Noninfectious sternal wound inflammation after coronary artery bypass grafting in a patient with myelodysplastic syndrome: A no‐touch approach

Pyoderma gangrenosum (PG) is a rare, chronic inflammatory noninfectious dermatosis. It is associated with underlying systemic or hematological diseases such as myelodysplastic syndrome (MDS) and can be triggered after surgery. Recognition and diagnosis of PG can be difficult as it can mimic a wound infection. Misdiagnosis could lead to invasive procedures which worsen the disease and have possible disastrous aftermath. A 74‐year‐old male with a history of MDS presents with an atypical sternal wound inflammation. Diagnosis confirmed PG after skin biopsy. No surgical or invasive procedures were performed and the patient was treated on an outpatient basis with prednisolone, clobetasol cream, and cyclosporine. This case shows the importance of a rapid diagnosis of the disease. Awareness is required for the diagnosis of PG in a wound with pronounced livid borders, without improvement after antibiotic treatment or worsening after debridement. Rapid diagnosis and treatment reduce high healthcare costs, morbidity, and mortality

Brain Pro-TCT:Quality improvement of delirium detection on a cardiothoracic surgical ward

1) Please declare any conflicts of interest below: The authors declare a potential conflict of interest but not a personal conflict of interest. Part of the costs for this study are covered by Heartcentre Twente Foundation. Prolira provided training and the DeltaScans during the study period free of charge and applied a discount to the disposable patch costs. 2) Ethics Approval: Ethical approval was waived by the Advisory committee Medisch Spectrum Twente at Enschede. The Institutional Review Board of Medisch Spectrum Twente has concluded that this study does not fall under the remit of the Medical Research Involving Human Subjects. 3) Context: The study was done on the cardiothoracic surgery ward at Thoraxcentrum Twente (Medisch Spectrum Twente, Enschede, the Netherlands), a tertiary teaching hospital. Patients 70 years or older who underwent cardiac surgery were included. The quality improvement team included nurse practitioners in cardiac surgery and psychiatry, a cardiac surgeon, nurses, a technical physician, and an epidemiologist. 4) Problem: Delirium is a common syndrome of acute brain failure, which often occurs in hospitalized older patients following cardiac surgery. Delirium after cardiac surgery is related to adverse long-term outcomes, more readmissions to hospital, and decreased cognitive and functional outcomes. Early detection of delirium allows early treatment of underlying causes. In standard care, we use a delirium observation scale score (DOSS). Recently, a single-channel electroencephalography (EEG) medical device was developed to screen delirium based on detection of delta waves (DeltaScan). Using DeltaScan in routine care may improve delirium detection and clinical outcomes. 5) Assessment of problem and analysis of its causes: Previous delirium studies in Thoraxcentrum Twente using DOSS as standard care reported an incidence of delirium of 13 to 17% in elective patients aged ≥45 years. Published and unpublished research data for cardiothoracic surgery wards show an increase of delirium detection by &gt;15% (absolute percentage growth), when DeltaScan was used in clinical studies. Nurses, nurse practitioners, and medical doctors were informed  about the aims of the study and importance of delirium screening. A nurse improvement project, including a workgroup, was started, where the importance of screening was emphasized. Before the implementation of the DeltaScan, nurses on the surgical ward received education and training. Medical doctors, residents, and nurse practitioners were trained on how to interpret the DeltaScan scores. 6) Intervention: First, we continued the DOSS as regular care for delirium screening; three measurements a day for the first three postoperative days. Second, DeltaScan was implemented as new regular care. DeltaScan measurements took place twice a day for at least three consecutive days. 7) Strategy for change: In February 2021 additional training of the DOSS for delirium screening began, and from April 2021 onwards, prospective data collection of the first group continued till May 2022. Training with DeltaScan started in March/April 2022. The DeltaScan data collection started in May 2022, and is still ongoing. 8) Measurement of improvement: The primary endpoints to measure improvement were incidence of delirium, and length of hospital stay. Secondary endpoints included delirium duration, adherence to delirium protocol, and costs related to the innovation. The innovation was deemed successful with an incidence increase from 15 to 30%, and a length of stay reduction with at least 1.5 days. This abstract is based on preliminary data until October 2022. 9) Effects of changes: In total 612 patients were included, with 450 patients in the DOSS group and 162 patients (interim results) in the DeltaScan group. Incidence of finding delirium increased from 15% to 25% (p = 0.008). Median length of hospital stay for delirium patients was reduced from 9 hospital nights to 5.5 nights (p = 0.002). Median duration of delirium decreased (not significantly) from 77 hours to 65 hours (p = 0.12). 10) Lessons learned: Involving all stakeholders early in the project helped to gain commitment to the innovation. The change was measured in a scientific study, as no formal results on effectivity are known at the moment. Introducing a new device for delirium screening arouses resistance. Reducing or removing this resistance remains difficult. 11) Messages for others: Involving all stakeholders in a working group for delirium screening helped to start an innovation, monitor benefits, and motivated colleagues to actually commit to the innovation. Screening for delirium with DeltaScan in our study leads to an increase of finding delirium, and reduced hospital stay (interim results) for patients after cardiothoracic surgery. It is unknown yet, whether this is cost-effective. We hypothesize that these results are expected to be similar for other patient groups such as geriatric or general surgical patients. 12) Please describe how you have involved patients, carers, or family members in the project: Patients and their relatives are informed about the risk of delirium and the impact of delirium before hospital admission. Relatives and patients are often informed during measurements on the importance of adequate delirium screening, where positive responses are often heard. No formal co-creation by patients was done, but informal feedback will be collected in the near future. </p

Can we predict a delirium after cardiac surgery?: A validation study of a delirium risk checklist

BACKGROUND: Delirium is a common temporary mental disorder that often occurs in patients who undergo cardiac surgery. It is important to prevent the negative side effects of delirium by identifying high-risk patients before surgery. Koster and colleagues designed a risk model to identify patients with an increased risk of postoperative delirium after cardiac surgery. AIM: The aim of this study was to validate the risk model for delirium and further improve the risk model. METHODS: A delirium risk checklist containing predictors associated with postoperative delirium was used during the preoperative outpatient screening in 329 patients. The delirium observation screening scale was used preoperatively and postoperatively to assess delirium. RESULTS: Compared with the model of Koster and colleagues age greater than 70 years and a history of delirium were confirmed as statistically significant predictors of postoperative delirium, while cognitive impairment and alcohol abuse were almost significant factors. The European system for cardiac operative risk evaluation (EuroSCORE), comorbidity and type of surgery could not predict a postoperative delirium again. The area under the curve of this model was 0.79 (95% confidence interval (CI) 0.73-0.86; P<0.001). Based on the data of this study the model was improved with the following independent predictors of postoperative delirium: age, more than one comorbidity, history of delirium and a lower standardised mini mental state examination score as with an area under the curve of 0.79 (95% CI 0.73-0.85; P<0.001). CONCLUSION: The risk model could not be fully validated. It is difficult to validate a risk model over time; there are different circumstances such as the increased focus on the prevention of delirium

Vroege delierdetectie na hartchirurgie: de Brain Pro-TCT studie

Achtergrond Delier (acute verwardheid) komt vaak voor nahartchirurgie en is geassocieerd met langere opnameduur, hogere mortaliteit en cognitieveachteruitgang. De delirium observatie screening score (DOSS) wordt MST-breed gebruiktdoor verpleegkundigen. Desondanks missen we veel patiënten met een delier. Deze studie vergelijkt de DOSS met de DeltaScan (1-kanaalsEEG apparaat) bij 70-plussers na hartchirurgie. Uitkomstmaten zijn incidentieen lengte van het delier, opnameduur en kosten. Methode Van april 2021 t/m mei 2022 gebruikten we de DOSS als screeningvan delier volgens MST-protocol, driemaal per dag op de verpleegafdeling. Aansluitendt/m heden worden patiënten gescreend met de DeltaScan, tweemaal per dag. Behandelingvan delier in beide groepen is conform MST-protocol. Delier wordt vastgesteldvolgens DSM-5 criteria. Statistische analyse is gedaan met een Fisher Exact en Mann-WhitneyU test. Resultaten (interim) In de DOSS-groep werden 444 patiënten geïncludeerd, waarvan67 met een delier (15%). Voorlopige resultaten van de Deltascan groep met 276patiënten laten een incidentie van 21% zien, een significante toename (p = 0.041).Duur van het delier nam niet-significant af van 77 [51 – 132] uur naar 69 [47 –96] uur, p = 0.19. Opnameduur na hartchirurgie was 9 [6 – 16]dagen in de DOSS-groep en 6 [5 – 10] dagen in de DeltaScan groep, p = 0.007.Kosten analyse volgt na de inclusie. Conclusie BrainPro-TCT is de eerste studie naar de effectiviteit van DeltaScan na hartchirurgie.Interim-analyse toont een hogere incidentie van delier en een reductie van deopnameduur zonder afname van de lengte van het delier

Brain Pro-TCT: Quality improvement of delirium detection on a cardiothoracic surgical ward

1) Please declare any conflicts of interest below: The authors declare a potential conflict of interest but not a personal conflict of interest. Part of the costs for this study are covered by Heartcentre Twente Foundation. Prolira provided training and the DeltaScans during the study period free of charge and applied a discount to the disposable patch costs. 2) Ethics Approval: Ethical approval was waived by the Advisory committee Medisch Spectrum Twente at Enschede. The Institutional Review Board of Medisch Spectrum Twente has concluded that this study does not fall under the remit of the Medical Research Involving Human Subjects. 3) Context: The study was done on the cardiothoracic surgery ward at Thoraxcentrum Twente (Medisch Spectrum Twente, Enschede, the Netherlands), a tertiary teaching hospital. Patients 70 years or older who underwent cardiac surgery were included. The quality improvement team included nurse practitioners in cardiac surgery and psychiatry, a cardiac surgeon, nurses, a technical physician, and an epidemiologist. 4) Problem: Delirium is a common syndrome of acute brain failure, which often occurs in hospitalized older patients following cardiac surgery. Delirium after cardiac surgery is related to adverse long-term outcomes, more readmissions to hospital, and decreased cognitive and functional outcomes. Early detection of delirium allows early treatment of underlying causes. In standard care, we use a delirium observation scale score (DOSS). Recently, a single-channel electroencephalography (EEG) medical device was developed to screen delirium based on detection of delta waves (DeltaScan). Using DeltaScan in routine care may improve delirium detection and clinical outcomes. 5) Assessment of problem and analysis of its causes: Previous delirium studies in Thoraxcentrum Twente using DOSS as standard care reported an incidence of delirium of 13 to 17% in elective patients aged ≥45 years. Published and unpublished research data for cardiothoracic surgery wards show an increase of delirium detection by >15% (absolute percentage growth), when DeltaScan was used in clinical studies. Nurses, nurse practitioners, and medical doctors were informed  about the aims of the study and importance of delirium screening. A nurse improvement project, including a workgroup, was started, where the importance of screening was emphasized. Before the implementation of the DeltaScan, nurses on the surgical ward received education and training. Medical doctors, residents, and nurse practitioners were trained on how to interpret the DeltaScan scores. 6) Intervention: First, we continued the DOSS as regular care for delirium screening; three measurements a day for the first three postoperative days. Second, DeltaScan was implemented as new regular care. DeltaScan measurements took place twice a day for at least three consecutive days. 7) Strategy for change: In February 2021 additional training of the DOSS for delirium screening began, and from April 2021 onwards, prospective data collection of the first group continued till May 2022. Training with DeltaScan started in March/April 2022. The DeltaScan data collection started in May 2022, and is still ongoing. 8) Measurement of improvement: The primary endpoints to measure improvement were incidence of delirium, and length of hospital stay. Secondary endpoints included delirium duration, adherence to delirium protocol, and costs related to the innovation. The innovation was deemed successful with an incidence increase from 15 to 30%, and a length of stay reduction with at least 1.5 days. This abstract is based on preliminary data until October 2022. 9) Effects of changes: In total 612 patients were included, with 450 patients in the DOSS group and 162 patients (interim results) in the DeltaScan group. Incidence of finding delirium increased from 15% to 25% (p = 0.008). Median length of hospital stay for delirium patients was reduced from 9 hospital nights to 5.5 nights (p = 0.002). Median duration of delirium decreased (not significantly) from 77 hours to 65 hours (p = 0.12). 10) Lessons learned: Involving all stakeholders early in the project helped to gain commitment to the innovation. The change was measured in a scientific study, as no formal results on effectivity are known at the moment. Introducing a new device for delirium screening arouses resistance. Reducing or removing this resistance remains difficult. 11) Messages for others: Involving all stakeholders in a working group for delirium screening helped to start an innovation, monitor benefits, and motivated colleagues to actually commit to the innovation. Screening for delirium with DeltaScan in our study leads to an increase of finding delirium, and reduced hospital stay (interim results) for patients after cardiothoracic surgery. It is unknown yet, whether this is cost-effective. We hypothesize that these results are expected to be similar for other patient groups such as geriatric or general surgical patients. 12) Please describe how you have involved patients, carers, or family members in the project: Patients and their relatives are informed about the risk of delirium and the impact of delirium before hospital admission. Relatives and patients are often informed during measurements on the importance of adequate delirium screening, where positive responses are often heard. No formal co-creation by patients was done, but informal feedback will be collected in the near future