Abstract 5: Management Of Intravenous tPA In Non-ICU Environments: Safety, Clinical Outcome, And Cost Savings

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Kisha C Coleman ◽  
Paola Palazzo ◽  
Reza B Shahripour ◽  
Amy L Brooks ◽  
Mary A Cronin ◽  
...  
Keyword(s):  
Critical Care ◽  
Stroke Unit ◽  
Cost Savings ◽  
Pressure Control ◽  
Cardiac Monitoring ◽  
Arterial Line ◽  
Systemic Hemodynamic ◽  
Stroke Units ◽  
Critical Care Admission ◽  
Iv Tpa

Background: Administration of IV tPA has traditionally necessitated admission to an ICU solely for monitoring, with relatively no need for extensive critical care services. Stroke Units that are capable of monitoring IV tPA patients have been proposed to reduce ICU use, but limited data exist that demonstrate safety. We report the largest series of non-ICU managed tPA cases in relation to safety and discharge outcomes. Methods: Consecutive cases admitted to our intermediate-level Stroke Unit spanning 2009-2011 were assembled. Unit capabilities include IV tPA management with nicardipine infusion for blood pressure control as needed, non-invasive or direct central/arterial line and cardiac monitoring, and BiPAP ventilation. Stroke Unit nurses underwent extensive orientation and participate in NET SMART Junior for continuing education. Overall sICH, and drip/ship sICH (parenchymal hemorrhage in combination with > 4 point increase on the NIHSS), systemic hemorrhage, and tPA related death rates were calculated, along with discharge mRS and total ICU cost savings per day. Results: A total of 302 Stroke Unit admissions for intravenous tPA occurred over the 3 year period, while another 31 (10%) were excluded due to critical care admission for systemic hemodynamic or pulmonary instability. Nicardipine infusions were used in 9 (10.5%) Stroke Unit tPA cases in 2009, 10 (9%) in 2010, and 14 (13%) in 2011. Overall sICH rate was 3.3% (n=10) and systemic hemorrhage rate was 2.9% (n=9) with 5 of these (56%) requiring transfusion. Estimated cost savings in total for this 3 year period was $362,400 for “avoided” ICU days. Conclusions: Intravenous tPA patients may be safely managed on non-ICU Stroke Units when nurses undergo extensive education to ensure clinical competence. Use of the ICU solely for management of tPA monitoring needs may constitute significant overuse of system resources at an expense that is not associated with additional safety benefit.

Abstract TP397: Dedicated Stroke Units With Bedside Monitoring and Better Blood Pressure Control

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Audrey Arango ◽  
Daniel Korya ◽  
Florence Chukwuneke ◽  
Yong-Bum Song ◽  
Jaskiran Brar ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Blood Pressure Control ◽  
Stroke Unit ◽  
Vital Signs ◽  
Pressure Control ◽  
Hemorrhagic Transformation ◽  
Hematoma Expansion ◽  
Stroke Units ◽  
Bedside Monitoring ◽  
The Mean

Background and Objective: Patients with ischemic or hemorrhagic stroke require strict BP control to prevent hemorrhagic transformation or hematoma expansion. Acute elevations in BP are often treated with IV labetalol. Dedicated stroke units often have automated bedside monitoring of vital signs. Standard automated BP monitoring alerts practitioners to trends that lead to more steady control of BP rather than frequent acute interventions. We evaluated patients who were treated in a stroke unit after the institution of automated bedside monitoring. Comparison was made to the number of times the patients were dosed acutely using labetalol with a control group of patients who were not receiving automated bedside monitoring. The objective was to determine if there was a significant difference in care. Methods: Patients were evaluated over a 12-month period (2014) after the incorporation of bedside automated BP monitoring in a dedicated stroke unit at a university affiliated, comprehensive stroke center. The number of times each patient during this time frame received IV labetalol for acute elevations in BP was compared with a time period spanning 12-months prior (2013); there was no automated BP monitoring performed. The average interventions were compared with a t-test by using SPSS V22. Comparisons of patient population and type of pathology were matched appropriately. Results: Of the 1,326 patients who presented for ischemic or hemorrhagic strokes during the 24-month period evaluated, 25 required multiple injections of IV labetalol for acute BP control. Of these, 12 patients were on automated vital signs and BP monitoring, and 13 were not. The mean number of IV labetalol interventions implemented in the group being monitored was 2.8, while the mean number of treatments given to patients not being monitored was 5.9 (p=.016). Conclusion: In our study there is a trend towards better blood pressure control with adequate adjustment of oral medications for monitored patients in our dedicated stroke unit. Prevention of sudden elevations in BP may translate into lower rates of hemorrhagic transformation or hematoma expansion and confer better outcomes in stroke patients. Larger prospective studies are required to corroborate our findings.

scholarly journals The Impact of Changing to an Algorithm-Based Clostridioides difficile Test on the Decision to Treat Clostridioides difficile

2020 ◽  
Vol 41 (S1) ◽  
pp. s407-s407
Author(s):  
Lana Dbeibo ◽  
Joy Williams ◽  
Josh Sadowski ◽  
William Fadel ◽  
Vera Winn ◽  
...  
Keyword(s):  
Critical Care ◽  
Toxic Megacolon ◽  
Adverse Outcomes ◽  
Clinical Criteria ◽  
Testing Method ◽  
Clostridioides Difficile ◽  
Critical Care Admission ◽  
The Impact ◽  
Test Result ◽  
Pcr Test

Background: Polymerase chain reaction (PCR) testing for the diagnosis of Clostridioides difficile infection (CDI) detects the presence of the organism; a positive result therefore cannot differentiate between colonization and the pathogenic presence of the bacterium. This may result in overdiagnosis, overtreatment, and risking disruption of microbial flora, which may perpetuate the CDI cycle. Algorithm-based testing offers an advantage over PCR testing as it detects toxin, which allows differentiation between colonization and infection. Although previous studies have demonstrated the clinical utility of this testing algorithm in differentiating infection from colonization, it is unknown whether the test changes CDI treatment decisions. Our facility switched from PCR to an algorithm-based testing method for CDI in June 2018. Objective: In this study, we evaluated whether clinicians’ decisions to treat patients are impacted by a test result that implies colonization (GDH+/Tox−/PCR+ test), and we examined the impact of this decision on patient outcomes. Methods: This is a retrospective cohort study of inpatients with a positive C. diff test between June 2017 and June 2019. The primary outcome was the proportion of patients treated for CDI. We compared this outcome in 3 groups of patients: those with a positive PCR test (June 2017–June 2018), those who had a GDH+/Tox−/PCR+ or a GDH+/Tox+ test result (June 2018–June 2019). Secondary outcomes included toxic megacolon, critical care admission, and mortality in patients with GDH+/Tox−/PCR+ who were treated versus those who were untreated. Results: Of patients with a positive PCR test, 86% were treated with CDI-specific antibiotics, whereas 70.4% with GDH+/Tox+ and 29.25% with GDH+/Tox−/PCR+ result were treated (P < .0001). Mortality was not different between patients with GDH+/Tox−/PCR+ who were treated versus those who were untreated (2.7% vs 3.4%; P = .12), neither was critical care admission within 2 or 7 days of test result (2% vs 1.4%; P = .15) and (4.1% vs 5.4%, P = .39), respectively. There were no cases of toxic megacolon during the study period. Conclusions: The change to an algorithm-based C. difficile testing method had a significant impact on the clinicians’ decisions to treat patients with a positive test, as most patients with a GDH+/Tox−/PCR+ result did not receive treatment. These patients did not suffer more adverse outcomes compared to those who were treated, which has implications for testing practices. It remains to be explored whether clinicians are using clinical criteria to decide whether or not to treat patients with a positive algorithm-based test, as opposed to the more reflexive treatment of patients with a positive PCR test.Funding: NoneDisclosures: None

Abstract WP72: Early Experience on Intravenous Tissue Plasminogen Activator Delivery in Mobile Stroke Unit Patients with Stroke Mimics

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Lila E Sheikhi ◽  
Stacey Winners ◽  
Pravin George ◽  
Andrew Russman ◽  
Zeshaun Khawaja ◽  
...  
Keyword(s):  
Plasminogen Activator ◽  
Tissue Plasminogen Activator ◽  
Stroke Unit ◽  
Early Experience ◽  
Final Diagnosis ◽  
Stroke Mimics ◽  
Intravenous Tissue Plasminogen Activator ◽  
Mobile Stroke Unit ◽  
Tissue Plasminogen ◽  
Iv Tpa

Background: A mobile stroke unit (MSU) allows for early delivery for intravenous tissue plasminogen activator (IV-tPA). A proportion of IV-tPA treated patients may turn out to be stroke mimics. We evaluated the rate and complications seen in stroke mimics treated with tPA from our early experience on MSU. Methods: Retrospective review of patients treated with IV-tPA on the MSU from 2014 to 2016. Charts were reviewed for confirmed strokes by imaging (MRI or CT) and hemorrhagic transformation. Stroke mimics were defined as those without imaging evidence of infarction and a final diagnosis which was not suspected to be stroke. Results: Among 62 patients treated with IV-tPA, 14 (28.6%) had a final diagnosis consistent with a stroke mimics. The majority of these occurred in the first year of the MSU program. Most common mimics included conversion disorder (n=5) and seizures (n=5). While the last known well to IV-tPA times were similar, the MSU door-to-needle time was significantly longer in stroke mimics (38 vs 31 minutes, p = 0.03). No intracerebral hemorrhages or other IV-tPA related complications were identified in the stroke mimics group. Conclusions: In our early experience with MSU, treatment of stroke mimics occurred without IV-tPA related complications. This does not appear to be due to rushed decision making.

Abstract P497: Re-analysis of the Systolic Blood Pressure Intervention Trial (SPRINT): The Renal Consequences of Intensive versus Standard Blood Pressure Lowering

Hypertension ◽  
2017 ◽  
Vol 70 (suppl_1) ◽  
Author(s):  
Leora Branfield Day ◽  
David M Naimark
Keyword(s):  
Blood Pressure ◽  
Lifetime Cost ◽  
Intensive Therapy ◽  
Cost Savings ◽  
Cost Effective ◽  
Pressure Control ◽  
Average Lifetime ◽  
Ckd Progression ◽  
Lifetime Horizon ◽  
Increased Risk

Background: BP management guidelines suggest that persons with CKD should be treated to a SBP ≤ 140 mmHg. SPRINT compared this target to intensive SBP lowering (≤ 120 mmHg) in persons with and without CKD and found a reduced rate of CV events and all-cause mortality (ACM). However intensive therapy was associated with an increased risk of AKI. We extrapolated the results of SPRINT over a lifetime horizon to determine whether in the long-term, the benefit in terms of the primary outcome would be less economically attractive when the risks of more frequent AKI and subsequent CKD progression were considered. Methods: We re-configured the CKD Simulator, a Markov model of CKD progression, AKI events, fatal and non-fatal CV events, and ESRD. We recalibrated the model to be representative of the SPRINT cohort and compared intensive vs. standard blood pressure control among 10 million simulated persons with and without CKD over their lifetimes. Marginal treatment costs were calculated and hazard ratios for AKI, CV events and ACM observed in SPRINT were applied to the monthly probabilities of these events in the intensive SBP arm. Results: Lifetime average, discounted, costs per person associated with intensive vs. standard SBP lowering were predicted to be $35,811 and $30,584, respectively. Quality-adjusted, discounted average lifespans were 196.05 and 190.47 months, respectively. The cost of each quality-adjusted life-year gained by adopting intensive over standard BP lowering would be $11,220, significantly below the accepted cost-effectiveness threshold of $50,000. Intensive SBP control would reduce the lifetime incidence of at least one CV event by 5.5%, but increase the incidence of at least one AKI episode and ESRD by 1.7% and 0.7%, respectively. These differences were associated with average lifetime cost savings per person of $459 for CV events, but losses of $161 and $2,889 for AKI and ESRD. Discussion: Intensive SBP management would be cost-effective and associated with a significant lifetime reduction in CV events. However, there would be an increase in the lifetime risk of AKI and ESRD, contributing to 58% of the total increase in cost of intensive relative to usual SBP control. Intensive SBP lowering should be adopted judiciously in persons at high risk of ESRD.

Celebrating the 100th Birthday of the Electrocardiogram: Lessons Learned From Research in Cardiac Monitoring

2002 ◽  
Vol 11 (4) ◽  
pp. 378-386 ◽  
Author(s):  
Barbara J. Drew
Keyword(s):  
Critical Care ◽  
Myocardial Ischemia ◽  
Current Trend ◽  
Torsade De Pointes ◽  
Acute Myocardial Ischemia ◽  
Lessons Learned ◽  
Cardiac Monitoring ◽  
Acute Ischemia ◽  
Antiarrhythmic Agents ◽  
St Segment

The electrocardiogram continues to be the gold standard for the diagnosis of cardiac arrhythmias and acute myocardial ischemia. The treatment of arrhythmias in critical care units has become less aggressive during the past decade because research indicates that antiarrhythmic agents can be proarrhythmic, causing malignant ventricular arrhythmias such as torsade de pointes. However, during the same period, the treatment of acute myocardial ischemia has become more aggressive, with the goal of preventing or interrupting myocardial infarction by using new antithrombotic and antiplatelet agents and percutaneous coronary interventions. For this reason, critical care nurses should learn how to use ST-segment monitoring to detect acute ischemia, which is often asymptomatic, in patients with acute coronary syndromes. Because the electrocardiographic lead must be facing the localized ischemic zone of the heart to depict the telltale signs of ST-segment deviation, the challenge is to find ways to monitor patients continuously for ischemia without using an excessive number of electrodes and lead wires. The current trend is to use reduced lead set configurations in which 5 or 6 electrodes, placed at convenient places on the chest, are used to construct a full 12-lead electrocardiogram. Nurse scientists at the University of California, San Francisco, School of Nursing are at the forefront in developing and assessing the diagnostic accuracy of these reduced lead set electrocardiograms.

The effect of two concentrations of heparin on arterial catheter patency

1990 ◽  
Vol 10 (5) ◽  
pp. 47-57 ◽  
Author(s):  
CS Bolgiano ◽  
PT Subramaniam ◽  
JM Montanari ◽  
L Minick
Keyword(s):  
Intensive Care Unit ◽  
Critical Care ◽  
Intensive Care ◽  
Hemodynamic Monitoring ◽  
Arterial Catheter ◽  
Arterial Line ◽  
Routine Procedure ◽  
Icu Patients ◽  
Catheter Patency

The use of invasive lines with heparinized fluid for hemodynamic monitoring is a routine procedure in critical care areas. The main objective of this study was to compare the duration of patency of indwelling arterial catheter lines and patient coagulation values when the recommended dilution of 1.0 U heparin/mL was used versus the use of only 0.25 U heparin/mL. One hundred four intensive care unit (ICU) patients were studied. There were no significant differences between the two groups in patency or coagulation values. The results of the study demonstrated that 0.25 U heparin/mL was sufficient to maintain arterial line patency for patients with lines in place for up to 3 days.

Variability in Critical Care–Related Charge Markups in Medicare Patients

2018 ◽  
Vol 84 (10) ◽  
pp. 1622-1625 ◽  
Author(s):  
Joshua Tseng ◽  
Harry C. Sax ◽  
Rodrigo F. Alban
Keyword(s):  
Internal Medicine ◽  
Critical Care ◽  
Endotracheal Intubation ◽  
Chest Tube ◽  
Critical Care Medicine ◽  
Tube Placement ◽  
Arterial Line ◽  
Fee For Service ◽  
Related Services ◽  
Line Placement

Charge markups for health care are variable and inflated several times beyond cost. Using the 2015 Medicare Provider Fee-For-Service Utilization and Payment Data file, we identified providers who billed for critical care hours and related procedures, including CPR, EKG interpretation, central line placement, arterial line placement, chest tube/thoracentesis, and emergent endotracheal intubation. Markup ratios (MRs), defined as the amount charged divided by the amount allowable, were calculated and compared; 42.1 per cent of physicians billing for critical care–related services were specialized in emergency medicine (EM). EM had the highest overall MR (median 4.99, IQR 3.60–6.88) and provided most of the services. MRs differed between genders in select cases (critical care hours: anesthesiology, EM, internal medicine, pulmonary and critical care medicine; CPR, pulmonary and critical care medicine; chest tube placement/thoracentesis, internal medicine). These differences in MR did not correspond to higher rates of Medicare allowable amounts ( P = NS). In conclusion, charge markups significantly varied by physician specialty. EM physicians had the highest MRs for most critical care–related services, including critical care hours, EKG interpretation, CPR, central venous line placement, and emergent endotracheal intubation. EM physicians also provided most of these services. Charge markups are associated with adverse consequences and represent potential targets for cost containment and consumer protection.

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