Northwest Community Hospital

Background: The optimal anticoagulation strategy for patients with intracerebral hemorrhage (ICH) and atrial fibrillation (AF) remains uncertain. Although direct oral anticoagulants (DOACs) have largely replaced warfarin as first-line therapy for stroke prevention in AF—due to their lower risk of intracranial bleeding and fewer drug–food interactions—their safety and efficacy in patients with both AF and recent ICH remain poorly defined. This study aimed to compare the rates of ischemic and hemorrhagic stroke between patients receiving DOACs versus warfarin following an ICH. Methods: We conducted a retrospective cohort study using the COSMOS EPIC database, identifying adult patients admitted with ICH and have AF diagnosis. Patients were included if they had a documented anticoagulation prescription within 180 days of discharge after the index ICH admission. Diagnoses were identified using ICD-10 codes. Patients were stratified into two groups based on anticoagulant type: DOAC or warfarin. Baseline demographic and clinical characteristics, including comorbidities, were compared. The primary outcomes were recurrent hemorrhagic stroke (ICH or subarachnoid hemorrhage) and ischemic stroke after anticoagulation initiation. Kaplan–Meier survival curves were generated to estimate the cumulative incidence of each outcome, and differences were assessed using log-rank tests. Results: A total of 2,473 patients met inclusion criteria. Patients in the DOAC group were slightly older than those in the warfarin group (mean age 73 vs. 71 years, p = 0.02); other baseline characteristics and comorbidities were comparable. During follow-up, ischemic stroke occurred in 3.5% of DOAC-treated patients and 3.1% of warfarin-treated patients ( p = 0.70). Hemorrhagic stroke occurred in 7.4% and 6.1% of patients in the DOAC and warfarin groups, respectively ( p = 0.68). Kaplan–Meier analysis demonstrated no significant difference in the cumulative incidence of hemorrhagic stroke ( p = 0.60) or ischemic stroke ( p = 0.80) between groups. Conclusion: In this large retrospective cohort of patients with AF and ICH, DOAC and warfarin had comparable risk of recurrent hemorrhagic or ischemic strokes. Prospective studies are needed to guide anticoagulation decisions in this high-risk group.

The objective of this systematic review is to determine the effects of IL-17 inhibitors on major adverse cardiovascular events (MACEs) in patients with either psoriasis (PsO) or psoriatic arthritis (PsA).A systematic literature search in three databases (Medline, Embase, and the Cochrane Library for Randomized Controlled Trials) was conducted on December 7, 2022 for randomized controlled trials of patients with PsO/PsA treated with IL-17 inhibitors that reported confirmed MACEs.Two reviewers screened titles and abstracts and identified papers for full-text review. Exclusion criteria included trials that included the previous use of biological disease-modifying anti-rheumatic drugs. The Mantel-Haenszel random-effect method was utilized to calculate risk ratios and heterogeneitywas measured by χ2test and I2statistics. Funnel plot analysis was undertaken to detect potential publication bias. Of the 919 references identified, nine RCT studies were included in the meta-analysis (n=2,096 patients). There was no statistically significant correlation between the use of IL-17 inhibitors and change in risk of MACEs (Risk Ratio 0.56; 95% CI 0.15 to 2.14;p= 0.40). Subgroup analysis of secukinumab or ixekizumab also did not demonstrate these changes. Additionally, there was no detectable dose-dependent effect of IL-17 inhibitors. In conclusion, IL-17 inhibitor use is not correlated with a change in MACE risk in patients with PsO/PsA who previously did not receivebiologic disease-modifying anti-rheumatic drugs.

Breast implant surgery is a popular plastic surgery procedure performed worldwide. Despite its global popularity, patients undergoing breast implant surgery are at risk for systemic illness and more than one form of cancer. We conducted a nursing workflow analysis at our facility and determined that it is not standard practice to screen patients for the presence or absence of breast implant devices at every health care encounter. This lack of screening for breast implant devices may adversely affect patient safety by hindering the rapid identification of systemic illness or cancer related to breast implant devices and delaying effective medical intervention. Based on the results of the workflow analysis, we initiated a formal call for nursing action. We identified a nursing workflow process to increase patient safety and developed a universal screening tool for implantable devices. We defined universal screening for implantable devices as assessing all patients for the presence or absence of an implantable device, specifically breast implant devices, at every health care encounter. Implementing a universal process for screening patients for implantable devices at every health care encounter can be easily formulated into a policy and procedure and/or an electronic health record (EHR) update or enhancement. This article discusses how we utilized a workflow process map to translate universal screening for implantable devices into an EHR enhancement.

BackgroundAn abdominal aortic aneurysm is a balloon-like swelling in the largest blood vessel of the body. AAAs are present in 10% of the population, and a ruptured AAA is associated with a 90% risk of death and $150000 cost of care.ObjectivesThe goal of our project is to streamline the process for getting a patient with a ruptured aneurysm to the operating room (OR) from the time they present in the emergency department (ED).MethodsOur implementation strategy included the use of lean six sigma tools and methodologies, intentional clinical process design, team-based training, computer modelling, and live simulation.ResultsThe impact of this work has been a decrease in time from ED to OR (217 to 45 min), leading to a 224% decline in complications, and decrease in LOS (15.2 to 5.4 days). Survival has dramatically increased to 90%. These changes have led to a $1.8 million dollar impact on operations, and our performance has improved from the 70% percentile to the top 1% in the country over the past year.ConclusionsThe main contributing factors for this improved care coordination centres around streamlining the process map from 172 steps to 33 steps, simplifying the communication matrix, cross training of staff to better understand each person’s role in patient care, and applying a control plan with close follow. The impact has been to successfully achieve the six aims of the Institute of Medicine, deliver world class care to our community, and espouse the mission and values of our healthcare system. 837 Figure 1Door to OR control chart (4/2015 – 6/2017) 837 Figure 2Length of stay (4/2015 – 6/2017) 837 Figure 3Length of stay (4/2015 – 6/2017)

In 2001, the Society of Critical Care Medicine published practice model guidelines that focused on the delivery of critical care and the roles of different ICU team members. An exhaustive review of the additional literature published since the last guideline has demonstrated that both the structure and process of care in the ICU are important for achieving optimal patient outcomes. Since the publication of the original guideline, several authorities have recognized that improvements in the processes of care, ICU structure, and the use of quality improvement science methodologies can beneficially impact patient outcomes and reduce costs. Herein, we summarize findings of the American College of Critical Care Medicine Task Force on Models of Critical Care: 1) An intensivist-led, high-performing, multidisciplinary team dedicated to the ICU is an integral part of effective care delivery; 2) Process improvement is the backbone of achieving high-quality ICU outcomes; 3) Standardized protocols including care bundles and order sets to facilitate measurable processes and outcomes should be used and further developed in the ICU setting; and 4) Institutional support for comprehensive quality improvement programs as well as tele-ICU programs should be provided.