Browsing by Author "Self, Wesley H."

Now showing 1 - 5 of 5
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    A call for collaboration and consensus on training for endotracheal intubation in the medical intensive care unit
    (BMC, 2020-10-22) Brown, Wade; Santhosh, Lekshmi; Brady, Anna K.; Denson, Joshua L.; Niroula, Abesh; Pugh, Meredith E.; Self, Wesley H.; Joffe, Aaron M.; O’Neal Maynord, P.; Carlos, W. Graham; Medicine, School of Medicine
    Endotracheal intubation (EI) is a potentially lifesaving but high-risk procedure in critically ill patients. While the ACGME mandates that trainees in pulmonary and critical care medicine (PCCM) achieve competence in this procedure, there is wide variation in EI training across the USA. One study suggests that 40% of the US PCCM trainees feel they would not be proficient in EI upon graduation. This article presents a review of the EI training literature; the recommendations of a national group of PCCM, anesthesiology, emergency medicine, and pediatric experts; and a call for further research, collaboration, and consensus guidelines.
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    Effect of a Self-care Intervention on 90-Day Outcomes in Patients With Acute Heart Failure Discharged From the Emergency Department: A Randomized Clinical Trial
    (American Medical Association, 2021) Collins, Sean P.; Liu, Dandan; Jenkins, Cathy A.; Storrow, Alan B.; Levy, Phillip D.; Pang, Peter S.; Chang, Anna Marie; Char, Douglas; Diercks, Deborah J.; Fermann, Gregory J.; Han, Jin H.; Hiestand, Brian; Hogan, Christopher; Kampe, Christina J.; Khan, Yosef; Lee, Sangil; Lindenfeld, JoAnn; Martindale, Jennifer; McNaughton, Candace D.; Miller, Karen F.; Miller-Reilly, Carolyn; Moser, Kelly; Peacock, W. Frank; Robichaux, Chad; Rothman, Russell; Schrock, Jon; Self, Wesley H.; Singer, Adam J.; Sterling, Sarah A.; Ward, Michael J.; Walsh, Cheryl; Butler, Javed; Emergency Medicine, School of Medicine
    Importance: Up to 20% of patients who present to the emergency department (ED) with acute heart failure (AHF) are discharged without hospitalization. Compared with rates in hospitalized patients, readmission and mortality are worse for ED patients. Objective: To assess the impact of a self-care intervention on 90-day outcomes in patients with AHF who are discharged from the ED. Design, setting, and participants: Get With the Guidelines in Emergency Department Patients With Heart Failure was an unblinded, parallel-group, multicenter randomized trial. Patients were randomized 1:1 to usual care vs a tailored self-care intervention. Patients with AHF discharged after ED-based management at 15 geographically diverse EDs were included. The trial was conducted from October 28, 2015, to September 5, 2019. Interventions: Home visit within 7 days of discharge and twice-monthly telephone-based self-care coaching for 3 months. Main outcomes and measures: The primary outcome was a global rank of cardiovascular death, HF-related events (unscheduled clinic visit due to HF, ED revisit, or hospitalization), and changes in the Kansas City Cardiomyopathy Questionnaire-12 (KCCQ-12) summary score (SS) at 90 days. Key secondary outcomes included the global rank outcome at 30 days and changes in the KCCQ-12 SS score at 30 and 90 days. Intention-to-treat analysis was performed for the primary, secondary, and safety outcomes. Per-protocol analysis was conducted including patients who completed a home visit and had scheduled outpatient follow-up in the intervention arm. Results: Owing to slow enrollment, 479 of a planned 700 patients were randomized: 235 to the intervention arm and 244 to the usual care arm. The median age was 63.0 years (interquartile range, 54.7-70.2), 302 patients (63%) were African American, 305 patients (64%) were men, and 178 patients (37%) had a previous ejection fraction greater than 50%. There was no significant difference in the primary outcome between patients in the intervention vs usual care arm (hazard ratio [HR], 0.89; 95% CI, 0.73-1.10; P = .28). At day 30, patients in the intervention arm had significantly better global rank (HR, 0.80; 95% CI, 0.64-0.99; P = .04) and a 5.5-point higher KCCQ-12 SS (95% CI, 1.3-9.7; P = .01), while at day 90, the KCCQ-12 SS was 2.7 points higher (95% CI, -1.9 to 7.2; P = .25). Conclusions and relevance: The self-care intervention did not improve the primary global rank outcome at 90 days in this trial. However, benefit was observed in the global rank and KCCQ-12 SS at 30 days, suggesting that an early benefit of a tailored self-care program initiated at an ED visit for AHF was not sustained through 90 days.
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    Fluid Response Evaluation in Sepsis Hypotension and Shock: A Randomized Clinical Trial
    (Elsevier, 2020) Douglas, Ivor S.; Alapat, Philip M.; Corl, Keith A.; Exline, Matthew C.; Forni, Lui G.; Holder, Andre L.; Kaufman, David A.; Khan, Akram; Levy, Mitchell M.; Martin, Gregory S.; Sahatjian, Jennifer A.; Seeley, Eric; Self, Wesley H.; Weingarten, Jeremy A.; Williams, Mark; Hansell, Douglas M.; Medicine, School of Medicine
    Background: Fluid and vasopressor management in septic shock remains controversial. In this randomized controlled trial, we evaluated the efficacy of dynamic measures (stroke volume change during passive leg raise) to guide resuscitation and improve patient outcome. Research question: Will resuscitation that is guided by dynamic assessments of fluid responsiveness in patients with septic shock improve patient outcomes? Study design and methods: We conducted a prospective, multicenter, randomized clinical trial at 13 hospitals in the United States and United Kingdom. Patients presented to EDs with sepsis that was associated hypotension and anticipated ICU admission. Intervention arm patients were assessed for fluid responsiveness before clinically driven fluid bolus or increase in vasopressors occurred. The protocol included reassessment and therapy as indicated by the passive leg raise result. The control arm received usual care. The primary clinical outcome was positive fluid balance at 72 hours or ICU discharge, whichever occurred first. Results: In modified intent-to-treat analysis that included 83 intervention and 41 usual care eligible patients, fluid balance at 72 hours or ICU discharge was significantly lower (-1.37 L favoring the intervention arm; 0.65 ± 2.85 L intervention arm vs 2.02 ± 3.44 L usual care arm; P = .021. Fewer patients required renal replacement therapy (5.1% vs 17.5%; P = .04) or mechanical ventilation (17.7% vs 34.1%; P = .04) in the intervention arm compared with usual care. In the all-randomized intent-to-treat population (102 intervention, 48 usual care), there were no significant differences in safety signals. Interpretation: Physiologically informed fluid and vasopressor resuscitation with the use of the passive leg raise-induced stroke volume change to guide management of septic shock is safe and demonstrated lower net fluid balance and reductions in the risk of renal and respiratory failure. Dynamic assessments to guide fluid administration may improve outcomes for patients with septic shock compared with usual care.
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    Improvement in Kansas City Cardiomyopathy Questionnaire Scores After a Self-Care Intervention in Patients With Acute Heart Failure Discharged From the Emergency Department
    (American Heart Association, 2021) Stubblefield, William B.; Jenkins, Cathy A.; Liu, Dandan; Storrow, Alan B.; Spertus, John A.; Pang, Peter S.; Levy, Phillip D.; Butler, Javed; Chang, Anna Marie; Char, Douglas; Diercks, Deborah B.; Fermann, Gregory J.; Han, Jin H.; Hiestand, Brian C.; Hogan, Christopher J.; Khan, Yosef; Lee, Sangil; Lindenfeld, JoAnn M.; McNaughton, Candace D.; Miller, Karen; Peacock, W. Frank; Schrock, Jon W.; Self, Wesley H.; Singer, Adam J.; Sterling, Sarah A.; Collins, Sean P.; Emergency Medicine, School of Medicine
    Background: We conducted a secondary analysis of changes in the Kansas City Cardiomyopathy Questionnaire (KCCQ)-12 over 30 days in a randomized trial of self-care coaching versus structured usual care in patients with acute heart failure who were discharged from the emergency department. Methods: Patients in 15 emergency departments completed the KCCQ-12 at emergency department discharge and at 30 days. We compared change in KCCQ-12 scores between the intervention and usual care arms, adjusted for enrollment KCCQ-12 and demographic characteristics. We used linear regression to describe changes in KCCQ-12 summary scores and logistic regression to characterize clinically meaningful KCCQ-12 subdomain changes at 30 days. Results: There were 350 patients with both enrollment and 30-day KCCQ summary scores available; 166 allocated to usual care and 184 to the intervention arm. Median age was 64 years (interquartile range, 55-70), 37% were female participants, 63% were Black, median KCCQ-12 summary score at enrollment was 47 (interquartile range, 33-64). Self-care coaching resulted in significantly greater improvement in health status compared with structured usual care (5.4-point greater improvement, 95% CI, 1.12-9.68; P=0.01). Improvements in health status in the intervention arm were driven by improvements within the symptom frequency (adjusted odds ratio, 1.62 [95% CI, 1.01-2.59]) and quality of life (adjusted odds ratio, 2.39 [95% CI, 1.46-3.90]) subdomains. Conclusions: In this secondary analysis, patients with acute heart failure who received a tailored, self-care intervention after emergency department discharge had clinically significant improvements in health status at 30 days compared with structured usual care largely due to improvements within the symptom frequency and quality of life subdomains of the KCCQ-12.
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    Troponin is unrelated to outcomes in heart failure patients discharged from the emergency department
    (Wiley, 2022-04-09) Fermann, Gregory J.; Schrock, Jon W.; Levy, Phillip D.; Pang, Peter; Butler, Javed; Chang, Anna Marie; Char, Douglas; Diercks, Deborah; Han, Jin H.; Hiestand, Brian; Hogan, Chris; Jenkins, Cathy A.; Kampe, Christy; Khan, Yosef; Kumar, Vijaya A.; Lee, Sangil; Lindenfeld, JoAnn; Liu, Dandan; Miller, Karen F.; Peacock, W. Frank; Reilly, Carolyn M.; Robichaux, Chad; Rothman, Russell L.; Self, Wesley H.; Singer, Adam J.; Sterling, Sarah A.; Storrow, Alan B.; Stubblefield, William B.; Walsh, Cheryl; Wilburn, John; Collins, Sean P.; Emergency Medicine, School of Medicine
    Background: Prior data has demonstrated increased mortality in hospitalized patients with acute heart failure (AHF) and troponin elevation. No data has specifically examined the prognostic significance of troponin elevation in patients with AHF discharged after emergency department (ED) management. Objective: Evaluate the relationship between troponin elevation and outcomes in patients with AHF who are treated and released from the ED. Methods: This was a secondary analysis of the Get with the Guidelines to Reduce Disparities in AHF Patients Discharged from the ED (GUIDED-HF) trial, a randomized, controlled trial of ED patients with AHF who were discharged. Patients with elevated conventional troponin not due to acute coronary syndrome (ACS) were included. Our primary outcome was a composite endpoint: time to 30-day cardiovascular death and/or heart failure-related events. Results: Of the 491 subjects included in the GUIDED-HF trial, 418 had troponin measured during the ED evaluation and 66 (16%) had troponin values above the 99th percentile. Median age was 63 years (interquartile range, 54-70), 62% (n = 261) were male, 63% (n = 265) were Black, and 16% (n = 67) experienced our primary outcome. There were no differences in our primary outcome between those with and without troponin elevation (12/66, 18.1% vs 55/352, 15.6%; P = 0.60). This effect was maintained regardless of assignment to usual care or the intervention arm. In multivariable regression analysis, there was no association between our primary outcome and elevated troponin (hazard ratio, 1.00; 95% confidence interval, 0.49-2.01, P = 0.994). Conclusion: If confirmed in a larger cohort, these findings may facilitate safe ED discharge for a group of patients with AHF without ACS when an elevated troponin is the primary reason for admission.