Expectations of Continuous Vital Signs Monitoring for Recognizing Complications After Esophagectomy: Interview Study Among Nurses and Surgeons

Background Patients undergoing esophagectomy are at serious risk of developing postoperative complications. To support early recognition of clinical deterioration, wireless sensor technologies that enable continuous vital signs monitoring in a ward setting are emerging. Objective This study explored nurses’ and surgeons’ expectations of the potential effectiveness and impact of continuous wireless vital signs monitoring in patients admitted to the ward after esophagectomy. Methods Semistructured interviews were conducted at 3 esophageal cancer centers in the Netherlands. In each center, 2 nurses and 2 surgeons were interviewed regarding their expectations of continuous vital signs monitoring for early recognition of complications after esophagectomy. Historical data of patient characteristics and clinical outcomes were collected in each center and presented to the local participants to support estimations on clinical outcome. Results The majority of nurses and surgeons expected that continuous vital signs monitoring could contribute to the earlier recognition of deterioration and result in earlier treatment for postoperative complications, although the effective time gain would depend on patient and situational factors. Their expectations regarding the impact of potential earlier diagnosis on clinical outcomes varied. Nevertheless, most caregivers would consider implementing continuous monitoring in the surgical ward to support patient monitoring after esophagectomy. Conclusions Caregivers expected that wireless vital signs monitoring would provide opportunities for early detection of postoperative complications in patients undergoing esophagectomy admitted to the ward and prevent sequelae under certain circumstances. As the technology matures, clinical outcome studies will be necessary to objectify these expectations and further investigate overall effects on patient outcome.

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Expectations of Continuous Vital Signs Monitoring for Recognizing Complications After Esophagectomy: Interview Study Among Nurses and Surgeons (Preprint)

10.2196/preprints.22387 ◽

2020 ◽

Author(s):

Mathilde van Rossum ◽

Jobbe Leenen ◽

Feike Kingma ◽

Martine Breteler ◽

Richard van Hillegersberg ◽

...

Keyword(s):

Postoperative Complications ◽

Clinical Outcome ◽

Clinical Outcomes ◽

Early Recognition ◽

Vital Signs ◽

Patient Characteristics ◽

Situational Factors ◽

Vital Signs Monitoring ◽

Surgical Ward ◽

The Impact

BACKGROUND Patients undergoing esophagectomy are at serious risk of developing postoperative complications. To support early recognition of clinical deterioration, wireless sensor technologies that enable continuous vital signs monitoring in a ward setting are emerging. OBJECTIVE This study explored nurses’ and surgeons’ expectations of the potential effectiveness and impact of continuous wireless vital signs monitoring in patients admitted to the ward after esophagectomy. METHODS Semistructured interviews were conducted at 3 esophageal cancer centers in the Netherlands. In each center, 2 nurses and 2 surgeons were interviewed regarding their expectations of continuous vital signs monitoring for early recognition of complications after esophagectomy. Historical data of patient characteristics and clinical outcomes were collected in each center and presented to the local participants to support estimations on clinical outcome. RESULTS The majority of nurses and surgeons expected that continuous vital signs monitoring could contribute to the earlier recognition of deterioration and result in earlier treatment for postoperative complications, although the effective time gain would depend on patient and situational factors. Their expectations regarding the impact of potential earlier diagnosis on clinical outcomes varied. Nevertheless, most caregivers would consider implementing continuous monitoring in the surgical ward to support patient monitoring after esophagectomy. CONCLUSIONS Caregivers expected that wireless vital signs monitoring would provide opportunities for early detection of postoperative complications in patients undergoing esophagectomy admitted to the ward and prevent sequelae under certain circumstances. As the technology matures, clinical outcome studies will be necessary to objectify these expectations and further investigate overall effects on patient outcome.

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Adaptive threshold-based alarm strategies for continuous vital signs monitoring

Journal of Clinical Monitoring and Computing ◽

10.1007/s10877-021-00666-4 ◽

2021 ◽

Author(s):

Mathilde C. van Rossum ◽

Lyan B. Vlaskamp ◽

Linda M. Posthuma ◽

Maarten J. Visscher ◽

Martine J. M. Breteler ◽

...

Keyword(s):

Early Detection ◽

Adverse Events ◽

Vital Sign ◽

Vital Signs ◽

Adaptive Threshold ◽

Situational Factors ◽

Alarm Fatigue ◽

Vital Signs Monitoring ◽

Surgical Ward ◽

Increased Sensitivity

AbstractContinuous vital signs monitoring in post-surgical ward patients may support early detection of clinical deterioration, but novel alarm approaches are required to ensure timely notification of abnormalities and prevent alarm-fatigue. The current study explored the performance of classical and various adaptive threshold-based alarm strategies to warn for vital sign abnormalities observed during development of an adverse event. A classical threshold-based alarm strategy used for continuous vital signs monitoring in surgical ward patients was evaluated retrospectively. Next, (combinations of) six methods to adapt alarm thresholds to personal or situational factors were simulated in the same dataset. Alarm performance was assessed using the overall alarm rate and sensitivity to detect adverse events. Using a wireless patch-based monitoring system, 3999 h of vital signs data was obtained in 39 patients. The clinically used classical alarm system produced 0.49 alarms/patient/day, and alarms were generated for 11 out of 18 observed adverse events. Each of the tested adaptive strategies either increased sensitivity to detect adverse events or reduced overall alarm rate. Combining specific strategies improved overall performance most and resulted in earlier presentation of alarms in case of adverse events. Strategies that adapt vital sign alarm thresholds to personal or situational factors may improve early detection of adverse events or reduce alarm rates as compared to classical alarm strategies. Accordingly, further investigation of the potential of adaptive alarms for continuous vital signs monitoring in ward patients is warranted.

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Data-driven approach to Early Warning Score-based alert management

BMJ Open Quality ◽

10.1136/bmjoq-2017-000088 ◽

2018 ◽

Vol 7 (3) ◽

pp. e000088 ◽

Cited By ~ 5

Author(s):

Muge Capan ◽

Stephen Hoover ◽

Kristen E Miller ◽

Carmen Pal ◽

Justin M Glasgow ◽

...

Keyword(s):

Patient Safety ◽

Early Warning ◽

Early Recognition ◽

Clinical Information ◽

Patient Characteristics ◽

The Elderly ◽

Early Warning Score ◽

The Right ◽

The Impact ◽

Alerting Systems

BackgroundIncreasing adoption of electronic health records (EHRs) with integrated alerting systems is a key initiative for improving patient safety. Considering the variety of dynamically changing clinical information, it remains a challenge to design EHR-driven alerting systems that notify the right providers for the right patient at the right time while managing alert burden. The objective of this study is to proactively develop and evaluate a systematic alert-generating approach as part of the implementation of an Early Warning Score (EWS) at the study hospitals.MethodsWe quantified the impact of an EWS-based clinical alert system on quantity and frequency of alerts using three different alert algorithms consisting of a set of criteria for triggering and muting alerts when certain criteria are satisfied. We used retrospectively collected EHRs data from December 2015 to July 2016 in three units at the study hospitals including general medical, acute care for the elderly and patients with heart failure.ResultsWe compared the alert-generating algorithms by opportunity of early recognition of clinical deterioration while proactively estimating alert burden at a unit and patient level. Results highlighted the dependency of the number and frequency of alerts generated on the care location severity and patient characteristics.ConclusionEWS-based alert algorithms have the potential to facilitate appropriate alert management prior to integration into clinical practice. By comparing different algorithms with regard to the alert frequency and potential early detection of physiological deterioration as key patient safety opportunities, findings from this study highlight the need for alert systems tailored to patient and care location needs, and inform alternative EWS-based alert deployment strategies to enhance patient safety.

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P5472Social economic deprivation and adverse clinical outcomes after acute coronary syndrome

European Heart Journal ◽

10.1093/eurheartj/ehz746.0426 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

Y C Lau ◽

J Latter ◽

A Jong ◽

R Weir

Keyword(s):

Clinical Outcome ◽

Secondary Prevention ◽

Clinical Outcomes ◽

Statistical Difference ◽

Independent Predictor ◽

Composite Endpoint ◽

Socioeconomic Deprivation ◽

Angiotensin Ii Receptor Blocker ◽

The Impact

Abstract Background NHS was created in 1948 to redress the healthcare inequality through provision of universal healthcare service in the UK. However even of late, significant health inequality persists. Socioeconomic deprivation is known to result in increased overall morbidity and mortality. Aim To assess the impact of socioeconomic deprivation (as categorised by Scottish Index of Multiple Deprivation, SIMD) on the medical management and clinical outcomes of patients with ACS (NSTEMI/STEMI) who were treated with PCI Methods A retrospective study of NSTEMI/NSTEMI patients after inpatient treatment with coronary angiogram and PCI. The parameters include basic demographics, risk factors, LV EF on echocardiogram, lipid profile and discharge medication. Individual's socioeconomic deprivation index, as described SIMD was also recorded (1 – most deprived and 10 – least deprived), and accordingly placed into quintile (SIMD 1–2, 3–4, 5–6,7 –8, 9–10). Follow-up for 24 months. Clinical outcome assessed was composite endpoint event of MACE. Results 357 from the lowest quintile (SIMD 1–2), 319 from SIMD 3–4, 191 from SIMD 5–6, 120 from SIMD 7–8, and 99 from the highest quintile (SIMD 9–10) were included. No statistical difference exists between age or gender. No difference in past medical history (inclusive of hypertension, diabetes, dyslipidemia, family history. No difference in incidence of nicotine use. Prescription of aspirin, P2Y12 inhibitors (clopidogrel, ticagrelor or prasugrel) as well as secondary prevention medications (such as ace inhibitor/angiotensin II receptor blocker, beta blocker, statin and GTN) were good and not statistically different between all groups. No statistical difference exists between all groups relating to pre-discharge LV ejection fraction on echocardiogram or random cholesterol level check on admission. 24 months follow-up demonstrated composite endpoint of MACE was statistically higher among patients of lowest socioeconomic quintile (Kaplan Meier plot, p<0.001). Step-wise multiple regression analysis also confirmed multiple socioeconomic deprivation as an independent predictor for more adverse clinical outcomes (p<0.001, R2=14.5%). Patients from the least deprived quintile possess survival advantage almost 14-folds as compared to those of most deprived group (Odd-ratio 13.8 (95% CI: 39.4–48.5)). Summary After an ACS event, despite initial coronary intervention and subsequent optimal prescription of prognostically beneficial secondary prevention medications, patients from the lower socioeconomic group (as described by SIMD) are still more likely to experience readmission for cardiovascular death, non-fatal myocardial infarction and non-fatal stroke. Socioeconomic deprivation has been shown to be an independent predictor of adverse clinical outcome for those who survived initial ACS. Acknowledgement/Funding None

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Mechanical Thrombectomy for Middle Cerebral Artery Division Occlusions: A Systematic Review and Meta-Analysis

Interventional Neurology ◽

10.1159/000477589 ◽

2017 ◽

Vol 6 (3-4) ◽

pp. 242-253 ◽

Cited By ~ 4

Author(s):

Hisham Salahuddin ◽

Aixa Espinosa ◽

Mark Buehler ◽

Sadik A. Khuder ◽

Abdur R. Khan ◽

...

Keyword(s):

Systematic Review ◽

Clinical Outcome ◽

Middle Cerebral Artery ◽

Clinical Outcomes ◽

Cerebral Artery ◽

Mechanical Thrombectomy ◽

Meta Analysis ◽

Total N ◽

Clinical Databases ◽

The Impact

Background: Middle cerebral artery division (M2) occlusion was significantly underrepresented in recent mechanical thrombectomy (MT) randomized controlled trials, and the approach to this disease remains heterogeneous. Objective: To conduct a systematic review and meta-analysis of outcomes at 90 days among patients undergoing MT for M2 middle cerebral artery (MCA) occlusions. Methods: Five clinical databases were searched from inception through September 2016. Observational studies reporting 90-day modified Rankin Scale scores for patients undergoing MT for M2 MCA occlusions with an M1 MCA control group were selected. The primary outcome of interest was good clinical outcome 90 days after MT of an M1 or M2 MCA occlusion. Secondary outcomes of interest included mortality and excellent clinical outcome, recanalization rates, significant intracerebral hemorrhage, and procedural complications. Results: A total of 323 publications were identified, and 237 potentially relevant articles were screened. Six studies were included in the analysis (M1 = 1,203, M2 = 258; total n = 1,461). We found no significant differences in good clinical outcomes (1.10 [95% CI, 0.83-1.44]), excellent clinical outcomes (1.07 [0.65-1.79]), mortality at 3 months (0.85 [0.58-1.24]), recanalization rates (1.06 [0.32-3.48]), and significant intracranial hemorrhage (1.19 [0.61-2.30]). Conclusions: MT of M2 MCA occlusions is as safe as that of main trunk MCA occlusions, and comparable in terms of clinical outcomes and hemorrhagic complications. Randomized clinical trials are needed to assess the impact of MT in patients with M2 occlusions, given that M1 MCA occlusions have different natural histories than M2 occlusions.

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Evaluation of a Pediatric Enoxaparin Dosing Protocol and the Impact on Clinical Outcomes

The Journal of Pediatric Pharmacology and Therapeutics ◽

10.5863/1551-6776-25.8.689 ◽

2020 ◽

Vol 25 (8) ◽

pp. 689-696

Author(s):

Kayla Wiltrout ◽

Jennifer Lissick ◽

Mike Raschka ◽

Amanda Nickel ◽

Dave Watson

Keyword(s):

Clinical Outcomes ◽

Pediatric Population ◽

Factor Xa ◽

Patient Characteristics ◽

Dose Finding ◽

Laboratory Evaluation ◽

Successful Resolution ◽

Secondary Objective ◽

The Impact ◽

Dosing Nomogram

OBJECTIVES Enoxaparin has been studied for prophylaxis and treatment of thromboembolism in the pediatric population. Dose-finding studies have suggested higher mean maintenance dose requirements in younger children; however, the current recommended dosing schema endorsed by the American College of Chest Physicians remains conservative, likely secondary to limited data on the safety and efficacy of escalated starting doses. Primary objectives of this study included the identification of patient characteristics and risk factors with associations to anti–factor Xa (anti-Xa) values. The secondary objective was to determine an association between the initial anti-Xa value and thrombus resolution. Safety outcomes related to bleeding were also assessed. METHODS This retrospective cohort study reviewed records of all pediatric patients ≤18 years of age who were initiated on therapeutic subcutaneous enoxaparin between October 1, 2008, and October 1, 2018, at Children's Hospitals and Clinics of Minnesota for an indication of incident thrombus (N = 283). RESULTS Successful resolution of thrombus was directly associated with attaining a therapeutic anti-Xa concentration upon first laboratory evaluation. Other characteristics with associations to initial anti-Xa values included age, body mass index, and certain diagnoses. The rate of composite bleeding was consistent across concentrations of anti-Xa (p = 0.4944). CONCLUSIONS Despite adherence to protocol, the current enoxaparin dosing nomogram is only successful at achieving a therapeutic anti-Xa concentration (0.5–1.0 unit/mL) 55.8% of the time. A more aggressive enoxaparin dosing nomogram is warranted, as delaying time to therapeutic anti-Xa values impacts clinical outcomes, specifically thrombus resolution. Further investigation into characteristics with association to anti-Xa concentrations is needed.

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Laparoscopic Primary Colorrhaphy for Acute Iatrogenic Perforations during Colonoscopy

Minimally Invasive Surgery ◽

10.1155/2013/823506 ◽

2013 ◽

Vol 2013 ◽

pp. 1-5 ◽

Cited By ~ 2

Author(s):

Eric M. Haas ◽

Rodrigo Pedraza ◽

Madhu Ragupathi ◽

Ali Mahmood ◽

T. Bartley Pickron

Keyword(s):

Postoperative Complications ◽

Thermal Injury ◽

Early Recognition ◽

Primary Repair ◽

Length Of Hospital Stay ◽

Patient Characteristics ◽

Open Procedure ◽

Direct Trauma ◽

The Mean ◽

Surgical Modality

Purpose. We present our experience with laparoscopic colorrhaphy as definitive surgical modality for the management of colonoscopic perforations.Methods. Over a 17-month period, we assessed the outcomes of consecutive patients presenting with acute colonoscopic perforations. Patient characteristics and perioperative parameters were tabulated. Postoperative outcomes were evaluated within 30 days following discharge.Results. Five female patients with a mean age of 71.4 ± 9.7 years (range: 58–83), mean BMI of 26.4 ± 3.4 kg/m2(range: 21.3–30.9), and median ASA score of 2 (range: 2-3) presented with acute colonoscopic perforations. All perforations were successfully managed through laparoscopic colorrhaphy within 24 hours of development. The perforations were secondary to direct trauma(n=3)or thermal injury(n=2)and were localized to the sigmoid(n=4)or cecum(n=1). None of the patients required surgical resection, diversion, or conversion to an open procedure. No intra- or postoperative complications were encountered. The mean length of hospital stay was 3.8 ± 0.8 days (range: 3–5). There were no readmissions or reoperations.Conclusion. Acute colonoscopic perforations can be safely managed via laparoscopic primary repair without requiring resection or diversion. Early recognition and intervention are essential for successful outcomes.

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Individual Differences in Responsiveness to Acupuncture: An Exploratory Survey of Practitioner Opinion

Medicines ◽

10.3390/medicines5030085 ◽

2018 ◽

Vol 5 (3) ◽

pp. 85 ◽

Cited By ~ 1

Author(s):

David Mayor ◽

Lara McClure ◽

J. Clayton McClure

Keyword(s):

Online Survey ◽

Survey Methods ◽

Patient Characteristics ◽

Situational Factors ◽

Free Text ◽

Practitioner Survey ◽

Specific Factors ◽

Treatment Responses ◽

The Impact ◽

Depth Response

Background: Previous research has considered the impact of personal and situational factors on treatment responses. This article documents the first phase of a four-stage project on patient characteristics that may influence responsiveness to acupuncture treatment, reporting results from an exploratory practitioner survey. Methods: Acupuncture practitioners from various medical professions were recruited through professional organisations to complete an online survey about their demographics and attitudes as well as 60 questions on specific factors that might influence treatment. They gave categorical (“Yes”, “No”, and “Don’t know”) and free-text responses. Quantitative and qualitative (thematic) analyses were then conducted. Results: There were more affirmative than negative or uncertain responses overall. Certain characteristics, including ability to relax, exercise and diet, were most often considered relevant. Younger and male practitioners were more likely to respond negatively. Limited support was found for groupings between characteristics. Qualitative data provide explanatory depth. Response fatigue was evident over the course of the survey. Conclusions: Targeting and reminders may benefit uptake when conducting survey research. Practitioner characteristics influence their appreciation of patient characteristics. Factors consistently viewed as important included ability to relax, exercise and diet. Acupuncture practitioners may benefit from additional training in certain areas. Surveys may produce more informative results if reduced in length and complexity.

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Population health impact of extended window thrombectomy in acute ischemic stroke

Interventional Neuroradiology ◽

10.1177/1591019920972209 ◽

2020 ◽

pp. 159101992097220

Author(s):

Minerva H Zhou ◽

Akash P Kansagra

Keyword(s):

Clinical Outcome ◽

Clinical Outcomes ◽

Clinical Trial Data ◽

Population Level ◽

Health Impact ◽

Stroke Severity ◽

Good Clinical Outcome ◽

Absolute Increase ◽

Stroke Center ◽

The Impact

Background Recent trials support endovascular thrombectomy (EVT) in select patients beyond the conventional 6-hour window. Objective In this work, we estimate the impact of extended window EVT on procedural volumes and population-level clinical outcomes using Monte Carlo simulation. Methods We simulated extending EVT eligibility in a system comprising an EVT-incapable primary stroke center (PSC) and EVT-capable comprehensive stroke center (CSC) using routing paradigms that initially direct patients to (1) the nearest center, (2) the CSC, or (3) either CSC or nearest center based on stroke severity. EVT eligibility and outcomes are based on HERMES, DEFUSE-3, and DAWN studies in the 0-6, 6-16, and 16-24 hour windows, respectively. Probability of good clinical outcome is determined by type and timing of treatment using clinical trial data. Results Relative increase in EVT volume in the three tested routing paradigms was 15.7-15.8%. The absolute increase in the rate of good clinical outcome 0.4% in all routing paradigms. NNT for extended window EVT was 239.9-246.4 among the entire stroke population. Conclusion Extended window EVT with DEFUSE-3 and DAWN criteria increases EVT volume and modestly improves population-level clinical outcomes.

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ECOG and BMI as preoperative risk factors for severe postoperative complications in ovarian cancer patients: results of a prospective study (RISC-GYN—trial)

Archives of Gynecology and Obstetrics ◽

10.1007/s00404-021-06116-5 ◽

2021 ◽

Author(s):

Melisa Guelhan Inci ◽

Julia Rasch ◽

Hannah Woopen ◽

Kristina Mueller ◽

Rolf Richter ◽

...

Keyword(s):

Risk Factors ◽

Ovarian Cancer ◽

Postoperative Complications ◽

Performance Status ◽

Eastern Cooperative Oncology Group ◽

Patient Characteristics ◽

Fresh Frozen Plasma ◽

Physical Status Classification ◽

Ecog Ps ◽

The Impact

Abstract Background Accompanying co-morbidities in patients with ovarian cancer are of major relevance for scheduling debulking surgery, especially in the anesthesiological consultations. Aim of this study was to evaluate the impact of co-morbidities and patient characteristics on postoperative complications. Methods Patients undergoing maximal cytoreductive surgery were prospectively enrolled from October 2015 to January 2017. Various variables were recorded, such as the Charlson comorbidity index, Eastern cooperative oncology group scale of performance status (ECOG PS) and the American society of anesthesiologists physical status classification system (ASA PS). Surgical complications were graded using the Clavien–Dindo criteria. Logistic regression models were used to analyze risk factors for severe postoperative complications. Results Of 106 enrolled patients, 19 (17.9%) developed severe postoperative complications grade ≥ IIIb according to Clavien–Dindo criteria. In the multivariable regression analysis impaired (ECOG PS) > 1 (odds ratio OR) 13.34, 95% confidence interval (CI) 1.74–102.30, p = 0.01), body mass index (BMI) > 25 kg/m2 (OR 10.48, 95% CI 2.38–46.02, p = 0.002) along with the use of intraoperative norepinephrine > 0.11 µg/kg/min (OR 4.69, 95% CI 1.13–19.46, p = 0.03) and intraoperative fresh frozen plasma (FFP) > 17 units (OR 4.11, 95% CI 1.12–15.14, p = 0.03) appeared as significant predictors of severe postoperative complications. Conclusion We demonstrated that neither the presence of a certain comorbidity nor the summation of the co-morbidities were associated with adverse outcome. Patient characteristics, such as ECOG PS > 1 and obesity (BMI > 25 kg/m2), are highly predictive factors for severe postoperative complications. The analysis of intraoperative data showed that the need for more than > 0.11 µg/kg/min of norepinephrine and transfusions of FFPs more than 17 units were strongly associated with severe postoperative complications.

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