QI Committee

Your patient has end-stage renal disease (ESRD) and is anuric on chronic hemodialysis (HD). He receives angiography while admitted for concern for ACS. Despite having his regularly scheduled HD the day prior and showing no signs of volume overload or metabolic disturbances after, he receives emergent HD post-procedure. Is this necessary or could he have just stayed on his usual HD schedule? A recent “Things We Do For No Reason” article in the Journal of Hospital Medicine addresses this question.

Highlights below:

– Main concerns for iodinated contrast material (ICM) in ESRD patients are reducing residual renal function (in patients that still make urine) and volume overload

– Newer contrast agents are low-osmolality and thought not to be directly toxic to the kidneys

– HD after contrast-exposure does not give a protective benefit in ESRD HD patients, anuric or not. Therefore, you can stick to the patient’s usual HD schedule and should not delay necessary contrast-studies in this population to schedule additional emergent HD afterwards

The following are the recommendations made by the authors:

– “Immediate post-procedural HD after ICM exposure in ESRD patients is not required.

– Do not delay vital diagnostic or therapeutic procedures requiring ICM in ESRD patients.

– The indication for HD is independent of contrast exposure in ESRD patients.”

Article: 

Ninan, J, Reddy, S, Qureshi, F. Things We Do for No Reason: Emergent hemodialysis after intravascular iodinated contrast exposure in chronic hemodialysis patients. J Hosp Med. 2022; 17: 653- 656. doi:10.12788/jhm.3683 

Do you need to place a central line in every patient requiring initiation of vasopressors

A very common scenario we see in the hospital is a patient in shock during which the decision to start vasopressors is made. Is central venous catheter (CVC) placement necessary in all of these patients? A recent “Things We Do For No Reason” article in the Journal of Hospital Medicine addresses this question.

Highlights below:

– The concern for peripheral administration of vasopressors is related to reports of skin necrosis and subsequent complications in cases of extravasation. However, systematic reviews have challenged this thought, and the risk of extravasation through peripheral IVs resulting in tissue injury is rare. Therefore, risks of peripherally-administered vasopressors should be weighed against the risks of CVC placement.

– Delayed administration of vasopressors in shock can lead to increased mortality

– Vasopressors can be safely initiated and infused through peripheral IVs but thought should be given to PIV size, site, monitoring, and infusion settings.

– Times when a CVC should be used to administer vasopressors include:

• Pre-existing CVC in place
• Lack of reliable PIV given clinical conditions
• Requiring multiple or high dose vasopressors
• Requiring vasopressors for anticipated duration > 24h
• The following are the recommendations made by Block et al in the article:
• “In adults who require a single vasopressor, initiate the infusion through a 20‐gauge or larger IV proximal to the wrist and distal to the AC fossa, preferably placed under ultrasound guidance.
• Place a second functioning PIV as “back‐up” in case extravasation of vasoactive infusion occurs.
• Develop a monitoring protocol which includes IV site assessment in addition to recognition and management of extravasation.
• Place a CVC for patients requiring high‐dose or multiple vasopressors or for patients requiring vasopressors for longer than 24 h.
• Tailor policies and procedures to individual institutions through multidisciplinary quality enhancement and safety committees.

Article:

Block, J. M. , Boateng, A. & Madhok, J. (2022). Journal of Hospital Medicine, 17 (7), 565-568. doi: 10.1002/jhm.12844.

• Use clinical judgment or an existing risk stratification system, such as MEWS or PEWS, to identify patients who may benefit from more or less monitoring.
• Forgo overnight vital sign checks for low-risk patients.
• Check overnight vitals for low-risk patients at 10 pm and 6 am.
• Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7204996/

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Dr. Gates and Dr. Astik are the physician leads for a project aimed at improving wound recognition, prevention and documentation. Please see the one-page informational sheet and word document for key background information and the updated process for all wounds. This initiative will be piloted on the medical floors and MICU, with increased Wound, Ostomy, and Continence Nurse (WONC) hiring underway to ensure adequate staffing to cover this process.

• Key process change for physicians: document all open skin lesions as wounds (rather than ulcers), upload pictures, and consult the wound care nurse!

-Mike

FY23_CR_AQSI_App_Details

On behalf of Dr. Abra Fant and Dr. Kevin O’Leary we are excited to announce that Central Region AQSI applications are open (see attached flyer). Project applications are due on June 17^th, 2022. The attached PDF has additional program details. Please forward this message to any colleagues that would be interested, or to anyone you feel would be great for the program. If you are interested in applying to AQSI, or if you have any questions, please email Bizhan Shahpar at bshahpar@nm.org to request application information.

Hello team!

As part of the AQSI Central program last year, our project called Leggo My Echo had the goal to reduce the overuse of inpatient echos (TTE’s) for low-risk, non-cardiac syncope. Mike Jiang and Pamela Wax helped develop this initiative under the leadership of David Goese, one of the hospital medicine attendings here at NMH.

We wanted to share changes that are being implemented to Epic to the Inpatient Echocardiogram order related to our project. Attached is an Epic Tip Sheet attached which explains them.

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The Epic changes are meant to encourage appropriate, thoughtful use of inpatient echos for syncope; and the data generated could possibly lead to future quality improvement project ideas. The Epic go-live date is Friday 2/11/22.

The following describes the changes which include adding the Canadian Syncope Risk Score to Epic, modifying the inpatient echo order to include indications rather than a free text “reason for ordering”, and a targeted BPA that fires when an echo is ordered for syncope.

We recommend filling out the Canadian Syncope Risk Score when ordering an echo for syncope when you are not sure if syncope could be cardiac or not. If the Canadian Syncope Risk Score is low or very low, then this can reassure that the echo likely is not needed.

Epic changes:

1. The inpatient echo (TTE) order will include buttons for reasons for ordering
   1. We hope this is equal or if anything faster than filling out previous echo order, which required filling out “Reason for echocardiogram” as free text. This should not change workflow significantly, please reach out if you feel it does
   2. If the indication is not listed, choose “Other” and write in the comments the reason for ordering
   3. We looked through hundreds of echos, grouped indications, included all the most common and worked with cardiology contacts on them so we hope the buttons will capture almost all reasons for ordering.

2. Added the Canadian Syncope Risk Score to Epic to Scoring Tools tab
   1. The Scoring Tools tab, which is a Tab on the top part of Epic, will now have the Canadian Syncope Risk Score which can be filled out and documented
   2. Scoring Tools was previously only available to Emergency Medicine physicians, now has expanded to all clinicians. This tab includes scoring tools like HEART score for chest pain or COWS for opioid withdrawal.

3. We added a targeted BPA which displays the Canadian Syncope Risk Score along with relevant vitals/lab/EKG data to make it as easy as possible to fill out the score.
   1. This BPA can be bypassed by clicking “Do Not Document”, in the case that you have suspicion for cardiac syncope and you are sure you want to do an echo

We would be happy to discuss more or arrange a demo at a faculty/residency meeting if it would interest anyone. Also, please email any feedback, suggestions, or collaboration ideas to Mike, Pamela, or David. We are hoping to reassess the changes in 1-2 months and make sure to address any issues that come up.

TL:DR – The Epic tip sheet attached explains changes to the inpatient echo order and adding the Canadian Syncope Risk Score to Epic for a quality improvement project on reducing the overuse of inpatient echos for low-risk non-cardiac syncope, which are going live on 2/11/22.

Thanks,

Mike, Pamela, and David on behalf of the AQSI Leggo My Echo Team