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Richard D Levy

Publications and source records attributed to Richard D Levy.

5 recordsLinked to original sources
PubMed2005

Interhospital transfers of patients with surgical emergencies: areas for improvement.

OBJECTIVE: To review mortality associated with interhospital transfers of patients with surgical emergencies from rural and peripheral metropolitan areas. DESIGN: A retrospective case note review. SETTING: All hospitals within an area health service including metropolitan and rural hospitals. SUBJECTS: All patients with a surgical emergency who died in hospital after interhospital transfer within an area health service. MAIN OUTCOME MEASURES: Factors associated with death and interhospital transfer. RESULTS: In total, 22 patients were identified. The mean age was 77 years. Thirty-six per cent of patients were assessed by a surgeon prior to transfer. The mean time taken for transfer was five hours. Ten patients were physiologically unstable prior to transfer. No medical escort accompanied these patients. Four patients deteriorated during the transport process. Seventy-three per cent of patients arrived out of normal working hours. Fifty per cent of patients required an operation within 24 hours of arrival. All of these patients had significant medical co-morbidities. Seventy-two per cent of these operations were performed out of hours as an emergency case. Twenty-three per cent did not receive any operative intervention or intensive care admission at the tertiary referral centre. Forty-one per cent of deaths were related to peritonitis and intra-abdominal soiling. CONCLUSIONS: Hospital systemic issues associated with mortality included extensive time delays in transfers, an inadequate transport process and frequent out-of-hours emergency operations. Patient features related to mortality included advanced age, significant medical co-morbidity and surgical pathology with a poor prognosis. Improvements concerning interhospital transfers of patients should address both systemic and patient issues.

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PubMed2005

Do surgeons need to look after unwell patients? The role of medical emergency teams.

BACKGROUND: Medical emergency teams (MET) have been shown to reduce in-hospital morbidity and mortality of surgical patients. The present study reviews the experience with the use of MET in the care of critically unwell surgical patients. METHODS: Data were prospectively collected on all patients in a general surgical unit of a tertiary referral centre meeting the criteria for activating a MET over a 6 month period. These data were retrospectively analysed with respect to surgical team and MET involvement in the care of these patients. RESULTS: Over the 6 month study period, 22 patients qualified for a MET response based on criteria of physiological instability. A MET was activated for 13 of these patients (59%), with the remainder being managed by direct consultation with intensive care and medical staff. Forty-six per cent of MET activations were outside of normal working hours. Respiratory distress including tachypnoea and desaturation was the most commonly identified physiological abnormality (13 patients), accounting for 62% of MET activations. A MET was activated by a surgical registrar in 46% of cases. Seventy-seven per cent of MET activations were preceded by at least one registrar level assessment without resolution of the patient's clinical deterioration. The most common MET interventions were supplementation of oxygen therapy and initiation of pharmacotherapy (11 patients). The surgical team complemented the MET response by providing detailed information regarding the patient's surgical condition, premorbid status (13 patients), organized transfer to the operating theatre (three patients), initiated blood transfusions (two patients) and deciding to order abdominal computed tomography (two patients). Urgent surgical decision making was required in 23% of MET activations. CONCLUSIONS: Medical emergency team activations for critically unwell surgical patients are complemented by surgical team involvement in the decision making and management process. The MET may be underutilized in the management of unwell surgical patients.

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PubMed2002

A multicenter study of the tolerability of tirofiban versus placebo in patients undergoing planned intracoronary stent placement.

BACKGROUND: The use of intravenous glycoprotein IIb/IIIa-receptor antagonists has been shown to improve outcomes in patients undergoing percutaneous transluminal coronary angioplasty (PTCA). Tirofiban has shown benefit in a wide range of patients presenting with acute coronary syndromes. Although this agent has been used in patients undergoing percutaneous coronary intervention, a literature search identified no prospective data comparing tirofiban with placebo in patients undergoing planned intracoronary stent placement. OBJECTIVE: This study examined the tolerability of tirofiban in patients undergoing percutaneous intervention with planned intracoronary stent placement. METHODS: This was a multinational, multicenter, prospective, randomized, double-blind, placebo-controlled trial in patients scheduled to undergo PTCA with planned intracoronary stent placement. Patients were randomized in a 3:2 ratio to receive tirofiban as an intravenous bolus (10 microg/kg over 3 minutes) and maintenance infusion (0.10 microg/kg per minute for 36 hours) or a bolus and infusion of placebo. All patients received periprocedural aspirin and heparin and an optional postprocedural thienopyridine (ticlopidine or clopidogrel). Laboratory and safety monitoring were performed throughout the 36 hours after the procedure and at hour 40 or hospital discharge. The primary end point was the proportion of patients with bleeding, defined according to Thrombolysis in Myocardial Infarction (TIMI) trial criteria. The number of patients with cardiac events (death, myo- cardial infarction, urgent revascularization) during the first 30 days after stent placement was also assessed. RESULTS: Eight hundred ninety-four patients (536 tirofiban, 358 placebo) were enrolled, all of whom received aspirin and heparin periprocedurally and optional ticlopidine or clopidogrel after the procedure. No significant between-group differences were observed in the incidence of TIMI major bleeding (0.2% tirofiban, 0.6% placebo) or any TIMI bleeding (3.2% and 1.7%, respectively). The incidence of TIMI minor bleeding was higher with tirofiban than with placebo (2.8% vs 0.6%). The 30-day incidence of the composite end point of any cardiac event was 3.9% in both groups. CONCLUSIONS: On a background of concomitant aspirin, heparin, and a thienopyridine, tirofiban was generally well tolerated in patients undergoing PTCA with planned intracoronary stent placement. Further investigation is needed to ascertain the optimal dosing of tirofiban and heparin to achieve reductions in ischemic complications of intracoronary stenting with an acceptable incidence of bleeding complications.

Angioplasty, Balloon, Coronary↗