How Anchoring Can Sink The Ship

Introduction: Anchoring bias is a type of heuristic that uses an initial source of information as an “anchor” for basis of decision making. Then judgments and thought processes are led by this sole foundation. There are many different types of influences and bias used in medical decision making, which has prompted concerns regarding their impact on diagnostic inaccuracies. Studies have identified “anchoring” conducted in medical literature, clinical vignettes and real life scenarios. These cognitive bias and aversions to ambiguities can lead to medical errors, inappropriate use of resources, and harm to the patient. We focus our case on the effects of anchoring diagnosis. Case Report: We describe a case of a 29 year old male with past medical history significant of chronic headaches, who presented to the emergency department from home via police escort for suspected polysubstance overdose. Police were called for questionable seizure and medication overdose. They were unsure what medications the patient took. The patient stated taking an unknown amount of prescribed clonazepam, sumatriptan and ibuprofen. He was unable to provide the timing or amount of ingestion. Physical exam was positive for confusion, bradycardia and hypertension. Urine drug screen was positive for amphetamine, benzodiazepine and cannabinoids. A few hours later the patient continued to appear drowsy with intermittent agitation requiring soft restraints. On hospital day 1, he was noted to be very lethargic, unresponsive and hypoxic on room air. Code blue was called and patient was intubated and transferred to the ICU. Upon reexamination, the patient’s pupils were dilated and fixed. Subsequent CT head showed a large 10 cm hyperdense right frontal lobe mass with resultant uncal herniation and severe hydrocephalus. This was suspicious for meningioma or tumor. After successful contact with the family and getting a history from the mother, she reported significant personality changes, increasingly odd behaviors, memory loss, worsened headaches and gait disturbances over multiple years. The mother had assumed the patient was using drugs. She also confirmed the number of pills left in the prescription bottles was accurate. At this point, the patient was transferred to a tertiary hospital for escalation of care and neurosurgical intervention where he ultimately died. Conclusion: We present a unique case of acute metabolic encephalopathy impacted by anchoring diagnosis of drug overdose that later confirmed a diagnosis of brain tumor. If we had spent more time obtaining all the facts, we could have gotten a CT head and arrived at a diagnosis before the patient herniated. Inability to recognize cognitive bias, runs the risk of diagnostic inaccuracies, unnecessary prescribed medications and underestimation of testing. More importantly, addressing anchoring allows the opportunity to decrease patient harm, guide future occurrences and tailor research towards minimizing these outcomes.https://scholarlycommons.henryford.com/merf2020caserpt/1107/thumbnail.jp

Project #91: Optimizing Vascular Access to Reduce CLABSI

Henry Ford Macomb Hospital experienced an increase in Central Line Associated Bloodstream Infections (CLABSI) in 2021. A significant portion were occurring in the MICU and were associated with Candida sp. Bloodstream infections negatively impact patient outcomes, provider workload, and are costly, with a median cost of $48,108 based on a meta-analysis conducted by AHRQ in 2017. By end of 2022, HFM aimed to reduce CLABSI incidence by 50%.https://scholarlycommons.henryford.com/qualityexpo2023/1004/thumbnail.jp

Acute Interstitial Pneumonia (Hamman Rich Syndrome)

Acute interstitial pneumonia (AIP - also known as Hamman-Rich syndrome) is an acute, rapidly progressive idiopathic pulmonary disease that often leads to fulminant respiratory failure and acute respiratory distress syndrome (ARDS). It can be distinguished clinically from other types of interstitial pneumonia by the rapid onset of respiratory failure in a patient without preexisting lung disease. Louis Hamman and Arnold Rich first described it in 1935 as a fulminating diffuse interstitial fibrosis of the lungs. In 1986, Katzenstein introduced the term AIP differentiating it from the group of chronic interstitial pneumonia. The American Thoracic Society (ATS) and European Respiratory Society (ERS) classify AIP under major idiopathic interstitial pneumonia, compared to other rare or unclassified idiopathic interstitial pneumonia

Interstitial (Nonidiopathic) Pulmonary Fibrosis

Nonidiopathic interstitial pulmonary fibrosis (non-IPF) describes a group of interstitial lung diseases (ILD) that cause inflammation and fibrosis of the lung interstitium leading to impaired gas exchange due to a known cause. Depending on the specific disorder, it can also affect the trachea, bronchi, bronchioles, alveoli, and pleura. Most of these diseases are characterized by their clinical, radiographic, pathologic, and physiologic findings. The classic features often include progressive shortness of breath and cough, chest imaging abnormalities, and inflammatory and fibrotic changes on histology. A restrictive pattern with a decreased diffusing capacity for carbon monoxide (DLCO) is often seen in pulmonary function testing (PFT)

Acute eosinophilic pneumonia in a hookah smoker.

Acute eosinophilic pneumonia (AEP) is a hypoxic respiratory illness which manifests as fever, diffuse pulmonary opacities on imaging, and eosinophilia of greater than 25% on broncho-alveolar lavage (BAL), in the absence of a known cause for pulmonary eosinophilia. Though yet indefinite, an acute hypersensitivity reaction to an inhaled antigen could be the underlying trigger for AEP. Case presentation: 20-year-old male patient, regular hookah smoker, previously healthy, presented to the emergency department (ED) with a 3-day history of productive cough and worsening shortness of breath. In the ED, patient was febrile (T 103), tachypneic, tachycardic, and saturating well on room air. Electrocardiogram showed sinus tachycardia. Chest X-ray revealed bilateral airspace opacities with small effusions, suspicious for either pulmonary edema or bilateral pneumonia. He received intravenous (IV) hydration, and was started on empiric antibiotics with Ceftriaxone and Azithromycin, to cover for community acquired pneumonia. ED course was complicated by hypoxia on room air, requiring supplemental O2 by nasal cannula, after which he was admitted to the medical intensive care unit (MICU). In the MICU, he had worsening hypoxia necessitating use of a high flow nasal cannula and ultimately, intubation. An echocardiogram did not show any evidence of left sided dysfunction, with preserved ejection fraction and normal PAP. Respiratory cultures were negative. Patient was diagnosed with Acute Respiratory Distress Syndrome (ARDS). Ventilator settings were adjusted accordingly, and antibiotics were continued. Two days into admission, bronchoscopy was performed with (BAL), cell count of which revealed 56% eosinophils. He was thus diagnosed with acute eosinophilic pneumonia (AEP) and was started on IV Methylprednisolone, with subsequent improvement in condition. He was extubated successfully, transferred to the general ward, and discharged home shortly thereafter, in good condition. Discussion: AEP is likely an acute hypersensitivity reaction to an inhaled antigen, causing respiratory failure. Several studies have identified cigarette smoking as being such an antigen, with a significant association between the latter and AEP. Such an association is yet to be proven between AEP and hookah smoking. Here, we present the case of a young male patient, regular hookah smoker, but otherwise healthy, who was diagnosed with acute eosinophilic pneumonia and treated as such, with positive outcome. In conclusion, it is worthwhile to note that with the rise in hookah-smoking trend, an ARDS like picture in such patients, should raise concern for AEP

Building and Validating a Computerized Algorithm for Surveillance of Ventilator-Associated Events

OBJECTIVE: To develop an automated method for ventilator-associated condition (VAC) surveillance and to compare its accuracy and efficiency with manual VAC surveillance SETTING: The intensive care units (ICUs) of 4 hospitals METHODS: This study was conducted at Detroit Medical Center, a tertiary care center in metropolitan Detroit. A total of 128 ICU beds in 4 acute care hospitals were included during the study period from August to October 2013. The automated VAC algorithm was implemented and utilized for 1 month by all study hospitals. Simultaneous manual VAC surveillance was conducted by 2 infection preventionists and 1 infection control fellow who were blinded to each another\u27s findings and to the automated VAC algorithm results. The VACs identified by the 2 surveillance processes were compared. RESULTS: During the study period, 110 patients from all the included hospitals were mechanically ventilated and were evaluated for VAC for a total of 992 mechanical ventilation days. The automated VAC algorithm identified 39 VACs with sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 100%. In comparison, the combined efforts of the IPs and the infection control fellow detected 58.9% of VACs, with 59% sensitivity, 99% specificity, 91% PPV, and 92% NPV. Moreover, the automated VAC algorithm was extremely efficient, requiring only 1 minute to detect VACs over a 1-month period, compared to 60.7 minutes using manual surveillance. CONCLUSIONS: The automated VAC algorithm is efficient and accurate and is ready to be used routinely for VAC surveillance. Furthermore, its implementation can optimize the sensitivity and specificity of VAC identification

Inferior Vena Cava diameter as a predictor of mortality in septic shock.

: Inferior Vena Cava (IVC) diameter and collapsibility index are non-invasive measurements commonly used in the assessment of intravascular volume status in critically ill patients in the intensive care unit (ICU). Information regarding the prognostic utility of IVC diameter in septic shock (SS) patients is scarce. We sought to determine the role of IVC diameter in predicting 90 day mortality in patients admitted to the ICU with SS and its association with central venous pressure (CVP). METHODS: We retrospectively evaluated 248 consecutive patients who were admitted to the ICU with SS from January 2011 to April 2013. Comprehensive baseline demographic, clinical and echocardiographic data were obtained. The association between CVP and death at 90 days was evaluated with univariate analysis. Multivariate regression analysis was used to identify clinical and echocardiographic predictors of 90-day mortality. Repeat multivariate analysis was then utilized to identify parameters associated with enlarged IVC size. RESULTS: Among the 248 patients (mean age, 64.9 ± 18 years; 51% men), baseline demographics were similar between survivors and deceased patients. Multivariate analysis revealed enlarged IVC diameter to be an independent predictor of mortality at 90 days (enlarged versus normal: OR: 2.02, 95% CI: 1.05-3.85, p\u3c0.05). Patients with enlarged IVC size were found to be older (68 vs 63; p\u3c0.05), have higher CVP on admission (12 mmHg vs 9 mmHg; p\u3c0.05), initial WBC (18k vs 13.5k; p\u3c0.05), intubation (62% vs 40%, p\u3c0.05), RA pressure (13 mmHg vs 7 mmHg; p\u3c0.05), and systolic pulmonary artery pressure (45 mmHg vs 35 mmHg; p\u3c0.05). They were also found to have lower LV ejection fraction (46% vs 55%; p\u3c0.05), cardiac index (2 vs 2.3; p\u3c0.05) and urine output within first 24 hours (505cc vs 754cc; p\u3c0.05). Intravenous fluid balance within the first 24 hours was similar between patients with enlarged and those with normal IVC diameters (2413cc vs 2420cc, p=0.99). Multivariate analysis revealed CVP to be a predictor of enlarged IVC size (OR 1.18, 95% CI: 1.03-1.35, p\u3c0.05). A relationship between CVP and mortality was established using univariate analysis, whereby an initial CVP ≥ 12mmHg was associated with increased odds of 90 day mortality (OR 1.35; 95% CI: 1.08-1.82, p\u3c0.05). CONCLUSIONS: Enlarged IVC diameter is a predictor of late mortality in SS patients. In these patients, IVC dilatation was not a reflection of increased IV fluid resuscitation. Instead, it was associated with an overall worse clinical status as evidenced by worse signs of SS and end organ damage. CVP is a predictor of enlarged IVC diameter and an initial CVP ≥ 12mmHg confers increased late mortality in SS patients. Further studies with larger sample size are needed to account for potential confounding factors

Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries

Background Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks. Methods The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned. Results A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P < 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31). Conclusion Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov)