Covenant Health System

Introduction: The purpose of this study was to investigate the trauma community’s use of the CAM scoring for delirium, and what shortfalls they believe it has in practice. Additionally, we wanted to discover what can be done to improve delirium care. Methods: A ten-question mixed-methods survey was sent to the members of the Society of Trauma Nurses via Email listserv. The survey included two open-response questions, allowing three responses for each question, and eight multiple-choice questions about delirium and delirium scoring. Results: There were 130 respondents who completed the survey. The majority (42.5%%) are using CAM-B for scoring delirium, however, it was shocking that we discovered 35% indicated currently not using any scoring for delirium. Sleep/wake cycle bundle was reported as the most utilized intervention with CAM-positive patients. Mandatory screening was the most suggested change for improvement of delirium management. Conclusions: A significant amount (35%) of our participants were not using any screening tool for delirium. Education of providers and nurses of the importance of CAM scoring as well as improving the utilization of the CAM score across all areas of inpatient care was indicated as much needed by participants. Those surveyed did not think that facilities had protocolized interventions when a patient was CAM positive, and also they expressed frustration with using the tool screening patients with traumatic brain injury and dementia. This is a potential practice improvement area to improve patient outcomes. The new unifying definition of delirium is a one of the many ways we are improving care for these patients, however this study indicated that additional research is needed to discover the best ways to educate nurses and providers on the importance of delirium and utilizing EMR communication now that the platform has become more advanced.

OBJECTIVESTraditional journal clubs have been shown to be insufficient in improving residents’ scholarly productivity, often due to the inability to sustain residents’ interest and participation. Additionally, the 2019 novel coronavirus (COVID-19) pandemic restrictions caused a decline in academic scholarly productivity across residency programs. We evaluated the impact of a resident-led research club called ‘journal café' on residents’ scholarly productivity by comparing scholarly output between the journal café members and non-members during the COVID-19 pandemic.METHODSThe journal café was established in the 2012/2013 academic year by internal medicine residents of a university residency program in Atlanta, Georgia, to foster self-directed collaboration among residents based on shared interests in academic research. The journal café runs independently of the residency program’s journal club. We categorized IM residents at our institution into journal café members and non-members and collected data on their research productivity during residency training and the COVID-19 pandemic. The survey was conducted between April and June 2021 and analyzed data presented using frequencies, tables, and appropriate charts.RESULTSSixty-eight residents (29 journal café members and 39 non-members) completed the survey (response rate of 85%). A significantly higher number of journal café members reported having five or more research publications (55.1% vs 7.1%, P < .001) and scientific presentations (48.3% vs 2.6%, P < .001) compared with non-members. Additionally, more journal café members published COVID-19-related research in peer-reviewed journals compared with non-members (68% vs 32%, n = 19). Finally, most of the residents cited the opportunity of a platform to share and brainstorm on research ideas as the reason for joining the journal café.CONCLUSIONWe found an association between journal café participation and increased scholarly activity, particularly during the COVID-19 pandemic. Independent resident-led research clubs supported by the residency program may complement the traditional journal clubs and enhance residents’ participation in research.

Clinicians sought to ascertain what frequency of vital signs best detects blood transfusion reactions. This review discusses early and delayed blood product transfusion reaction detection through the lens of scientific literature. A comprehensive appraisal of published literature was conducted using Integrative Research Review methodology through June 2022 not limited to English or research in Cumulative Index to Nursing and Allied Health Literature, Cochrane Library of Systematic Reviews, Medline and PubMed. Full-text articles in the final sample included four articles discussing vital signs detecting blood transfusion reactions and four articles reporting the importance of adding physical assessments for early reaction detection. None of the studies provided evidence regarding how often vital signs should be monitored to detect transfusion reactions. No studies included identical screening components for detecting blood product transfusion reactions. Main themes emerged including variations in what was included in vital signs, importance of respiratory assessment, inclusion of physical assessment, nurse documentation and reporting compliance, and patient and family inclusion in transfusion reaction recognition. Vital sign components varied across reviewed studies. Respiratory rate and pain were not always included in 'vital signs' to identify transfusion reactions. Only low-level data and no clinical trials loosely informing frequency of vital sign monitoring to transfusion reaction detection were found. Respiratory (to include oxygen saturation, lung sounds and respiratory rate) and pain assessment emerged as crucial to acute and delayed transfusion reaction recognition. The disconnect between 'vital signs' and the varied vital sign components reported to detect transfusion reactions in scientific literature requires further exploration.

The coronavirus disease 2019(COVID-19) pandemic globally impacted healthcare due to surges in infected patients and respiratory failure. The pandemic escalated nursing burnout syndrome (NBS) across the workforce, especially in critical care environments, potentially leading to long-term negative impact on nurse retention and patient care. To compare self-reported burnout scores of frontline nurses caring for COVID-19 infected patients with burnout scores captured before the pandemic and in non-COVID-19 units from two prior studies. The descriptive study was conducted using frontline nurses working in eight critical care units based on exposure to COVID-19 infected patients. Nurses were surveyed in 2019 and in 2020 using Maslach Burnout Inventory (MBI), Well Being Instrument, and Stress-Arousal Adjective Checklist (SACL) instruments. Researchers explored relationships between survey scores and working in COVID-19 units. Nurses working in COVID-19 units experienced more emotional exhaustion (EE) and depersonalization (DP) than nurses working in non-COVID units (p= .0001). Pre-COVID nurse burnout scores across six critical care units (EE mean = 15.41; p= .59) were lower than burnout scores in the COVID-19 intensive care units (EE mean = 10.29; p= .74). Clinical significance (p= .08) was noted by an EE subscale increase from low prepandemic to moderate during the pandemic. Pinpointing associations between COVID-19 infection and nurse burnout may lead to innovative strategies to mitigate burnout in those caring for the most critically ill individuals during future pandemics. Further research is required to establish causal relationships between sociodemographic and work-related psychological predictors of NBS.

Cardiogenic shock (CS) is a recognized complication of peripartum cardiomyopathy (PPCM) associated with poor prognosis. Although racial and ethnic disparities have been described in the occurrence and outcomes of PPCM, it is unclear if these disparities persist among patients with PPCM and CS. To evaluate the temporal trends in CS incidence among hospitalized patients with PPCM stratified by race and ethnicity and to investigate the racial and ethnic differences in hospital mortality, mechanical circulatory support (MCS) use, and heart transplantation (HT). This multicenter retrospective cohort study included hospitalized patients with PPCM complicated by CS in the US from 2005 to 2019 identified from the National Inpatient Sample (NIS). Data analysis was conducted in November 2021. PPCM complicated by CS. The main outcome was incidence of CS in PPCM stratified by race and ethnicity. The secondary outcome was racial and ethnic differences in hospital mortality, MCS use, and HT. Of 55 804 hospitalized patients with PPCM, 1945 patients had CS, including 947 Black patients, 236 Hispanic patients, and 702 White patients, translating to an incidence rate of 35 CS events per 1000 patients with PPCM. The mean (SD) age was 31 (9) years. Black and Hispanic patients had higher CS incidence rates (39 events per 1000 patients with PPCM) compared with White patients (33 events per 1000 patients with PPCM). CS incidence rates significantly increased across all races and ethnicities over the study period. Overall, the odds of developing CS were higher in Black patients (aOR, 1.17 [95% CI, 1.15-1.57]; P < .001) and Hispanic patients (aOR, 1.37 [95% CI, 1.17-1.59]; P < 001) compared with White patients during the study period. Compared with White patients, the odds of in-hospital mortality were higher in Black (adjusted odds ratio [aOR], 1.67 [95% CI, 1.21-2.32]; P = .002) and Hispanic (aOR, 2.20 [95% CI, 1.45-3.33]; P < .001) patients. Hispanic patients were more likely to receive any type of MCS device (aOR, 2.23 [95% CI, 1.60-3.09]; P < .001), intraaortic balloon pump (aOR, 1.65 [95% CI, 1.11-2.44]; P < .001), and ventricular assisted device (aOR, 4.45 [95% CI, 2.45-8.08]; P < .001), compared with White patients. Black patients were more likely to receive VAD (aOR, 2.69 [95% CI, 1.63-4.42]; P < .001) compared with White patients. Black and Hispanic patients were significantly less likely to receive HT compared with White patients (Black patients: aOR, 0.51 [95% CI, 0.33-0.78]; P = .02; Hispanic patients: aOR, 0.15 [95% CI, 0.06-0.42]; P < .001). These findings highlight significant racial disparities in mortality and HT among hospitalized patients with PPCM complicated by CS in the US. More research to identify factors of racial and ethnic disparities is needed to guide interventions to improve outcomes of patients with PPCM.

Bronchoscopy can be used to resolve respiratory failure caused by tenacious mucus plugs. However, emergent bronchoscopy to resolve mucus plugging is not always available in small rural hospitals around the country. We present a case in which increasing the positive end-expiratory pressure settings on the ventilator resulted in immediate improvement in patient oxygenation and imaging findings during a respiratory emergency caused by mucus plugging.

In-hospital acute kidney injury (IH-AKI) has been reported in a significant proportion of patients with COVID-19 and is associated with increased disease burden and poor outcomes. However, the mechanisms of injury are not fully understood. We sought to determine the significance of race on cardiopulmonary outcomes and in-hospital mortality of hospitalized COVID-19 patients with AKI. We conducted a retrospective cohort study of consecutive patients hospitalized in Grady Health System in Atlanta, Georgia between February and July 2020, who tested positive for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) on qualitative polymerase-chain-reaction assay. We evaluated the primary composite outcome of in-hospital cardiac events, and mortality in blacks with AKI versus non-blacks with AKI. In a subgroup analysis, we evaluated the impact of AKI in all blacks and in all non-blacks. Of 293 patients, effective sample size was 267 after all exclusion criteria were applied. The mean age was 61.4 ± 16.7, 39% were female, and 75 (28.1%) had IH-AKI. In multivariable analyses, blacks with IH-AKI were not more likely to have in-hospital cardiac events (aOR 0.3, 95% Confidence interval (CI) 0.04-1.86, p = 0.18), require ICU stay (aOR 0.80, 95% CI 0.20-3.25, p = 0.75), acute respiratory distress syndrome (aOR 0.77, 95% CI 0.16-3.65, p = 0.74), require mechanical ventilation (aOR 0.51, 95% CI 0.12-2.10, p = 0.35), and in-hospital mortality (aOR 1.40, 95% CI 0.26-7.50, p = 0.70) when compared to non-blacks with IH-AKI. Regardless of race, the presence of AKI was associated with worse outcomes. Black race is not associated with higher risk of in-hospital cardiac events and mortality in hospitalized COVID-19 patients who develop AKI. However, blacks with IH-AKI are more likely to have ARDS or die from any cause when compared to blacks without IH-AKI.

The peridural membrane (PDM) is a well-defined structure between dura mater and the wall of the spinal canal. The spine may be viewed as a multi-segmented joint, with the epidural cavity and neural foramina as joint spaces and PDM as synovial lining. The objective of this investigation was to determine if PDM has histological characteristics of synovium. Samples of the PDM of the thoraco-lumbar spine were taken from 23 human cadavers and analyzed with conventional light microscopy and confocal microscopy. Results were compared to reports on similar analyses of synovium in the literature. Histological distribution of areolar, fibrous, and adipose connective tissue in PDM was similar to synovium. The PDM has an intima and sub-intima. No basement membrane was identified. CD68, a marker for macrophage-like-synoviocytes, and CD55, a marker for fibroblast-like synoviocytes, were seen in the lining and sub-lining of the PDM. Multifunctional hyaluronan receptor CD44 and hyaluronic acid synthetase 2 marker HAS2 were abundantly present throughout the membrane. Marked presence of CD44, CD55, and HAS2 in the well-developed tunica muscularis of blood vessels and in the body of the PDM suggests a role in the maintenance and lubrication of the epidural cavity and neural foramina. Presence of CD68, CD55, and CD44 suggests a scavenging function and a role in the inflammatory response to noxious stimuli. Thus, the human PDM has histological and immunohistochemical characteristics of synovium. This suggests that the PDM may be important for the homeostasis of the flexible spine and the neural structures it contains.

A peridural membranous layer exists between the bony wall of the spinal canal and the dura mater, but reports on the anatomy of this structure have been inconsistent. The objective of this study is to give a precise description of the peridural membrane (PDM) and to define it unambiguously as a distinct and unique anatomical entity. Thirty-four cadaveric sections of human thoraco-lumbar spines were dissected. On gross examination, the PDM appears as a smooth hollow tube that covers the bony wall of the spinal canal. An evagination of this tube into the neural foramen contains the exiting spinal nerve. The entire epidural venous plexus, including its extension into the neural foramina, is contained in the body of the PDM. Histological examination of the PDM shows a variable distribution of veins arteries, lymphatics, and nerves embedded in a continuous sheath of fibrous, areolar, and adipose tissue. The posterior longitudinal ligament may be considered a dense condensation of fibrous tissue within the membrane. Thus, the PDM is a unique, continuous, and complete anatomical structure. In the spinal canal, the PDM is adjacent to the periosteum. In the neural foramen, suprapedicular PDM and pedicular periosteum separate anatomically to form a suprapedicular compartment, bounded anteriorly by the intervertebral disc and posteriorly by the facet joint. Trauma or degeneration of the disc or facet joint may lead to inflammation and pain sensitization of PDM. This protective mechanism may be of considerable importance for the functioning of the spine under conditions of strain.

ABSTRACT People living with HIV (PLWH) have a significant risk for experiencing a 30-day readmission; many of which may be potentially preventable readmissions (PPR). The objective of this study was to evaluate 30-day readmission rates for PLWH and identify risk factors for PPR. This was a single center retrospective study. Patients were included if they were ≥18 years of age, had a diagnosis of HIV, and were admitted to University of New Mexico Hospitals between 1 January 2010 and 31 December 2014 and readmitted within 30-days of the index admission. Preventability of readmission was defined using previously published criteria. Of the 908 identified admissions for PLWH during 2010–2014, 162 (17.8%) were 30-day readmissions. A total of 60 patient readmissions met study inclusion criteria, of which 55% were determined to be PPR. Multivariate logistic regression analysis revealed that being discharged on ≥10 medications (OR 3.92, 95% CI 1.181–13.043) and having an appointment scheduled upon discharge (OR 3.59, 95% CI 1.057–12.212) were significantly associated a PPR. These results further highlight the vulnerability of this patient population and help to identify risk factors for PPR. Targeted transitions of care interventions that address polypharmacy may help to reduce PPR among PLWH.