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Background: The amount of time spent on the electronic health record is often cited as a contributing factor to burnout and work-related stress in nurses. Increased electronic health record use also reduces the time nurses have for direct contact with patients and families. There has been minimal investigation into the amount of time intensive care unit nurses spend on the electronic health record. Objective: To quantify the amount of time spent by intensive care unit nurses on the electronic health record. Methods: In this observational study, active electronic health record use time was analyzed for 317 intensive care unit nurses in a single institution from January 2019 through July 2020. Monthly data on electronic health record use by nurses in the medical, neurosurgical, and surgical-trauma intensive care units were evaluated. Results: Full-time intensive care unit nurses spent 28.9 hours per month on the electronic health record, about 17.5% of their clinical shift, for a total of 346.3 hours per year. Part-time nurses and those working as needed spent 20.5 hours per month (17.6%) and 7.4 hours per month (14.2%) on the electronic health record, respectively. Neurosurgical and medical intensive care unit nurses spent 25.0 hours and 19.9 hours per month, respectively. Nurses averaged 23 clicks per minute during use. Most time was spent on the task of documentation at 12.3 hours per month, which was followed by medical record review at 2.6 hours per month. Conclusion: Intensive care unit nurses spend at least 17% of their shift on the electronic health record, primarily on documentation. Future interventions are necessary to reduce time spent on the electronic health record and to improve nurse and patient satisfaction. [ABSTRACT FROM AUTHOR]

Background: Use of the electronic health record (EHR) is a standard component of modern patient care. Although EHRs have improved since inception, cumbersome workflows decrease the time for residents to spend on clinical and educational activities. This study aims to quantify the time spent interacting with the EHR during a 3‐year emergency medicine (EM) residency. Methods: System records of time spent actively engaged in EHR use were analyzed for 98 unique EM residents over a period of 5 years from July 2015 to June 2020. Time spent on the EHR was totaled to give a career time, with a "work month" defined as a 4‐week period of 70.5 h per week, based on Accreditation Council for Graduate Medical Education work hour restrictions for EM residents. Engagement in specific activities such as chart review, documentation preparation, and order entry were separately analyzed. Results: Over their 3‐year training, a resident interacted with the EHR for 2,171 continuous hours. This amounts to 30.8 work weeks or 7.7 work months. Chart review was the most time‐intensive activity at 11.42 weeks. Documentation accounted for 9.91 weeks, with an average career total of 7,280 notes created. Additionally, each resident spent 4.57 weeks on order entry, with 46,347 orders entered during training. While the number of charts opened increased after first year of residency, average time spent on each activity per patient decreased. Conclusions: This unique study quantifies the total time an EM resident spends on the EHR during a 3‐year residency. Use of the EHR accounted for over 7.5 work months or nearly 21% of their training. Residents spend a substantial portion of their training interacting with the EHR and workflow improvements to reduce EHR time are critical for maximizing training time. [ABSTRACT FROM AUTHOR]

Introduction: Early removal of urinary catheters is an effective strategy for catheter-associated urinary tract infection (CAUTI) prevention. We hypothesized that a nurse-directed catheter removal protocol would result in decreased catheter utilization and CAUTI rates in a surgical trauma intensive care unit (STICU). Methods: We performed a retrospective, cohort study following implementation of a multimodal CAUTI prevention bundle in the STICU of a large tertiary care center. Data from a 19-month historical control were compared to data from a 15-month intervention period. Pre- and postintervention indwelling catheter utilization and CAUTI rates were compared. Results: Catheter utilization decreased significantly with implementation of the nurse-driven protocol from 0.78 in the preintervention period to 0.70 in the postintervention period (P < .05). As a result of the bundle, the CAUTI rate declined significantly, from 5.1 to 2.0 infections per 1000 catheter-days in the pre- vs postimplementation period (Incident Rate Ratio [IRR]: 0.38, 95% confidence interval: 0.21-0.65). Conclusions: Implementation of a nurse-driven protocol for early urinary catheter removal as part of a multimodal CAUTI intervention strategy can result in measurable decreases in both catheter utilization and CAUTI rates. [ABSTRACT FROM AUTHOR]

Percutaneous dilatational tracheotomy (PDT) has become increasingly popular and has gained widespread acceptance. The modern PDT procedure has also evolved to whereby it can be safely performed by surgeons and nonsurgeons in the ICU. Moreover, bedside PDT has proven clinical outcomes and can save hospital resources. As such, PDT done in the ICU is now a widely performed procedure, often being the tracheostomy procedure of choice. Today, many pulmonologists and intensivists who can use bedside PDT do not perform this procedure; it is conceivable this practice may expand, especially among pulmonologists and intensivists. Although numerous indications exist for tracheostomy, the focus of this article is limited to bedside PDT for prolonged mechanical ventilation, which is the most common indication for this procedure. We describe the logistics and operations needed for programs to incorporate PDT into routine ICU care. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the safety and technical success of inferior vena cava (IVC) filter retrieval in the setting of aorto-iliac arterial strut penetration.Materials and Methods: IVC filter registries from six large United States IVC filter retrieval practices were retrospectively reviewed to identify patients who underwent IVC filter retrieval in the setting of filter strut penetration into the adjacent aorta or iliac artery. Patient demographics, implant duration, indication for placement, IVC filter type, retrieval technique and technical success, adverse events, and post procedural clinical outcomes were identified. Arterial penetration was determined based on pre-procedure CT imaging in all cases. The IVC filter retrieval technique used was at the discretion of the operating physician.Results: Seventeen patients from six US centers who underwent retrieval of an IVC filter with at least one strut penetrating either the aorta or iliac artery were identified. Retrieval technical success rate was 100% (17/17), without any major adverse events. Post-retrieval follow-up ranging from 10 days to 2 years (mean 4.6 months) was available in 12/17 (71%) patients; no delayed adverse events were encountered.Conclusions: Findings from this series suggest that chronically indwelling IVC filters with aorto-iliac arterial strut penetration may be safely retrieved. [ABSTRACT FROM AUTHOR]

BACKGROUND/OBJECTIVE: The study explored whether premorbid substance use disorder (SUD) predicts acute traumatic brain injury (TBI) outcomes. METHODS: 143 participants with moderate (34.2%) and severe (65.8%) TBI were enrolled at two Level 1 trauma center inpatient brain injury rehabilitation units. Acute outcomes were measured with the Disability Rating Scale (DRS), the FIMTM; self and informant ratings of the Patient Competency Rating Scale (PCRS); self and family rating of the Frontal Systems Behavioral Scale (FrSBe), and the Neurobehavioral Rating Scale-Revised (NRS-R). RESULTS: Hierarchical linear modeling revealed that SUD history significantly predicted trajectories of PCRS clinician ratings, PCRS self-family and PCRS self-clinician discrepancy scores, and more negative FrSBE family ratings. These findings indicate comparatively greater post-injury executive functions (EF) impairments, particularly self-awareness (SA) of injury-related deficits, for those with SUD history.No significant SUD*time interaction effectwas found for FIM or NRS-R scores. CONCLUSIONS: SUD history and TBI are associated with impaired SA and EF but their co-occurrence is not a consistent predictor of acute post-injury functional outcomes. Pre-morbid patient characteristics and rater expectations and biases may moderate associations between SA and recovery after TBI. [ABSTRACT FROM AUTHOR]

Inferior vena cava (IVC) filters are the mainstay for pulmonary embolic prophylaxis in patients with high venous thromboembolic (VTE) risk—in particular, patients with acute VTE (deep venous thrombosis and/or pulmonary embolism) who have contraindication to therapeutic anticoagulation. Technology continues to evolve regarding IVC filters, with the most exciting changes over the past several decades including techniques of percutaneous insertion from laparotomy and retrieval of these devices. This paper will review current IVC filter designs and concepts and will discuss developments on the horizon. [ABSTRACT FROM PUBLISHER]

Primary and acquired abdominal pathology accounts for a significant proportion of sepsis and SIRS in the ICU population. Abdominal processes often present a difficult diagnostic dilemma in the truly critically ill patient who, due to hemodynamic instability or severe acute respiratory distress syndrome (ARDS) requiring high-level ventilatory support, is at significant risk during transport to radiology department. Furthermore, the accuracy of radiologic studies in the ICU setting is often limited. Laparoscopy provides a “minimally invasive” definitive modality to diagnose intra-abdominal problems. It may quickly provide the necessary information to define further management. In selective circumstances, it may actually allow appropriate intervention. However, the overall mortality of patients who undergo diagnostic laparoscopy in the ICU is high regardless of diagnostic findingsduring this procedure. Although not a technically difficult procedure, diagnostic laparoscopy does require a certain skill level, especially when limited time and unfavorable patient physiology are taken into account. The use of diagnostic laparoscopy should be limited to patients in whom a therapeutic intervention is feasible. [ABSTRACT FROM AUTHOR]

The author discusses benefits and risks associated with implantation of inferior vena cava (IVC) filters. Topics discussed include relevance of IVC filters for prevention of pulmonary embolism (PE) in venous thromboembolism (VTE) patients, permanent IVC filters being classified as higher-risk class III devices by the US Food and Drug Administration (FDA) and implications of their use such as IVC thrombosis and filter fracture.

The development of percutaneous techniques has allowed vena cava filters to be safely placed at the bedside. Such procedures appear uniquely suited for critically ill patients as they avoid the inherent risks associated with transportation. We report a ''medical intensivist's'' experience with the placement of 13 percutaneous vena cava filters. Vena cava filters were successfully placed in 12 of 13 patients as confirmed by postplacement venacavograms; 1 placement attempt was aborted because of a completely occluded inferior vena cava. These results suggest that with appropriate training and supervision, medical intensivists can safely insert vena cava filters in the intensive care unit setting. Such a practice appears safe, reduces patient risk associated with intrahospital transport, and may promote cost containment. [ABSTRACT FROM AUTHOR]

Objective. Tension pneumothorax can lead to cardiovascular collapse and death. In the prehospital setting, needle thoracostomy for emergent decompression may be lifesaving. Taught throughout the United States to emergency medical technicians (EMTs) and physicians, the true efficacy of this procedure is unknown. Some question the utility of this procedure in the prehospital setting, doubting that the needle actually enters the pleural space. This study was designed to determine if needle decompression of a suspected tension pneumothorax would access the pleural cavity as predicted by chest computed tomography (CT). Methods. We retrospectively reviewed consecutive adult trauma patients admitted to a level I trauma center between January and March 2005. We measured chest wall depth at the second intercostal space, midclavicular line on CT scans. Data on chest wall thickness were compared with the standard 4.4-cm angiocatheter used for needle decompression. Results. Data from 110 patients were analyzed. The mean age of the patients was 43.5 years. The mean chest wall depth on the right was 4.5 cm (± 1.5 cm) and on the left was 4.1 cm (± 1.4 cm). Fifty-five of 110 patients had at least one side of the chest wall measuring greater than 4.4 cm. Conclusions. The standard 4.4-cm angiocatheter is likely to be unsuccessful in 50% (95% confidence interval = 40.7-59.3%) of trauma patients on the basis of body habitus. In light of its low predicted success, the standard method for treatment of tension pneumothorax by prehospital personnel deserves further consideration. [ABSTRACT FROM AUTHOR]

The article focuses on the guidelines for the use of retrievable and convertible vena cava filters, based from report of the Society of Interventional Radiology Multidisciplinary Consensus Conference. Key information regarding the approved changes to the directions to the use of filters by the U.S. Food and Drug Administration are discussed. Instructions on the clinical application of the nonpermanent vena cava filters are also presented.

Venous thromboembolism (VTE) in trauma patients is a capricious problem that continues to plague trauma surgeons and critical care physicians alike. Pharmacologic preventions of VTE with anticoagulants are often contraindicated in the trauma patient because of risk of bleeding diathesis. Mechanical prophylaxis in the form of venous compression boots often cannot be placed because of external fixators, swelling, and so forth. Providing effective VTE prophylaxis, while at the same time providing definitive care for the trauma patient, can be a nightmare. This review will first discuss the incidence and prevalence of VTE, as well as investigate the condition's diagnosis and treatment. Solutions to frequently encountered clinical dilemmas in managing VTE in trauma patients are considered in the form of frequently asked questions. Diagnostic techniques such as magnetic resonance venography, D-dimer, and various computed tomography methods are evaluated. Recent literature on preventive pharmacologic therapies is explored. The authors also consider whether vena cava filters prevent pulmonary embolism in trauma patients. [ABSTRACT FROM AUTHOR]

Hypothesis: Ventral abdominal hernias represent a frequent and often formidable clinical problem, especially in obese patients. Because laparoscopic ventral hernia repair (LVHR) results in few complications and a low recurrence rate, the use of minimally invasive techniques in this subgroup of patients may minimize perioperative complications and failure rates. Design: Retrospective review of prospectively collected data. Setting: Tertiary care hospital. Patients: One hundred sixty-three obese patients (body mass index [calculated as weight in kilograms divided by the square of height in meters], ≥30) who underwent LVHR at our institution between July 1, 1998, and December 31, 2003. Intervention: Laparoscopic ventral hernia repair with an expanded polytetrafluoroethylene mesh. Main Outcome Measures: Patient age, sex, body mass index, size of fascial defect and mesh, operating time, operative blood loss, length of hospitalization, complications, and hernia recurrences. Results: Ninety-eight women and 65 men, with a mean body mass index of 38, underwent LVHR. Twenty patients (12.3%) had 21 postoperative complications. There was no perioperative mortality. The mean length of hospital stay was 2.6 days. The recurrence rate was 5.5% at a mean follow-up of 25 months (range, 1-73 months). Conclusions: A low rate of conversion to laparotomy, minimal perioperative morbidity, and the absence of perioperative mortality in this series indicate the safety of LVHR in obese patients with complex hernias. In addition, a success rate of more than 94.5% suggests improved efficacy of LVHR compared with the historical rates among control subjects undergoing open surgery. In experienced hands, LVHR may be the approach of choice for most patients with a body mass index of 30 or more. [ABSTRACT FROM AUTHOR]

The use of vena cava filters has increased rapidly over the past few years to more than 140,000 filters inserted worldwide in 2003. Continued improvements in filter design have increased the safety of intravascular caval filtration. Although there are many factors attributed to this increase, the most significant contributing factor has been the development of optional vena cava filters. That is, filters that can be left as a permanent device or can be removed endovascularly at a later date. Three filters are approved for removal in the United States, the Günther Tulip, the OptEase, and the Recovery. Recent reports have demonstrated the safety and feasibility of these devices in appropriate patients, but a number of questions have arisen regarding their use. [ABSTRACT FROM AUTHOR]

Various sources of ultrasonic and thermal energy have been developed to facilitate blood vessel ligation. However, their efficacy in sealing lymphatics has not been clearly established to date. We hypothesized that the electrosurgical bipolar vessel sealer (EBVS) produces reliable and durable sealing of large lymphatic vessels in a porcine model. Thoracic ducts from 4 adult pigs were explanted and sealed at multiple levels by using 3 different EBVS devices: LigaSure Atlas, XTD, and V. Fifteen seals (5 per group) were analyzed for sealing time and visual quality. Seal burst strength was measured by using a graduated pressure saline injection system. Twelve intact seals also underwent a histologic analysis. The mean overall burst strength of the seals was 271+/-78 mm Hg (127 to 360 mm Hg). The burst pressures in the 3 groups were not statistically different. The overall mean time to achieve a seal was 5.1+/-2.2 seconds (3 to 10 seconds). Seals were achieved significantly faster in the V group (4.1+/-0.6 seconds) compared with the Atlas (6.3+/-2.3 seconds) and XTD (6.4+/-2.6 seconds) groups. Qualitative seal assessment revealed minimal sticking and charring, a favorable degree of seal tissue clarity, and desiccation in the 3 groups. Histologic analysis demonstrated a fusion of lymphovascular channels with a complete obliteration of the lumens. We demonstrated that the use of EBVS results in a fast and effective sealing of large porcine lymphatic vessels. The seals created by all 3 devices burst at markedly supraphysiologic intraluminal pressures. Ongoing randomized human trials may prove the clinical benefits of the routine use of EBVS devices for various tissue dissections. [ABSTRACT FROM AUTHOR]

Introduction: The development of new energy sources for hemostasis has facilitated advanced laparoscopic procedures. Few studies, however, have documented the strength of the vessels sealed or the extent of surrounding lateral thermal injury, two important factors in maintaining hemostasis while preventing injury to surrounding structures. This study compared the burst pressure and extent of thermal injury of vessels sealed with the 5-mm laparoscopic PlasmaKinetics™ sealer (PK) (Gyrus Medical, Maple Grove, Minnesota) and the 5-mm laparoscopic LigaSure™ sealing device (LS) (Valleylab, Boulder, Colorado). Methods: Arteries in three sizes (2-3 mm, 4-5 mm, and 6-7 mm) were harvested from domestic pigs. Eight to 17 specimens from each size were randomly sealed with the PK, and the same number with the LS. Burst pressures were measured in mm Hg. The extent of thermal injury, determined by coagulation necrosis, was measured microscopically in millimeters after staining the transected vessels with hematoxylin and eosin. Descriptive statistics, including means and standard deviations, are reported. Student's t-test and ANOVA were performed to determine significance (P < .05). Results: The mean bursting pressures of the PK and the LS were equal in the 2-3 mm vessels (397 vs. 326 mm Hg, P = .49). The PK bursting pressures were significantly less than the LS in the 4-5 mm (389 vs. 573 mm Hg, P = .02) and the 6-7 mm groups (317 vs. 585 mm Hg, P = .0004). As vessel size increased, the PK was associated with significantly lower burst pressures, while the LS was associated with progressively higher burst pressures (P = .035). Thermal spread was not significantly different between the PK and the LS in the 2-3 mm (1.5 vs. 1.2 mm, P = .27), the 4-5 mm (2.4 vs. 2.4 mm, P = .79), or the 6-7 mm vessel size groups (3.2 vs. 2.5 mm, P = .32). Increasing vessel size, regardless of instrument used, was associated with increased thermal injury (P < .0001). Conclusion: The LS produces supraphysiologic seals with significantly higher bursting pressures than the PK in vessels ranging from 4 to 7 mm. The PK seals become progressively weaker while the LS seals increase in strength as the vessel size increases. Although thermal spread increases with vessel size, the degree of lateral thermal injury is no different between the two instruments. [ABSTRACT FROM AUTHOR]

Advanced laparoscopy in the morbidly obese patient is technically challenging. Having the proper instrumentation and equipment available is a major component of technical success. Items routinely used during surgery performed on patients of normal size must often be modified or substituted when morbidly obese patients undergo surgery. In this article, we review the specific tools necessary for the sate and proper completion of laparoscopic Roux-en-Y gastric bypass, in addition to various alternatives that can be helpful when other procedures are performed on morbidly obese patients. [ABSTRACT FROM AUTHOR]

Background: The endoscopic removal of cecal polyps can be complicated by hemorrhage, perforation, or incomplete resection. Laparoscopic radical appendectomy represents a safe alternative for the definitive resection and accurate pathologic evaluation of selected cecal polyps. Methods: Patients with cecal cap polyps not involving the ileocecal valve were candidates for laparoscopic radical appendectomy. Intraoperative colonoscopy and resection of the appendix and cecum to the level of the ileocecal valve were accomplished via three midline ports. For each patient, histologic evaluation by frozen section ruled out malignancy and ensured complete resection. Results: Five patients, four of whom had significant medical comorbidities, presented with large adenomatous polyps contained within the cecum. Each polyp was determined to be unresectable endoscopically; therefore, a laparoscopic radical appendectomy was performed. One patient with cirrhosis also underwent intraoperative liver ultrasonography and biopsies, which contributed to the longest operative time and hospital stay. The histologic diagnosis by frozen section was benign for each patient. The mean operative time was 95 minutes, and the mean length of hospital stay was 1.8 days. No postoperative complications were observed during a mean follow-up of 6 months. Conclusion: Laparoscopic "radical appendectomy" is an effective treatment for selected cecal adenomatous polyps. Our ability to resect the polyps completely and avoid a standard right hemicolectomy supports this approach. [ABSTRACT FROM AUTHOR]

Background: In the past, prior abdominal surgery was often felt to be a contraindication to laparoscopic cholecystectomy. The presence of adhesions precludes using a simple paraumbilical open approach for insufflation and initial trocar insertion because of an increased risk of bowel perforation and the difficulty in obtaining adequate exposure. Patients and Methods: We report 32 consecutive patients with previous upper midline incisions who underwent laparoscopic cholecystectomy with cholangiography and describe the technique and lateral positioning to facilitate this approach. Results: In our series, there were no complications. The mean length of hospital stay was 1.3 days, and the conversion rate to an open procedure was 3%: one patient who had had 22 previous abdominal operations. Conclusion: Laparoscopic cholecystectomy performed with the patient in the lateral position is safe and effective for patients who have had previous midline incisions. [ABSTRACT FROM AUTHOR]

Reports on the identification of the first multidrug-resistant strain of Salmonella harboring a plasmid-mediated AMPC beta-lactamase in the United States. Medical condition of an 18-year-old pregnant women who was transferred to a facility for percutaneous drainage of an infected choledochal cyst; Medications given to the patient at the time of discharged.

Background and Purpose: The extent of lateral spread of tissue injury is important in the success of a primary anastomosis. We compared the injury produced by the Laparo-sonic™ Coagulation Shears and the Ligasure™ system. Materials and Methods: Ureters were harvested from domestic farm pigs and ligated with the Laparo-sonic (N = 13) or Ligasure (N = 9) system. The tissues were then fixed, stained, and examined by two pathologists without knowledge of the type of treatment. Results: The mean length of thermal damage from the Ligasure was 2.11 mm (range 1.0-4.0 mm) whereas it was 1.92 (range 0.5-4.25 mm) from the Laparo-sonic system. The difference is not statistically significant. Conclusion: Debridement of as much as 5 mm of each cut end produced by the Laparo-sonic or Ligasure system may be beneficial in reducing stricture and leak. [ABSTRACT FROM AUTHOR]

The article presents views of the author on an article related to relevance of caval filtration protection for venous thromboembolism (VTE) patients who cannot receive anticoagulation. Topics discussed include inferior vena cava (IVC) filter being a replacement for anticoagulation in patients susceptible for pulmonary embolism, relevance of filters for patients with hip fractures and prophylactic use of the filters.