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At least 847 records · Page 47Linked to original sources

PubMed2004

Impact of a rapid rule-out protocol for pulmonary embolism on the rate of screening, missed cases, and pulmonary vascular imaging in an urban US emergency department.

STUDY OBJECTIVE: This study tests the hypothesis that implementation of a point-of-care emergency department (ED) protocol to rule out pulmonary embolism would increase the rate of evaluation without increasing the rate of pulmonary vascular imaging or ED length of stay and that less than 1.0% of patients with a negative protocol would have an adverse outcome. METHODS: A baseline study was conducted on patients with suspected pulmonary embolism at an urban ED to establish baseline measurements performed when only pulmonary vascular imaging was available to rule out pulmonary embolism. The intervention protocol used pretest probability assessment, a whole-blood d -dimer assay, and an alveolar dead-space measurement to rule out pulmonary embolism. The main outcomes were diagnosis of venous thromboembolism or sudden unexpected death within 90 days. RESULTS: During baseline, 453 of 61,322 patients (0.74%; 95% confidence interval [CI] 0.67% to 0.81%) underwent pulmonary vascular imaging, and 8% (95% CI 6% to 11%) of scan results were positive; 1.20% (95% CI 0.39% to 2.78%) of untreated discharged patients were anticoagulated for venous thromboembolism or died unexpectedly within 90 days. The median length of stay was 385 minutes. After intervention, 1,460 of 102,848 patients (1.42%; 95% CI 1.35% to 1.49%) were evaluated for pulmonary embolism. Seven hundred fifty-two patients had a negative protocol and 5 of 752 (0.66%; 95% CI 0.20% to 1.54%) had venous thromboembolism within 90 days, none with unexpected death. After intervention, the rate of pulmonary vascular imaging tended to decrease (0.64%; 95% CI 0.59% to 0.69%), and more scans (11%; 95% CI 9% to 14%) were read as positive; the length of stay decreased to 297 minutes. CONCLUSION: A point-of-care pulmonary embolism rule-out protocol doubled the rate of screening for pulmonary embolism in the ED, had a false negative rate of less than 1.0%, did not increase the pulmonary vascular imaging rate, and decreased length of stay.

Adult↗

PubMed2005

Prospective performance assessment of an out-of-hospital protocol for selective spine immobilization using clinical spine clearance criteria.

STUDY OBJECTIVE: We determine whether the use of an emergency medical services (EMS) protocol for selective spine immobilization would result in appropriate immobilization without spinal cord injury associated with nonimmobilization. METHODS: A 4-year prospective study examined EMS and hospital records for patients after the implementation of an EMS protocol for selective spine immobilization. EMS personnel were trained to perform and document a spine injury assessment for out-of-hospital trauma patients with a mechanism of injury judged sufficient to cause a spine injury. The assessment included these clinical criteria: altered mental status, evidence of intoxication, neurologic deficit, suspected extremity fracture, and spine pain or tenderness. The protocol required immobilization for patients with a positive assessment on any of those criteria. Outcome characteristics included the presence or absence of spine injury and spine injury management. RESULTS: The study collected data on 13,483 patients; 126 of the patients were subsequently excluded from the study because of incomplete data, leaving a study sample of 13,357 patients with complete data. Spine injuries were confirmed in the hospital records for 3% (n=415) of patients, including 50 patients with cord injuries and 128 patients with cervical injuries. Sensitivity of the EMS protocol was 92% (95% confidence interval [CI] 89.4 to 94.6%) resulting in nonimmobilization of 8% of the patients with spine injuries (33 of 415). None of the nonimmobilized patients sustained cord injuries. The specificity was 40% (95% CI 38.9 to 40.5%). CONCLUSION: The use of our selective immobilization protocol resulted in spine immobilization for most patients with spine injury without causing harm in cases in which spine immobilization was withheld.

Adolescent↗

PubMed2004

Reading-related oculomotor testing and training protocols for acquired brain injury in humans.

Many individuals with acquired brain injury (ABI) report reading problems of oculomotor origin. These may include frequent loss of place, skipping of lines and difficulty shifting to the next line of print. We describe two protocols for the testing and training of reading-related eye movements in adult individuals with ABI (traumatic brain injury [TBI] and stroke with hemianopia), who experience oculomotor-based symptoms when reading. These protocols use objective eye movement recording techniques and computer-based stimulus presentation and analysis. One protocol tests and the other trains basic horizontal and vertical versional eye movements (fixation, saccades and pursuit), as well as reading eye movements using simulated single and multiple line dynamic arrays. In addition, a reading rating-scale questionnaire is administered before and after completion of training to assess subjective reading improvement. In all paradigms, the target consists of a 0.5 degrees luminous square, which is displayed on a computer monitor positioned 40 cm from the subject along the midline. All testing and training are conducted under binocular viewing conditions with optical correction in place. There are two modes of training: normal internal oculomotor visual feedback either alone (4 weeks) or in conjunction with external oculomotor auditory feedback (4 weeks) administered in a counterbalanced manner within each diagnostic group. Training is performed 1 h, twice weekly for the 8 weeks. Oculomotor testing is conducted before, midway and after training. Following training, reading-related eye movements and reading ability improved as assessed both subjectively and objectively. These protocols provide a systematic approach to the quantitative and comprehensive testing and training of reading-related eye movement skills and behaviors in the ABI population manifesting oculomotor-based reading dysfunctions. Furthermore, the training protocol results in the rapid remediation of the eye movement deficits, which appear to transfer to activities of daily living.

Brain Injuries↗

PubMed2005

The mathematical modelling of adjuvant chemotherapy scheduling: incorporating the effects of protocol rest phases and pharmacokinetics.

In this paper the modelling objective is to determine the drug alternation time which minimises the formation of resistant tumour cells when delivering two non-cross resistant chemotherapeutics given such drugs cannot be delivered simultaneously and constraints due to pharmacokinetics and protocol rest phases. We initially consider cell cycle phase non-specific models, as investigated by Goldie and Coldman. By extending previous work, these models are generalised to consider chemotherapeutic S-phase specificity. We find with the cell cycle phase non-specific models that once the alternation time of the drugs is reduced below a critical threshold, a substantial improvement in protocol outcome is predicted. Extensive improvements are also observed for the S-phase specific investigation if the drugs can be alternated extremely rapidly. However, this is typically impossible due to pharmacokinetic constraints. Under such circumstances, the most appropriate choice of the alternation time can depend sensitively on the median and variance of the tumour cell cycle time in a complicated manner. For schedulings motivated by Capecitabine protocols, we find that switching the drugs only once, or at most twice, between rest phases gives the most reliable alternation time. The main and novel conclusion of this paper is the modelling prediction that one must be much more specific in the choice of the protocol alternation time if attempting to observe the improvements promised by Goldie and Coldman's alternation hypothesis for the rest phases, pharmacokinetics and delivery mechanisms typically encountered in cell cycle phase specific chemotherapy protocols.

Algorithms↗

PubMed2005

Results of a protocol of transfusion threshold and surgical technique on transfusion requirements in burn patients.

INTRODUCTION: Blood loss and high rates of transfusion in burn centers remains an area of ongoing concern. Blood use brings the risk of infection, adverse reaction, and immunosuppression. METHODS: A protocol to reduce blood loss and blood use was implemented. Analysis included 3-year periods before and after institution of the protocol. All patients were transfused for a hemoglobin below 8.0 gm/dL. RESULTS: Operations per admission did not change during the two time periods (0.78 in each). Overall units transfused per operation decreased from 1.56+/-0.06 to 1.25+/-0.14 units after instituting the protocol (p<0.05). Also, units transfused per admission decreased from 1.21+/-0.15 to 0.96+/-0.06 units of blood (p<0.05). This was noticed particularly in burns of less than 20% surface area, declining from 386 to 46 units after protocol institution, from 0.37 to 0.04 units per admission, and from 0.79 to 0.08 units per operation in this group of smallest burns. There was no change noted in the larger burns. CONCLUSIONS: This study suggests that a defined protocol of hemostasis, technique, and transfusion trigger should be implemented in the process of burn excision and grafting. This will help especially those patients with the smallest burns, essentially eliminating transfusion need in that group.

Blood Loss, Surgical↗

PubMed2006

Effect of protocol compliance to cardiac arrest identification by emergency medical dispatchers.

OBJECTIVES: The objective of the study was to assess the effect of protocol compliance to the accuracy of cardiac arrest (CA) identification by the dispatchers. METHODS: The study was conducted prospectively over a 1-year period in 1996. The calls categorized as non-traumatic CAs by the dispatcher and calls where the patient was in non-traumatic CA when ambulance crew arrived were included in the study. The data was collected from emergency call tape recordings and ambulance run sheets. The compliance to the protocol was defined as gathering information to two questions: (1) Is the patient awake or can she/he be awakened? and (2) Is she/he breathing normally? RESULTS: The number of calls included in the study was 776 and the dispatchers identified 83% of the CAs. The protocol was adhered in 52.4% of calls, more often in witnessed than unwitnessed cases (72.3% versus 45.0%, P<0.001). In correctly identified CAs, the protocol compliance was 49.4%. The compliance was higher in cases of unidentified CAs (60.3%, P=0.0326) and in cases of wrongly identified as CAs (false positives, 61.9%, P=0.0276). CONCLUSIONS: A high identification rate of CAs seems to be achievable despite poor protocol compliance by dispatchers.

Allied Health Personnel↗

PubMed1995

Protocol therapy for acute asthma: therapeutic benefits and cost savings.

BACKGROUND: To evaluate the therapeutic and financial benefits of protocol therapy for acute asthma using standard medications. MATERIALS AND METHODS: This study employed a sequential design in which the influence of an asthma care path on hospital admissions, length of stay (LOS) in the emergency department, and return visits were evaluated for 1 year. This information was contrasted with similar data obtained from the 8 months immediately before the protocol was implemented (preprotocol) and a 12-month period after strict adherence to it had declined (admixture). RESULTS: In all, 526 acute exacerbations of asthma were treated with the care path, and 429 and 558 episodes were evaluated during the preprotocol and admixture periods, respectively. There were no significant differences between the presenting clinical or physiologic features of any group. With the protocol, 77% of the patients resolved their symptoms within 1:47 +/- 0.02 hours:minutes of arrival in the emergency department with a 2% return rate within 24 hours. The algorithms used quickly identified those needing hospitalization. Patients not meeting the criteria for discharge after receiving the treatments employed typically did not resolve their symptoms for days (average hospital stay 4.1 +/- 0.2 days). Compared with the preprotocol period, the care path significantly reduced the LOS by 50 minutes, the number of urgent and intensive care unit admissions by 27% and 41%, respectively, and the frequency of return visits within 24 hours by 66%. Charges to patients and third-party payors decreased $395,000. When adherence to the protocol diminished, LOS, admissions, and returns rose significantly toward preprotocol values and the financial benefits were lost. CONCLUSIONS: Asthma protocol therapy, based primarily upon aggressive use of sympathomimetics in association with serial monitoring of key indices of improvement, provides prompt and efficient relief for acute exacerbations of asthma. Such an approach yields significant financial benefit while quickly identifying individuals who require hospitalization, and it also detects physician practice patterns that can have potentially detrimental impacts on patient care.

Acute Disease↗

PubMed2003

A computerized method of visual acuity testing: adaptation of the early treatment of diabetic retinopathy study testing protocol.

PURPOSE: To develop a computerized method of visual acuity testing for clinical research as an alternative to the standard Early Treatment for Diabetic Retinopathy Study (ETDRS) testing protocol, and to evaluate its test-retest reliability and concordance with standard ETDRS testing. DESIGN: Test-retest reliability study. METHODS: Multicenter setting of a study population of 265 patients at three clinical sites. Visual acuity was measured with both the electronic visual acuity testing algorithm (E-ETDRS) and standard ETDRS protocol (S-ETDRS) twice on one eye of each patient. E-ETDRS testing was conducted using the electronic visual acuity tester (EVA), which utilizes a programmed Palm (Palm, Inc, Santa Clara, California, USA) hand-held device communicating with a personal computer and 17-inch monitor at a test distance of 3 meters. RESULTS: For the E-ETDRS protocol, test-retest reliability was high (r = 0.99; with 89% and 98% of retests within 0.1 logMAR and 0.2 logMAR of initial tests, respectively) and comparable with that of S-ETDRS testing (r = 0.99; with 87% and 98% of retests within 0.1 logMAR and 0.2 logMAR of initial test, respectively). The E-ETDRS and S-ETDRS scores were highly correlated (r = 0.96 for initial tests and r = 0.97 for repeat tests). Based on estimates of 95% confidence intervals, a change in visual acuity of 0.2 logMAR (10 letters) from a baseline level is unlikely to be related to measurement variability using either the E-ETDRS or the S-ETDRS visual acuity testing protocol. CONCLUSIONS: The E-ETDRS protocol has high test-retest reliability and good concordance with S-ETDRS testing. The computerized method has advantages over the S-ETDRS testing in electronically capturing the data for each tested letter, requiring only a single distance for testing from 20/12 to 20/800, potentially reducing testing time, and potentially decreasing technician-related bias.

Adolescent↗

PubMed1996

Use of the flare-up protocol with high dose human follicle stimulating hormone and human menopausal gonadotropins for in vitro fertilization in poor responders.

OBJECTIVE: To analyze the effect of high dose human FSH in combination with hMG with a flare-up leuprolide acetate (LA) protocol in patients undergoing IVF at risk for a poor response. DESIGN: Prospective. SETTING: Free-standing ambulatory IVF center. PATIENTS: Two hundred eighty-four patients underwent a LA screening test for IVF. Patients with a lack of flare response were considered at risk for a poor response and underwent ovarian stimulation with the flare-up LA protocol in combination with high dose human FSH and hMG. RESULTS: The poor responder group was compared with the good responders on the flare-up LA protocol and to patients undergoing ovulation induction with a luteal phase LA protocol. There were 53 poor responder flare-up LA cycles, 177 good responder flare-up LA cycles, and 54 luteal phase LA cycles. The cancellation rate was higher in poor flare-up LA responders (11.3 percent) compared with good flare-up LA responders (1.1 percent) and luteal phase LA cycles (1.8 percent). Peak E2 levels, number of oocytes, and number of embryos were significantly higher in the good flare-up LA responders. Fertilization rate was similar in all groups. Ongoing pregnancy rate per retrieval was 28 percent in good responders, 29 percent in poor responders, and 33 percent in luteal phase LA patients. Only one patient (0.4 percent) was hospitalized for severe ovarian hyperstimulation. CONCLUSION: The flare-up protocol with high-dose human FSH and hMG is a very good alternative for patients who are at high risk for a poor response. Although peak E2 and number of oocytes were significantly lower in this group, the patients who responded had the same fertilization and pregnancy rate as the good responders. Cancellation rate remains high in poor responders.

Adult↗

PubMed1998

Congenital diaphragmatic hernia: developing a protocolized approach.

BACKGROUND/PURPOSE: The purpose of this study was to evaluate the evolving outcome of newborns who have congenital diaphragmatic hernia (CDH) using a protocolized approach to management, which includes extracorporeal membrane oxygenation (ECMO) and to present the details of such a management protocol. METHODS: A retrospective chart review was conducted of the neonatal outcome of near-term (>34 weeks' gestation) newborns with CDH all referred to the Royal Alexandra Hospital either before or after delivery. A protocol was developed that included antenatal assessment, the use of antenatal steroids, planned delivery, use of prophylactic surfactant, pressure limited gentle ventilation, permissive hypercarbia and hypoxia, and venovenous ECMO, if indicated. RESULTS: Sixty-five infants with CDH were treated from February 1989 through August 1996. Twenty-three infants were inborn, 20 of whom were antenatal referrals. Overall, 51 of the 65 infants survived (78%). Thirteen of the 23 inborn infants survived with conservative management, and 10 required ECMO, of whom, eight were long-term survivors. Thirty-eight infants required ECMO, and 26 survived (68%), whereas there were only two deaths among the 27 conservatively treated infants. Eighteen of 20 inborn infants with an antenatal diagnosis survived, compared with 13 of 21 (62%) outborn infants. An antenatal diagnosis before 25 weeks' gestation was associated with a 60% survival rate. Sixty-three percent of infants whose best postductal PaO2 value before ECMO was less than 100 torr survived, and 7 of 11 infants with a best postductal PaO2 value of less than 50 torr before ECMO survived (64%). The average age at surgery progressively increased over time both for infants who did not require ECMO (1.3 days to 5.8 days; P = .01) and for infants who received ECMO (1.9 days to 8.2 days; P = .016). CONCLUSIONS: The use of a protocolized management for infants with CDH has been associated with improving outcome in a population at high risk. The components (either separately or combined) of these protocolized approaches need to be tested in prospective trials to determine their true benefit. In addition, there is a need to evaluate prospectively the outcomes of infants with CDH born in ECMO centers compared with those infants born in other tertiary care neonatal units to determine the most appropriate management of the fetus with CDH.

Analysis of Variance↗

PubMed1996

Development and validation of an emergency department screening and referral protocol for victims of domestic violence.

STUDY OBJECTIVE: To describe the development, design, and validation of an emergency department protocol for the identification, documentation, and referral of victims of domestic violence. METHODS: We based protocol development and design on a departmental needs assessment. The validation component involved the screening of women 16 years and older treated in the ED during a 2-week period at both triage (stage 1) and nursing assessment (stage 2). Sensitivity and specificity of the triage screen were determined. RESULTS: The departmental needs assessment revealed several important limiting factors that motivated the design of the protocol. In response, the protocol design included a two-stage screening process, stage 1 taking place at triage and stage 2 as part of the nursing assessment. During the 2-week validation study, 595 women 16 years and older were treated in the ED, but complete two-stage screening data were obtained for only 114 (19%). Of the patients who were appropriately screened, eight screened positive at stage 1 and two of the eight were confirmed at stage 2. Two additional cases were identified at stage 2 in whom violence had not been suspected at stage 1. Triage screen sensitivity was 50%, specificity 95%. Of the women properly screened at both stages, 3.5% were identified as victims of domestic violence. CONCLUSION: We identified many obstacles to implementation of an ED domestic violence screening and referral protocol, demonstrating that evaluation is imperative in determining actual clinical impact.

Adolescent↗

PubMed1997

On-line medical control versus protocol-based prehospital care.

STUDY OBJECTIVE: To compare on-scene time, appropriateness of therapy, and accuracy of paramedic clinical assessments when prehospital care was provided with the use of on-line medical control (OLMC) by EMS-certified nurses from a single base station or by paramedics using chief complaint-based protocols. METHODS: We assembled a prospective before-and-after series to compare OLMC (phase 1) and protocol (phase 2) care rendered by all paramedics in a single urban municipality using a single base station. The subjects were consecutively enrolled patients who met protocol inclusion criteria and presented with altered level of consciousness, nontraumatic chest pain, or shortness of breath. For both phases, EMS and corresponding ED records were compiled; all references identifying phase were removed. After establishing interrater reliability, we randomly assigned charts to one of two reviewers for scoring. Complaint-specific scoring elements included on-scene time, assessments performed, presence or absence of indications for common treatments, treatments given, paramedic diagnosis, and emergency physician diagnosis. The percentages of inappropriate treatment decisions and paramedic diagnostic accuracy (versus that of the receiving emergency physician) were calculated. RESULTS: Phase 1 comprised 287 patients, phase 2 294. Interrater reliability between the two scorers was high. Of 2,190 elements scored jointly, the raters agreed in 97%, with kappa-values ranging from .6 to 1.0. On-scene time was 1 minute shorter during phase 2 (95% confidence interval [CI] for difference in median time, 0 to 2 minutes; P < .03). From phase 1 to phase 2 (relative risk [RR], 1.5; 95% CI, 1.0 to 2.1), inappropriate treatment decisions decreased from 7.4% to 5.1%. The percentage of cases in which paramedics and physicians were in complete diagnostic agreement was high (77% to 78%) and did not change across phases. CONCLUSION: The use of protocols resulted in small improvements in both on-scene time and the appropriateness of therapeutic decisions, without a change in agreement between paramedic and physician. Protocol care for these three chief complaints is clinically safe and, by reducing training and staffing considerations, may offer a cost-effective alternative to OLMC.

Clinical Protocols↗

PubMed2001

Using protocols to improve the outcomes of mechanically ventilated patients. Focus on weaning and sedation.

The use of nonphysician-directed protocols and guidelines for the management of sedation and weaning has been shown to reduce the duration of mechanical ventilation for patients with acute respiratory failure when compared with conventional physician-directed practices. Practitioners in ICUs frequently are needed to perform multiple tasks and to evaluate numerous elements of clinical information in the care of the critically ill. In this complex environment, protocols and guidelines are one strategy for ensuring that specific tasks are carried out in a timely manner. Simple-to-employ methods for facilitating changes and improvements in the care of hospitalized patients recently have been proposed. These methods emphasize the importance of developing a culture of cooperation within the ICU so protocols and guidelines can be implemented successfully. Such a culture should embrace changes in medical practices in the ICU if they are associated with improved clinical outcomes. The results of studies evaluating the use of protocols and guidelines have important implications for general critical care practices, because many ICUs do not have physicians who are constantly at the patient's bedside. The need for effective communication from the bedside caregiver (e.g., nurse, respiratory therapist, pharmacist, technician) to the physician, so that treatment orders can be changed appropriately, usually results in some delay in the implementation of treatment changes. Protocols are one method for potentially reducing those delays and ensuring that medical care is administered in a more standardized and efficient manner.

Clinical Protocols↗

PubMed2003

Relapse prevention in patients with schizophrenia: the application of an intervention protocol in nursing practice.

This article describes the results of a survey conducted among nurses who work in psychiatric care. Within the experimental condition of a randomized controlled trial, they executed an intervention protocol to prevent psychotic relapses among patients with schizophrenia. The central objective of this protocol was early recognition of the warning signs of psychosis and timely performance of actions intended to re-establish the equilibrium of the patient. The nurses were asked about the execution of the intervention, their experiences with it, and their evaluation. The nurses actually did execute the protocol in large measure and also made use of opportunities to tailor it to the individual patient. For the most part, the nurses judged that the intervention protocol contributed significantly to the treatment of the patient. The survey also revealed a number of difficulties in the execution of the protocol that deserve attention in the future.

Clinical Protocols↗

PubMed2002

Scientific review of EORTC trials: the functioning of the New Treatment Committee and Protocol Review Committee.

New anticancer treatments (new therapeutic strategies or new compounds) require careful development in which cancer clinical trials are an essential element. Two scientific committees, namely the New Treatment Committee and the Protocol Review Committee, ensure the review of all EORTC protocols with respect to the interest and originality, methodology, feasibility and relevance within the EORTC framework. Both Committees are involved early in the evaluation of the new concept proposal and follow all aspects (methodology, administrative, regulatory) of the protocol development process. Throughout its 25 years of existence, the Protocol Review Committee has streamlined drug and protocol evaluations and has developed standard operating procedures to handle those reviews in a very efficient and fast manner. Since 1997, the New Treatment Committee has contributed to strengthening the EORTC during the development process with the aim of ensuring an optimal flow of information on new drugs between laboratory and clinical research divisions.

Clinical Protocols↗

PubMed2002

Evaluation of a sedation protocol for intubated critically ill children.

The aim of this study was to conduct an evaluation of a sedation protocol that transfers some decision-making authority for analgesia and sedation, within clearly defined parameters, to nurses in a pediatric intensive care unit (PICU). The sedation protocol used in this study was appropriate for any age group. The clinical course of 10 patients admitted to the PICU during a 5-month interval who were on the sedation protocol during their stay was examined using retrospective chart review. Time intervals when patients were on the protocol were compared with clinically comparable time intervals, in terms of acuity, when the same patient received conventional management. Data were collected on the number of days a child was ventilated, the number of days in the PICU, the number of days hospitalized and severity of illness. Additionally, data were collected on the amounts of sedation and analgesia required and the incidence of under-sedation. Physician and nurse satisfaction with the sedation protocol was examined using a self-report survey. The findings of this study indicate that the delegation of decision-making authority for analgesia and sedation to PICU nurses can provide effective and timely management of patient comfort, without an increase in morbidity, in a manner that is more satisfying for physicians and nurses.

Child↗

PubMed2000

Carotid endarterectomy outcomes research: reduced resource utilization using a clinical protocol.

BACKGROUND AND PURPOSE: The purpose of this study was to examine the necessity of intensive care unit (ICU) utilization following carotid endarterectomy (CEA) and to identify patients who can be managed postoperatively on a vascular unit using a clinical protocol. METHODS: Medical records of 50 patients admitted to the ICU following elective CEA were reviewed retrospectively for patient characteristics, morbidity, mortality, length of stay (LOS), and ICU intervention. Prospectively, the next 200 patients were routed to either a vascular unit or ICU, based on a clinical protocol. Endpoints were mortality, stroke, myocardial infarction, total hospital LOS, ICU LOS, and ICU intervention. RESULTS: There were no significant differences in morbidity or mortality between patients admitted to the vascular unit and those admitted to the ICU. Of patients evaluated prospectively, 129 (63%) were admitted directly to the vascular unit. Of the 73 patients admitted to the ICU, 63% required direct intervention compared with only 54% of patients in the retrospective series (P=0.001). In addition, after institution of the protocol, ICU LOS decreased significantly from 1.4 to 0.6 days (P<0.001). The hospital cost savings using this protocol averaged $1043 per patient. CONCLUSIONS: A clinical protocol can select patients for admission to the ICU or the vascular unit following CEA without increase in morbidity or mortality. Selective use of the ICU conserved resources, decreased ICU LOS, and provided substantial cost savings.

Aged↗

PubMed2003

Efficacy of a consensus protocol therapy in adults with acute, severe asthma.

BACKGROUND: International guidelines recommend multiple doses of inhaled beta2-agonists and anticholinergics plus early administration of systemic corticosteroids for acute, severe asthma. This study examined the efficacy of this protocol in adults and analyzed those factors associated with unresponsiveness to the protocol therapy. OBJECTIVE: Ninety-three consecutive patients 18 to 55 years old presenting for treatment of acute asthma with a peak expiratory flow rate (PEFR) < or = 50% of the predicted value were analyzed. METHODS: All subjects received 400 microg of salbutamol every 20 minutes for three doses and 400 microg of oxitropium bromide with each of the three salbutamol doses by means of a metered-dose inhaler with a spacer device, plus intravenously 8 mg betamethasone. PEFR was measured at baseline and at 20, 40, 60, and 120 minutes. RESULTS: Sixty-nine percent of subjects improved sufficiently to be discharged. In 31% of subjects, the protocol therapy failed. There were no significant differences in age, sex, smoking status, or beta-agonist use within 6 hours between the two groups. Logistic regression analysis demonstrated that a PEFR < 35% of the predicted value at presentation (odds ratio [OR]; 16.3, 95% confidence interval [CI] 4.5 to 59.9), viral respiratory tract infection symptoms > or = 2 days (OR, 4.8, 95% CI 1.3 to 17.1), and asthma hospitalization in the past year (OR, 4.6, 95% CI 1.1 to 19.9) were significantly associated with unresponsiveness to the protocol. CONCLUSIONS: Unresponsiveness to protocol therapy occurs in nearly one-third of individuals presenting with acute, severe asthma. Our findings underscore the need to explore more effective strategies for improving lung function and reducing hospital admission rates.

Acute Disease↗