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Transradial Angiography: Coming to a Consensus

Transradial Angiography: Coming to a Consensus

Research indicates that the adoption of transradial angiography increased 10-fold between 2007 and 2011 in the United States. Randomized and observational studies have suggested that radial access reduces bleeding and vascular complication risks. Other studies have shown the approach reduces costs, increases patient satisfaction, and reduces mortality in some high-risk patients. 3 Major Recommendations To provide a guide to operators who are early in their adoption of radial procedures or are contemplating adoption, the Society for Cardiovascular Angiography and Intervention (SCAI) published a consensus statement in Catheterization and Cardiovascular Interventions. The document issued three major recommendations: 1. Preserve the radial artery and utilize practices that preserve radial artery patency. 2. Minimize patient and operator radiation exposure during radial procedures. 3. Transradial primary PCI for patients with STEMI should be performed only after sufficient experience is achieved in elective cases. “To monitor for and reduce the risk of radial artery occlusion, we recommend using adequate anticoagulation, the smallest profile equipment possible to minimize trauma to the radial artery and still obtain high-quality images, and non-occlusive hemostasis at the end of the procedure,” says Sunil V. Rao, MD, FSCAI, who served as lead author of the SCAI consensus statement (Table 1). “It’s important to keep enough pressure on the radial artery to obtain hemostasis but not so much that the antegrade flow is prevented.” The consensus statement also recommends that operators monitor for radial artery occlusions immediately after a radial procedure and during follow-up. SCAI recommends using ultrasound Doppler measurements or the reverse Barbeau test to accomplish this task. Radiation: Operator Considerations SCAI has published much information on reducing patient and...
Grading the Nation’s Support for Emergency Care

Grading the Nation’s Support for Emergency Care

Since 2006, the American College of Emergency Physicians (ACEP) has periodically released a state-by-state report card on America’s emergency care environment. In 2014, the third installment of the report card was released. “The information from ACEP’s report card provides clinicians with data on how well emergency care is supported in the United States,” says Jon Mark Hirshon, MD, MPH, PhD, FACEP, who served as chair of the task force that directed the development of the report card. ACEP’s most recent report card forecasts an expanding role for EDs under the Affordable Care Act (ACA) and describes the harm that is being done from fewer resources and greater demands. It measures conditions and policies under which emergency care is being delivered rather than the quality of care that is being provided by hospitals and emergency providers. The report card grades states on 136 measures in five categories, including: Most EDs Scored Poor Grades According to the 2014 report card, the continued failure of state and national policies to support emergency care is endangering patients who require emergent and urgent care. Overall, the United States received a near-failing D+ grade. In a breakdown of the five categories of the report card, the nation received a D- in the access to emergency care category; a C- in the medical liability environment and disaster preparedness categories; and a C in the quality and patient safety category as well as the public health and injury prevention category. The District of Columbia ranked first in the nation with a B- grade, a mark that surpassed Massachusetts, which held the top spot in the 2009 report...
Smoking Cessation in People With HIV/AIDS

Smoking Cessation in People With HIV/AIDS

Published research shows that cigarette smoking rates among people living with HIV/AIDS are substantially higher than those of the general public. “The prevalence of smoking adults in the United States is about 18%, but that figure increases to approximately 50% for people with HIV/AIDS,” says Damon J. Vidrine, DrPH, MS. “Furthermore, people with HIV/AIDS are at higher risk from the adverse health consequences of smoking, including heart disease, cancer, pulmonary disease, and overall mortality.” A recent study found that more than 60% of deaths among people living with HIV/AIDS can be attributed to smoking. “Smoking can also interfere with the efficacy of medications used to keep HIV/AIDS under control,” adds Ellen R. Gritz, PhD. Despite compelling evidence suggesting that people with HIV/AIDS could benefit considerably from smoking cessation treatment, large-scale trials conducted exclusively in these patients are scarce. “Few studies have looked at interventions that have been effective for long-term smoking abstinence in these patients,” says Dr. Gritz. “We need more studies that focus on the unique needs of people with HIV/AIDS in the context of this patient group being economically disadvantaged.” A Unique Smoking Cessation Intervention Dr. Gritz, Dr. Vidrine, and colleagues had a study published in Clinical Infectious Diseases that compared a usual care (UC) approach with an innovative cell phone counseling-based smoking cessation intervention in low-income, multiethnic people with HIV/AIDS who smoked. “We wanted to develop and implement a smoking cessation intervention that addressed the complex medical and social needs encountered by these patients,” says Dr. Vidrine. “This is one of the largest studies to look at a smoking cessation intervention that exclusively targets people living...
Reducing Ambulance Diversions

Reducing Ambulance Diversions

Recent data indicate that about 45% of EDs in the United States report being “on diversion” at some point within a given year to alleviate crowding. “Although ambulance diversion has been used for quite some time, several studies link these diversions to negative consequences,” explains M. Kit Delgado, MD, MS. “These include prolonged transport times, delays in care, higher mortality, and lower hospital revenue.” Efforts have been made to reduce ambulance diversion in the past. These strategies include implementing ED patient-flow improvements. “Optimizing front end operations, such as patient triage, registration, and tracking, is also important,” says Dr. Delgado. “Other improvement efforts include adopting hospital-wide full capacity protocols to expedite the transfer of admitted patients from EDs to inpatient units.” New Insights on Diversion & Crowding Questions remain about the strategies that can best reduce diversion without increasing ED crowding and how best to coordinate these efforts. In the Western Journal of Emergency Medicine, Dr. Delgado and colleagues had a study published that systematically reviewed simulation model investigations. “Our overall goal was to gain insights on how to optimally reduce ambulance diversion,” Dr. Delgado says. The analysis identified 10 studies that used simulations modeling ambulance diversion as a result of ED crowding or inpatient capacity problems. Results showed that ambulance diversion only minimally improved ED waiting room times. Strategies that were found to reduce diversion considerably include: 1. Adding holding units for inpatient boarders. 2. Adding ED-based fast tracks. 3. Improving lab turnaround times. 4. Smoothing out elective surgery caseloads. “The desired effect of reducing ED waiting room times by diverting ambulances is likely to be very small,” says...
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