Early Tracheostomy — Evidence

ACP-PIER, which provides evidence-based guidance for clinical care, gives the following recommendations:

• Individualize decisions to convert an endotracheal tube to a tracheostomy based on anticipated duration of mechanical ventilation and patient-centered factors.
• Realize that, although full consensus does not exist, earlier tracheostomy may be associated with a shorter duration of mechanical ventilation and ICU stay.

After summarizing the evidence ACP-PIER comments “…trials offer no high quality data on the subject.”

In light of the inconclusive evidence Bradley D. Freeman in the June 2008 isse of Critical Care Medicine describes how:  “A standardized approach in which the decision for tracheostomy is based on objective  measures of weaning performance may be a means of using this procedure more consistently and effectively.”  Included in the article is the actual protocol and tracheostomy consult note.

Freeman BD and others.  Tracheostomy protocol:  experience with development and potential utility.  Critical Care Medicine  2008 June; 36(6)1742-1748.  PMID 18496369.

In the same issue of Critical Care Medicine the editorial  “Tracheostomy protocol compliance: herding cats?*” discusses Bradley Freeman’s protocol article.  While acknowledging the preliminary nature of the study and the problems inherent getting physicians to adopt protocols, the commenter suggests that “this may be may be just the breakthough we need to use tracheostomy in a more consistent and effective fashion.”

Liu L.  Tracheostomy protocol compliance: herding cats?*  Critical Care Medicine2008 June; 36(6):1959-1960.  PMID 18520851

For more information, please check this PubMed search of selected articles from 2005 to date.

PMID: 18496369

Venous Thromboembolism in Surgery–A Preventable Complication

The supplement to the American Journal of Surgery January 2010 issue includes the following articles

1. Risk Assessment as a Guide for the Prevention of the Many Faces of Venous Thromboembolism.  Joseph a. Caprini.
2. Prevention and Management of Venous Thromboembolism in the Surgical Patient: Options by Surgery Type and Individual Patient Risk Factors. James E. Muntz and Franlin A. Michota.
3. Mandated Quality Measures and Economic Implications of Venous Thromboembolism Prevention and Management.

The importance of this topic is highlighted by the introduction’s opening sentence:   “Venous thromboembolism (VTE) is a major health problem and has been identifies as the number 1 preventable cause of death in hospitalized patients.”

 

Transitions of Care

Transitions of Care Consensus Policy Statement American College of Physicians-Society of General Internal Medicine-Society of Hospital Medicine-American Geriatrics Society-American College of Emergency Physicians-Society of Academic Emergency Medicine.  J Gen Intern Med.  2009 Apr 3. PMID 19343456.

Other recent articles (click on PMID number for complete citation)

1. Assessing the quality of transitional care: further applications of the care transitions measures.  PMID 18388847.
2. Care transitions for hospitalized patients.  PMID 18298981.
3. The care transitions intervention: results of a randomized controlled trail.  PMID 17000937.
4. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care.  PMID 17327525.
5. Failure at the transition of care: challenges in the discharge of the vulnerable elderly patient.  PMID 18698595.
6. Hospital discharge of older adults.  How nurses can ease the transition.  PMID 17519609.
7. Hospitalists and care transitions: the divorce of inpatient and outpatient care.  PMID 18780917.
8. Improving the complex nature of care transitions; review.  PMID 17873723.
9. Lost in transition:  challenges and opportunities for improving the quality of transitional care.  PMID 15466770.
10. Primary care physicians’ links to other physicians through Medicare patients: the scope of care coordination.  PMID 19221375.
11. Tying up loose ends: discharging patients with unresolved medical issues.  PMID 17592105.