Impact of a multidisciplinary workflow on safety and management of patients with heparin-induced thrombocytopenia

PURPOSE

Heparin-induced thrombocytopenia (HIT) is a serious complication of heparin administration. Management strategies are complex and include discontinuing heparin products, initiating alternative anticoagulants, interpreting laboratory test results, documenting heparin allergies, and providing patient education. Medication error reports and a retrospective review conducted at an academic medical center revealed an opportunity for a quality improvement initiative and led to the creation of a multidisciplinary workflow for the management of HIT. In a pre-post study, the impact of the multidisciplinary workflow on the safety and management of HIT was evaluated.

METHODS

The preimplementation group consisted of adult patients tested for suspected HIT from April 4, 2014, through May 31, 2016; the postimplementation group consisted of adult patients tested from November 1, 2016, through October 31, 2018. The primary outcome was the incidence of heparin product administration while HIT testing was ongoing. The secondary outcome was the rate of appropriate heparin allergy documentation.

RESULTS

The incidence of heparin product administration while HIT testing results were pending was significantly reduced, from 54.2% to 20.0% (P < 0.001), after workflow implementation. The rate of appropriate heparin allergy documentation significantly increased, from 95.0% to 100% (P < 0.001).

CONCLUSION

Implementation of a multidisciplinary workflow for the management of HIT significantly reduced the incidence of heparin administration while testing was ongoing and improved the rate of appropriate heparin allergy documentation.

Evaluation of the Safety of Intravenous Thiamine Administration in a Large Academic Medical Center

BACKGROUND/OBJECTIVE

Previous literature describes increased incidence of infusion-related reactions when administering thiamine doses greater than 100 mg as an intravenous (IV) push. The purpose of this evaluation was to assess the safety of administering higher doses of thiamine as IV push compared to infusion.

METHODS

A single-center, retrospective review was performed from June to October 2017. Included patients were aged 18 years or older and received 1 dose of IV thiamine 200 mg or greater. Patients were divided into 2 groups: group 1 included patients who received 200-mg IV push and, group 2 included patients who received any dose greater than 200 mg. The primary objective was to quantify and compare rate of adverse reactions between the 2 groups. Institutional thiamine prescribing practices were examined. Wilcoxon Rank Sum and Fischer exact tests were performed.

RESULTS

Sixty-six percent of patients were male, and the median age was 55 years (interquartile range [IQR]: 44-63). Fifty percent received 200-mg IV push, 20% received a combination of IV infusion and IV push, and 30% received IV infusion. Adverse reactions possibly due to thiamine administration occurred in 4 (2.0%) patients. One patient received 200 mg via IV infusion, while 3 received 200 mg via IV push. There was no significant difference in adverse reaction rate between IV push and IV infusion administrations (P = .640).

CONCLUSION

Our results support administering thiamine doses of 200 mg or less as an IV push. Given lack of robust safety data, it is recommended to continue to dilute doses greater than 200 mg and infuse over 30 minutes.

Evaluation of the impact of enhanced recovery after surgery protocol implementation on maternal outcomes following elective cesarean delivery

BACKGROUND

Despite significant improvements in outcomes following non-obstetric surgery with implementation of enhanced recovery after surgery (ERAS) protocols, development of these protocols for cesarean delivery is lacking. We evaluated implementation of an ERAS protocol for patients undergoing elective cesarean delivery, specifically the effect on opioid consumption, pain scores and length of stay as well as complications and re-admissions.

METHODS

An ERAS protocol was developed and implemented for women undergoing elective cesarean delivery. The protocol construction included specific evidence-based items applicable to peripartum management and these were grouped into the three major phases of patient care: antepartum, intrapartum and postpartum. A before-and-after study design was used to compare maternal outcomes. To account for confounders between groups, a propensity matched scoring analysis was used. The primary outcome was postpartum opioid use in mg-morphine equivalents (MMEQ).

RESULTS

We included 357 (n=196 before; n=161 after) women who underwent elective cesarean delivery. A significant difference in opioid consumption (28.4 ± 24.1 vs 46.1 ± 37.0 MMEQ, P <0.001) and in per-day postoperative opioid consumption (10.9 ± 8.7 vs 15.1 ± 10.3 MMEQ, P <0.001), lower peak pain scores (7 [5-9] vs 8 [7-9], P=0.007) and a shorter hospital length of stay (2.5 ± 0.5 vs 2.9 ± 1.2 days, P <0.001) were found after the introduction of the ERAS protocol.

CONCLUSIONS

Implementation of ERAS protocols for elective cesarean delivery is associated with significant improvements in analgesic and recovery outcomes. These improvements in quality of care suggest ERAS protocols should be considered for elective cesarean delivery.

Evaluation of gravimetric-based technology-assisted workflow for nonhazardous sterile product preparation

Purpose

The impact of a gravimetric-based technology-assisted workflow (TAWF) system on the nonhazardous compounded sterile product (CSP) error capture rate, production times, and pharmacy staff perceptions of compounding methods was evaluated.

Methods

For 2 weeks prior to TAWF implementation, staff used a punch clock to document production times with a volumetric method. Preimplementation error data were captured in a previous study; TAWF software captured error and time data in the postimplementation period. An online staff survey was administered before and 90 days after TAWF implementation to evaluate perceptions of the 2 methods.

Results

The error capture rates were 0.47% in the preimplementation period and 41.48% in the postimplementation period. The median time to prepare CSPs was significantly shorter in the preimplementation period versus the postimplementation period (p < 0.0001). The median time to check CSPs was significantly shorter at both 90 days (p < 0.0001) and 180 days (p = 0.0006) after TAWF implementation. When asked if the current method was the safest and the most accurate method for preparation, staff members’ perceptions improved from neutrality to agreement when the TAWF was implemented. Staff members were in agreement that the volumetric method was faster than the gravimetric TAWF method but were neutral as to whether the latter was the preferred compounding method.

Conclusion

The study results indicated that gravimetric-based TAWF preparation of nonhazardous CSPs is slower than manual volumetric preparation but can improve the error capture rate. Staff perceived the gravimetric TAWF method to be the safest and most accurate for producing CSPs.

Low speed maneuvering flight of the rose-breasted cockatoo (Eolophus roseicapillus). II. Inertial and aerodynamic reorientation

The reconfigurable, flapping wings of birds allow for both inertial and aerodynamic modes of reorientation. We found evidence that both these modes play important roles in the low speed turning flight of the rose-breasted cockatoo Eolophus roseicapillus. Using three-dimensional kinematics recorded from six cockatoos making a 90 degrees turn in a flight corridor, we developed predictions of inertial and aerodynamic reorientation from estimates of wing moments of inertia and flapping arcs, and a blade-element aerodynamic model. The blade-element model successfully predicted weight support (predicted was 88+/-17% of observed, N=6) and centripetal force (predicted was 79+/-29% of observed, N=6) for the maneuvering cockatoos and provided a reasonable estimate of mechanical power. The estimated torque from the model was a significant predictor of roll acceleration (r(2)=0.55, P<0.00001), but greatly overestimated roll magnitude when applied with no roll damping. Non-dimensional roll damping coefficients of approximately -1.5, 2-6 times greater than those typical of airplane flight dynamics (approximately -0.45), were required to bring our estimates of reorientation due to aerodynamic torque back into conjunction with the measured changes in orientation. Our estimates of inertial reorientation were statistically significant predictors of the measured reorientation within wingbeats (r(2) from 0.2 to 0.37, P<0.0005). Components of both our inertial reorientation and aerodynamic torque estimates correlated, significantly, with asymmetries in the activation profile of four flight muscles: the pectoralis, supracoracoideus, biceps brachii and extensor metacarpi radialis (r(2) from 0.27 to 0.45, P<0.005). Thus, avian flight maneuvers rely on production of asymmetries throughout the flight apparatus rather than in a specific set of control or turning muscles.

Low speed maneuvering flight of the rose-breasted cockatoo (Eolophus roseicapillus). I. Kinematic and neuromuscular control of turning

Maneuvering flight has long been recognized as an important component of the natural behavior of many bird species, but has been the subject of little experimental work. Here we examine the kinematics and neuromuscular control of turning flight in the rose-breasted cockatoo Eolophus roseicapillus (N=6), testing predictions of maneuvering flight and control based on aerodynamic theory and prior kinematic and neuromuscular studies. Six cockatoos were trained to navigate between two perches placed in an L-shaped flight corridor, making a 90 degrees turn midway through each flight. Flights were recorded with three synchronized high-speed video cameras placed outside the corridor, allowing a three-dimensional reconstruction of wing and body kinematics through the turn. We simultaneously collected electromyography recordings from bilateral implants in the pectoralis, supracoracoideus, biceps brachii and extensor metacarpi radialis muscles. The cockatoos maneuvered using flapping, banked turns with an average turn radius of 0.92 m. The mean rate of change in heading during a complete wingbeat varied through the turn and was significantly correlated to roll angle at mid-downstroke. Changes in roll angle were found to include both within-wingbeat and among-wingbeat components that bear no direct relationship to one another. Within-wingbeat changes in roll were dominated by the inertial effects while among-wingbeat changes in roll were likely the result of both inertial and aerodynamic effects.

Flight control in the hawkmoth Manduca sexta: the inverse problem of hovering

The inverse problem of hovering flight, that is, the range of wing movements appropriate for sustained flight at a fixed position and orientation, was examined by developing a simulation of the hawkmoth Manduca sexta. Inverse problems arise when one is seeking the parameters that are required to achieve a specified model outcome. In contrast, forward problems explore the outcomes given a specified set of input parameters. The simulation was coupled to a microgenetic algorithm that found specific sequences of wing and body motions, encoded by ten independent kinematic parameters, capable of generating the fixed body position and orientation characteristic of hovering flight. Additionally, we explored the consequences of restricting the number of free kinematic parameters and used this information to assess the importance to flight control of individual parameters and various combinations of them. Output from the simulated moth was compared to kinematic recordings of hovering flight in real hawkmoths; the real and simulated moths performed similarly with respect to their range of variation in position and orientation. The simulated moth also used average wingbeat kinematics (amplitude, stroke plane orientation, etc) similar to those of the real moths. However, many different subsets of the available kinematic were sufficient for hovering flight and available kinematic data from real moths does not include sufficient detail to assess which, if any, of these was consistent with the real moth. This general result, the multiplicity of possible hovering kinematics, shows that the means by which Manduca sexta actually maintains position and orientation may have considerable freedom and therefore may be influenced by many other factors beyond the physical and aerodynamic requirements of hovering flight.

Implant-Associated Infections: An Overview

The discovery of a 5500-year-old dental implant near Gebel Ramlah, Egypt, marks the earliest discovery of a medical prosthesis. It would not be until the 20th century, however, that this ancient concept would resurface on a wide scale basis. With the introduction of physiologically inert biomaterials in the 1950s, the field of surgical implants has emerged as arguably one of the greatest medical advancements of our time. It is now estimated that millions of patients worldwide have received some type of prosthesis. This forces us to appreciate the impact of implant-associated infections on patients today and mandates that we as a medical community be prepared to manage these infections effectively. This article provides an in-depth review of the current most commonly used prosthetic devices and the infections that accompany them. We examine the epidemiology, diagnosis, prevention, and treatment of various implant-associated infections within the fields of general, plastic, orthopedic, dental, and neurosurgery. We will highlight the recent technological advancements and future prospects. We will also draw attention to the need for further research in this ever growing field.

Comparative power curves in bird flight

The relationship between mechanical power output and forward velocity in bird flight is controversial, bearing on the comparative physiology and ecology of locomotion. Applied to flying birds, aerodynamic theory predicts that mechanical power should vary as a function of forward velocity in a U-shaped curve. The only empirical test of this theory, using the black-billed magpie (Pica pica), suggests that the mechanical power curve is relatively flat over intermediate velocities. Here, by integrating in vivo measurements of pectoralis force and length change with quasi-steady aerodynamic models developed using data on wing and body movement, we present mechanical power curves for cockatiels (Nymphicus hollandicus) and ringed turtle-doves (Streptopelia risoria). In contrast to the curve reported for magpies, the power curve for cockatiels is acutely concave, whereas that for doves is intermediate in shape and shows higher mass-specific power output at most speeds. We also find that wing-beat frequency and mechanical power output do not necessarily share minima in flying birds. Thus, aspects of morphology, wing kinematics and overall style of flight can greatly affect the magnitude and shape of a species' power curve.