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Biomedical subjects

M A DeVita

Publications and source records attributed to M A DeVita.

At least 19 recordsLinked to original sources
PubMed2006

Use of a standardized protocol to decrease medication errors and adverse events related to sliding scale insulin.

PROBLEM: Sliding scale insulin (SSI) is frequently used for inpatient management of hyperglycemia and is associated with a large number of medication errors and adverse events including hypoglycemia and hyperglycemia. DESIGN: Observational before and after study evaluating the impact of implementation of a standardized SSI protocol and preprinted physician order form. SETTING: University Hospital in Pittsburgh, PA, USA. STRATEGY FOR CHANGE: Guidelines for the use of SSI were created by an interdisciplinary committee and implemented in non-intensive care units. In addition, a preprinted physician order sheet was developed which included the guidelines and an option for ordering one of three standardized insulin sliding scales or a patient specific scale. EFFECT OF CHANGE: One year after implementation the physician order form was used for 91% of orders and, overall, 86% of SSI orders followed the guidelines. The number of prescribing errors found on chart review was reduced from 10.3 per 100 SSI patient-days at baseline to 1.2 at 1 year (p = 0.03). The number of hyperglycemia episodes 1 year after implementation decreased from 55.9 to 16.3 per 100 SSI patient-days. LESSONS LEARNT: The protocol was readily accepted by hospital staff and was associated with decreased prescribing errors and decreased frequency of hyperglycemia.

Blood Glucose↗
PubMed2005

Improving medical emergency team (MET) performance using a novel curriculum and a computerized human patient simulator.

PROBLEM: Advance cardiac life support (ACLS) training does not address coordination of team resources to improve the ability of teams to deliver needed treatments reliably and rapidly. Our objective was to use a human simulation training educational environment to develop multidisciplinary team skills and improve medical emergency team (MET) performance. We report findings of a crisis team training course that is focused on organization. SETTING: Large center for human simulation training at a university affiliated tertiary care hospital. PARTICIPANTS: Ten courses were delivered and 138 clinically experienced individuals were trained (69 critical care nurses, 48 physicians, and 21 respiratory therapists). All participants were ACLS trained and experienced in responding to cardiac arrest situations. COURSE DESIGN: Each course had four components: (1) a web based presentation and pretest before the course; (2) a brief reinforcing didactic session on the day of the course; (3) three of five different simulated scenarios; each followed by (4) debriefing and analysis with the team. Three of five simulator scenarios were used; scenario selection and order was random. Trainees did not repeat any scenario or role during the training. Participants were video recorded to assist debriefing. Debriefing focused on reinforcing organizational aspects of team performance: assuming designated roles independently, completing goals (tasks) assigned to each role, and directed communication. MEASURES FOR IMPROVEMENT: Participants graded their performance of specific organizational and treatment tasks within specified time intervals by consensus. Simulator "survival" depended on supporting oxygenation, ventilation, circulation within 60 seconds, and delivering the definitive treatment within 3 minutes. EFFECTS OF CHANGE: Simulated survival (following predetermined criteria for death) increased from 0% to 89%. The initial team task completion rate was 10-45% and rose to 80-95% during the third session. LESSONS LEARNT: Training multidisciplinary teams to organize using simulation technology is feasible. This preliminary report warrants more detailed inquiry.

Computer Simulation↗
PubMed2004

Use of medical emergency team responses to reduce hospital cardiopulmonary arrests.

BACKGROUND: Medical emergency team (MET) responses have been implemented to reduce inpatient mortality, but data on their efficacy are sparse and there have been no reports to date from US hospitals. OBJECTIVES: To determine how the incidence and outcomes of cardiac arrests have changed following increased use of MET. METHODS: Objective criteria for MET activation were created and disseminated as part of a crisis management program, after which there was a rapid and sustained increase in the use of MET. A retrospective analysis of clinical outcomes was performed to compare the incidence and mortality of cardiopulmonary arrest before and after the increased use of MET. RESULTS: A retrospective analysis of 3269 MET responses and 1220 cardiopulmonary arrests over 6.8 years showed an increase in MET responses from 13.7 to 25.8 per 1000 admissions (p<0.0001) after instituting objective activation criteria. There was a coincident 17% decrease in the incidence of cardiopulmonary arrests from 6.5 to 5.4 per 1000 admissions (p = 0.016). The proportion of fatal arrests was similar before and after the increase in use of MET. CONCLUSIONS: Increased use of MET may be associated with fewer cardiopulmonary arrests.

Clinical Protocols↗
PubMed2004

Use of medical emergency team (MET) responses to detect medical errors.

BACKGROUND: No previous studies have investigated whether medical emergency team (MET) responses can be used to detect medical errors. OBJECTIVES: To determine whether review of MET responses can be used as a surveillance method for detecting medical errors. METHODS: Charts of all patients receiving MET responses during an 8 month period were reviewed by a hospital based Quality Improvement Committee to establish if the clinical deterioration that prompted the MET response was associated with a medical error (defined as an adverse event that was preventable with the current state of medical knowledge). Medical errors were categorized as diagnostic, treatment, or preventive errors using a descriptive typology based on previous published reports. RESULTS: Three hundred and sixty four consecutive MET responses underwent chart review and 114 (31.3%) were associated with medical errors: 77 (67.5%) were categorized as diagnostic errors, 68 (59.6%) as treatment errors, and 30 (26.3%) as prevention errors. Eighteen separate hospital care processes were identified and modified as a result of this review, 10 of which involved standardization. CONCLUSIONS: MET review may be used for surveillance to detect medical errors and to identify and modify processes of care that underlie those errors.

Emergency Service, Hospital↗
PubMed2001

The death watch: certifying death using cardiac criteria.

In the past, inadequate diagnostic instruments sometimes led to incorrect diagnoses of death, so careful and prolonged observation--the "death watch"--was required. Diagnostic instruments are now accurate and determining the presence or absence of circulation and cerebral function is easy in virtually all cases. Still, ambiguity and controversy in diagnosing death persists because the current criteria, irreversible cessation of cardiac or whole brain function, are ambiguous. Recent reintroduction of non-heart-beating organ donation has highlighted the controversy. Data on the ability to achieve restoration of spontaneous circulation are quite consistent, but they support several different sets of reasonable death criteria. This article concludes with a rejection of a fixed notion of "irreversibility" because it does not conform to current practice, is potentially deleterious to social events at the time of death, and the reversibility of cardiopulmonary arrest is dependent on available means of resuscitation. Finally, the time required to ensure irreversible cessation of cardiac function despite potential intervention is too broad to be clinically applicable and is unreasonable. Diagnosis of death should be based on the context in which it occurs because the medical means available determine what is irreversible.

Brain Death↗
PubMed2001

Honestly, do we need a policy on truth?

Physicians are taught that the foundation of the physician-patient relationship is trust, and trust is based in part on truthfulness. While drawing important "lines in the sand" regarding whether and why to tell the truth, ethics codes promulgating honesty fail to provide clinicians with guidance regarding what is the truth, as well as when and how to disclose it. These issues may be at the core of why an adverse event is left undisclosed. Consistently being truthful in the setting of an error is particularly difficult and requires overcoming a number of institutional and personal barriers. The article concludes that if delivering "the truth" is important, then articulation of criteria for determining what should be told, by whom, and when is essential. A policy that considers the practical issues and provides guidance may be useful.

Disclosure↗
PubMed2000

Observations of withdrawal of life-sustaining treatment from patients who became non-heart-beating organ donors.

OBJECTIVE: Non-heart-beating organ donation for transplantation is increasing despite the concern whether all the donors are dead. This concern is based on the adequacy of documentation of death and the appropriate duration that circulation and respiration should be absent before death certification. No studies have examined the documentation and deaths of patients who became non-heart-beating organ donors. DESIGN: Retrospective study of observational data. PATIENTS: All non-brain-dead patients who became non-heart-beating organ donors at the University of Pittsburgh Medical Center from January 1, 1993, to June 30, 1998, were identified. Records for 15 of 16 patients were available for review. MEASUREMENTS AND MAIN RESULTS: Adequacy of documentation, extubation time, onset of severe hypotension, duration of absent circulation before death was certified, and the time of incision for organ procurement were ascertained. Twelve of 15 records had all required clinical documentation. The mean age of patients was 46.5 +/- 5.7 yrs. All 15 patients were extubated before death and had femoral arterial catheters; one had a biventricular assist device discontinued. The time of hypotension and pulselessness was not documented for one and three patients, respectively. All 12 patients with documentation had > or =2 mins of absent circulation. Time from certification to incision for procurement was 1.1 +/- 2.3 mins. CONCLUSIONS: In a small study of non-heart-beating organ donation, circulation never resumed after >1 min of absent circulation, suggesting that 2 mins of absent circulation is sufficient to certify death. Three of 15 patients had inadequate documentation. Gaps and inconsistencies in documentation may raise concern about the potential for abuse.

Adult↗
PubMed2000

Patients, families, and organ donation: who should decide?

Although 69 to 75 percent of U.S. adults say they would be willing to become organ donors, half of the families that are asked to consider donating the organs of a deceased family member refuse to consent. This discrepancy is most noticeable when the refusal of a family conflicts with the known wishes of a patient. It is the practice of nearly all organ procurement organizations in the United States not to procure organs or tissue when families refuse, even if the patient's wishes have been documented. Recently, the Center for Organ Recovery and Education (CORE) adopted a controversial policy of acting on the documented wishes of individuals to donate, independent of family consent. An examination of the moral and political issues raised by this policy lead to the conclusion that the CORE policy is not only justified, but morally required.

Decision Making↗
PubMed1993

Procuring organs from a non-heart-beating cadaver: a case report.

Organ transplantation is an accepted therapy for major organ failure, but it depends on the availability of viable organs. Most organs transplanted in the U.S. come from either "brain-dead" or living related donors. Recently organ procurement from patients pronounced dead using cardiopulmonary criteria, so-called "non-heart-beating cadaver donors" (NHBCDs), has been reconsidered. In May 1992, the University of Pittsburgh Medical Center (UPMC) enacted a new, complicated policy for procuring organs from NHBCDs after the elective removal of life support. Seventeen months later only one patient has become a NHBCD. This article describes her case and the results of interviews with the health care team and the patient's family. The case and interviews are discussed in relation to several of the ethical concerns previously raised about the policy, including potential conflicts of interest, the definition of cardiopulmonary death, and a possible net decrease in organ donation. The conclusion is reached that organ procurement from non-heart-beating cadavers is feasible and may be desirable both for the patient's family and the health care providers.

Academic Medical Centers↗
PubMed1993

History of organ donation by patients with cardiac death.

When successful solid organ transplantation was initiated almost 40 years ago, its current success rate was not anticipated. But continuous efforts were undertaken to overcome the two major obstacles to success: injury caused by interrupting nutrient supply to the organ and rejection of the implanted organ by normal host defense mechanisms. Solutions have resulted from technologic medical advances, but also from using organs from different sources. Each potential solution has raised ethical concerns and has variably resulted in societal acclaim, censure, and apathy. Transplant surgery is now well accepted, and the list of transplant candidates has grown far quicker than the availability of organs. More than 30,000 patients were awaiting organs for transplantation at the end of March 1993. While most organs came from donors declared dead by brain criteria, the increasing shortage of donated organs has prompted a reexamination of prior restrictions of donor groups. Recently, organ procurement from donors with cardiac death has been reintroduced in the United States. This practice has been mostly abandoned by the U.S. and some, though not all, other countries. Transplantation has been more successful using organs procured from heart-beating, "brain dead" cadavers than organs from non-heart-beating cadavers. However, recent advances have led to success rates with organs from non-heart-beating donors that may portend large increases in organ donation and procurement from this source.

Brain Death↗
PubMed1993

Development of the University of Pittsburgh Medical Center policy for the care of terminally ill patients who may become organ donors after death following the removal of life support.

In the mid 1980s it was apparent that the need for organ donors exceeded those willing to donate. Some University of Pittsburgh Medical Center (UPMC) physicians initiated discussion of possible new organ donor categories including individuals pronounced dead by traditional cardiac criteria. However, they reached no conclusion and dropped the discussion. In the late 1980s and the early 1990s, four cases arose in which dying patients or their families requested organ donation following the elective removal of mechanical ventilation. Controversy surrounding these cases precipitated open discussion of the use of organ donors pronounced dead on the basis of cardiac criteria. Prolonged deliberations by many committees in the absence of precedent ultimately resulted in what is, to our knowledge, the country's first policy for organ donation following elective removal of life support. The policy is intricate and conservative. Care was taken to include as many interested parties as possible in an effort to achieve representative and broad based support. This paper describes the development of the UPMC policy on non-heart-beating organ donation.

Attitude of Health Personnel↗
PubMed1993

Incidence and natural history of phrenic neuropathy occurring during open heart surgery.

OBJECTIVE: To study the incidence of phrenic neuropathy following coronary artery bypass grafting and determine long-term outcome. DESIGN: Prospective observational. SETTING: Surgical ICU in a university hospital, out-patient follow-up. PATIENTS: Ninety-two consecutive patients undergoing open heart surgery. INTERVENTIONS: None. MEASUREMENTS: Chest radiographs (CXR) 48 to 72 h post-operatively, ultrasonography of diaphragm, phrenic nerve conduction studies, diaphragmatic electromyogram, each repeated every 1 to 3 months until normal. MAIN RESULTS: Seventy-eight of 92 (78 percent) patients had abnormal radiographs, 42 of 78 (54 percent) with abnormal CXRs had abnormal diaphragm motion, 24 of 42 (57 percent) with abnormal motion had phrenic neuropathy. Patients with normal diaphragm motion improved faster than those without; patients with normal nerve conduction (and abnormal motion) improved faster than those with abnormal nerve conduction. CONCLUSIONS: Phrenic neuropathy is relatively common if sensitive tests are utilized for diagnosis. Nerve conduction studies can predict duration of morbidity. Most patients have low morbidity and recover fully. Abnormal diaphragm motion alone is not diagnostic of phrenic nerve injury.

Aged↗
PubMed1993

Mask continuous positive airway pressure in AIDS.

FMCPAP and NCPAP therapy is an effective modality for treating patients with PCP, hypoxia, and respiratory insufficiency. The therapy decreases intrapulmonary shunting and improves oxygenation. It is safe and, in some cases, can be provided outside of an intensive care unit. The major benefit of MCPAP is that it postpones (and sometimes obviates) the need for intubation and mechanical ventilation. This may provide adequate time for a trial of therapy, education, ethical discussions, and completion of personal matters by patients. It is conceivable that failure to respond to MCPAP may provide prognostic information to help guide further therapy. Further outcome studies are needed to clarify this issue. Adding MCPAP to mechanical ventilation and conventional mask oxygen therapy increases the options that practitioners can use to provide the best titrated care for their patients.

Acquired Immunodeficiency Syndrome↗