WakeMed

To evaluate the effect of attending neonatologist presence on first attempt neonatal intubation success and adverse events. Retrospective review of National Emergency Airway Registry for Neonates (NEAR4NEOS) intubations October 2014-December 2022. Univariate and multivariate analyses were performed to estimate associations between attending presence and outcomes. Among 12,652 intubation encounters, attendings were present for 8391 (66%) intubations by more junior operators. On univariate analysis, attending presence was associated with higherfirst attempt intubation success (OR 1.11, 95% CI 1.04-1.2). However, on multivariate analysis, attending presence was associated with lower first attempt success (aOR 0.78, 95% CI 0.70-0.86) and intubation requiring ≥3 intubation attempts (aOR 1.39, 95% CI 1.21-1.60). After adjustment, attending presence was associated with lower odds of first attempt intubation success. Reasons for this may include appropriate anticipation of high-risk intubations, altered team dynamics or unmeasured confounding biases.

Delirium is highly prevalent and grossly underdiagnosed in the acute care setting, especially in older adults. Despite evidence to support strategies to identify and manage delirium, non-intensive care areas often lack standardized processes. The aims of this project were to identify and implement evidence-based practices (EBPs) for detecting and managing delirium in non-ICU patients aged 65 years and older who were admitted with a hip fracture diagnosis. Guided by the Iowa Model for EBP Implementation and Sustainability, a 16-week pilot on a 40-bed surgical unit was conducted. Workflows and processes were developed by a multidisciplinary team that included clinical nurse champions. Key interventions included twice-daily delirium screening using the Brief Confusion Assessment Method (bCAM), the creation of a new delirium care plan, and the optimization of a geriatric order panel with both pharmacologic and non-pharmacologic options. Following the 16-week pilot, delirium identification increased by 100.7 %, with a positive screening rate of 29.7 %, closely aligning with reported prevalence rates in the literature. There was 100 % activation of the delirium care plan for patients who screened positive for delirium during their admission. Patient outcomes, including falls, restraint use, and length of stay, were monitored during the project, but were not significantly impacted. This project demonstrates the integration of evidence-based strategies for delirium into non-ICU care spaces. The multidisciplinary approach and inclusion of bedside nurses as change champions foster sustainability and scalability, creating an initial pathway for Age-Friendly care. The project team achieved its goal of implementing evidence-based processes to improve the detection and management of delirium in older adults. Future work will focus on optimizing workflows and expanding this model across the health system.

Objectives:Identify treatment and describe outcomes and complications of acute anterior and posterior sternoclavicular joint dislocation.Design:Retrospective case series.Setting:Twelve level-one trauma centers.Patient/Participants:One hundred twenty-five patients with acute sternoclavicular joint dislocation, most were male (67%), White (61%), 18–29 years old (57%), involved in a motorized collision (60%), with anterior (35%) or posterior (65%) sternoclavicular joint dislocation treated by operative or nonoperative technique.Main Outcome Measurements:Outcomes and complications of joint instability, post-traumatic arthritis, neurovascular injury, chronic pain, and cosmetic deformities after operative and nonoperative treatment of anterior and posterior acute sternoclavicular joint dislocation are reported.Results:Thiry-nine (48%) posterior dislocations received surgery as initial management, whereas 5/44 (11%) of the anterior dislocations received acute surgery. The most common fixation techniques included suture fixation repair (39%), plate fixation (30%), percutaneous reduction (18%), and graft reconstruction (9%). Fifty-four (43%) patients from the entire cohort had complications after initial treatment. Eighteen complications occurred among the operative group (41%) and 36 in the nonoperative group (44%). The most common complications were pain (20%), decreased range of motion (14%), and joint instability (10%) requiring secondary fixation.Conclusion:Both operative and nonoperative management of sternoclavicular joint dislocations had a high rate of complications among anterior and posterior joint dislocations. However, a similar incidence of complications and outcomes occurred comparing anterior or posterior injuries with or without operative treatment. Therefore, clinicians need to evaluate each patient individually taking into account, patient factors, injuries, symptoms, and risks to determine if surgery is required.Level of Evidence:Therapeutic Level III.

To assess nurse and parent perspectives of a neonatal intensive care unit (NICU) redesign from open-bay (OPBY) to single-family rooms (SFR). We analyze interviews with NICU nurses and surveys with parents/guardians of neonates discharged from the NICU in the OPBY compared to SFR settings. The SFR design increased privacy, eased facilitation of sterile and isolation procedures, and improved perceived comfort of parent participation in breastfeeding and kangaroo, or skin-to-skin, care. Increased privacy in the SFR design also resulted in unintended consequences including limited visibility of the healthcare team and increased need for clinician-parent communication. Policies and procedures meant to keep families safe during COVID-19 further decreased parents' perceived access to and responsiveness of the healthcare team. Supportive policies and procedures promoting increased clinician-parent communication and additional parental supports may need to accompany transitions to SFRs to realize improvements in parental assessments of quality of care.

Sepsis is the leading cause of inpatient mortality in the United States. The optimal timing and volume of fluid resuscitation for septic shock remain a topic of debate. This study evaluated the effect of time to completion of at least 30 mL/kg of fluid and the impact of smaller fluid volumes on hospital outcomes among patients with septic shock. Retrospective cohort study in a large community healthcare system (310,000 annual emergency visits) of all adults (age ≥ 18 yr) admitted from January 2017 to December 2022 with an International Classification of Diseases, 10th Revision diagnosis of sepsis and an initial emergency department (ED) systolic blood pressure (SBP) less than 90 mm Hg, mean arterial blood pressure less than 65 mm Hg, and/or lactate greater than or equal to 4 mmol/L. The main outcomes include hospital mortality, ICU admission, mechanical ventilation, and vasopressor use. The relationship between time to completion of 30 mL/kg and the main outcomes was assessed using generalized linear models. Among the 1602 patients who met inclusion criteria, 1190 (74.3%) received at least 30 mL/kg of fluid after ED arrival. The overall mortality rate was 24.2%, with 28.7% requiring mechanical ventilation and 64.3% requiring vasopressors. Receipt of at least 30 mL/kg between 2 and 3 hours from the time of initial ED SBP (time zero) was associated with lower odds of mortality (odds ratio [OR], 0.61; 95% CI, 0.39-0.97; p = 0.04) and mechanical ventilation use (OR, 0.43; 95% CI, 0.29-0.65; p < 0.01) compared with other intervals. Compared with receiving 30 mL/kg or greater, receiving at least 20 but less than 30 mL/kg within the first hour was associated with the lowest odds of mortality (OR, 0.33; 95% CI, 0.11-0.97; p = 0.04). Our findings show that receipt of 30 mL/kg of fluid within 3 hours is associated with reduced mortality and the need for mechanical ventilation among patients with septic shock. These results support the current Surviving Sepsis Campaign fluid recommendations.

Hypothermia begun less than 6 hours after birth reduces death or disability in infants with encephalopathy due to hypoxia-ischemia at 36 or more weeks' gestation. Trials of hypothermia for infants younger than 36 weeks' gestation are lacking. To assess the probability that hypothermia at less than 6 hours after birth decreases death or disability in infants 33 to 35 weeks' gestation with moderate or severe hypoxic-ischemic encephalopathy. This randomized clinical trial was conducted between July 2015 and December 2022 for infants 33 to 35 weeks' gestation with moderate or severe hypoxic-ischemic encephalopathy at less than 6 hours after birth. Bayesian and intention-to-treat analyses were prespecified. The setting included 19 US Neonatal Research Network centers. Data were analyzed from March 2023 to November 2024. Infants received unblinded targeted esophageal temperature management. Infants with hypothermia were maintained at 33.5 °C (acceptable 33-34 °C) for 72 hours and then rewarmed. Infants with normothermia were to be maintained at 37 °C (acceptable 36.5-37.3 °C). Composite of death or disability (moderate or severe) at 18 to 22 months' corrected age adjusted for level of encephalopathy and center. A total of 168 infants with hypothermia and normothermia were preterm (mean [SD] age, 34.0 [0.8] weeks' gestation and 34.1 [0.8] weeks' gestation, respectively), while 46 of 88 (52%) and 45 of 80 (56%) were male, respectively. Randomization occurred at mean (SD) 4.5 (1.2) hours and 4.5 (1.3) hours for the groups with hypothermia and normothermia, respectively. The primary outcome occurred in 29 of 83 infants (35%) with hypothermia and 20 of 69 infants (29%) with normothermia (adjusted relative risk [hypothermic/normothermic], 1.11; 95% credibility interval, 0.74-2.00), and death occurred in 18 of 88 infants (20%) with hypothermia and 9 of 78 infants (12%) with normothermia (adjusted relative risk, 1.38; 95% credibility interval, 0.79-2.85). Bayesian analysis with neutral prior indicated 74% probability of increased death or disability and 87% probability of increased death with hypothermia. Among infants 33 to 35 weeks' gestation with hypoxic-ischemic encephalopathy, hypothermia at less than 6 hours' age did not reduce death or disability at 18 to 22 months' corrected age. ClinicalTrials.gov Identifier: NCT01793129.

BackgroundIn many institutions, infectious diseases (ID) consultations are requested via electronic order entry and the reason for consultation is included as free text in the order. We employed an unsupervised clustering algorithm to determine whether the consult order text can be used to ascertain clinically meaningful groups among patients for whom ID consultation is requested.Figure 1.Example Word Cloud ‘Clusters’ of Free-Text Reasons for Infectious Disease Consultation and Corresponding Subject Matter Expert InterpretationMethodsWe examined the initial ID consultation for all Duke University Health System inpatients receiving consultation from 1/1/2014 - 12/31/2023. The free text “Reason for Consult?” field in the consultation order was extracted, transformed into a weighted vector format using Term-Frequency Inverse-Document Frequency, and categorized using an unsupervised K-means clustering algorithm; Algorithm parameters were adjusted to optimize clinical relevance of the clusters. Within each patient cluster, we evaluated mortality and hospital length of stay, with patients censored at their time of last contact with the health system.Figure 2.Kaplan-Meier Survival Estimates for Each ClusterResults37,848 unique patients with an ID consultation during the study period were evaluated, and 35,197 had free-text reasons associated with the electronic consult order. A combination of the K-means Elbow Method, silhouette score, and subject matter expert evaluation identified that approximately 10 clusters were optimal to categorize the dataset. Word clouds were generated for each cluster (Figure 1) and expert assessment identified the central theme of each cluster (Table 1). We identified unique patient characteristics or syndromes in nine of the patient clusters, while the final cluster was characterized as a ‘generic’ ID consult. One-year mortality varied according to cluster (Figure 2) with the highest mortality seen in the ‘Hematologic Malignancy’ category, and lowest mortality in the ‘Complicated Wound Infection’ and ‘HIV Management’ categories.ConclusionAn unsupervised clustering algorithm allowed for the identification of clinically meaningful groups of ID consultations. If validated in other settings, this approach could present an accessible way to understand qualitative and prognostic trends in ID clinical practice.Table 1.Cluster Characteristics*Institutional policy at the end of study period requires Infectious Disease consultation for patients with HIV, new lung transplant recipients, patients with candidemia or Staphylococcus aureus bacteremia, and patients for whom restricted antibiotics are requested.**Infinite median survival times indicate that the Kaplan-Meier survival curve did not cross the 50% threshold through the evaluated period.DisclosuresKristen Dicks, MD, UpToDate: Advisor/Consultant Nicholas A. Turner, MD, MHSc, PDI: Research contract|Purio Labs: Research contract