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Biomedical subjects

J G Stevenson

Publications and source records attributed to J G Stevenson.

At least 19 recordsLinked to original sources
PubMed1999

Adherence to physician training guidelines for pediatric transesophageal echocardiography affects the outcome of patients undergoing repair of congenital cardiac defects.

Intraoperative echocardiography is widely accepted as being useful during a variety of cardiac surgical procedures. Several applications have been reported during the repair of congenital cardiac defects. National organizations, including the Society of Pediatric Echocardiography and the American Society of Echocardiography, have published guidelines for the provision of at least minimum standards of training and quality for a variety of cardiac ultrasonography procedures. Few data exist concerning whether adherence to such guidelines affects the performance of ultrasonography studies or patient outcome. This study is an outcome-based analysis of intraoperative transesophageal echocardiography performed during repair of congenital cardiac defects during 5-month periods in 2 different years. In year 1, examinations were performed by physicians who met the guidelines for pediatric transesophageal echocardiography published by the American Society of Echocardiography. Those performing examinations in year 2 did not meet those guidelines. Significant differences between the years were found for adequacy of echocardiographic recordings, return to bypass for further surgery based on echocardiographic results, and prevalence and detection of significant residual problems by intraoperative echocardiography. It is concluded that patient outcome is affected beneficially when intraoperative transesophageal echocardiography is performed by physicians who meet the published guidelines, and whose sole responsibility is the performance of echocardiography.

Clinical Competence↗
PubMed1997

Peer review and continuous quality improvement of pharmacists' clinical interventions.

A peer-review-based continuous quality improvement (CQI) program for improving pharmacists' clinical interventions at a hospital is described. With the implementation of pharmaceutical care at Detroit Receiving Hospital came the need for a CQI system to validate and improve this type of patient care. A peer-review group (PRG) was formed. The PRG decided to review 60 pharmacist interventions per month for clinical appropriateness, accuracy of entry into the computer, documentation in the medical record by the pharmacist, and implementation if accepted by the physician. Interventions are assigned to individual reviewers, and final decisions on the appropriateness and correctness of the selected interventions are made at periodic PRG meetings. In its first year the PRG met nine times and evaluated 409 interventions; 96% of the interventions were judged clinically appropriate, 62% were accurately entered into the computer, 62% were documented in the medical record by the pharmacist, and 92% were implemented if accepted by the physician. Meetings, additional reviews, and inservice sessions were used to address deficiencies in the interventions; these efforts led to improvements. The clinical appropriateness of documented interventions was included as a medication use indicator in the hospital CQI program. A peer-review-based CQI process allowed a hospital to effectively monitor and improve the quality and documentation of interventions recommended by pharmacists.

Hospital Bed Capacity, 300 to 499↗
PubMed1996

Outsourcing the preparation of parenteral nutrient solutions.

A hospital pharmacy's experience with using an outsourcing center to prepare parenteral nutrient solutions (PNs) is described. In 1994 the pharmacy at a 340-bed level 1 trauma center selected an outsourcing center located 20 miles away to provide PN-compounding services; the center is licensed as a manufacturer and has an extensive quality control program. The necessary telephone and computer links were established. When a PN order is received, the pharmacist simply dials into the outsourcing computer system and enters the order. At 1400, a pharmacist dials into the system to verify all PN orders entered for that day. After 1500, personnel at the outsourcing center print labels and compound the solutions, which are delivered by courier within a few hours. The net savings during the first year of outsourcing PNs were estimated at about $59,000. The savings were attributable to the elimination of a technician full-time equivalent (FTE), a reduction in pharmacist labor, and favorable contract provisions; money was saved even though the service's PN-preparation fees outweighed the savings from reductions in labor. The hospital's onsite inventory of PN supplies decreased by $5800, and storage space was freed for other uses. Very few problems were associated with the service provided. Outsourcing the preparation of parenteral nutrient solutions reduced personnel, inventory, and expenditures in a hospital pharmacy.

Contract Services↗
PubMed1996

Implementing comprehensive pharmaceutical services at an academic tertiary care hospital.

The implementation and impact of comprehensive pharmaceutical services at a hospital are described. Before 1992, pharmaceutical services at Detroit Receiving Hospital and University Health Center were comparable to those of many departments serving similar academic tertiary care institutions. A major conflict with the principles of pharmaceutical care existed in that specific tasks were assigned to pharmacists, so that up to four pharmacists may have been involved in one patient's drug therapy while other patients were ignored. Several steps were taken to solve this problem. The department's mission and vision statements were modified to embrace pharmaceutical care. The support of administration and department leaders was secured, pharmacist evaluations were adjusted to make pharmaceutical care skills baseline competencies, and staffing was reconfigured. A voluntary pharmaceutical care committee was formed to transform pharmaceutical services at the hospital. It was decided that all staff pharmacists would provide clinical and distributive services on a rotating basis. The drug distribution system was altered to free more pharmacist time for patient care, and two technician positions were added. The clinical program was made more patient focused. The program was implemented in a stepwise manner beginning in September 1992. Computerized systems for tracking workload and documenting clinical interventions and drug cost savings were established. Later changes included making pharmacists responsible for all patients on a medical service rather than for specific problems in a particular location and changing scheduling to enhance the continuity of care. The number of clinical interventions by pharmacists increased from 3,563 in 1993 to 15,476 (projected) in 1995, and drug cost savings and avoidance increased from $239,248 in 1992 to $562,402 (projected) in 1995. Major change was necessary to implement comprehensive pharmaceutical services at an academic tertiary care hospital.

Cost Savings↗
PubMed1996

Hemodynamic effects of amrinone in children after Fontan surgery.

After Fontan repair in children, we performed a prospective, open-label study to evaluate the effect of amrinone on pulmonary vascular resistance (PVRI). Eight patients who underwent the Fontan repair had baseline arterial pressure, left atrial pressure, central venous pressure, and cardiac output measured postoperatively. Hemodynamic measurements were repeated after amrinone 4.5 mg/kg. The PVRI tended to decrease, but the change was not statistically significant. Although the systemic vascular resistance decreased to 802 +/- 222 from 941 +/- 191 dynes.s.cm-5.m-2 (P < 0.05), mean arterial blood pressure was unchanged. Cardiac index (3.8 +/- 1.2 to 4.7 +/- 1.6 L.min-1.m-2) and stroke volume index (23.6 +/- 6.7 to 30.5 +/- 8.1 mL.beat-1.m-2) increased, and heart rate decreased (160 +/- 21 to 151 +/- 24 bpm) (P < 0.05). Colloid transfusion during amrinone bolus administration was 13.9 mL/kg. The mean serum amrinone concentration was 4.2 micrograms/mL at the end of bolus and clearance was 2.24 mL.kg-1.min-1. Arrhythmias and thrombocytopenia were not noted. We conclude that amrinone administration is effective in increasing cardiac output in children who have undergone a Fontan repair.

Amrinone↗
PubMed1995

Evolution of echocardiography in neonatal diagnosis.

In the late 1960's, Edler and Lundström introduced ¿ultrasoundcardiography¿ for the evaluation of congenital heart disease. Initial evaluations using A- and M-mode echocardiography produced non-invasive diagnosis of many defects, including specific complex malformations such as hypoplastic left heart, Ebstein's malformation, endocardial cushion defect and transposition, all with single crystal techniques. Normal values for dimensions related to patient size and indices of function developed at that time remain as components of contemporary examinations. Two-dimensional imaging technology has evolved from 20 channels on Bom's linear array to 128-channel systems currently providing detailed imaging of structures as small as neonatal coronary arteries. The contribution of Doppler techniques for qualitative evaluation of blood flow characteristics has been greatly augmented by both the quantitative Doppler methods for accurate assessment of pressure gradients and pulmonary pressure, and by the development of color Doppler display of intracardiac and intravascular flow. These contributions have come from centers worldwide, with many initial and ongoing contributions from Lund. The evolution of instruments, and of application, now provides neonatal echocardiographic delineation of anatomic detail, function and hemodynamics of sufficient clarity and accuracy to replace the need for invasive study, or alternative technologies, in most cases.

Ebstein Anomaly↗
PubMed1995

Role of intraoperative transesophageal echocardiography during repair of congenital cardiac defects.

Intraoperative epicardial echocardiography has been available for several years, and has been demonstrated to be very useful in intraoperative echocardiography. With the availability of small pediatric transesophageal (TEE) probes, it has become possible to perform intraoperative TEE in infants and children of all sizes. With advantages of serial assessment of anatomy, function and flow, and lack of interference in the operative field, TEE has become routine in many surgical centers. Our experience supports its routine use in nearly all patients undergoing repair of congenital heart disease. We generally use pediatric probes in patients less than 15 kg and adult size probes for those over 15 kg. Examinations are performed before and after bypass for use in surgical planning, anesthetic and hemodynamic management, and in evaluation of repairs. In 44 of 667 (6.6%) cases, TEE findings prompted a return to bypass for further surgery or revision of surgery. In 75% of these patients, the problem identified by TEE was relieved, and patients had a good outcome. The benefit obtained by avoiding later reoperation in these patients has also proved cost-effective, supporting the use of TEE on a routine basis. Complications have been few (24/667, 3.5%), without long-term sequelae. They include failure to insert the TEE probe (1.2%), airway obstruction (0.9%), vascular compression (0.7%), tracheal extubation (0.6%) and gastric incision (0.1%); several of these complications are now considered avoidable. Intraoperative TEE offers major advantages in intraoperative assessment and management of patients undergoing repair of congenital heart disease.

Child↗
PubMed1994

Intraoperative transesophageal echocardiography of coronary artery fistulas.

Coronary artery fistula is a rare abnormality but one with substantial surgical importance, as operation abolishes the fistulous shunt volume, progressive coronary dilatation, and potential coronary steal. Prior reports emphasize the utility of direct inspection on cardiopulmonary bypass, with visualization of drainage of blood or cardioplegia from the fistulous connection, to define the drainage site. We report 3 patients in whom intraoperative transesophageal echocardiography was used for precise localization of the fistulous drainage site, selective demonstration of vessels feeding the fistulas, and documentation of abolition of fistulous flow, all without need for cardiopulmonary bypass. In addition, the technique provides for continuous monitoring of ventricular function, providing the opportunity to detect inadvertent ischemic effects of ligation. This approach appears to have considerable utility.

Child, Preschool↗
PubMed1994

Evaluation of cilazapril versus captopril in patients with mild to moderate essential hypertension.

OBJECTIVE: Cilazapril, a long-acting angiotensin converting enzyme (ACE) inhibitor, was evaluated against captopril for safety and efficacy in the treatment of mild to moderate essential hypertension. METHODS: One hundred thirty-two patients were randomly assigned to receive cilazapril, 2.5 mg once daily; 62 patients were randomly assigned to receive captopril, 25 mg twice daily. If necessary, dosage was increased to 5.0 mg cilazapril, once daily or 50 mg captopril, twice daily. Adjunctive hydrochlorothiazide (12.5 mg once daily) was later added to this higher dosage, if required. RESULTS: After eight weeks of monotherapy, sitting diastolic blood pressure (SDBP) had decreased 7.5 mm Hg from baseline for cilazapril-treated patients, versus 5.6 mm Hg for captopril-treated patients. These decreases were 7.6 mm Hg and 6.8 mm Hg for cilazapril and captopril, respectively, at Week 12. At Week 8, 36.5% of patients receiving cilazapril had achieved a SDBP of 90 mm Hg or less, versus 26.0% of captopril-treated patients. The overall responder rate at Week 8 was 47.1% for cilazapril and 34.0% for captopril. None of these differences between the two treatment groups were statistically significant. Both drugs alone or in combination with hydrochlorothiazide were well tolerated during the 12-week treatment period. CONCLUSION: The results of this study indicate that cilazapril, alone or with adjunctive hydrochlorothiazide, is effective and well tolerated as treatment for mild to moderate hypertension.

Adult↗