroke within the next 10 years. “In addition, the CHA2DS2-VASc is recommended for stratifying the risk for stroke,” says Dr. Meschia. “Patients with a score of 0 on the CHA2DS2-VASc do not require anticoagulants, but those with a score of 2 or higher should receive these therapies.” He adds that patients with a score of 1 on CHA2DS2-VASc can be considered for anticoagulants.   Women & Stroke According to the AHA/ASA, women have higher stroke risks if they are pregnant, use oral contraceptives, use hormone replacement therapy, have migraines, and/or have depression. The guidelines recognize the different risk factors women face throughout their...
Using Readbacks to Enhance Patient Safety

Using Readbacks to Enhance Patient Safety

Normal readback orders have been recommended as a patient safety initiative for physicians, surgeons, and staff in order to reduce the incidence of perioperative complications that can result from verbal communication breakdowns. “Many hospitals nationwide have started to implement readbacks as a mandatory protocol, but progress in adopting this strategy has been slow,” says Philip F. Stahel, MD, FACS. “Few studies have assessed the feasibility and acceptability of readbacks among operating room (OR) staff.” Perceptions & Barriers to Readback Implementation In BMC Surgery, Dr. Stahel and colleagues had a study published that aimed to understand the perceptions of and barriers to implementing readbacks from the viewpoint of OR personnel. “We also wanted to determine the willingness of OR personnel to attend future training modules and specific scenarios in which readbacks may be effective,” Dr. Stahel says. Results were then compared between surgery and anesthesia departments and between specific staff roles, including attending or midlevel providers, resident physicians, and nursing staff. “Our results showed that respondents overwhelmingly believed readbacks help reduce communication errors and improve patient safety,” says Dr. Stahel. “Most respondents—both from surgery and anesthesiology departments—strongly agreed that participating in readback training programs would be beneficial. Resident physicians, however, were less likely to feel that readbacks reduced communication errors when compared with other providers and nursing staff. They were also less willing to attend short training modules on readbacks.” Overall, readbacks were believed to have an important role in patient handoffs, patient orders regarding critical results, counting and verifying surgical instruments, and delegating multiple perioperative tasks. “The biggest challenge in implementation, however, appeared to revolve around determining what kind of...
Heart Disease Awareness Among Women

Heart Disease Awareness Among Women

In 1997, a national survey commissioned by the American Heart Association (AHA) documented that awareness of cardiovascular disease (CVD) among women was low. Since that time, the AHA and other organizations have launched campaigns to raise awareness and educate women about the hazards of CVD. In 2003, the AHA named its national initiative Go Red for Women. During the decade after the initial launch of this campaign, the rate of awareness of CVD as the leading killer of women nearly doubled. During that same time, the mortality rate caused by CVD dropped by about half for both men and women. Analyzing Trends of CVD Awareness in Women Since 1997, the AHA has conducted similar surveys triennially to evaluate national awareness of CVD among women. In 2013, the AHA published the results of the most recent survey in Circulation as part of a study that evaluated trends in awareness of CVD among women between 1997 and 2012. The analysis also assessed knowledge of CVD symptoms as well as preventive behaviors and barriers to CVD prevention among women aged 25 and older. According to the findings, the rate of awareness of CVD as the leading cause of death in women nearly doubled over the 15-year period, rising from 30% in 1997 to 56% in 2012 (Table 1). The most common reasons for women taking preventive actions were to improve health and to feel better, not to live longer. In 1997, women were more likely to say that cancer was the leading killer of women, but that trend reversed in 2012.   “The rate of awareness overall has not changed significantly in the...
Identifying Post-Op Complications for Readmission in General Surgery

Identifying Post-Op Complications for Readmission in General Surgery

In June 2009, CMS began publishing 30-day readmission data for select medical diseases, resulting in hospital readmissions becoming an important metric for measuring the quality of patient care. The changing regulations issued by CMS means that hospital reimbursements can be reduced based on an adjustment factor determined by a hospital’s expected and observed 30-day readmission rates. These changes have also raised the bar for decreasing unnecessary surgical readmissions. In addition to the financial implications, unplanned hospital readmissions further limit hospital resources. For each patient readmitted, there is an opportunity lost to treat another patient who needs care (see also, Strategies for Reducing Hospital Readmissions). “Reducing the number of 30-day readmissions after surgery is important for institutions as well as patients,” says John F. Sweeney, MD, FACS. “Developing a better understanding of the predictors of readmission for general surgery patients will allow hospitals to develop programs to decrease readmission rates. Surgical patients are different from medical patients because surgery, in and of itself, places them at risk for readmission, above and beyond their medical problems. There is an opportunity to intervene preoperatively to decrease the risk of readmission postoperatively.” Important New Data on Hospital Readmission In the Journal of the American College of Surgeons, Dr. Sweeney and colleagues had a study published that analyzed patient records of 1,442 general surgery patients operated on between 2009 and 2011. Of them, 163 patients (11.3%) were readmitted to the hospital within 30 days of discharge. There is a paucity of information focusing on readmission rates among surgical patients, says Dr. Sweeney. “Although factors associated with 30-day readmission after general surgery procedures are multifactorial,...
Decreasing VAP Risk in the ED

Decreasing VAP Risk in the ED

Ventilator-associated pneumonia (VAP) results in increased morbidity, mortality, and healthcare costs. Unfortunately, clinical evidence of VAP occurs 48 hours or more after intubation, meaning it manifests days after the disease process has begun in the ED. Efforts are needed to implement interventions to reduce VAP risk in the ED setting and to make prevention a higher priority. Prevention Strategies For Decreasing VAP There is compelling evidence that pre-hospital and ED intubation, as well as ED length of stay, are risk factors for the development of VAP, particularly in the trauma population. In the March 2012 Journal of Emergency Medicine, my colleagues and I had an article published that identified several strategies to help EDs reduce the risk of VAP: Backrest Elevation: Continuous backrest elevation of 30° to 45° is recommended for all intubated ED patients without contraindications. A collaborative effort is required to ensure compliance. Oral Care: Oral care strategies should be implemented in the ED as early as possible. These include a chlorhexidine application to the oral cavity immediately after intubation and every 12 hours thereafter. Endotracheal Tubes (ETTs): Reducing the use of ETTs with non-invasive ventilation strategies may reduce VAP incidence. Guidelines suggest that intubation should be avoided, if possible. Cuff Pressure Management: The movement of secretions from the oral cavity into the subglottic space and eventually into the lungs increases the risk of VAP. An effective ETT cuff seal may reduce secretion movement. ETT cuff pressure monitoring should be performed as soon as possible after intubation, and pressures should be maintained between 20 cm H2O and 30 cm H2O in the ED and continued at regular...
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