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The Singing Nurse

The Singing Nurse

Patients who heard him as he walked the halls belting out old love songs and Broadway hits started to request he sing to them. Soon, serenading the sick became part of his daily rounds, gaining him the moniker “The Singing Nurse.” Reported by Ann Simmons/ Video by Trishna Patel Source: Los Angeles...
My Turning Point

My Turning Point

As an incurable compulsive introspect, I tend to brood, ponder, contemplate, and (of course) muse on “big ideas,” such as: • What makes people choose things which cause themselves harm? • Are some people better people than others, or are they just more skilled at hiding their problems? • Is pain really a bad thing, or is our aversion to it a sign of human weakness? • Does God ever wear a hat? • Do dogs watch Oprah? • Why did I put “big ideas” in quotes? Tough questions. Lately I’ve been contemplating the nature of human awareness: • Is self-awareness (the ability to think of ourselves in the third person) a uniquely human trait, and is lack of self-awareness the essence of mental illness? • Is empathy, or other-awareness the highest of human traits? Is this what the biblical idea of being “made in the image of God” really means? Yeah, that’s a lot deeper than about dogs watching Oprah. The second of these questions seems to be a very important dividing point in people’s ability to have good relationships with others. Our ability to put ourselves into the place of others, pondering their motives, thoughts, and emotions, goes a very long way in helping us develop deep relationships and avoiding causing inadvertent pain. It also seems to be a trait that is in short supply in our health care system. I am amazed and deeply disturbed by how callously many my patients have been treated by some of my colleagues. Patients are seemingly treated as a commodity, a necessary evil required for billing of services. Burnout and...
Summary of New Healthcare Attire Guidelines

Summary of New Healthcare Attire Guidelines

Are banning wrist watches and providing hooks for white coats realistic solutions for reducing infections?   A new guideline released from the Society for Healthcare Epidemiology of America (SHEA) provides recommendations on reducing transmission of healthcare-associated infections (HAIs) through guidance of healthcare personnel (HCP) attire in non-operating room settings. The recommendations, published in Infection Control and Hospital Epidemiology, are based on limited evidence, theoretical rationale, and practical considerations. Acknowledging that more appropriately designed studies should be funded and performed to better define the relationship between HCP attire and HAIs, the following are based on evidence-based measures to prevent HAIs: 1)      “Bare below the elbows”: HCPs should wear short sleeves, no wristwatches or jewelry, and no ties during clinical practice. Even though the prevention impact is unknown, the recommendations rationalize that it is supported by “biological plausibility” and is unlikely to cause harm. 2)      White coats: Facilities that mandate or strongly recommend the use of white coats should require that HCPs possess 2 or more white coats in addition to institution-provided on-site laundering at no or low cost.  Institutions should also provide coat hooks so that HCPs can remove and hang their white coat before patient contact. 3)      Other HCP apparel: Use of other specific apparel items can’t be limited because transmission of pathogens remains undetermined. However, neckties, for example, should be secured. 4)      Laundering: Any apparel worn that comes in direct contact with patients or the patient environment should be laundered after daily use, no less frequently than once a week. 5)      HCP footwear: All footwear should have closed toes, low heels, and non-skid soles. The article also delves...

STS 2014: Preventing SSIs in CABG

The Particulars: Surgical site infections (SSIs) can increase mortality, readmission rates, lengths of stay, and costs when compared with no SSIs. Investigators report that there is a need to reduce the rate of SSIs after isolated CABG with donor site surgery. Data Breakdown: A study team of cardiothoracic surgeons, nurses, and support personnel analyzed inconsistencies and variations in their processes to determine if these procedures mirrored best practices. Areas for improvement were identified and rapidly acted upon. Changes made included using chlorohexidine oral rinses until discharge, disposable EKG leads, silver impregnated mid-sternal dressings, new sutures, and surgical techniques. All processes were then standardized. From March 2012 to March 2013, the SSI rate dropped to 0.7 per 100 procedures, with no SSIs observed since May 2012. Take Home Pearl: Identifying where surgical procedures do not mirror best practices and implementing changes to address these shortcomings appears to help eliminate SSIs after isolated CABG with donor site...

STS 2014: TAVR Availability Improves Outcomes

The Particulars: Recently, transcatheter aortic valve replacement (TAVR) became a commercially available treatment for aortic stenosis in the United States. Little is known about the impact that TAVR has had on the overall volume and outcomes from aortic valve interventions of any kind at a national level. Data Breakdown: For a study, investigators evaluated the overall volume and outcomes from aortic valve interventions at U.S. hospitals from 2008 to 2012. During the study period, the total annual volume of aortic valve interventions increased from 34,699 to 43,282. Even among high-risk cases, overall mortality associated with aortic valve replacement (AVR) decreased from 8.9% in 2011 to 7.0% in 2012. Take Home Pearl: The introduction of TAVR appears to have increased the number of patients eligible for AVR while also decreasing patient mortality...

STS 2014: Long-Term Survival After Pediatric Heart Transplants

The Particulars: Research indicates that the average survival rate for adult heart transplant recipients is currently 10 years. Little is known about survival rates among pediatric heart transplant recipients. Data Breakdown: Researchers from California studied survival rates beyond 15 years among pediatric heart transplant recipients. More than half of study participants (54.3%) survived at least 15 years past their surgery. In these patients, the average ejection fraction was 62.0%. Graft vasculopathy and renal complications were the main factors that limited long-term survival. Take Home Pearls: More than half of pediatric heart transplant recipients appear to live beyond 15 years after their surgery. These patients appeared to have reasonable cardiac function and quality of life after...

Discrediting a Paper About Discredited Practices

According to a study in the Mayo Clinic Proceedings, 146 papers appearing in the New England Journal of Medicine over the first decade of this century contradicted medical practices previously thought to be effective. The paper’s findings were widely publicized. There was talk in the New York Times of inertia hindering change and allowing ineffective treatments to continue for years. The full text of the paper and a supplement containing a brief summary of all 146 discredited practices are available online. I decided to see for myself if any practices relating to general surgery were included in the paper and found 11. Two of them seemed highly debatable to me. Number 43 on the list was a comparison of open mesh to laparoscopic mesh inguinal hernia repair that appeared in NEJM on 4/29/04. This was the critique: “A laparoscopic approach to repair inguinal hernias with mesh was thought to have lower hernia recurrence rates and less post-operative pain. This multicenter, randomized trial in a VA population found that the laparoscopic approach led to a higher rate of complications and a higher rate of recurrences when repairing primary inguinal hernias.”  It definitively closed the door on laparoscopic inguinal hernia repair. Or did it? Follow-up letters to the editor pointed out that the laparoscopic recurrence rate of 10% in the VA study was much higher than in other reported series, and the size of the mesh (~8.0 cm) used in the laparoscopic cohort was much smaller than the 10 cm x 15 cm that most experts recommended. How has the VA paper affected surgeons’ choice of technique for hernia repair? A...
Needle-Free Vaccines

Needle-Free Vaccines

One hundred sixty years after the invention of the needle and syringe, we’re still using them to deliver vaccines; it’s time to evolve. Biomedical engineer Mark Kendall demos the Nanopatch, a one-centimeter square vaccine that can be applied painlessly to the skin. He shows how this tiny piece of silicon can overcome four major shortcomings of the modern needle and syringe, at a fraction of the cost. Source:...
A Data-Driven Approach for Nurse Staffing

A Data-Driven Approach for Nurse Staffing

Unplanned nurse turn­over is a primary threat to a hospital’s sustainability. Foremost, the price of replacing new nurses is exorbitantly expensive, costing a hospital up to $82,000 or more per nurse. Studies also suggest that high nurse turnover can contribute to increases in patient deaths and failure-to-rescue incidents. It has also correlated with increased rates of infection and longer hospital stays in published research. Compounding the problem is that nurses often struggle during periods of high turnover to work closely together in partnerships with physicians and other caregivers. Decreased staff satisfaction and loyalty are common during periods of high nurse turnover. Causes of Nurse Turnover There are a number of factors that contribute to high attrition rates in nursing, but here are some of the most common reasons plaguing the new nurse population: Opinion-based staffing: In many cases, hospital departments still rely on opinion-based staffing practices that provide zero visibility into overtime, unit needs, and patient acuity. Relying on manual paper-based processes, nurse management has to use their gut—not facts—to optimize staff scheduling and management. Poor patient matching: Opinion-based staffing often matches nurses with patients outside their scope of practice or experience levels. Staffing based on patient needs requires a data-driven process that creates the perfect balance of both objectivity and professional nursing judgment. Ineffective new nurse onboarding: It has been estimated that 60% of new nurses are leaving their position by their second year due to low job satisfaction and heavy workloads. Fortunately, new strategies and tools are emerging to stop turnover before it happens. One such example of these innovative approaches has been the adoption of a...
Using SMBG in the Insulin-Naïve

Using SMBG in the Insulin-Naïve

Achieving glycemic control is paramount to helping patients prevent the development of diabetes-related complications. According to William H. Polonsky, PhD, CDE, several tools are available to monitor the day-to-day trends in glycemia, one of the most important of which has been self-monitoring of blood glucose (SMBG). “SMBG has been considered a key component of patient management,” he says. “There remains widespread agreement that SMBG should be available to all patients with diabetes regardless of their current treatment strategy.” In Diabetes Care, Dr. Polonsky and colleagues had a study published showing that appropriate use of structured SMBG significantly improves glycemic control in insulin-naïve patients with type 2 diabetes (Table 1). The analysis also revealed that structured SMBG facilitated more timely and aggressive treatment changes without decreasing general well-being. Despite these findings, a number of other recent reports have challenged the notion that all patients should use SMBG because it may have little impact on glycemic control. Structure Matters Implementing SMBG in unstructured ways without training patients and clinicians is likely to be a waste of resources. However, the findings of recent studies that have challenged SMBG use do not mean that this monitoring strategy should be eliminated from clinical use. “Like any good tool, SMBG may be used well or poorly,” says Dr. Polonsky. “Unlike a medication, SMBG is not uniformly administered across all patients and settings.” SMBG varies considerably by the clinical question it addresses and the recommended frequency and timing of tests. The expertise of patients regarding its use and the involvement and knowledge of clinicians in interpreting and responding to SMBG data are other important factors. Dr....
Combating Malnutrition

Combating Malnutrition

With as many as one in three patients entering the hospital malnourished, physicians and other healthcare providers must understand the adverse effects malnutrition has on patient outcomes. It delays recovery from illness and increases complications as well as frequency of hospital admissions and length of stay. Research has shown measurable and positive effects when malnourished patients receive nutritional treatment. For patients with at least one known subsequent readmission, oral nutrition supplementation provided during hospitalization has been associated with a significant reduction in the probability of 30-day readmission. Studies have also shown that nutrition interventions can significantly reduce the risk of pressure ulcers. For gastrointestinal surgery patients, nutrition interventions have led to substantial reductions in overall complications. Nutrition Care Model One of the most critical aspects to comprehensively identify and treat malnutrition is to drive interdisciplinary collaboration among dietitians, nurses, hospitalists, and other physicians. To address this issue, the Alliance to Advance Patient Nutrition published a consensus paper outlining the problem of malnutrition and recommended steps to improve outcomes. The alliance describes a nutrition care model that offers practical ways for healthcare providers in hospitals to collaborate to promptly diagnose and treat malnourished patients and those at risk for malnutrition. The model emphasizes the following six principles: • Create an institutional culture where all stakeholders value nutrition. • Redefine clinicians’ roles to include nutrition care. • Recognize and diagnose all malnourished patients and those at risk. • Rapidly implement comprehensive nutrition interventions and continued monitoring. • Communicate nutrition care plans. • Develop a comprehensive discharge nutrition care and education plan. For each of these steps, there are specific actions physicians can take to make...
Guidelines for Managing Fever & Neutropenia in Cancer Patients

Guidelines for Managing Fever & Neutropenia in Cancer Patients

Neutropenia, a common condition among cancer patients that is caused by low levels of neutrophils, can be caused by cancer itself or by the types of chemotherapy used. People with neutropenia are much more likely to develop infections when compared with those who have normal blood counts. Febrile neutropenia occurs when patients with neutropenia develop fevers, which are a sign of possible infection. Typically, febrile neutropenia is treated by immediately hospitalizing patients and providing them with intravenous antibiotics to prevent life-threatening complications, such as sepsis. Recent studies, however, suggest that select patients who are at low risk of complications related to febrile neutropenia may be eligible for outpatient treatment. The American Society of Clinical Oncology (ASCO) has issued a clinical practice guideline update on the management of neutropenia with fever and for the prevention of related infections in cancer patients. ASCO also endorsed a related guideline for children with cancer. To develop these guidelines, an expert panel systematically reviewed evidence from relevant medical literature, including 47 seminal articles. “These guidelines are intended to help physicians identify patients at high risk of medical complications related to neutropenia with fever,” says Christopher R. Flowers, MD, MS, who co-chaired the ASCO expert panel that drafted the guideline for adults. “They also provide clarity on when preventive treatment for infection is needed.” Additionally, guidance is offered on managing select patients who can be managed safely at home during febrile neutropenia episodes. Hospitalizations & Assessing Risks According to Dr. Flowers, a priority of ASCO’s guidelines was to help clinicians identify patients with febrile neutropenia who do not require hospitalization. “The guideline will help spare...
The Modern Surgery Department Chairmen

The Modern Surgery Department Chairmen

At hospitals throughout the country, surgery department chairmen have an important leadership role with regard to faculty and student affairs, budgetary requirements, research, and alumni and community relations. “There is general agreement that academic surgical departments are experiencing tremendous changes,” says Douglas P. Slakey, MD. “There’s a growing uncertainty among surgical department chairmen about the future of funding, expectations, and job priorities.” Complicating matters is that there is no established standard for the position of surgery department chairman. Few studies have evaluated the responsibilities of surgery department chairmen, their methods of support, the determinants of job performance success, and the concerns of people who hold these positions, according to Dr. Slakey. “Given the importance of these positions, it behooves us to learn the details of current job requirements and about job-related stress and satisfaction. This information can be used to help medical schools provide the resources that are necessary to improve how these leaders are selected. It may also help to reduce turnover and increase the likelihood of long-term commitments.” Surveying the Scene In a study published in JAMA Surgery, Dr. Slakey and colleagues had a survey published that sought to better understand the complexities of the modern day surgical chairman’s position. “Our goal was to globally assess the allocation of time for the surgery department chair’s responsibilities,” says Dr. Slakey. The study team received 72 survey responses from current chairmen.   Most respondents to the survey reported that they maintained a clinical practice that consumed about 25% of their workweek. However, surgical department chairs attended an average of 4.3 essential meetings per year. In addition, research was not...

ISET 2014: Bioresorbable Scaffold Beneficial

The Particulars: Drug-eluting bioresorbable vascular scaffolds (BVS)—which naturally dissolve into the blood stream within 18 to 24 months—have been found to effectively treat coronary artery disease. However, studies have yet to determine the effectiveness of BVS in peripheral arterial disease. Data Breakdown: Among patients with PAD participating in a study, 100% of arteries treated with BVS remained open at 6 months follow-up. Blockages were reduced from an average of 80% prior to treatment to 13% after treatment. Use of BVS also helped avoid the breaks, prolonged irritation, delayed in-stent restenosis, and inferences with MRI imaging or surgery that are associated with permanent stents. Take Home Pearl: Treatment of PAD with BVS appears to be effective in opening blocked arteries, while avoiding some of the side effects associated with permanent...
Assessing Quality in Acute Care Surgery

Assessing Quality in Acute Care Surgery

Emergency and trauma surgeries are increasingly being performed by the same providers, often using the same resources. It has been implied that improvements in care for one of these populations could enhance the care of the other, but few analyses have compared the quality of care provided to each type of surgery group. New Research In the Archives of Surgery, my colleagues and I had a study published that evaluated the relationship between trauma and elective general surgery (ELGS) and emergency general surgery (EMGS) care. Our hypothesis was that there would be similarities in mortality and serious morbidity outcomes because of the crossover in providers and resources used. We compared performance among 46 hospitals to determine how well these institutions performed across populations with regard to outcomes. Our findings indicated that there were no significant relationships between trauma and EMGS mortality or between trauma and ELGS mortality. We also didn’t observe any significant relationships between trauma and EMGS morbidity or between trauma and ELGS morbidity. Furthermore, no hospital had consistently good or poor outcomes across the surgical populations assessed in the analysis. Examining Implications Based on our findings, research and quality improvement efforts should focus on how to improve EMGS care. Many performance improvement measures have been devoted to trauma surgery, but few have focused on EMGS patients. The National Trauma Databank contains records on more than 2 million patients. The American College of Surgeons has established the Trauma Quality Improvement Program for benchmarking trauma centers. Similar data banks and benchmarking efforts that focus on quality of care provided to EMGS patients are in the early stages of development...

ISET 2014: Novel Technology Promising in PE

The Particulars: The EkoSonic Endovascular System is a device that uses ultrasound to accelerate the action of anticoagulants. Studies have yet to compare the technology to standard intravenous anticoagulation in the treatment of patients with submassive pulmonary embolism (PE). Data Breakdown: Swiss research found that patients with PE who were treated with the EkoSonic Endovascular System and recombinant tissue plasminogen activator experienced a statistically significant reduction in right heart strain within 24 hours, when compared with heparin alone. The average right ventricle/left ventricle ratio for those in the EkoSonic group decreased from 1.28 at baseline to 0.99 at 24 hours, with no adverse outcomes observed. Take Home Pearl: The EkoSonic Endovascular System appears to be clinically superior to anticoagulation with heparin alone in reversing right ventricular dilation at 24 hours in patients with PE, without any apparent adverse...

ISET 2014: Nitinol Stents Maintain QOL in PAD

The Particulars: Research indicates that approximately one-third of patients with untreated peripheral arterial disease (PAD)-induced intermittent claudication develop critical limb ischemia. Stent therapy has been the mainstay of treatment for patients with PAD, but little is known about the long-term outcomes of stent therapy in this population. Data Breakdown: For a study, self-expanding nitinol stents were placed in superficial femoral artery blockages in 250 patients with PAD. At 3 years follow-up, 72.7% of arteries remained open in 209 patients. Of the 3.6% of stents that fractured, all were in the least severe blockages and therefore continued to keep the arteries open. Blood pressure in the legs, symptoms, and walking speed and distanced remained improved at 3 years. Take Home Pearls: Stent therapy for patients with PAD appears to maintain artery openings in nearly three-quarters of patients at 3 years follow-up. Improved quality of life also appears to be...
STS 2014

STS 2014

New research is being presented at STS 2014, the 50th Annual Meeting of the Society of Thoracic Surgeons, from January 25 to 29 in Orlando.   STS leaders describe some of the must-attend weekend sessions, including STS/AATS Tech-Con 2014, the Practice Management Summit, and the Parallel Surgical Symposia. The Daily Show Get More: Daily Show Full Episodes,The Daily Show on Facebook Learn more about the STS 50th Annual Meeting Thomas B. Ferguson Lecturer, Bassem Youssef, a CT Surgeon/TV host in this short video. Watch here as STS surgeon leaders share why you should attend the STS 50th Annual Meeting Jan. 25-29, 2014 in Orlando. Meeting Highlights Long-Term Survival After Pediatric Heart Transplants TAVR Availability Improves Outcomes Preventing SSIs in CABG   News From the Meeting Practice Management Summit to Address Changes in CT Surgical Practice STS Recognizes Douglas J. Mathisen for Significant Contributions, Leadership David Fullerton Named President of The Society of Thoracic Surgeons G. Alexander Patterson Earns Bakken Scientific Achievement Award   More From the Meeting Registration Program-at-a-Glance Abstract Book Late-Breaking Abstracts Pricing Chart STS University Lectures Information for International...
Top 5 Cardiology Features of 2013

Top 5 Cardiology Features of 2013

The top features from 2013 cover guidelines for ischemic heart disease and unstable angina/non-ST segment elevation myocardial infarction, atrial fibrillation management, and more! 5)      Guidelines for Managing Stable Ischemic Heart Disease 4)      Blood Pressure & End-Stage Renal Disease in Patients With CKD 3)      Key Concepts in Managing Afib 2)      UA/NSTEMI: A Guideline Update 1)      A Closer Look at Statin...
Unhealthy Heart Behaviors: Getting Ahead of the Curve

Unhealthy Heart Behaviors: Getting Ahead of the Curve

The American Heart Association (AHA) has set a 2020 goal of improving the heart health of all Americans by 20% while reducing deaths from cardiovascular disease (CVD) and stroke by 20%. The AHA’s 2020 goals were designed strategically to help all individuals prevent declines in their current health behaviors and take a step toward better heart health by progressing toward ideal healthy lifestyle behaviors. “To achieve these goals, prevention is the top priority,” says Bonnie Spring, PhD. “Major strides have been made toward reducing risks for CVD and stroke, but the significant economic toll linked to these health challenges necessitates a new approach.” According to recent estimates, direct annual CVD-related costs are projected to triple, rising from $272 billion in 2010 to $818 billion in 2030. A Call to Action In 2013, the AHA released a science advisory, published in Circulation, emphasizing the importance of greater efforts to preserve cardiovascular health from childhood and to treat health risk behaviors into older ages. The call-to-action statement addresses three novel approaches to attain the AHA’s 2020 goals: 1. Preserving positive cardiovascular health by promoting healthy lifestyle behaviors. 2. Treating unhealthful behaviors in addition to risk biomarkers. 3. Combining individual-level and population-based health promotion strategies that steer the public toward the next level of improved cardiovascular health. “Clinicians need to treat unhealthy behaviors as aggressively as they treat high blood pressure (BP), cholesterol, and other CVD risk factors,” says Dr. Spring, who was lead author of the AHA statement. “It’s a paradigm shift from only treating biomarkers to also helping people change unhealthy behaviors.” Clinicians already treat physical risk factors, but people...
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