Biomedical subjects

R L Jayes

Publications and source records attributed to R L Jayes.

7 recordsLinked to original sources

PubMed1996

Variations in the use of do-not-resuscitate orders in ICUS. Findings from a national study.

STUDY OBJECTIVES: To describe the variation in frequency of do-not-resuscitate (DNR) orders in 42 US ICUs and to examine the relationship between published guidelines and qualitative observations about terminal care in 9 ICUs. DESIGN: Prospective inception cohort. SETTING: Forty-two ICUs in 40 US hospitals with more than 200 beds: 26 randomly selected and 14 large tertiary-care volunteers. PARTICIPANTS: A consecutive sample of 17,440 ICU admissions during 1988 to 1990. MEASUREMENTS AND RESULTS: We used age, race, comorbid conditions, disease, functional status, and acute physiology score on ICU day 1 to predict the likelihood of a DNR order for each patient. A cross-validated model was then used to predict variations in the risk of an ICU DNR order from 0 to 45% (area under receiver operating characteristic curve = 0.9). The model was then used to compare aggregate observed with predicted frequency of ICU DNR orders. Finally, we compared observations of DNR practices by a team of clinical and organizational researchers at 9 of the 42 ICUs with published guidelines and risk-adjusted DNR frequency: 1,577 admissions (9%) had DNR orders written in the ICU (range, 1.5 to 22%). The ICU site was a significant (p < 0.0001) predictor of variance in the patient level model. DNR orders were written significantly (p < 0.05) less frequently than predicted in 5 and more frequently than predicted in 3 of 42 ICUs. Nonwhite patients had significantly (p = 0.0001) fewer DNR orders after adjustment. The research team's implicit judgments following on-site analysis failed to distinguish ICUs with more or less DNR orders than predicted. Site-visited ICUs exhibited practices to emulate and practice to avoid. CONCLUSIONS: The frequency of ICU DNR orders can be predicted based on individual risk factors for groups of ICU patients. After adjusting for differences in patient characteristics, there is significant variation in the frequency of DNR orders in a national sample of ICUs. These variations may be due to unmeasured differences in patient characteristics such as treatment preferences, religious affiliation, educational level, or physician practices. We found no relationship between risk-adjusted DNR order frequency and adherence to published guidelines.

APACHE↗

PubMed1993

Do-not-resuscitate orders in intensive care units. Current practices and recent changes.

OBJECTIVES: To describe the characteristics of patients with do-not-resuscitate (DNR) orders and the frequency and timing of these orders in a representative sample of intensive care units (ICUs) and to compare practices from 1980 to 1990. DESIGN: Prospective inception cohort. SETTING: A total of 42 ICUs in 40 US hospitals with 200 or more beds; 26 randomly selected hospitals and 14 large, tertiary care hospitals that volunteered to be studied. PARTICIPANTS: A consecutive sample of 17,440 ICU admissions from 1988 to 1990. MEASUREMENTS: Patient demographic characteristics, comorbid conditions, disease, and physiological abnormalities. MAIN OUTCOME MEASURES: Frequency and timing of DNR orders; ICU resource use before and after DNR orders; and patients' hospital and ICU discharge status. RESULTS: Physicians wrote DNR orders for 1577 ICU admissions (9%) (hospital range, 1.5% to 22%). Patients with ICU DNR orders were older, more functionally impaired, had more comorbid illness, a higher severity of illness, and required the use of more ICU resources compared with patients without DNR orders. Compared with data from a similar survey from 1979 to 1982, ICU DNR orders were more frequent in 1988 to 1990 (9% vs 5.4%; P < .001) and preceded 60% of all in-unit deaths compared with only 39% in 1979 to 1982 (P < .001). Do-not-resuscitate orders were written sooner (for 3.6% vs 2.0% of patients on day 1 in the ICU) and patients with DNR orders remained in the ICU longer in 1988 to 1990 (2.8 vs 1.4 days) than in 1979 to 1982, and had lower ICU and hospital mortality rates (64% vs 74%, P < .001; and 85% vs 94%, P < .001). CONCLUSIONS: Over the last decade physicians and patients' families set limits earlier and more frequently in cases likely to have poor outcomes. We attribute this change to a greater dialogue about setting limits to care and a greater knowledge of treatment outcomes among physicians and families. These changes in practice preceded implementation of the Patient Self-determination Act, designed to ensure patient autonomy for decisions about life-sustaining therapy.

Adult↗

PubMed1993

Disseminated pneumocystosis presenting as a pleural effusion.

Extrapulmonary pneumocystosis recently has been reported in a number of tissues. Most cases occurred in patients receiving aerosolized pentamidine prophylaxis. We report a case of disseminated pneumocystosis presenting as a large pleural effusion without apparent lung involvement where Pneumocystis carinii was the only pathogen identified. The absence of parenchymal lesions on chest x-ray film, the lack of hypoxemia and the minimal uptake of gallium all argue against significant lung involvement. The patient was successfully treated with chest tube drainage, intravenous and inhaled pentamidine and orally administered dapsone and trimethoprim. The addition of inhaled pentamidine to intravenously administered pentamidine may have increased pleural fluid levels substantially and its use coincided with the patient's improvement.

Administration, Inhalation↗

PubMed1992

Do patients' coronary risk factor reports predict acute cardiac ischemia in the emergency department? A multicenter study.

The objective of the present study was to determine whether the presence of the classical coronary risk factors increases the likelihood of acute cardiac ischemia beyond that expected from clinical presentation and electrocardiogram. Clinical data and reports of classical coronary risk factors were collected prospectively from 1743 patients without clinically obvious coronary disease. Patients were selected from 5773 emergency department patients at 6 hospitals who presented with symptoms suggesting acute ischemia. We used logistic regression to determine the relative risk of each risk factor report for acute ischemia. In women, the presence of classical risk factor reports does not increase the risk of acute ischemia. In men, only diabetes and family history of myocardial infarction significantly increase the risk (p less than 0.05). The relative risks are 2.4 and 2.1, respectively, and are small compared to those conferred by chest pain (12.1), an abnormal ST segment (8.7), or an abnormal T wave (5.3). For a patient presenting to the emergency department, the classical coronary risk factors convey minimal risk for acute cardiac ischemia, especially when compared to the overwhelming importance of the chief complaint and the ECG.

Adult↗

PubMed1990

Outcomes in SUPPORT.

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Activities of Daily Living↗

PubMed1989

Donor specific transfusions or cyclosporine for related-donor kidney transplantation?

DST and cyclosporine are two immunosuppressive strategies to improve first year graft survival in high MLC, one-haplotype matched, living-related donor kidney transplantation. However, each has disadvantages: The conventional strategy of DST may sensitize the recipient to donor antigens, precluding transplantation from that donor, and cyclosporine may increase graft failure due to nephrotoxicity. We used decision analysis to compare these two strategies. We assumed that the risk of sensitization by DST is 12%, that graft failure in the first year is equal in both strategies, but that the annual probability of graft failure in later years is 2.6% with DST and from 2.7% to 3.6% with cyclosporine. Patients sensitized by DST and patients with graft failure undergo dialysis while awaiting cadaveric donor transplantation using cyclosporine. Outcomes were assessed as quality-adjusted years of survival. The analysis was deliberately biased to favor DST, the conventional strategy. Quality-adjusted life expectancy for a 40-year-old patient in both strategies is from 17.7 to 19.1 years. The difference between the DST and cyclosporine strategies ranges from -0.7 to +0.6 years. Given current data on sensitization by DST, long-term cyclosporine nephrotoxicity, and deliberate biases favoring the DST strategy, we conclude that there is no substantive advantage of the DST strategy. Cyclosporine is equally efficacious for recipients of high MLC, one-haplotype matched kidney transplants, and may be preferred for transplants from more distant relatives and unrelated living donors.

Blood Transfusion↗

PubMedDate not supplied

Physician electrocardiogram reading in the emergency department--accuracy and effect on triage decisions: findings from a multicenter study.

OBJECTIVE: To determine how well physicians in emergency departments read electrocardiographic (ECG) ST-segment and T-wave changes and how this affects triage decisions. METHODS: In the emergency departments of six teaching and nonteaching hospitals, the authors prospectively collected physicians' ECG readings and clinical data for 2,320 patients presenting with possible acute cardiac ischemia from 1979 to 1981. RESULTS: Compared with electrocardiographers, the study physicians misread as normal 41% of abnormal ST segments and 36% of abnormal T waves, and misread as abnormal 14% of normal ST segments and 17% of normal T waves. Trainees were significantly more sensitive readers of T-wave changes but less specific readers of both ST-segment and T-wave changes when compared with other physicians. Suboptimal triage was more likely when abnormal ST segments or T waves were misread as normal (22% vs. 11%, p less than 0.001, and 18% vs. 14%, p = 0.08, respectively). Conversely, coronary care unit (CCU) admission for patients without acute cardiac ischemia was more likely when normal ST segments were misread as abnormal (23% vs. 13%, p less than 0.0001). CONCLUSIONS: Physicians in emergency departments often misread the ST segments and T waves of patients with possible acute cardiac ischemia. Misreading is related to suboptimal triage and unnecessary CCU admission. Training emergency physicians to make these distinctions more accurately could improve medical care and hospital utilization.

Adult↗