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Investigating the Scope of Resident Patient Care Handoffs within Neurosurgery  [PDF]
Maya A. Babu, Brian V. Nahed, Robert F. Heary
PLOS ONE , 2012, DOI: 10.1371/journal.pone.0041810
Abstract: Introduction Handoffs are defined as verbal and written communications during patient care transitions. With the passage of recent ACMGE work hour rules further limiting the hours interns can spend in the hospital, many fear that more handoffs will occur, putting patient safety at risk. The issue of handoffs has not been studied in the neurosurgical literature. Methods A validated, 20-question online-survey was sent to neurosurgical residents in all 98 accredited U.S. neurosurgery programs. Survey results were analyzed using tabulations. Results 449 surveys were completed yielding a 56% response rate. 63% of neurosurgical residents surveyed had not received formal instruction in what constitutes an effective handoff; 24% believe there is high to moderate variability among their co-residents in terms of the quality of the handoff provided; 55% experience three or more interruptions during handoffs on average. 90% of neurosurgical residents surveyed say that handoff most often occurs in a quiet, private area and 56% report a high level of comfort for knowing the potential acute, critical issues affecting a patient when receiving a handoff. Conclusions There needs to be more focused education devoted to learning effective patient-care handoffs in neurosurgical training programs. Increasingly, handing off a patient adequately and safely is becoming a required skill of residency.
Year in review 2010: Critical Care - neurocritical care
Michael T Scalfani, Michael N Diringer
Critical Care , 2011, DOI: 10.1186/cc10423
Abstract: Several important contributions to the field of neurocritical care were published in Critical Care during 2010. These articles can be gathered into six key areas: diagnostic criteria, delirium and encephalopathy, predicting neurologic outcome after cardiac arrest, subarachnoid hemorrhage (SAH) and outcome from neurocritical care.Favorable outcome from bacterial meningitis requires rapid diagnosis and immediate initiation of antibiotic therapy [1], yet distinguishing between bacterial and nonbacterial meningitis can sometimes prove difficult. The use of cerebrospinal fluid (CSF) lactate, as opposed to conventional tests (such as CSF glucose, CSF/plasma glucose ratio, CSF protein concentration, and CSF leukocyte count), has been investigated in a number of studies to distinguish between bacterial and nonbacterial meningitis.Huy and coworkers performed a literature review and meta-analysis to evaluate the usefulness of CSF lactate concentration for this purpose [2]. From the 25 studies they identified, the authors concluded that CSF lactate alone had a high degree of accuracy in distinguishing between bacterial and nonbacterial meningitis and performs better than the conventional tests routinely used. CSF lactate was found to be less useful if its concentration was low, but when elevated it was helpful, especially if the diagnosis was otherwise inconclusive. This suggests that any elevation in CSF lactate concentration above normal for the assay used could be employed as a diagnostic marker despite the difference in cut-off values caused by variance in methods, instruments and hospital laboratories. While the authors conclude CSF lactate is a useful marker to distinguish between bacterial and nonbacterial meningitis, it is not meant to replace conventional tests as they are necessary to diagnose meningitis. Rather, interpretation of lactate alone is a better discriminator between bacterial and nonbacterial meningitis than conventional tests. As a result, measurements o
Anemia and red blood cell transfusion in neurocritical care
Andreas H Kramer, David A Zygun
Critical Care , 2009, DOI: 10.1186/cc7916
Abstract: The first portion of this paper is a narrative review of the physiologic implications of anemia, hemodilution, and transfusion in the setting of brain-injury and stroke. The second portion is a systematic review to identify studies assessing the association between anemia or the use of red blood cell transfusions and relevant clinical outcomes in various neurocritical care populations.There have been no randomized controlled trials that have adequately assessed optimal transfusion thresholds specifically among brain-injured patients. The importance of ischemia and the implications of anemia are not necessarily the same for all neurocritical care conditions. Nevertheless, there exists an extensive body of experimental work, as well as human observational and physiologic studies, which have advanced knowledge in this area and provide some guidance to clinicians. Lower hemoglobin concentrations are consistently associated with worse physiologic parameters and clinical outcomes; however, this relationship may not be altered by more aggressive use of red blood cell transfusions.Although hemoglobin concentrations as low as 7 g/dl are well tolerated in most critical care patients, such a severe degree of anemia could be harmful in brain-injured patients. Randomized controlled trials of different transfusion thresholds, specifically in neurocritical care settings, are required. The impact of the duration of blood storage on the neurologic implications of transfusion also requires further investigation.A key paradigm in the management of neurocritical care patients is the avoidance of 'secondary' cerebral insults [1-3]. The acutely injured brain is vulnerable to systemic derangements, such as hypotension, hypoxemia, or fever, which may further exacerbate neuronal damage [4-7]. Thus, critical care practitioners attempt to maintain a physiologic milieu that minimizes secondary injury, thereby maximizing the chance of a favorable functional and neurocognitive recovery.Anemia is
Predictors for good functional outcome after neurocritical care
Ines C Kiphuth, Peter D Schellinger, Martin K?hrmann, Jürgen Bardutzky, Hannes Lücking, Stephan Kloska, Stefan Schwab, Hagen B Huttner
Critical Care , 2010, DOI: 10.1186/cc9192
Abstract: We retrospectively investigated 796 consecutive patients admitted to a non-surgical neurologic intensive care unit over a period of two years (2006 and 2007). Demographic and clinical parameters were analyzed. Depending on the diagnosis, we grouped patients according to their diseases (cerebral ischemia, intracranial hemorrhage (ICH), subarachnoid hemorrhage (SAH), meningitis/encephalitis, epilepsy, Guillain-Barré syndrome (GBS) and myasthenia gravis (MG), neurodegenerative diseases and encephalopathy, cerebral neoplasm and intoxication). Clinical parameters, mortality and functional outcome of all treated patients were analyzed. Functional outcome (using the modified Rankin Scale, mRS) one year after discharge was assessed by a mailed questionnaire or telephone interview. Outcome was dichotomized into good (mRS ≤ 2) and poor (mRS ≥ 3). Logistic regression analyses were calculated to determine independent predictors for good functional outcome.Overall in-hospital mortality amounted to 22.5% of all patients, and a good long-term functional outcome was achieved in 28.4%. The parameters age, length of ventilation (LOV), admission diagnosis of ICH, GBS/MG, and inoperable cerebral neoplasm as well as Therapeutic Intervention Scoring System (TISS)-28 on Day 1 were independently associated with functional outcome after one year.This investigation revealed that age, LOV and TISS-28 on Day 1 were strongly predictive for the outcome. The diagnoses of hemorrhagic stroke and cerebral neoplasm leading to neurocritical care predispose for functional dependence or death, whereas patients with GBS and MG are more likely to recover after neurocritical care.Within the last decades, specialized neurocritical intensive care units (NICU) have evolved from bigger, multi-disciplinary ICUs [1]. This specialization has led to a decrease in both in-hospital mortality and length of hospital stay without associated effects on readmission rates and long-term mortality [2]. Nevertheless, case fa
Resident training in pathology: From resident's point of view  [cached]
Kemal K?SEMEHMETO?LU,Berrak GüMü?KAYA ?CAL,Esra Zeynep CO?KUNO?LU,?lke ?ULHA
Türk Patoloji Dergisi , 2008,
Abstract: In many recent studies in the literature have described and commented on “competency based resident training” in pathology. According to this model, competencies are subclassified in 6 main categories: Patient care, medical knowledge, practice based learning and improvement, interpersonal and communication skills, professionalism, and systems based practice. Assessment of competency forms the main component of this model.Under the framework of Ankara Society of Pathology, a working group, composed of 11 residents, 6 of which representing the Training and Research Hospitals of Ministry of Health and the rest representing the university hospitals in Ankara, was established in order to participate in the think-tank about resident training in pathology. A questionnaire, composed of 12 questions, was prepared. According to this questionnaire, the number of trainers in the university hospitals is much higher than in the commercial hospitals. While the total number of cases and cases per resident do not differ between the university and commercial hospitals, microscopes used for the educational purposes are significantly less in the commercial hospitals, that is due to less number of binocular microscopes. The amount of resident training program, which consists of intra and intersectional meetings, are similar in the university and commercial hospitals, however, theoretic lectures are given only in 3 departments. Residents working in the university hospitals have obviously heavier burden than in the commercial hospitals. Lastly, residents generally exclaimed that the time dedicated to the macroscopy training is less sufficient than time used for the microscopy training.The factors affecting the training of resident in pathology are divided into two main groups: 1) Factors directly affecting training (quality of trainer, time dedicated for education, feed back, eg.) and 2) Conditions which waste residents' time. For instant, workload which does need qualified staff and increases the burden on residents may be reassigned to medical secretary or pathology assistants; therefore energy of residents can be saved for educational activities. Optimization of physical working conditions, assortment of training programs, rotation in lacking subjects and consultations will enhance the quality of the education of the resident. Feedback assessment of trainer and trainee is an essential part of a training program.In conclusion, an ideal resident from the resident's point of view is the person who is endowed with medical and pathological knowledge, orderly interrelates with s
Advanced cerebral monitoring in neurocritical care  [cached]
Barazangi Nobl,Hemphill III J
Neurology India , 2008,
Abstract: New cerebral monitoring techniques allow direct measurement of brain oxygenation and metabolism. Investigation using these new tools has provided additional insight into the understanding of the pathophysiology of acute brain injury and suggested new ways to guide management of secondary brain injury. Studies of focal brain tissue oxygen monitoring have suggested ischemic thresholds in focal regions of brain injury and demonstrated the interrelationship between brain tissue oxygen tension (P bt O 2 ) and other cerebral physiologic and metabolic parameters. Jugular venous oxygen saturation (SjVO 2 ) monitoring may evaluate global brain oxygen delivery and consumption, providing thresholds for detecting brain hypoperfusion and hyperperfusion. Furthermore, critically low values of P bt O 2 and SjVO 2 have also been predictive of mortality and worsened functional outcome, especially after head trauma. Cerebral microdialysis measures the concentrations of extracellular metabolites which may be relevant to cerebral metabolism or ischemia in focal areas of injury. Cerebral blood flow may be measured in the neurointensive care unit using continuous methods such as thermal diffusion and laser Doppler flowmetry. Initial studies have also attempted to correlate findings from advanced neuromonitoring with neuroimaging using dynamic perfusion computed tomography, positron emission tomography, and Xenon computed tomography. Additionally, new methods of data acquisition, storage, and analysis are being developed to address the increasing burden of patient data from neuromonitoring. Advanced informatics techniques such as hierarchical data clustering, generalized linear models, and heat map dendrograms are now being applied to multivariable patient data in order to better develop physiologic patient profiles to improve diagnosis and treatment.
Retrospective agreement and consent to neurocritical care is influenced by functional outcome
Ines C Kiphuth, Martin K?hrmann, Joji B Kuramatsu, Christoph Mauer, Lorenz Breuer, Peter D Schellinger, Stefan Schwab, Hagen B Huttner
Critical Care , 2010, DOI: 10.1186/cc9210
Abstract: We investigated 704 consecutive patients admitted to a nonsurgical neurocritical care unit over a period of 2 years (2006 through 2007). Demographic and clinical parameters were analyzed, and the patients were grouped according to their diagnosis. Functional outcome, retrospective consent to neurocritical care, and satisfaction with hospital stay was obtained by mailed standardized questionnaires. Logistic regression analyses were calculated to determine independent predictors for consent.High consent and satisfaction after neurointensive care (91% and 90%, respectively) was observed by those patients who reached an independent life one year after neurointensive care unit (ICU) stay. However, only 19% of surviving patients who were functionally dependent retrospectively agreed to neurocritical care. Unfavorable functional outcome and the diagnosis of stroke were independent predictors for missing retrospective consent.Retrospective agreement to neurocritical care is influenced by functional outcome. Especially in severely affected stroke patients who cannot communicate their preferences regarding life-sustaining therapy, neurocritical care physicians should balance the expected burdens and benefits of treatment to meet the patients' putative wishes. Efforts should be undertaken to identify predictors for severe disability after neurocritical care.In the past, physicians did not routinely seek permission from patients before initiating diagnostic and therapeutic procedures, regardless of the risk [1]. However, in recent years, emphasis has been shifted from physician sovereignty to patient autonomy, obliging physicians to expect and encourage patient participation in decision making after having given them all available relevant information, thus obtaining the patient's informed consent to perform the given procedure [2,3]. Neurologic patients in need of intensive care, however, may not be capable of participating in the informed-consent process, because of reduced c
Resident training in pathology: Expectations and suggestions  [cached]
Banu B?LEZ?K??,?zge HAN,Gül?in ALTINOK,Murat ALPER
Türk Patoloji Dergisi , 2008,
Abstract: In this report, we summarized the result of the panel discussion about pathology residency training program. Especially, training atmosphere including laboratories, rotations, evaluation of autopsy, macroscopy, microscopy, and general resident responsibilities were discussed. Obligation of standardization of residency training program was stressed.
Year in review 2011: Critical Care - neurocritical care
Salah G Keyrouz, Michael N Diringer
Critical Care , 2012, DOI: 10.1186/cc11825
Abstract: This past year's contributions from the field of Neuroscience to Critical Care have been varied, covering an array of topics and diseases. These include stroke, subarachnoid hemorrhage, hypothermia, meningitis, peripheral nervous system diseases, and delirium, which captured the lion's share. We review these articles, discuss their scientific contribution to the field, and their clinical relevance below.Delirium is a common condition in the ICU, though likely more encountered in general ICU than neurointensive care units. Among other things, it is associated with increased length of stay and mortality [1,2]. Because of its high prevalence and morbid consequences, delirium is an important topic in critical care research. In 2011, five articles addressing issues including pathophysiology, diagnosis and treatment of delirium were published in Critical Care.McGrane and colleagues [3] sought to investigate a possible relationship between serum procalcitonin, C-reactive protein and delirium. Procalcitonin and C-reactive protein are inflammatory biomarkers that have been linked to many acute neurological conditions, like stroke, and other critical illnesses [4]. This prospective cohort study was part of a double-blind, randomized controlled trial comparing dexmedetomidine and lorazepam for sedation of mechanically ventilated patients (Maximizing Efficacy of Target Sedation and Reducing Neurological Dysfunction or MENDS) [5]. Data were analyzed for 87 (of 103) patients enrolled in MENDS. Higher levels of procalcitonin, but not C-reactive protein, were associated with fewer delirium/coma free days (odds ratio (OR) 0.5, 95% confidence interval (CI) 0.3 to 1.0; P = 0.04), but neither biomarker showed a relationship with 28-day survival. Some of these results were contradicted by another study led by Van den Boogaard and colleagues [6], which was a prospective observational single center study of 100 critically ill patients (50 with and 50 without delirium). These patients were
Resident training in pathology: General overview
Türk Patoloji Dergisi , 2008,
Abstract: The chaos in the law related to “regulations of medical specialty” has negative effect on the training of pathology residency programs in our country. There are enormous effort to close the gap by the medical specialists via their societies or federations. Training in pathology commission of Federation of Turkish Pathology Societies has finished their work related to “The schedule of training of pathology residency” and “logbook”. The panel deals with training in pathology residency are part of these efforts. Requirements of rotations to the other institutions were treated too. It is considered more appropriate that the federation regulates rotations for sub specializations. Systematic approach is requiring for education. Each pathology department should have an education team. It is recommended that a senior pathologist become the head of the team. This organization could solve the most of the problems. Satisfaction of residents and trainers will be increased by the schedule of training of pathology residency; logbook, written feedbacks and competency based resident training and assessment that organized by these education teams/units.
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