User login
Cardiovascular medicine and surgery
COVID-19 and the cardiovascular system
With the global outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) ongoing, there is increased awareness of the cardiovascular manifestations and implications of COVID-19. Approximately 20% of inpatients with COVID-19 have acute cardiac injury (defined as cardiac troponin elevation) (Shi S, et al. JAMA Cardiol. 2020 Mar 25. doi: 10.1001/jamacardio.2020.0950). Moreover, in one cohort, both acute cardiac injury and preexisting cardiovascular disease (CVD) were associated with COVID-19 hospital mortality: 69% with elevated troponin levels and underlying CVD vs 7.6% with neither (Guo T, et al. JAMA Cardiol. 2020 Mar 27. doi: 10.1001/jamacardio.2020.1017). Moreover, case reports suggest COVID-19 may present as myopericarditis, cardiomyopathy, acute on chronic decompensated heart failure, and acute coronary syndrome (Fried JA, et al. Circulation. 2020 Apr 3. doi: 10.1161/circulationaha.120.047164). Adding to this clinical variability, one case series suggests that electrocardiographic ST-segment elevation may not reliably identify obstructive coronary disease (Bangalore S, et al. N Engl J Med. 2020 Apr 17. doi: 10.1056/NEJMc2009020). Intriguingly, the angiotensin-converting enzyme 2 (ACE2) protein is the functional receptor for SARS-CoV-2 cell entry, and ACE2 is highly expressed in pulmonary and cardiac cells (Driggin E, et al. J Am Coll Cardiol. 2020;75[18]:2352). Given the central role of ACE2 and the renin-angiotensin-aldosterone (RAAS) system in cardiovascular pathophysiology and pharmacotherapy, RAAS modulation could have beneficial and/or detrimental effects with COVID-19 (Vaduganathan M, et al. N Engl J Med. 2020;382:1653). Available evidence and societal guidelines support continuing RAAS antagonists in patients per established clinical practice (Mancia G, et al. N Engl J Med. 2020 May 1. doi: 10.1056/NEJMoa2006923); (Mehra MR, et al. N Engl J Med. 2020 May 1. doi: 10.1056/NEJMoa2007621). A better understanding of the direct and indirect effect of SARS-CoV-2 on the cardiovascular system will require additional evidence.
Benjamin B. Kenigsberg, MD
Fellow-in-Training Steering Committee Member
Thrombotic events in COVID-19: Implications and evolving practice recommendations
A startling potential complication of infection with SARS-CoV2 has been the reported predisposition to thrombotic events. Mortality in COVID-19 patients is associated with notable increases in hemostatic parameters such as levels of
Vascular societies led by International Society on Thrombosis and Haemostasis (ISTH) have published consensus recommendations for guidance. If no contraindications exist, pharmacologic venous thromboembolism (VTE) prophylaxis with unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH) is recommended for hospitalized patients with moderate or severe COVID-19 without disseminated intravascular coagulation (DIC). VTE prophylaxis should also be considered for patients with moderate or severe COVID-19 and in DIC but without overt bleeding. There is insufficient evidence to consider routine therapeutic or intermediate-dose parenteral anticoagulation with UFH or LMWH. Many institutions have developed protocols advising therapeutic-intensity anticoagulation when certain thresholds of
Saiprakash B. Venkateshiah, MD, FCCP,
Chair
Gabriela Magda, MD
Fellow-in-Training Steering Committee Member
Interprofessional Team
Quality of interprofessional collaboration in the medical intensive care unit: perceptions by caregivers
A recent study examining caregivers’ perceptions of team interactions and interprofessional collaborative practice (IPCP) behaviors offers new, exciting insights on the importance of interprofessional team functioning in the medical intensive care unit (MICU) (Chen DW, et al. J Gen Intern Med. 2018;33[10]:1708).
The Support Person Jefferson Teamwork Observation Guide (JTOG)TM survey was administered to 161 random caregivers of patients hospitalized in a single large urban academic medical center MICU between May 2016 and December 2016. The survey tool was designed to elicit the perceptions of caregivers regarding team functioning. Survey questions were directly mapped to the 2011 Interprofessional Education Collaborative (IPEC) Expert Panel core competencies for IPCP and divided into four domains (values/ethics; interprofessional communication; roles/responsibilities; teams/teamwork).
Also appended to the surveys were additional follow-up questions that addressed the overall satisfaction with the team and general attitudes regarding the importance of interprofessional team-based care. Caregivers agreed on the importance of health-care professionals working together as a team to provide patient care (3.97/4.00 Likert scale 4 = extremely important). Caregivers expressed satisfaction with the MICU team (3.74/4.00). Furthermore, caregivers agreed that the MICU team demonstrated competencies in all four domains of IPCP: values/ethics (3.55/4.00), interprofessional communication (3.58/4.00), roles/responsibilities (3.61/4.00), and teams/teamwork (3.64/4.00). Caregivers felt the MICU team provided patient/family-centered care (sub-competency 3.58/4.00). Notably, the overall caregiver survey scores detailing how well each MICU team functioned were positively correlated to overall satisfaction with the MICU team (r = 0.596 P < .01).
Limitations of the study included:
1. The sample is from a single institution, and perceptions of caregivers cannot be applied to all populations.
2. No information regarding patient, such as diagnosis, was obtained.
3. Caregivers satisfied with care might be more likely to participate.
4. No distinction was made between data collected from caregivers surveyed in the resident-fellow staffed MICU vs NP-staffed MICU.
It has been described that ineffective teamwork and team communication in health care settings are associated with increased patient harm and sentinel events (Kohn LT et al. Washington (DC): National Academies Press(US); 2000); (Page A, Washington (DC): National Academies Press (US); (The Joint Commission. Sentinel Event Alert 2008, 40); (Brennan TA, et al. N Engl J Med. 1991;324:370). Cultural differences between members of the health-care team and established hierarchies of control have been identified as barriers to communication and teamwork in ICUs (Alexanian JA, et al. J Crit Care Med. 2015;43[9]:1880); (Manias E, Street A. Int J Nurs Stud. 2001;38[2]:129).
Overall, the findings from this study emphasize the importance of interprofessional communication and teamwork in the MICU and delivery of patient/family-centered care from the caregivers’ perspective. The unique insight into caregivers’ perspectives on specific team behaviors may be the basis for future quality improvement initiatives.
Justin K. Lui, MD,
Mary Jo Farmer, MD, PhD, FCCP
Kristina E. Ramirez, RRT, MPH, FCCP
Cardiovascular medicine and surgery
COVID-19 and the cardiovascular system
With the global outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) ongoing, there is increased awareness of the cardiovascular manifestations and implications of COVID-19. Approximately 20% of inpatients with COVID-19 have acute cardiac injury (defined as cardiac troponin elevation) (Shi S, et al. JAMA Cardiol. 2020 Mar 25. doi: 10.1001/jamacardio.2020.0950). Moreover, in one cohort, both acute cardiac injury and preexisting cardiovascular disease (CVD) were associated with COVID-19 hospital mortality: 69% with elevated troponin levels and underlying CVD vs 7.6% with neither (Guo T, et al. JAMA Cardiol. 2020 Mar 27. doi: 10.1001/jamacardio.2020.1017). Moreover, case reports suggest COVID-19 may present as myopericarditis, cardiomyopathy, acute on chronic decompensated heart failure, and acute coronary syndrome (Fried JA, et al. Circulation. 2020 Apr 3. doi: 10.1161/circulationaha.120.047164). Adding to this clinical variability, one case series suggests that electrocardiographic ST-segment elevation may not reliably identify obstructive coronary disease (Bangalore S, et al. N Engl J Med. 2020 Apr 17. doi: 10.1056/NEJMc2009020). Intriguingly, the angiotensin-converting enzyme 2 (ACE2) protein is the functional receptor for SARS-CoV-2 cell entry, and ACE2 is highly expressed in pulmonary and cardiac cells (Driggin E, et al. J Am Coll Cardiol. 2020;75[18]:2352). Given the central role of ACE2 and the renin-angiotensin-aldosterone (RAAS) system in cardiovascular pathophysiology and pharmacotherapy, RAAS modulation could have beneficial and/or detrimental effects with COVID-19 (Vaduganathan M, et al. N Engl J Med. 2020;382:1653). Available evidence and societal guidelines support continuing RAAS antagonists in patients per established clinical practice (Mancia G, et al. N Engl J Med. 2020 May 1. doi: 10.1056/NEJMoa2006923); (Mehra MR, et al. N Engl J Med. 2020 May 1. doi: 10.1056/NEJMoa2007621). A better understanding of the direct and indirect effect of SARS-CoV-2 on the cardiovascular system will require additional evidence.
Benjamin B. Kenigsberg, MD
Fellow-in-Training Steering Committee Member
Thrombotic events in COVID-19: Implications and evolving practice recommendations
A startling potential complication of infection with SARS-CoV2 has been the reported predisposition to thrombotic events. Mortality in COVID-19 patients is associated with notable increases in hemostatic parameters such as levels of
Vascular societies led by International Society on Thrombosis and Haemostasis (ISTH) have published consensus recommendations for guidance. If no contraindications exist, pharmacologic venous thromboembolism (VTE) prophylaxis with unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH) is recommended for hospitalized patients with moderate or severe COVID-19 without disseminated intravascular coagulation (DIC). VTE prophylaxis should also be considered for patients with moderate or severe COVID-19 and in DIC but without overt bleeding. There is insufficient evidence to consider routine therapeutic or intermediate-dose parenteral anticoagulation with UFH or LMWH. Many institutions have developed protocols advising therapeutic-intensity anticoagulation when certain thresholds of
Saiprakash B. Venkateshiah, MD, FCCP,
Chair
Gabriela Magda, MD
Fellow-in-Training Steering Committee Member
Interprofessional Team
Quality of interprofessional collaboration in the medical intensive care unit: perceptions by caregivers
A recent study examining caregivers’ perceptions of team interactions and interprofessional collaborative practice (IPCP) behaviors offers new, exciting insights on the importance of interprofessional team functioning in the medical intensive care unit (MICU) (Chen DW, et al. J Gen Intern Med. 2018;33[10]:1708).
The Support Person Jefferson Teamwork Observation Guide (JTOG)TM survey was administered to 161 random caregivers of patients hospitalized in a single large urban academic medical center MICU between May 2016 and December 2016. The survey tool was designed to elicit the perceptions of caregivers regarding team functioning. Survey questions were directly mapped to the 2011 Interprofessional Education Collaborative (IPEC) Expert Panel core competencies for IPCP and divided into four domains (values/ethics; interprofessional communication; roles/responsibilities; teams/teamwork).
Also appended to the surveys were additional follow-up questions that addressed the overall satisfaction with the team and general attitudes regarding the importance of interprofessional team-based care. Caregivers agreed on the importance of health-care professionals working together as a team to provide patient care (3.97/4.00 Likert scale 4 = extremely important). Caregivers expressed satisfaction with the MICU team (3.74/4.00). Furthermore, caregivers agreed that the MICU team demonstrated competencies in all four domains of IPCP: values/ethics (3.55/4.00), interprofessional communication (3.58/4.00), roles/responsibilities (3.61/4.00), and teams/teamwork (3.64/4.00). Caregivers felt the MICU team provided patient/family-centered care (sub-competency 3.58/4.00). Notably, the overall caregiver survey scores detailing how well each MICU team functioned were positively correlated to overall satisfaction with the MICU team (r = 0.596 P < .01).
Limitations of the study included:
1. The sample is from a single institution, and perceptions of caregivers cannot be applied to all populations.
2. No information regarding patient, such as diagnosis, was obtained.
3. Caregivers satisfied with care might be more likely to participate.
4. No distinction was made between data collected from caregivers surveyed in the resident-fellow staffed MICU vs NP-staffed MICU.
It has been described that ineffective teamwork and team communication in health care settings are associated with increased patient harm and sentinel events (Kohn LT et al. Washington (DC): National Academies Press(US); 2000); (Page A, Washington (DC): National Academies Press (US); (The Joint Commission. Sentinel Event Alert 2008, 40); (Brennan TA, et al. N Engl J Med. 1991;324:370). Cultural differences between members of the health-care team and established hierarchies of control have been identified as barriers to communication and teamwork in ICUs (Alexanian JA, et al. J Crit Care Med. 2015;43[9]:1880); (Manias E, Street A. Int J Nurs Stud. 2001;38[2]:129).
Overall, the findings from this study emphasize the importance of interprofessional communication and teamwork in the MICU and delivery of patient/family-centered care from the caregivers’ perspective. The unique insight into caregivers’ perspectives on specific team behaviors may be the basis for future quality improvement initiatives.
Justin K. Lui, MD,
Mary Jo Farmer, MD, PhD, FCCP
Kristina E. Ramirez, RRT, MPH, FCCP
Cardiovascular medicine and surgery
COVID-19 and the cardiovascular system
With the global outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) ongoing, there is increased awareness of the cardiovascular manifestations and implications of COVID-19. Approximately 20% of inpatients with COVID-19 have acute cardiac injury (defined as cardiac troponin elevation) (Shi S, et al. JAMA Cardiol. 2020 Mar 25. doi: 10.1001/jamacardio.2020.0950). Moreover, in one cohort, both acute cardiac injury and preexisting cardiovascular disease (CVD) were associated with COVID-19 hospital mortality: 69% with elevated troponin levels and underlying CVD vs 7.6% with neither (Guo T, et al. JAMA Cardiol. 2020 Mar 27. doi: 10.1001/jamacardio.2020.1017). Moreover, case reports suggest COVID-19 may present as myopericarditis, cardiomyopathy, acute on chronic decompensated heart failure, and acute coronary syndrome (Fried JA, et al. Circulation. 2020 Apr 3. doi: 10.1161/circulationaha.120.047164). Adding to this clinical variability, one case series suggests that electrocardiographic ST-segment elevation may not reliably identify obstructive coronary disease (Bangalore S, et al. N Engl J Med. 2020 Apr 17. doi: 10.1056/NEJMc2009020). Intriguingly, the angiotensin-converting enzyme 2 (ACE2) protein is the functional receptor for SARS-CoV-2 cell entry, and ACE2 is highly expressed in pulmonary and cardiac cells (Driggin E, et al. J Am Coll Cardiol. 2020;75[18]:2352). Given the central role of ACE2 and the renin-angiotensin-aldosterone (RAAS) system in cardiovascular pathophysiology and pharmacotherapy, RAAS modulation could have beneficial and/or detrimental effects with COVID-19 (Vaduganathan M, et al. N Engl J Med. 2020;382:1653). Available evidence and societal guidelines support continuing RAAS antagonists in patients per established clinical practice (Mancia G, et al. N Engl J Med. 2020 May 1. doi: 10.1056/NEJMoa2006923); (Mehra MR, et al. N Engl J Med. 2020 May 1. doi: 10.1056/NEJMoa2007621). A better understanding of the direct and indirect effect of SARS-CoV-2 on the cardiovascular system will require additional evidence.
Benjamin B. Kenigsberg, MD
Fellow-in-Training Steering Committee Member
Thrombotic events in COVID-19: Implications and evolving practice recommendations
A startling potential complication of infection with SARS-CoV2 has been the reported predisposition to thrombotic events. Mortality in COVID-19 patients is associated with notable increases in hemostatic parameters such as levels of
Vascular societies led by International Society on Thrombosis and Haemostasis (ISTH) have published consensus recommendations for guidance. If no contraindications exist, pharmacologic venous thromboembolism (VTE) prophylaxis with unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH) is recommended for hospitalized patients with moderate or severe COVID-19 without disseminated intravascular coagulation (DIC). VTE prophylaxis should also be considered for patients with moderate or severe COVID-19 and in DIC but without overt bleeding. There is insufficient evidence to consider routine therapeutic or intermediate-dose parenteral anticoagulation with UFH or LMWH. Many institutions have developed protocols advising therapeutic-intensity anticoagulation when certain thresholds of
Saiprakash B. Venkateshiah, MD, FCCP,
Chair
Gabriela Magda, MD
Fellow-in-Training Steering Committee Member
Interprofessional Team
Quality of interprofessional collaboration in the medical intensive care unit: perceptions by caregivers
A recent study examining caregivers’ perceptions of team interactions and interprofessional collaborative practice (IPCP) behaviors offers new, exciting insights on the importance of interprofessional team functioning in the medical intensive care unit (MICU) (Chen DW, et al. J Gen Intern Med. 2018;33[10]:1708).
The Support Person Jefferson Teamwork Observation Guide (JTOG)TM survey was administered to 161 random caregivers of patients hospitalized in a single large urban academic medical center MICU between May 2016 and December 2016. The survey tool was designed to elicit the perceptions of caregivers regarding team functioning. Survey questions were directly mapped to the 2011 Interprofessional Education Collaborative (IPEC) Expert Panel core competencies for IPCP and divided into four domains (values/ethics; interprofessional communication; roles/responsibilities; teams/teamwork).
Also appended to the surveys were additional follow-up questions that addressed the overall satisfaction with the team and general attitudes regarding the importance of interprofessional team-based care. Caregivers agreed on the importance of health-care professionals working together as a team to provide patient care (3.97/4.00 Likert scale 4 = extremely important). Caregivers expressed satisfaction with the MICU team (3.74/4.00). Furthermore, caregivers agreed that the MICU team demonstrated competencies in all four domains of IPCP: values/ethics (3.55/4.00), interprofessional communication (3.58/4.00), roles/responsibilities (3.61/4.00), and teams/teamwork (3.64/4.00). Caregivers felt the MICU team provided patient/family-centered care (sub-competency 3.58/4.00). Notably, the overall caregiver survey scores detailing how well each MICU team functioned were positively correlated to overall satisfaction with the MICU team (r = 0.596 P < .01).
Limitations of the study included:
1. The sample is from a single institution, and perceptions of caregivers cannot be applied to all populations.
2. No information regarding patient, such as diagnosis, was obtained.
3. Caregivers satisfied with care might be more likely to participate.
4. No distinction was made between data collected from caregivers surveyed in the resident-fellow staffed MICU vs NP-staffed MICU.
It has been described that ineffective teamwork and team communication in health care settings are associated with increased patient harm and sentinel events (Kohn LT et al. Washington (DC): National Academies Press(US); 2000); (Page A, Washington (DC): National Academies Press (US); (The Joint Commission. Sentinel Event Alert 2008, 40); (Brennan TA, et al. N Engl J Med. 1991;324:370). Cultural differences between members of the health-care team and established hierarchies of control have been identified as barriers to communication and teamwork in ICUs (Alexanian JA, et al. J Crit Care Med. 2015;43[9]:1880); (Manias E, Street A. Int J Nurs Stud. 2001;38[2]:129).
Overall, the findings from this study emphasize the importance of interprofessional communication and teamwork in the MICU and delivery of patient/family-centered care from the caregivers’ perspective. The unique insight into caregivers’ perspectives on specific team behaviors may be the basis for future quality improvement initiatives.
Justin K. Lui, MD,
Mary Jo Farmer, MD, PhD, FCCP
Kristina E. Ramirez, RRT, MPH, FCCP