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Background: Ideally, percutaneous, mechanical closure of defects of the atrial septum should completely resolve shunt. To achieve this goal, more information is needed about the factors associated with device failure. Methods: Consecutive patients with cryptogenic neurological events who had severe baseline Valsalva shunt (Spencer Grade 5-5+) and intracardiac echocardiography (ICE) defined patent foramen ovale (PFO) who underwent percutaneous PFO closure with the GORE(®) HELEX Septal Occluder device were evaluated for residual 3-month shunt by transcranial Doppler (TCD). Results: We closed 315 PFO patients with the HELEX devices: 15, 20, 25, 30 mm devices in 19, 138, 150, and 8 patients, respectively. Severe residual Valsalva shunt (TCD Grade 5-5+) at 3 months occurred in 23 of 315 (7%) of all patients and in 2 of 108 (2%), 5 of 86(6%), and 16 of 121 (13%) patients with none, Grade 4, and Grade 5-5+ baseline rest shunt, respectively (P = 0.002). At 3 months, rest shunting was essentially abolished by closure. The percent of patients with severe residual Valsalva shunt was also related to device size: 15 mm (0%), 20 mm (4%), 25 mm (10%), and 30 mm (25%) (P = 0.008) and to atrial septal aneurysm. All of these variables were independent predictors of failure by multivariate logistic regression. Conclusions: In an ICE-defined PFO population characterized by severe baseline Valsalva shunt and a high incidence of persistent (rest) shunting, the GORE(®) HELEX Septal Occluder device effectively reduces both provoked and persistent shunt. The causes of device failure are multifactorial. Larger devices perform less reliably suggesting the need for size-specific modifications to improve closure of more severe defects. (J Interven Cardiol 2011;24:366-372). [ABSTRACT FROM AUTHOR]

Purpose. Analyse racial disparities in clinical outcomes after stroke in inpatient rehabilitation facilities (IRF). Methods. Analyses based on data from a multi-center prospective observational cohort study on inpatient stroke rehabilitation in six IRFs from across the United States. Multivariate models examined racial disparities in functional outcomes upon discharge, taking into account patient characteristics and detailed information on processes of care. Results. In the moderate stroke group (N = 397), functional scores on admission were not significantly different between African-Americans and whites. In the severe stroke group (N = 335), whites showed significantly lower functional scores at admission [Functional Independence Measurement, (FIM)], mean scores, 44 versus 49 for African-Americans, p < 0.001). Multivariate analyses predicting discharge motor FIM score found no significant differences between African-American and white stroke patients (p = 0.2194 and p = 0.3547 in the moderate and severe stroke group, respectively). Conclusion. Controlling for patient characteristics, therapy intensity and processes of care results in non-significant differences between African-Americans and whites in motor FIM scores upon discharge. The absence of significant differences in recovery while patients were on the rehabilitation unit suggests that racial disparities in long-term functional recovery after stroke are likely to have originated before or after the inpatient rehabilitation stay. [ABSTRACT FROM AUTHOR]

Presents a clinical practice improvement study undertaken to determine how variation in patient characteristics and clinical processes impact patient outcomes. Improvement of outcomes for patients hospitalized with congestive heart failure; Evaluation of care against accepted guidelines; Patient care process variables associated with better outcomes.

Background: Timely diagnosis of heart failure (HF) and rapid optimisation of guideline-directed medication therapy (GDMT) improves patients qualities of life, reducing mortality and morbidity. Previous papers describe the role of pharmacists in medication optimisation, but not in the diagnosis of HF., Aim: To describe the development, implementation, and evaluation of pharmacist-led heart failure clinics with respect to time from referral to diagnosis, time from diagnosis to first review with a specialist, and the proportion receiving optimal GDMT 180 days after diagnosis., Setting: Community outpatient clinics in rural west Wales, United Kingdom., Development: Two experienced non-medical prescribing pharmacists, one of whom had additional diagnostic qualifications in cardiology, delivered the clinic., Implementation: Patients referred with suspected HF were risk-stratified to urgent (within 14 days of referral) or routine (within 42 days) review, based on natriuretic peptide levels. Patients attended the clinic for assessment, including physical examination, electrocardiogram, and echocardiogram. Those with HF with reduced ejection fraction were initiated on drug treatment and referred to the follow-up pharmacist-led GDMT clinic., Evaluation: A sample of 100 patients was evaluated (50 from pre-existing and 50 from new service). Median time from referral to diagnosis reduced from 61 days (IQR 47-115) to 16 days (IQR 10.5-27.5) for urgent and 19 days (IQR 11.5-33) for routine. Median time to first appointment following diagnosis reduced from 54 days (IQR 36-60.5) to 14 days (IQR 9.75-28.75) (p value < 0.0001), and proportion of patients achieving GDMT at 180 days following diagnosis improved from 24 to 86% (p value < 0.0001)., Conclusion: This pharmacist HF diagnostic clinic and medication optimisation clinic improved time to diagnosis, time to first specialist review, and proportion of patients' achieving GDMT optimisation in a rural healthcare setting., (© 2024. Crown.)

Objective: Constipation is commonly diagnosed in our pediatric emergency department (ED). Care has varied significantly, with a heavy reliance on abdominal radiography (AR) for the diagnosis of and inpatient management for bowel cleanout. We implemented a standardized approach to caring for patients presenting to a pediatric ED with symptoms consistent with constipation, emphasizing clinical history, physical examination, less reliance on AR, and standardized home management., Methods: Using quality improvement (QI) methodology, a multidisciplinary group developed an ED constipation management pathway, encouraging less reliance on AR for diagnosis and promoting home management over inpatient bowel cleanout. The pathway included a home management "gift basket" containing over-the-counter medications and educational materials to promote successful bowel cleanout. Outcome measures included pathway utilization, AR rate, ED cost and length of stay, and ED admission rate for constipation., Results: Within 3 months, >90% of patients discharged home with an ED disposition diagnosis of constipation left with standardized educational materials and home medications. Staff education and feedback, pathway and gift basket changes, and a higher threshold for inpatient management led to significant decreases in AR rate (73.3%-24.6%, P < .001), average per-patient cost ($637.42-$538.85), length of stay (223-196 minutes, P < .001), and ED admission rate (15.3%-5.4%, P < .001), with no concerning missed diagnoses or increases in ED revisit rate., Conclusions: An ED QI project standardizing the care of pediatric constipation was implemented successfully, leading to a sustainable decrease in resource utilization. The next phase of the project will focus on collaborating with community providers to reduce ED utilization., (Copyright © 2018. Published by Elsevier Inc.)

Objectives: To evaluate whether a quality improvement intervention reduces sternal wound infection rates in children after cardiac surgery., Design: This is a pre- and postintervention quality improvement study., Setting: A 16-bed cardiac ICU in a university-affiliated pediatric tertiary care children's hospital., Patients: All patients undergoing cardiac surgery via median sternotomy from January 2010 to December 2014 are included. The sternal wound infection rates for primary closure and delayed sternal closure are reported per 100 sternotomies. The hospital-acquired infection records were used to identify preintervention cases, while postintervention cases were collected prospectively., Intervention: Implementation of a sternal wound prevention bundle during the preoperative, intraoperative, and postoperative periods for cardiac surgical cases., Measurements and Main Results: During the preintervention period, 32 patients (3.8%) developed sternal wound infection, whereas only 19 (2.1%) developed sternal wound infection during the postintervention period (p = 0.04). The rates of sternal wound infection following primary closure were not significantly different pre- and postintervention (2.4% vs 1.6%; p = 0.35). However, patients with delayed sternal closure had significantly lower postintervention infection rates (10.6% vs 3.9%; p = 0.02)., Conclusions: Implementation of a sternal wound prevention bundle during the perioperative period was associated with lower sternal wound infection rates in surgeries with delayed sternal closure.

Introduction: Bronchiolitis is the leading cause of hospitalization among infants and young children. Because of its frequency, a clinical practice guideline for bronchiolitis was implemented in this population in an effort to decrease costs and the number of diagnostic evaluations performed and medications used without increasing length of stay or transfers to the pediatric intensive care unit., Methods: A retrospective chart review of 322 pediatric admissions to a rural community hospital was conducted (169 before guideline implementation and 153 after guideline implementation), and data were categorically stratified into three groups for comparison purposes. Descriptive statistics were used to analyze the data, with a p value < .05 defining significance., Results: During the project period, patients with a mean age of 9.6 months were admitted to the hospital with bronchiolitis. Statistically significant decreases in cost per day and decreases in use of antibiotics and chest radiographs were achieved without increasing length of stay or pediatric intensive care unit transfers., Discussion: This project demonstrated feasibility in implementing an evidence-based clinical practice guideline in a rural hospital to improve patient outcomes., (Copyright © 2015 National Association of Pediatric Nurse Practitioners. Published by Elsevier Inc. All rights reserved.)

Formal algebras are among the most powerful and general mechanisms for expressing quantitative relational statements; yet, even university engineering students, who are relatively proficient with algebraic manipulation, struggle with and often fail to correctly deploy basic aspects of algebraic notation (Clement, 1982). In the cognitive tradition, it has often been assumed that skilled users of these formalisms treat situations in terms of semantic properties encoded in an abstract syntax that governs the use of notation without particular regard to the details of the physical structure of the equation itself (Anderson, 2005; Hegarty, Mayer, & Monk, 1995). We explore how the notational structure of verbal descriptions or algebraic equations (e.g., the spatial proximity of certain words or the visual alignment of numbers and symbols in an equation) plays a role in the process of interpreting or constructing symbolic equations. We propose in particular that construction processes involve an alignment of notational structures across representation systems, biasing reasoners toward the selection of formal notations that maintain the visuospatial structure of source representations. For example, in the statement "There are 5 elephants for every 3 rhinoceroses," the spatial proximity of 5 and elephants and 3 and rhinoceroses will bias reasoners to write the incorrect expression 5E = 3R, because that expression maintains the spatial relationships encoded in the source representation. In 3 experiments, participants constructed equations with given structure, based on story problems with a variety of phrasings. We demonstrate how the notational alignment approach accounts naturally for a variety of previously reported phenomena in equation construction and successfully predicts error patterns that are not accounted for by prior explanations, such as the left to right transcription heuristic.

Background: Percutaneous, mechanical closure of defects of the atrial septum fails to completely resolve shunting in up to 20% of cases. Little is known about the factors associated with device failure., Methods: We measured the left atrial opening (X), right atrial opening (Z), tunnel length (Y), septum secundum, device-septum primum separation, and tunnel compressibility of the patent foramen ovale (PFO) in 301 patients with cryptogenic neurological events, PFO anatomy, and severe Valsalva shunting (Spencer Grade 5-5+). All patients then underwent percutaneous closure with the GORE®HELEX Septal Occluder device and were evaluated at 3 months for residual shunt by transcranial Doppler (TCD)., Results: Severe residual Valsalva shunt (TCD Grade 5-5+) was found at 3 months in 21 of 301 (7%) patients. X, Y, and Z were associated with failure with a high degree of statistical significance, whereas the width of the septum secundum, device-septum primum separation, and tunnel compressibility were not. An unanticipated finding was that 14 of 35 (40%) patients sized with a large balloon failed compared with 9 of 280 (3%) sized with a small balloon (P < 0.0001). In the multivariate logistic regression model, X (P = < 0.0001) and balloon size (P < 0.0001) were both strong predictors of failure., Conclusions: In an intracardiac echocardiography-defined PFO population, characterized by severe baseline Valsalva shunt and a high incidence of persistent (rest) shunting, association of six intracardiac measurements to closure device failure by multivariate logistic regression showed that the width of the left atrial opening was a strong predictor of residual shunting. An unanticipated finding was that use of a large sizing balloon was also strongly associated with failure., (©2012, Wiley Periodicals, Inc.)

Objectives: To examine the patterns of rehabilitation after elective and nonelective hip arthroplasty and its association with outcomes over an episode of postacute care., Design: Data were obtained from a multisite prospective observational cohort study and its companion follow-up study. Patterns of care were measured by the combination of settings of care where hip arthroplasty patients received rehabilitation therapy. Main outcome measure was motor portion of the functional independence measure., Results: Approximately 90% of hip arthroplasty patients received rehabilitation care from more than one setting. Eight patterns of care were identified in the follow-up period. Patterns of subsequent care were driven more by initial setting than by etiology. Nonelective hip arthroplasty patients had lower motor functional independence measure scores and used more rehabilitation services than did elective hip arthroplasty patients. Patterns of care were modest factors (accounted for only 7% of variance) in predicting patient motor functional independence measure over an episode of postacute care., Conclusions: Etiology of hip arthroplasty is associated with amounts of rehabilitation care used and outcomes. After the initial postacute rehabilitation setting, patients continued to receive considerable amounts of therapy in various settings. It is important to look beyond a single setting of care to an entire episode of care when examining clinical outcomes.

Objectives: To identify resident and wound characteristics associated with Stage 2 pressure ulcer (PrU) healing time in nursing home residents., Design: Retrospective cohort study with convenience sampling., Setting: One hundred two nursing homes participating in the National Pressure Ulcer Long-Term Care Study (NPULS) in the United States., Participants: Seven hundred seventy-four residents aged 21 and older with length of stay of 14 days or longer who had at least one initial Stage 2 (hereafter Stage 2) PrU., Measurements: Data collected for each resident over a 12-week period included resident characteristics and PrU characteristics, including area when first reached Stage 2. Data were obtained from medical records and logbooks., Results: There were 1,241 initial Stage 2 PrUs on 774 residents; 563 (45.4%) healed. Median time to heal was 46 days. Initial area was significantly associated with days to heal. Using Kaplan-Meier survival analyses, median days to heal was 33 for small (1 to 4 cm(2)) ulcers. Using Cox proportional hazard regression models to examine effects of multiple variables simultaneously, small and medium ulcers and ulcers on residents with agitation and those who had oral eating problem healed more quickly, whereas ulcers on residents who required extensive assistance with seven to eight activities of daily living (ADLs), who temporarily left the facility for the emergency department (ED) or hospital, or whose PrU was on an extremity healed more slowly., Conclusion: PrUs on residents with agitation or with oral eating problems were associated with faster healing time. PrUs located on extremities, on residents who went temporarily to the ED or hospital, and on residents with high ADL disabilities were associated with slower healing time. Interaction between PrU size and place of onset was also associated with healing time. For PrU onset before or after admission to the facility, smaller size was associated with faster healing time.

Concern that opioids hasten death may be among the reasons that pain is treated inadequately in populations with advanced illness. Studies that assess the true risks are needed. To determine whether survival after last opioid dose change is associated with opioid dosing characteristics and other factors, data from the National Hospice Outcomes Project, a large prospective cohort study involving 13 U.S. hospice programs, were analyzed. Of 1,306 patients, 725 received opioids and underwent at least one dose change before death. Subsamples based on maximum opioid dose compared patients receiving usual doses with those receiving high-dose therapy. Spearman rank correlations examined bivariate associations between survival after final dose change and other variables, including dose in morphine equivalent mg and percentage dose increase. Multivariate least squares regression analyses determined associations between survival and other variables, including those significant in bivariate analyses. The mean+/-SD number of days between final dose change and death was 12.46+/-23.11. Multivariate models demonstrated a significant association between shorter survival and higher opioid dose, a cancer diagnosis, unresponsiveness, and pain of <5 on a 0-10 scale, but none of these models explained >10% of the variance in time till death. Analyses of subsamples did not reveal additional effects of dose. This analysis revealed that opioid dosing was associated with time till death, but this factor would explain very little of the variation in survival. In a hospice population, survival is influenced by complex factors, many of which may not be measurable. Based on these findings, concern about hastening death does not justify withholding opioid therapy.

Background: Portions of the prospective, multi-institutional National Veterans Affairs Surgical Quality Improvement Program were used to develop and validate a perioperative risk index to predict abdominal wound dehiscence after laparotomy., Methods: Perioperative data from 17,044 laparotomies resulting in 587 (3.4%) wound dehiscences performed at 132 Veterans Affairs Medical Centers between October 1, 1996, and September 30, 1998, were used to develop the model. Data from 17,763 laparotomies performed between October 1, 1998, and September 30, 2000, resulting in 562 (3.2%) dehiscences were used to validate the model. Models were developed using multivariable stepwise logistic regression with preoperative, intraoperative, and postoperative variables entered sequentially as independent predictors of wound dehiscence. The model was used to create a scoring system, designated the abdominal wound dehiscence risk index., Results: Factors contributing significantly to the model and their point values (in parentheses) for the risk index include CVA with no residual deficit (4), history of COPD (4), current pneumonia (4), emergency procedure (6), operative time greater than 2.5 h (2), PGY 4 level resident as surgeon (3), clean wound classification (-3), superficial (5), or deep (17) wound infection, failure to wean from the ventilator (6), one or more complications other than dehiscence (7), and return to OR during admission (-11). Scores of 11-14 are predictive of 5% risk of dehiscence while scores of >14 predict 10% risk., Conclusions: This abdominal wound dehiscence risk index identifies patients at risk for dehiscence and may be useful in guiding perioperative management.

Objectives: To adapt the adult Comprehensive Severity Index (CSI) for hospitalized pediatric patients and evaluate the ability of the CSI to predict common outcomes., Study Design: Adult CSI was modified by a panel of pediatric subspecialists from 10 children's hospitals. Predictive power was evaluated by using retrospective data collected from 16,495 randomly selected children admitted to these hospitals from April 1995 through September 1996. Outcomes were mortality, length of stay (LOS), and cost., Results: Admission CSI score predicted mortality well (Hosmer-Lemeshow tests: P =.41-.98) and discriminated well (area under receiver operating characteristic [ROC] curve range = 0.80-0.99) within 9 case-mix groups with > or =10 deaths (P <.0001). Maximum CSI score explained the variation in LOS (r2 = 0.13-0.67) and cost (r2 = 0.08-0.73) within 32 case-mix groups (P <.005). Significant differences existed in admission and maximum average CSI scores across sites in 26 and 29 of 32 case-mix groups, respectively (P <.05). CSI had better predictability than Pediatric Risk of Mortality., Conclusions: The age- and disease-specific pediatric CSI score correlates highly with LOS, cost, and mortality in hospitalized children and can help determine the best clinical practices for specific diseases and adjust for differences in severity of illness across providers.

Objective: Hospital care for children with viral lower respiratory illness (VLRI) is highly variable, and its relationship to severity and impact on outcome is unclear. Using the Pediatric Comprehensive Severity Index, we analyzed the correlation of institutional practice variation with severity and resource utilization in 10 children's medical centers., Methods: Demographics, clinical information, laboratory results, interventions, and outcomes were extracted from the charts of consecutive infants with VLRI from 10 children's medical centers. Pediatric Component of the Comprehensive Severity Index scoring was performed at admission and at maximum during hospitalization. The correlation of patient variables, interventions, and resource utilization at the patient level was compared with their correlation at the aggregate institutional level., Results: Of 601 patients, 1 died, 6 were discharged to home health care, 4 were discharged to rehabilitative care, and 2 were discharged to chronic nursing care. Individual patient admission severity score correlated positively with patient hospital costs (r = 0.48), but institutional average patient severity was negatively correlated with average institutional costs (r = -0.26). Maximal severity score correlated well with costs (r = 0.66) and length of stay (LOS; r = 0.64) at the patient level but poorly at the institutional level (r = 0.07 costs; r = 0.40 LOS). The institutional intensity of therapy was negatively correlated with admission severity (r = -0.03) but strongly correlated with costs (r = 0.84) and LOS (r = 0.83)., Conclusions: Institutional differences in care practices for children with VLRI were not explained by differences in patient severity and did not affect the children's recovery but correlated significantly with hospital costs and LOS.

Background: The role of perioperative nutrition in surgical patients remains controversial. We performed a Clinical Practice Improvement (CPI) study that, while controlling for severity of illness, explored the relationship between the timing and amount of parenteral or enteral nutrition, with two outcomes: length of stay (LOS) and total charges in patients undergoing open intestinal operations., Materials and Methods: A CPI study was conducted at eight hospitals to determine which process steps were associated with shorter LOS and lower charges. Hospital charts were abstracted for over 800 components of detailed patient, process, and outcome measures. Severity of illness was measured multiple times during the stay using the Comprehensive Severity Index, a disease-specific physiologic severity measurement instrument. Data on 1007 patients undergoing intestinal operations, 183 of whom received nutritional support, were then analyzed using multiple regression procedures. Early (within 48 h of surgery) and sufficient (60% of protein and calorie goals) nutrition, patient variables, and a severity of illness measure were included as independent variables and LOS and hospital charges were used as dependent variables., Results: Mean patient age was 58 years. After controlling for severity of illness, patients who received early and sufficient nutrition had significantly shorter LOS (11.9 days) and lower charges ($34,602) than patients who received early (13.3; $36,452), sufficient (14.6, $39,883), or neither early nor sufficient (14.8, $38,578) (P < or = 0.0001 for early and sufficient versus all other groups)., Conclusions: CPI methodology provides a detailed view of the actual relationship between the timing and the amount of nutrition with LOS and hospital charge outcomes., (Copyright 2001 Academic Press.)