Browsing by Author "Meagher, Ashley"

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    Bringing Clinical Organizational Ethics into Practice
    (2024-05) Swartwood, Brigitte Rene; Beckman, Emily; Haberski, Raymond; Hartsock, Jane; Helf, Paul R.; Meagher, Ashley
    This dissertation consists of four papers that focus on the integration of clinical organizational ethics (COE) concepts into clinical practice. As defined by Miller and Hartsock, COE is a distinct area of ethics that addresses recurrent clinical ethics dilemmas. These dilemmas are issue-based and arise directly from patient care, yet these issues affect multiple patients. The resolution of these dilemmas are often revisions of procedures, policies, or practices.1 By analyzing specific organizational-level policies and practices, I attempt to ground these theoretical ideas by considering their impact on clinical outcomes. These four papers illustrate the integration of COE into practice in three ways: conceptually, empirically, and through recommendation of change in practice. "Victims of Violence, Hospital Policies, and Potential for Bias" and "Opioid Prescribing, Hidden Influences, and the Cultural Impact of Christianity" conceptually discuss a policy or practice affecting clinical care. "Victims ofViolence ... " investigates the implications of No Information Status policies and suggests that they may burden bedside staff while providing a false sense of safety and may exacerbate existing health disparities. "Opioid Prescribing ... " examines how Christian frameworks may be implicitly shaping clinicians' approaches to opioid prescribing within the setting of chronic nonmalignant pain management. "Evaluation of Security Emergency Responses: Racial Disparities in Activation" uses empirical evidence to discuss racial disparities in security emergency responses (SERs) within a hospital. This paper used a retrospective, descriptive cohort study to illustrate ethical implications of polices that exacerbate health disparities. Finally, "The Importance of Data Collection in SERs" proposes a framework for collecting data and addressing SER challenges within an organization. This improvement in hospital practices will provide opportunities to address some of the complex challenges surrounding SERs. Collectively, these papers aim to fill gaps in the literature, challenge implicit biases, and address specific challenges in clinical care using a Clinical Organizational Ethics framework.
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    Delirium and neuropsychological recovery among emergency general surgery survivors (DANE): study protocol for a randomized controlled trial and collaborative care intervention
    (BMC, 2023-10-03) Mohanty, Sanjay; Holler, Emma; Ortiz, Damaris; Meagher, Ashley; Perkins, Anthony; Bylund, Peggy; Khan, Babar; Unverzagt, Frederick; Xu, Hupuing; Ingraham, Angela; Boustani, Malaz; Zarzaur, Ben; Surgery, School of Medicine
    Background: Delirium is a complex neuropsychiatric syndrome which consists of acute and varying changes in cognition and consciousness. Patients who develop delirium are at increased risk for a constellation of physical, cognitive, and psychological disabilities long after the delirium has ended. Collaborative care models integrating primary and specialty care in order to address patients with complex biopsychosocial needs have been demonstrated to improve outcomes in patients with chronic diseases. The purpose of this study is to evaluate the ability of a collaborative care model on the neuropsychologic recovery of delirium survivors following emergency surgery. Methods: This protocol describes a multicenter (eight hospitals in three states) randomized controlled trial in which 528 patients who develop delirium following emergency surgery will be randomized to either a collaborative care model or usual care. The efficacy of the collaborative care model on cognitive, physical, and psychological recovery in these delirium survivors will then be evaluated over 18 months. Discussion: This will be among the first randomized clinical trials in postoperative delirium survivors evaluating an intervention designed to mitigate the downstream effects of delirium and improve the neuropsychologic recovery after surgery. We hope that the results of this study will add to and inform strategies to improve postoperative recovery in this patient group.
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    Early or Late Gastrografin Challenge for the Non-Operative Management of Small Bowel Obstruction
    (2020-09-10) Holder, Erik; Murphy, Patrick; Meagher, Ashley; Rodriguez, Rachel
    Introduction: Gastrogafin (GG) challenge is becoming the standard of care for the non-operative management of adhesive small bowel obstruction (aSBO). Protocols vary in the timing of GG challenge from early (≤ 24 hours) to late (> 24 hours). Concerns remain regarding the safety of early GG due to inadequate stomach and bowel decompression raising fear of complication such as aspiration. Few studies have investigated the relationship between the timing of GG and patient outcomes, including time to OR, length of stay or complication rate. We hypothesized early GG challenge would be non-inferior to late GG challenge and would have shorter length of stay. Methods: A retrospective cohort study of 215 patients over two years (2018-2019) who underwent non-operative management of adhesive SBO. We stratified patients by timing of GG challenge, ≤ 24 hours (Early GG) or > 24hours (Late GG). Our primary outcome was success of GG challenge defined by discharge without an operation. Secondary outcomes included bowel resection, re-admission rate, hospital length of stay, and mortality. Our non-inferiority margin was 4%. We used the Chen Quasi-Exact method to determine confidence intervals for small sample sizes to determine non-inferiority. Continuous data was assessed by one-way ANOVA and categorical data with Fischer’s Exact test. Results: A total of 215 patients underwent planned non-operative management of adhesive SBO over the study period, of whom 102 received a GG challenge. Early GG was administered in 33 (32%), Late GG was administered in 79 (68%). There was no difference in age or gender, but more African Americans received Late GG (40% vs 15%, p = 0.01). The need for operative intervention was lowest in the early group, 6.1% compared to 17.7% in the late group. The difference of -11.6% [95% CI -22.9% - 3.3%] was non-inferior (p=0.03) but did not meet superiority. No patient receiving Early GG required bowel resection compared to 5 (35%) in the Late GG group (p = 0.45). Hospital length of stay was a median of 3 (IQR 2) for Early GG compared to 4 (IQR 8) for Late GG (p < 0.001). There was no difference in mortality, re-admission rates, ICU admission or ICU length of stay between groups. Conclusion: Early GG challenge (≤ 24 hours) is non-inferior to late GG challenge (> 24 hours) for the non-operative management of adhesive SBO. Patients who received early GG had a shorter length of stay, and no complications associated with early GG. Additionally, fewer patients who received early GG received a bowel resection, although this is not statistically significant. This indicates need for multi-center evaluation of GG administration and development of practice management guidelines for patients with adhesive SBO. We recommend early GG challenge to decrease the time for operative decision making and reduce length of stay. A prospective study comparing early versus late GG challenge is needed to determine optimal timing.
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    Postoperative Pancreatic Fistula Following Traumatic Splenectomy: A Morbid and Costly Complication
    (Elsevier, 2022-12) Arnold, Peter; Belchos, Jessica; Meagher, Ashley; Robbins, Christopher; Sparks Joplin, Tasha; Ortiz, Damaris; Ferries, Ian; Hartwell , Jennifer; Surgery, School of Medicine
    Introduction: Development of clinically relevant postoperative pancreatic fistula (CR-POPF) in adult splenectomies following trauma occur in 1%-3% of cases. We hypothesized that the use of sutures in splenic hilum ligation compared to staples was associated with a reduced rate of CR-POPF incidence. Methods: Adult trauma patients (age ≥17 y) that underwent nonelective splenectomy from 2010 to 2020 were retrospectively evaluated from the trauma registries of all three adult level 1 trauma centers in Indiana. Patients were excluded if they were pregnant, currently incarcerated, expired within 72 h of admission, or had a pancreatic injury diagnosed preoperatively or intraoperatively. A Firth logistic regression using a penalized-maximum likelihood estimate for rare events was used for univariate predictive modeling (SPSS 28.0) of surgical technique on CR-POPF development. Results: Four hundred nineteen adult splenectomies following trauma were conducted; 278 were included. CR-POPF developed in 14 cases (5.0%). Sutures alone were used in 200 cases: seven developed CR-POPF (3.5%). Staples alone or in combination with sutures were used in 74 cases: seven developed CR-POPF (9.5%). There was no statistically significant difference between the use of sutures alone compared to the use of staples alone (P = 0.123) or in combination (P = 0.100) in CR-POPF incidence. Conclusions: Our 10-y retrospective review of CR-POPF finds the complication to be rare but morbid. This study was underpowered to show any difference in surgical technique. However, we do propose a new institutional norm that CR-POPF develop in 5% of splenectomies after trauma and conclude that further study of optimal technique for emergent splenectomy is warranted.