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Acute Care Telehealth In The News

Read how acute care telehealth is leveraging technology to provide better access to high-quality acute care. 

Recent Posts

May 18, 2022
Changing The Ending of The Tale of Two Levels of Care, Remotely
John DePetrillo, MD, FACP

By John DePetrillo, MD, FACP The chronic workforce shortage plaguing hospitals large and small is not waning as hospitalization associated with COVID-19 starts to recede. Many hospitals are having to curtail services; a few have shut their doors. More often, lack of available ICU beds has increased critically ill patient dwell time in the Emergency Department, often spanning hours to days waiting for an ICU bed.  This increases the length of stay for these patients, thus increasing hospital cost   The ability of Equum Medical to expand their services outside of the walls of the ICU has had a large impact on this patient cohort.  By actively managing these patients, we have been able to provide ICU level care in […]

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April 11, 2022
Equum Medical joins the American Telemedicine Association to promote telehealth's role in broadening access to quality care
EQUUM Medical

Equum Medical, a leader in acute care telehealth, has joined the American Telemedicine Association (ATA) to fulfill a common mission of using virtual care services to deliver high quality and effective care for all Americans, regardless of geography.

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April 11, 2022
When Healthcare Goes Remote, It Should Be For A Reason
EQUUM Medical

Just as my life has been a tale of two worlds, from a childhood in a small Texas town with few prospects to a physician entrepreneur in New York, so has the nature of the market space I work in: telehealth.

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April 5, 2022
ISQUA Virtual Event Impact of E Health March 2022
EQUUM Medical

This presentation will focus on these concepts of reliability and resiliency through the construct of Patient Flow with the proposal that with the goal of a HRO hospital concentrating on this metric, efficiency in operations and clinical outcomes can be achieved. At first the operational and clinical interventions to Patient Flow will be presented independently, followed by an introduction to an enterprise architecture that combines both systems in a united design.

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Interesting Articles

WHAT IS TELE-ICU AND HOW DOES IT WORK?

EQUUM MEDICAL AT HOUSTON METHODIST HOSPITAL. On their best days, as they work together to orchestrate and deliver tele-ICU care from different places, bedside and remote teams might feel akin to a symphony, says Dr. Sarah Pletcher, vice president and executive medical director of virtual care at Houston Methodist.
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TELEMEDICINE PROGRAM FINANCIAL OUTCOMES

Background: ICU telemedicine improves access to high-quality critical care, has substantial costs, and can change financial outcomes. Detailed information about financial outcomes and their trends over time following ICU telemedicine implementation and after the addition of logistic center function has not been published to our knowledge.
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HOSPITAL MORTALITY, LENGTH OF STAY, & PREVENTABLE COMPLICATIONS

Context: The association of an adult tele-intensive care unit (ICU) intervention with hospital mortality, length of stay, best practice adherence, and preventable complications for an academic medical center has not been reported...
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ASSOCIATION OF UNIT-LEVEL TELECRITICAL CARE INTENSITY OF SERVICE AND LENGTH OF STAY IN THE INTENSIVE CARE UNIT

Background: Telecritical care (TCC) has been shown to improve outcomes in the intensive care unit (ICU). A TCC was developed and implemented a nocturnal TCC across 10 ICUs in our Health System. TCC coverage patterns and level of involvement vary among ICUs...
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ICU Telemedicine Implementation and Risk-Adjusted Mortality Differences Between Daytime and Nighttime Coverage

Background: ICU telemedicine augmentation has been associated with improvements in clinical and financial outcomes in many cases, but not all. Understanding this discrepancy is of interest given the clinical impact and intervention cost...
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Rapid Implementation and Adaptation of a Telehospitalist Service to Coordinate and Optimize Care for COVID-19 Patients

Background/Introduction: The COVID-19 pandemic poses enormous resource challenges to hospitals. Telemedicine is increasingly recognized as an attractive tool to alleviate resource strains. Herein we describe the rapid implementation and sequential process improvement (PI) of a centralized telehospitalist...
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Intensive care unit telemedicine: alternate paradigm for providing continuous intensivist care

Objective: Intensive care units (ICUs) account for an increasing percentage of hospital admissions and resource consumption. Adverse events are common in ICU patients and contribute to high mortality rates and costs. Although evidence demonstrates reduced complications and mortality when intensivists...
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Effects of Telemedicine ICU Intervention on Care Standardization and Patient Outcomes: An Observational Study

Objectives: Given the numerous recent changes in ICU practices and protocols, we sought to confirm whether favorable effects of telemedicine ICU interventions on ICU mortality and length of stay can be replicated by a more recent telemedicine ICU intervention...
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Implementing and Optimizing Inpatient Access to Dermatology Consultations via Telemedicine: An Experiential Study

Background/Introduction: In-house dermatology consultation services for hospitalized patients are not universally available in acute care hospitals. We encountered an unanticipated access gap for in-person dermatology consultations in our tertiary care hospital that routinely cares for...
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Optimizing Tele-ICU Operational Efficiency Through Workflow Process Modeling and Restructuring

Little is known on how to best prioritize various tele-ICU specific tasks and workflows to maximize operational efficiency. We set out to: 1) develop an operational model that accurately reflects tele-ICU workflows at baseline, 2) identify workflow changes that optimize operational efficiency...
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Legal Perspectives on Telemedicine Part 2: Telemedicine in the Intensive Care Unit and Medicolegal Risk

Abstract: Tele-intensive care unit (tele-ICU) implementation has been shown to improve clinical and financial outcomes. The expansion of this new care delivery model has outpaced the development of its accompanying regulatory framework...
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Legal Perspectives on Telemedicine Part 1: Legal and Regulatory Issues

About: Telemedicine is defined as the remote delivery of clinical care services through audio-visual conferencing technology. A shortage of care practitioners combined with an aging population with disproportionately increasing care utilization patterns has created a "perfect storm,"...
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Telemedicine in the ICU: clinical outcomes, economic aspects, and trainee education

Purpose of review: The evidence base for telemedicine in the ICU (tele-ICU) is rapidly expanding. The last 2 years have seen important additions to our understanding of when, where, and how telemedicine in the ICU adds value.
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Evaluating Tele-ICU Implementation Based on Observed and Predicted ICU Mortality: A Systematic Review and Meta-Analysis

Objectives: Past studies have examined numerous components of tele-ICU care to decipher which elements increase patient and institutional benefit. These factors include review of the patient chart within 1 hour, frequent collaborative data reviews, mechanisms for rapid laboratory/alert review, and interdisciplinary rounds...
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ICU Telemedicine Implementation and Risk-Adjusted Mortality Differences Between Daytime and Nighttime Coverage

ICU telemedicine augmentation has been associated with improvements in clinical and financial outcomes in many cases, but not all. Understanding this discrepancy is of interest given the clinical impact and intervention cost. A recent meta-analysis noted an association with mortality reduction and standardized mortality ratio (SMR) before ICU telemedicine implementation of > 1.
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Tele ER and Tele ICU Webinar

Join us on June, 29th @ 11:30AM EDT If you are a virtual care provider, healthcare provider, payer, MedTech or you are simply interested in the topic, join us in this informal discussion focused on Tele ER and Tele ICU. Perfect opportunity to listen, engage and share your thoughts on the topic.

Featuring

Brian Rosenfeld, MD
EVP, EQUUM Medical

Lou Silverman
CEO at Hicuity Health

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Equum Medical Raises $20 Million of Growth Equity from Heritage Group

NEW YORK, Aug. 24, 2021 /PRNewswire/ -- Equum Medical, a leading provider of acute care telehealth and teleICU solutions, today announced that it raised $20 million in growth equity from Heritage Group. The funding will enable Equum Medical to further enhance its service model and broaden the reach of its experienced team of clinicians across the United States and beyond.
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Equum Medical Raises $20M to Expand Acute Care Telehealth Solutions

What You Should Know – Equum Medical, a New York City-based provider of acute care telehealth and teleICU solutions, today announced that it raised $20 million in growth equity from Heritage Group.
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Equum Medical Raises $20M in Growth Equity Funding

Equum Medical, a NYC-based provider of acute care telehealth and teleICU solutions, raised $20m in growth equity funding. Heritage Group made the investment. The company intends to use the funds to further enhance its service model and broaden the reach of its team of clinicians across the United States and beyond.
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Rapid Implementation and Adaptation of a Telehospitalist Service to Coordinate and Optimize Care for COVID-19 Patients

Background/Introduction: The COVID-19 pandemic poses enormous resource challenges to hospitals. Telemedicine is increasingly recognized as an attractive tool to alleviate resource strains. Herein we describe the rapid implementation and sequential process improvement (PI) of a centralized telehospitalist service to coordinate and optimize management of large number of COVID-19 patients in a tertiary and quaternary care hospital very close to the New York City epicenter.
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Effects of Telemedicine ICU Intervention on Care Standardization and Patient Outcomes: An Observational Study

Given the numerous recent changes in ICU practices and protocols, we sought to confirm whether favorable effects of telemedicine ICU interventions on ICU mortality and length of stay can be replicated by a more recent telemedicine ICU intervention.
READ THE FULL ARTICLE

Implementing and Optimizing Inpatient Access to Dermatology Consultations via Telemedicine: An Experiential Study

In-house dermatology consultation services for hospitalized patients are not universally available in acute care hospitals. We encountered an unanticipated access gap for in-person dermatology consultations in our tertiary care hospital that routinely cares for complex high acuity patients with multiple comorbidities. To bridge this gap in specialist expertise in a timely manner, we expeditiously designed and implemented a telemedicine-supported inpatient dermatology consultation service.
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Global health, global surgery and mass casualties. I. Rationale for integrated mass casualty centres

It has been well-documented recently that 5 billion people globally lack surgical care. Also well-documented is the need to improve mass casualty disaster response. Many of the United Nations (UN) Sustainable Development Goals (SDGs) for 2030—healthcare and economic milestones—require significant improvement in global surgical care, particularly in low-income and middle-income countries. Trauma/stroke centres evolved in high-income countries with evidence that 24/7/365 surgical and critical care markedly improved morbidity and mortality for trauma and stroke and for cardiovascular events, difficult childbirth, acute abdomen. Duplication of emergency services, especially civilian and military, often results in suboptimal, expensive care. By combining all healthcare resources within the ongoing healthcare system, more efficient care for both individual emergencies and mass casualty situations can be achieved.
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Machine Learning and Artificial Intelligence in Neurocritical Care: a Specialty-Wide Disruptive Transformation or a Strategy for Success

Neurocritical care combines the complexity of both medical and surgical disease states with the inherent limitations of assessing patients with neurologic injury. Artificial intelligence (AI) has garnered interest in the basic management of these complicated patients as data collection becomes increasingly automated.
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Telemedicine in the ICU clinical outcomes, economic aspects, and trainee education

The evidence base for telemedicine in the ICU (tele-ICU) is rapidly expanding. The last 2 years have seen important additions to our understanding of when, where, and how telemedicine in the ICU adds value.
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Deciphering factors that influence the value of tele-ICU programs

Becker C, Fusaro M, Scurlock C. Deciphering Factors that Influence the Value of tele-ICU Programs. Intensive Care Medicine. 2019 45(7) 1046-1051.
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Legal Perspectives on Telemedicine Part 2: Telemedicine in the Intensive Care Unit and Medicolegal Risk

Tele-intensive care unit (tele-ICU) implementation has been shown to improve clinical and financial outcomes. The expansion of this new care delivery model has outpaced the development of its accompanying regulatory framework. In the first part of this commentary we discussed legal and regulatory issues of telemedicine in general and expanded on tele-ICU implementation in particular. Major legal and regulatory barriers to expansion remain, including uncertainty regarding license portability and reimbursement. In this second part we discuss the effects of telemedicine implementation on the various aspects of medicolegal risk and risk mitigation, with a particular focus on tele-ICU. There is a paucity of legal data regarding the effect of tele-ICU implementation on medicolegal risk. We will therefore systematically discuss the effects of tele-ICU on the various root causes of medical error. Given the substantial capital and operational investment that must be undertaken to build and run a tele-ICU, any reduction in risk adds to the financial return on investment and further decreases barriers to implementation.
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Legal Perspectives on Telemedicine Part 1: Legal and Regulatory Issues

Telemedicine is defined as the remote delivery of clinical care services through audio-visual conferencing technology. A shortage of care practitioners combined with an aging population with disproportionately increasing care utilization patterns has created a “perfect storm,” which since the late 1990s has propelled telemedicine as a potential solution to bridge this supply/demand and access gap. In critical care approximately 20% of nonfederal adult intensive care unit (ICU) beds in the US today are supported by some form of tele-ICU coverage. The literature has shown with increasing clarity during the last decade that correct tele-ICU implementation improves outcomes and has the potential to significantly improve the financial performance of health care systems. As is often the case in technology-driven innovations, the legal and regulatory framework has been moving slower than the clinical adoption of this new care delivery model, which is true not just in critical care, but in other medical specialties as well. This 2-part series focuses on legal perspectives on telemedicine. The first part discusses legal and regulatory challenges of telemedicine in general, with a more in-depth focus on tele-ICU. The second part will discuss the effects of telemedicine implementation on medicolegal risk, using the litigious critical care environment as an example.
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Evaluating Tele-ICU Implementation Based on Observed and Predicted ICU Mortality: A Systematic Review and Meta-Analysis*

Past studies have examined numerous components of tele-ICU care to decipher which elements increase patient and institutional benefit. These factors include review of the patient chart within 1 hour, frequent collaborative data reviews, mechanisms for rapid laboratory/alert review, and interdisciplinary rounds. Previous meta-analyses have found an overall ICU mortality benefit implementing tele-ICU, however, subgroup analyses found few differences. The purpose of this systematic review and meta-analysis was to explore the effect of tele-ICU implementation with regard to ICU mortality and explore subgroup differences via observed and predicted mortality.
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International teleconsultation on conjoined twins leading to a successful separation: a case report

Conjoined twins are identical twins that have incompletely separated in utero. The prognosis for conjoined twins is poor and management in a skilled tertiary care centre is paramount for definitive care. We describe our experience with a telemedical consultation on conjoined twins in The Dominican Republic from our eHealth centre in Valhalla, NY. The patients were two month old, female, pygopagus conjoined twins. A multidisciplinary teleconference was initiated with the patients, their family, the referring paediatrician and our team. Based on this teleconsultation, the team felt as though the twins may be amenable to a surgical separation. They presented to our centre in Valhalla, NY, for a detailed physical examination and series of imaging studies. Soon after, the patients underwent a successful 21 h separation procedure and were discharged 12 weeks later. To our knowledge, this is one of the first reports of an international teleconsultation leading to a successful conjoined twin separation procedure.
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The Utility of Teleultrasound to Guide Acute Patient Management

Ultrasound has evolved into a core bedside tool for diagnostic and management purposes for all subsets of adult and pediatric critically-ill patients. Teleintensive care unit coverage has undergone a similar rapid expansion period throughout the United States. Round-the-clock access to ultrasound equipment is very common in today's intensive care unit, but 24/7 coverage with staff trained to acquire and interpret point-of-care ultrasound in real time is lagging behind equipment availability. Medical trainees and physician extenders require attending level supervision to ensure consistent image acquisition and accurate interpretation. Teleintensivists can extend the utility of ultrasound by supervising and guiding providers without or with only partial training in ultrasound, and also by extending direct trainee ultrasound supervision to time periods when no direct bedside attending supervisor is available, and when treatment decisions otherwise would have been made without supervision and feedback on image acquisition and interpretation. Nursing staff without ultrasound training can also be directed to perform basic ultrasound exams, which may have immediate diagnostic and/or treatment consequences, thereby overcoming access barriers in the absence of physicians or physician extenders. We discuss 4 real-life clinical scenarios in which teleintensivist supervision extended and standardized bedside ultrasound exams to guide management decisions which significantly impacted patient outcomes.
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Tele-Ultrasound to Guide Management of a Patient with Circulatory Shock

A 65-year-old man with a medical history of chronic obstructive pulmonary disease and ethanol abuse presented to the emergency department with tachypnea, tachycardia, and an altered mental status. He was hypotensive at 90/60 mm Hg. Examination of the patient showed confusion and decreased left-sided breath sounds. The serum laboratory values were significant for a urea nitrogen level of 77 mg/dL and creatinine level of 6.49 mg/dL. A chest roentgenogram revealed hyperinflated lungs and a large left-sided infiltrate. The patient was treated with antibiotics and 2500 mL of crystalloid fluid, and admitted to the intensive care unit (ICU). Within 1 hour of arrival to the ICU, an arterial blood gas revealed a serum pH of 7.15, and the patient required intubation. Twenty minutes later, the patient became hypotensive and was placed on a norepinephrine infusion.
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Telemedicine and Tele-ICU: The Evolution and Differentiation of a New Medical Field

Telemedicine (tele-intensive care unit [tele-ICU]) is defined as the remote delivery of clinical (critical) care services through audiovisual conferencing technology. The last decade has seen an explosion of new telecommunication technology, which in aggregate has propelled telemedicine into a more and more common role both in the in-hospital and out-of-hospital settings, spanning almost all specialties and subspecialties, from neurology1 to trauma surgery2 to behavioral health,3 and extending beyond clinical care services into other usage areas like remote patient and provider education and training, quality improvement, and clinical trial execution, as well as clinical research.
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Telemedicine for Trauma and Emergency: the eICU

The USA and most of the Western world face several major healthcare challenges including an aging population, lack of critical care physicians, and importantly a lack of financial resources. Telemedicine in the ICU makes possible to use intensivists from major medical centers to provide critical care services in small hospitals in remote areas that otherwise will not be able to care for their sick and injured patients.
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Telemedicine in the ICU

Critical care medicine, like no other field in medicine, is in a period of limited resources. This comes at a time when the demand for critical care expertise is starting a period of exponential growth, as baby-boomers age and increasingly need the ICU. All of this is occurring when health care resources are scarce and the US debt to gross domestic product ratio is at an all time high.
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Telemedicine in the Intensive Care Unit

Critical care medicine, like no other field in medicine, is in a period of limited resources. This comes at a time when the demand for critical care expertise is starting a period of exponential growth, as baby boomers age and increasingly need the ICU. All of this is occurring when health care resources are scarce and the US debt to gross domestic product ratio is at an all time high.
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A multicenter population-based effectiveness study of teleintensive care unit-directed ventilator rounds demonstrating improved adherence to a protective lung strategy, decreased ventilator duration and decreased intensive care unit mortality.

The purpose of the study is to determine if teleintensive care unit (ICU)-directed daily ventilator rounds improved adherence to lung protective ventilation (LPV), reduced ventilator duration ratio (VDR), and ICU mortality ratios
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The ICU will see you now: efficient–equitable admission control policies for a surgical ICU with batch arrivals

Intensive Care Units (ICUs) are frequently the bottleneck in a hospital system, limiting patient flow and negatively impacting profits. This article examines admission control policies for a surgical ICU where patients arrive in batches. This problem is formulated as a Markov Decision Process (MDP) with an objective function that allows for varying degrees of emphasis on efficiency versus equity. Equity concerns are driven by a combination of surgery type and operating surgeon and are captured in a robust manner in the proposed models. A simple and efficient heuristic solution method related to our MDP formulation is proposed that provides a performance guarantee. The proposed admissions policy is applied to a real setting motivated by the cardiothoracic surgical ICU at Mount Sinai Medical Center in New York; the results demonstrate that the ICU can achieve large equity gains with no efficiency losses.
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Nighttime Intensivist Staffing and Mortality among Critically Ill Patients

Hospitals are increasingly adopting 24-hour intensivist physician staffing as a strategy to improve intensive care unit (ICU) outcomes. However, the degree to which nighttime intensivists are associated with improvements in the quality of ICU care is unknown.
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A Model to Create an Efficient and Equitable Admission Policy for Patients Arriving to the Cardiothoracic ICU

Objective: To develop queuing and simulation-based models to understand the relationship between ICU bed availability and operating room schedule to maximize the use of critical care resources and minimize case cancellation while providing equity to patients and surgeons.
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Adjuvant Therapy With Methylene Blue in the Treatment of Postoperative Vasoplegic Syndrome Caused by Carcinoid Crisis After Tricuspid Valve Replacement

AN INCREASING BODY of literature continues to show the benefits of methylene blue in cases of refractory hypotension caused by the systemic inflammatory response syndrome (SIRS), septic shock, or vasoplegic syndrome. 1 , 2 Methylene blue, by its indirect inhibition of bradykinin, may alleviate the hypotension associated with carcinoid crisis. The authors report the successful use of methylene blue to treat refractory hypotension in a patient with carcinoid syndrome who underwent a tricuspid valve replacement.
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Needs Assessment for Business Strategies of Anesthesiology Groups' Practices

Progress has been made in understanding strategic decision making influencing anesthesia groups' operating room business practices. However, there has been little analysis of the remaining gaps in our knowledge. We performed a needs assessment to identify unsolved problems in anesthesia business strategy based on Porter's Five Forces Analysis. The methodology was a narrative literature review. We found little previous investigation for 2 of the 5 forces (threat of new entrants and bargaining power of suppliers), modest understanding for 1 force (threat of substitute products or services), and substantial understanding for 2 forces (bargaining power of customers and jockeying for position among current competitors). Additional research in strategic decisions influencing anesthesia groups should focus on the threat of new entrants, bargaining power of suppliers, and the threat of substitute products or services.
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The economics of glycemic control in the ICU in the United States

Currently the USA has an aging population, with increasing deficits and a healthcare system that most would agree is in need of repair. Finding ways to curtail costs is urgently needed. Attention to glycemic control and metabolic care offers a cost-effective method of treatment to reduce complications.
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Glycemic Control and Nutritional Strategies in the Cardiothoracic Surgical Intensive Care Unit—2010: State of the Art

Patients in the cardiothoracic surgical intensive care unit are generally critically ill and undergoing a systemic inflammatory response to cardiopulmonary bypass, ischemia/reperfusion, and hypothermia. This presents several metabolic challenges: hyperglycemia in need of intensive insulin therapy, catabolism, and uncertain gastrointestinal tract function in need of nutritional strategies. Currently, there are controversies surrounding the standard use of intensive insulin therapy and appropriate glycemic targets as well as the use of early enteral nutrition ± parenteral nutrition. In this review, an approach for intensive metabolic support in the cardiothoracic surgical intensive care unit is presented incorporating the most recent clinical evidence. This approach advocates an IIT blood glucose target of 80-110 mg/dL if, it can be implemented safely, with early nutrition support (using parenteral nutrition as needed) to prevent a critical energy debt.
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Targeting value in health care: how intensivists can use business principles to make strategic decisions.

In 1979 Michael E. Porter, PhD, published a seminal paper on how five competitive forces shape strategy within an industry (Figure 1). (1) Grasp of these forces is a cornerstone of any business strategy course, and executives frequently perform a five forces analysis when determining if a strategic decision is correct or if an industry is worth future investment. [FIGURE 1 OMITTED] The forces that govern competition in business in general apply to medicine overall and to critical care as a specialty. Since intensivists work in high-cost areas of hospitals taking care of critically ill patients who use disproportionate hospital resources, they are uniquely positioned to add value in our current health care system. To better position themselves in the coming economic environment, intensivists must increasingly assume hospital leadership positions and apply sound business principles. It is imperative that they understand the structure of the industry and forces that govern it to properly formulate successful business strategies. We present an argument for understanding and using a Porter's Five Forces analysis of critical care. We argue that intensivist groups that target value in their analysis will have a tactical advantage relative to intensivist groups that do not. Value is a difficult term to define, particularly in health care. Porter defines value as health outcome per dollar spent. (2) This differs from past attempts at health reform that focused on simple cost reduction. Improving outcomes per unit of cost is inherently cheaper in the long run as better health is less expensive than poor health. (3)
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Adjuvant Therapy with Methylene Blue in the Treatment of Right Ventricular Failure after Pulmonary Embolectomy

Severe pulmonary embolism often leads to right ventricular failure after surgical embolectomy secondary to ischaemia reperfusion injury and acute lung injury (ALI). Acute right ventricular dysfunction is traditionally treated with inotropes and vasopressors to maintain cardiac output and coronary perfusion as well as selective pulmonary vasodilators to provide right ventricular afterload reduction. We report the first case of utilisation of methylene (MB) in a patient with acute right ventricular failure and vasoplegic shock after surgical pulmonary embolectomy.
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Predictive Model for Postoperative Delirium in Cardiac Surgical Patients

Delirium is a common complication following cardiac surgery, and the predictors of delirium remain unclear. The authors performed a prospective observational analysis to develop a predictive model for postoperative delirium using demographic and procedural parameters. A total of 112 adult postoperative cardiac surgical patients were evaluated twice daily for delirium using the Richmond Agitation-Sedation Scale (RASS) and Confusion Assessment Model for the ICU (CAM-ICU). The incidence of delirium was 34% (n = 38). Increased age (odds ratio [OR] = 2.5; 95% confidence interval [CI] = 1.6-3.9; P < .0001, per 10 years) and increased duration of surgery (OR = 1.3; 95% CI = 1.1-1.5; P = .0002, per 30 minutes) were independently associated with postoperative delirium. Gender, BMI, diabetes mellitus, preoperative ejection fraction, surgery type, length of cardiopulmonary bypass, intraoperative blood component administration, Acute Physiology and Chronic Health Evaluation II score, Sequential Organ Failure Assessment score, and Charlson Comorbidity Index, were not independently associated with postoperative delirium.
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Impaired Postoperative Hyperglycemic Stress Response Associated with Increased Mortality in Patients in the Cardiothoracic Surgery Intensive Care Unit

To describe the association of tight glycemic control with intensive insulin therapy and clinical outcome among patients in the cardiothoracic surgery intensive care unit.
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Invited Commentary

We congratulate the authors [1] on performing a relatively small yet innovative study that measured airway impedance in patients before and after cardiac surgery. Using the forced oscillation technique, airway resistance Raw, and stiffness (E) were measured and compared in patients requiring cardiopulmonary bypass (CPB) versus off-pump coronary artery bypass (OPCAB) cases, as well as obese patients (body mass index [BMI] > 30) versus non-obese patients (BMI < 30). Their findings suggest that there is an increase in Raw that peaks on postoperative (POD) day 1 in obese patients (BMI > 30) that returned to normal by POD #6. There is also an increase in E that peaks on POD #2 in obese patients and CPB patients that did not return to baseline by POD #6. As respiratory failure after cardiac surgery is associated with significant morbidity and mortality and imposes a significant health care burden, it is important to understand that these changes may represent treatment opportunities that have been unrealized to this point [2, 3, 4].
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Determinants of Surgical Outcome in Patients With Isolated Tricuspid Regurgitation

Background— We sought to identify preoperative predictors of clinical outcomes after surgery in patients with severe tricuspid regurgitation.
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A Practical Approach to the Nutritional Management of Mechanically Ventilated Children: A Review

Context: Malnutrition is associated with a longer duration of mechanical ventilation and an increased risk of healthcare-acquired infections in critically ill children who are mechanically ventilated. Objectives: Therefore, nutritional therapy plays a critical role in the initiation and duration of mechanical ventilation and clinical outcomes in such patients. Data Sources: This review was conducted by searching the Web of Science, Scopus, Embase, and Medline databases. A combination of related mesh terms and keywords was used to find the relevant articles. Finally, we screened search results through titles and abstracts and related articles were enrolled in the review process. We tried to address all aspects of nutritional management of mechanically ventilated critically ill children.
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Critique of normoglycemia in intensive care evaluation: survival using glucose algorithm regulation (NICE-SUGAR) – a review of recent literature

The publication of the long awaited results of the Normoglycaemia in Intensive Care Evaluation – Survival Using Glucose Algorithm Regulation (NICE-SUGAR) trial generated intense controversy in the area of glycemic control in the critically ill. NICE-SUGAR reported results in direct contrast to the original Leuven study and challenged the legitimacy of a mortality benefit of tight glycemic control in the intensive care unit (ICU). This review of the recent literature critically examines the salient differences between NICE-SUGAR and the original Leuven study.
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Use of Inhaled Epoprostenol in Transition to Extubation in a Patient After Implantation of a Ventricular Assist Device

PULMONARY ARTERY HYPERTENSION (PAH) is a life-threatening condition characterized by an increase in arterial pressure and vascular resistance in the pulmonary circulation. 1 It is defined by a mean pulmonary artery pressure (PAP) of more than 25 mmHg at rest or more than 30 mmHg during exercise. 2 PAH may aggravate right-heart failure, which is present in many patients after cardiac surgery requiring cardiopulmonary bypass. This is particularly important in patients who have had placement of a left ventricular assist device (LVAD) as the right ventricle benefits from afterload reduction in the pulmonary circulation. Therefore, in these and other situations, such as orthotopic heart transplant and either single- or double-lung transplant, it is beneficial to lower pulmonary pressures by pharmacologic measures. However, treatment with intravenous (IV) pulmonary vasodilators may reduce systemic blood pressure as well, leading to systemic hypotension and may impair coronary perfusion and right-heart performance. Thus, these patients commonly are treated with inhaled agents such as epoprostenol or nitric oxide postoperatively to reduce pulmonary afterload while avoiding reductions in systemic pressure. To accomplish this, patients must remain intubated until their requirements for inhaled pulmonary vasodilators decrease and can be safely discontinued.
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Impact of new technologies on metabolic care in the intensive care unit

PURPOSE OF REVIEW: Technological innovations in the ICU have lead to extraordinary advances in modern critical care. Renal replacement therapy (RRT) innovations and ventricular assist devices (VAD) are now becoming common interventions in the ICU environment. The purpose of this article is to describe the impact of RRT and VAD on critical care medicine with particular reference to metabolic care.
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Successful Conservative Management of Tracheal Injury After Forceful Coughing During Extubation: A Case Report

A-56-year-old woman underwent carpal tunnel release surgery under general anesthesia. Thirty minutes after extubation, the patient complained of chest discomfort with dyspnea. Swelling of the neck and upper anterior chest was observed. Computed tomography of the chest showed tracheal rupture at the brachiocephalic trunk level, and bronchoscopy demonstrated a 5 cm linear tracheal defect in the posterior membranous wall, 6 cm proximal to the carina. Surgical repair of the tracheal injury was impossible due to its location. The patient was managed with intubation, mechanical ventilator care, and antibiotics. She made a full and uncomplicated recovery and was discharged 18 days after the original injury. When suspicious symptoms appear in patients receiving mechanical ventilation support, an immediate and accurate diagnostic process should be undertaken to rule out endotracheal tube-related tracheal injuries and to avoid potentially lethal complications.
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Intensive Metabolic Support : Evolution and Revolution

Objective - To describe a new aspect of critical care termed intensive metabolic support. Methods - We performed a MEDLINE search of the English-language literature published between 1995 and 2008 for studies regarding the metabolic stages of critical illness, intensive insulin treatment, and intensive metabolic support in the intensive care unit, and we summarize the clinical data. Results - Intensive metabolic support is a 3-component model involving metabolic control and intensive insulin therapy, early nutrition support, and nutritional pharmacology aimed at preventing allostatic overload and the development of chronic critical illness. To improve clinical outcome and prevent mortality, intensive metabolic support should start on arrival to the intensive care unit and should end only when patients are in the recovery phase of their illness. Conclusions -Intensive metabolic support should be an essential part of the daily treatment strategy in critical care medicine. This will involve a newfound and extensive collaboration between the endocrinologist and the intensivist. We call for well-designed future studies involving implementation of this protocol to decrease the burden of chronic critical illness. (Endocr Pract. 2008;14:1047-1054)
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Chromium Infusion Reverses Extreme Insulin Resistance in a Cardiothoracic ICU Patient

Insulin resistance is common and often multifactorial in acutely critically ill patients. At our institution, glycemic control is achieved in these patients using an intravenous insulin protocol. The authors present a case in which a patient developed severe insulin resistance following surgical repair of a thoracic aorta aneurysm. Postoperatively, the patient required 2110 units of insulin over 40 hours while receiving pressors and glucocorticoids. After the administration of intravenous chromium at 3 μg/h, the blood sugar normalized and insulin therapy was discontinued. This case represents a unique approach using intravenous chromium to achieve glycemic control in a patient with extreme insulin resistance and acute critical illness. Prospective clinical trials using intravenous chromium may provide the means to optimize intensive insulin therapy for critically ill patients.
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Predictors and Outcome of Gastrointestinal Complications in Patients Undergoing Cardiac Surgery

To determine the incidence and independent predictors of gastrointestinal complications (GICs) following cardiac surgery. Summary Background Data: Gastrointestinal ischemia and hemorrhage represent a rare but devastating complication following heart surgery. The profile of patients referred for cardiac surgery has changed during the last decade, questioning the validity of previously reported incidence and risk factors. Methods: We retrospectively analyzed prospectively collected data from 4819 patients undergoing cardiac surgery between 1998 and 2004. Patients with GICs were compared with the entire patient population. Study endpoints were mortality, postoperative morbidities, and long-term survival.
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Effective Management of Refractory Postcardiotomy Bleeding With the Use of Recombinant Activated Factor VII

Severe coagulopathy after cardiovascular surgery may lead to intractable bleeding and is associated with increased mortality and morbidity. Recent studies have suggested that recombinant activated factor VII (rFVIIa) may play a role in decreasing postoperative bleeding. Herein we report our experience with the off-label use of rFVIIa in patients with refractory postcardiotomy bleeding.
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The “To Err is Human” report and the patient safety literature

The “To Err is Human” report published by the Institute of Medicine (IOM) in 1999 called for a national effort to make health care safer. Although the report has been widely credited with spawning efforts to study and improve safety in health care, there has been limited objective assessment of its impact. We evaluated the effects of the IOM report on patient safety publications and research awards.
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Self-Reported Impulsivity is Correlated with Laboratory-Measured Escape Behavior

Aggression has been previously correlated with impulsive personality. In the present study, Barratt Impulsiveness Scale (BIS) scores of 40 male controls aged 15–40 years were related to the frequency of free-operant aggressive and escape responses toward a fictitious antagonist. Participants earned “points” worth money with repeated button presses on a fixed-ratio schedule and were provoked by the periodic subtraction of a point. These subtractions were blamed on the behavior of a (fictitious) other participant, and aggressive responses (presses of a separate button) were defined as those emitted by the participant with an intent to subtract earnings from the other (fictitious) participant. BIS scores were not correlated with frequency of point-subtracting (aggressive) responses to the point subtractions, but they were correlated with the frequency of escape responses on a third button, which the participant was told would protect his points from subtraction for an unspecified period of time. These results suggest that among normal controls, impulsivity might be characterized by some sensitivity to aversive stimuli.
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Hospital Telehealth – Top Level Summary

Signify Research Ltd a premier global healthcare research firm has released "Hospital Telehealth World 2022" - the first stand alone analysis of the global telehealth market landscape. Market size, strategic organizational share, and trends are captured. Equum Medical is proud to be recognized in this report as a Quadrant Leader in Acute-Inpatient Professional Clinical Services. This positioning represents our strategic growth beyond Tele-ICU through Equum's comprehensive Acute Care Professional Clinical Services Portfolio.
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