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Archive for November, 2014

Piedmont Heart Institute Announces First Implantation of the HeartMate III™

Monday, November 24th, 2014

As part of its ongoing commitment to provide care for advanced heart failure patients in Georgia, Piedmont Heart Institute recently announced its first implantation of the HeartMate III™ Left Ventricular Assist System (LVAS). Piedmont is one of five centers across the country to begin implanting the HeartMate III™ Left Ventricular Assist Device (LVAD) during the early safety phase of the clinical trial.

The HeartMate III™ LVAD is a small, implantable mechanical device that helps circulate blood throughout the body. Sometimes called a “heart pump” or “VAD” it is designed to supplement the pumping function of the heart for patients with hearts too weak to pump blood adequately on their own. The fully magnetically levitated technology foundation is designed to lower adverse event rates through improved hemocompatibility, while enhancing ease of surgical placement with its compact size. The HeartMate III™ U.S. clinical trial is a randomized non-inferiority study comparing HeartMate III™ with HeartMate II®™.

“The number of patients being diagnosed with advance heart failure in Georgia continues to rise,” said David Dean, M.D., surgical director of Piedmont Heart Institute. “Unfortunately, the number of donor hearts remains stagnant. LVAD therapy can be a lifeline to these patients, providing them the gift of time as either destination therapy or a bridge to heart transplant.”

Created in 2010, Piedmont Heart Institute’s LVAD program was the largest HeartMate II®™ new start program in the country, with Dr. Dean and his team implanting 33 of the devices in its first year alone. Since then, the program has achieved national attention for its success and over 170 patients have benefited from access to LVAD therapy.

More than five million people in the U.S. are afflicted with congestive heart failure (CHF). Of these, more than 250,000 are advanced cases, with an annual mortality rate of 80 percent.

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Study Shows that Survival Rates Have Improved in Out-of-Hospital Cardiac Arrests

Monday, November 24th, 2014

Researchers have determined that survival rates from out-of-hospital cardiac arrests (OHCA) improved in communities across the U.S. between 2005 and 2012. Improvements that impacted survival rates were noted in both pre-hospital and in-hospital care. Bystander CPR (cardiopulmonary resuscitation) and on-site automated external defibrillator (AED) use improved during the interval as well.

The results were published online in the journal Circulation on Sat., Nov. 15.

The study started in Atlanta in 2005, under the direction of co-author Bryan McNally, MD, MPH, associate professor of emergency medicine at Emory University School of Medicine and in the Rollins School of Public Health. Since then, more than 600 EMS agencies and 1,000 hospitals in 29 states representing a population footprint of 85 million people have been included in its findings.

“This study is about getting back to the basics, and teaching community members to start CPR if someone is in need, rather than waiting on emergency personnel to arrive,” says McNally. “We have found that once communities see the data that pre-hospital care saves lives, that data is the driver to make changes and improvements for their community members.”

Based on data from a large prospective clinical registry called the Cardiac Arrest Registry to Enhance Survival (CARES), 70,027 U.S. patients who experienced OHCA were analyzed. During that time, the researchers found improved rates of survival in both shockable and non–shockable cardiac arrest rhythms, accompanied by lower rates of neurological disability among survivors.

The study found overall OHCA survival increased from 5.7 percent at the start of the analysis in 2005-2006 to 7.2 percent in 2008 to 8.3 percent in 2012. For patients found in ventricular fibrillation or tachycardia, the survival increased from 16.1 to 27.9 percent during the same time period. Improved survival was due to higher rates of pre-hospital survival, where risk adjusted rates increased from 14.3 percent in 2005-2006 to 20.8 percent in 2012. Rates of bystander CPR and AED use also increased during the study period and partly accounted for pre-hospital survival trends.

“As we approach the 10-year anniversary of the CARES program, study data suggests survival rates from OHCA are trending in the right direction,” says McNally. “With many states on board, we hope this message continues to get out in the communities to benefit even more cardiac arrest patients.”

With the help of organizations such as the American Red Cross, American Heart Association and others, more focus has been placed on promoting bystander CPR, use of AEDs and other performance efforts.

“In conclusion, improvements were seen in both pre-hospital and in-hospital survival rates, which were accompanied by lower rates of neurological disability over time among survivors, ” says Paul S. Chan, MD, MSc, associate professor of medicine at Mid America Heart Institute in Kansas City, MO, and first author of the study. “These findings show the importance of this study and the existing work that needs to continue in communities that recognize the value of measuring outcomes and benchmarking care to improve survival from this condition.”

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Glucose Management in the Hospital

Monday, November 24th, 2014

By Bruce W. Bode, M.D., FACE

From ATLANTA Medicine, Vol. 85, No. 4

Glucose ManagementElevated glucose in the hospital is very common, occurring in more than 38 percent of patients. The presence of hyperglycemia has been shown to increase morbidity and mortality as well as total cost of care1,2.

Over one third of these patients have newly discovered hyperglycemia and are confirmed upon testing as having pre-exiting diabetes1. Studies have shown that patients with unrecognized diabetes have three times greater mortality and morbidity than those with recognized diabetes1. If diabetes is not addressed during the hospital stay, in addition to morbidity and mortality being increased, readmission rates are as high as 31 percent in this population3.

Studies to obtain near normalize glucose in the hospital environment have had mixed results, often due to unacceptable hypoglycemia (BG <40 mg/dL), which in itself increases mortality4,5,6. When hypoglycemia is avoided, recent studies have shown very low rates in morbidity or mortality with a reduction in total cost of care when glucose is controlled in the 100 to 140 mg/dL range compared to 140 to 180 mg/dL range7,8.

Based on the above facts, it is essential for all hospitals to have protocols to identify all patients with hyperglycemia, to treat patients safely to near normal glucose without hypoglycemia, and to discharge the patient with a case-specific plan to manage their glucose in a near normal range until seen by their primary care team.

There are steps a hospital or hospital system should do to minimize the impact of hyperglycemia in the hospital. The majority of these steps have been implemented at the Piedmont Hospital, Atlanta campus.

Identify Patients with Hyperglycemia

  1. Screen all high-risk patients with a fingerstick point-of-care glucose (POC) measurement upon admission to the ICU or hospital floor. High risk is defined as patients prone to diabetes or hyperglycemia, which include all patients who are elderly, are obese, have an infection, have cardiovascular disease, are in the ICU, are on steroids or have a known family history of diabetes.
  1. If glucose is above 140 mg/dL, begin fingerstick POC testing AC TID and HS. If glucose is less than 140 mg/dL upon repeat testing, one can stop testing. If glucose is greater than 140 mg/dL or in all patients with known diabetes, draw an A1C and implement correction dose insulin with rapid-acting insulin (lispro, aspart or glulisine) for any glucose above 140 mg/dL The formula we use is (BG-100)/correction factor equals units of rapid-acting insulin. The correction factor (CF) is often 40 to start but can be determined by two formulas: CF = 3000/weight in KG or CF = 1700/total daily dose of insulin.

Treatment of Hyperglycemia

  1. If the patient’s pre-existing diabetes and glucose is controlled at home on basal bolus insulin, one can continue current insulin regimen and adjust accordingly to keep BG in a safe range (70 to 140 pre-meal and less than 180 post-meal). Always give the basal dose and correction dose but hold the meal dose if not eating. If patient is on pre-mixed insulin, it is best to transition them to basal bolus therapy listed below to avoid hypoglycemia.
  1. If the patient is newly diagnosed with diabetes or pre-exiting diabetes with glucoses >180 mg/dl, one must start either SC or IV insulin therapy depending on whether the patient can eat or how high their glucose is.
  1. If the patient is able to eat, not critically ill and glucose is less than 300 mg/dL, one can start weight-based insulin on the following formula: weight in KG times 0.5 (or times 0.3 in renal impaired or age >72 years old) equals the amount of total daily insulin (TDD). The basal dose (glargine or detemir) is 50 percent of the TDD given at bedtime. The meal dose (rapid-acting insulin) is 50 percent of the TDD divided by three given in proportion to the food (carbs) consumed at each meal.
    If half the meal is eaten, give one half the meal dose. A correction dose of rapid acting insulin is given for any BG > 140 mg/dL. The correction dose is BG-100/CF where CF is calculated by 1700/TDD. POC BG testing should be done AC TID, HS and 0300.
    As stated above, always give the basal dose and correction dose but hold the meal dose if not eating. One must adjust the individual basal and bolus doses to be in a safe and acceptable glucose range, ideally 70 to 140 mg/dL pre-meal, but higher targets may be acceptable (80 to 180 mg/dL). All oral agents should be stopped, especially sulfonylureas.
  1. If the patient is critically ill, unable to eat or has a glucose >300 mg/dL, one should start IV insulin per hospital protocol. This is best done using a computerized system such as Glucommander7,9 to avoid any hypoglycemia, obtain near normal glycemia in a reasonable time (<6 hours) as well as simplifying the workload on the nursing staff.
    The formula used in the Glucommander is (BG-60) x a multiplier equals units of IV regular insulin given every hour. The starting multiplier is 0.02 for all patients except in post-op CV patients we recommend a starting multiplier of 0.068.
    POC glucose testing is done every hour till stable then every two hours. The computerized system adjusts the multiplier and tells the RN when to check the glucose and does all the calculations for the RN to get the glucose in a pre-specified glucose target range.
    At Piedmont, we use 100 to 140 mg/dL for all patients except CV surgery patients, for which we use 90 to 120 mg/dL. It is recommended to have dextrose containing IVFs; at Piedmont we use D10 at 50 ml/hr or D5 at 100 ml/hr. Potassium levels should monitored and adjusted at least daily and more often if out of range. Patients should not eat any calories while on IV insulin unless a meal dose is given to cover the carbs of that meal.

Once stable and able to eat, one should transition all known diabetes patients and any other patient with an A1C >6.5 percent to basal bolus therapy based on weight as listed above or using the current multiplier once at goal. The formula to calculate TDD based on the multiplier is 1,000 times the multiplier equals the TDD. The basal dose should be started at least four hours before stopping the IV insulin, and the bolus and correction dose should be given at meal times based on the above formulas.

If transitioning to enteral feedings, one should start basal insulin twice daily, given every 12 hours with correction dose insulin every four hours, and once stable, every six hours for any glucose >140 mg/dL. The total basal dose is 1,000 times the multiplier. The CF is 1700/TDD. The basal dose should be adjusted up and down by 20 percent to keep the glucose in an acceptable target range (80 to 160 mg/dL). If enteral feedings are temporarily stopped, one should start D10 at 50 ml/hr and hold the basal dose till enteral feedings are resumed.

If transitioning to TPN, one should add 80 percent of the TDD determined by the IV insulin requirement to the TPN and adjust daily to keep the glucose in acceptable range. If the patient has not been on IV insulin, one can add one unit of regular insulin for every 10 grams of dextrose in the TPN bag. Correction dose is given every four hours, and once stable every six hours for any BG >140 mg/dL.

Treatment of Hypoglycemia

  1. All hospitals must have a hypoglycemia protocol. If glucose is <70 mg/dL and patient is conscious, one should treat with 15 grams of oral glucose and recheck in 15 minutes and retreat again as needed. If not able to swallow, give IV dextrose using the formula ml of D50 equals 100 minus the BG value or give ½ amp of D50 IV push.
  1. Prevention of hypoglycemia is crucial by using the above formulas and adjusting insulin by 20 percent for any BG <80 mg/dL that was caused by that insulin. Also, giving insulin post meal in proportion to the food consumed also minimizes hypoglycemia. In addition, having a dedicated hyperglycemic team and using computerized IV and SC dosing system prevents most hypoglycemia. Raising glycemic targets higher (80 to 160 mg/dL or 100 to 160 mg/dL) in patients prone to hypoglycemia such as elderly or renal impaired is another option.

 Discharge Planning and Recommendations

  1. Discharge planning is best started upon admission by screening and recognizing unrecognized diabetes and poorly controlled. If A1C is at goal upon admission without hypoglycemia, one can return to their prior pre-admission diabetes treatment. If A1C is not at goal, one must discharge the patient on a treatment plan that will keep their glucoses at goal till seen by their primary care team.
    If A1C is above 8 percent, one should recommend full basal bolus therapy upon discharge for most patients. If A1C is above 6.5 percent but less than 8 percent, many patients can be controlled on oral hypoglycemic agents such as metformin and/or DPP-4 inhibitors. If needed, the patient can continue to use correction dose insulin as needed or add basal insulin to metformin with or without incretin therapy. Sulfonylurea use is discouraged due to high risk of hypoglycemia, especially in the elderly and renal impaired patient.
  1. All patients new to diabetes should be discharged home with a glucose monitor and have instructions when to see their primary care team and where to receive further self-management training and education about their diabetes.

References

  1. Umpierrez, GE et al. J Clin Endocrinol Metab 2002; 87: 978-982
  2. Krinsley JS et al. Mayo Clin Proc. 2003; 78:1471-1478
  3. Robbins JM et al. Med Care 2006; 44:292-296
  4. The NICE-SUGAR Study Investigators. N Engl J Med. 2009; 360:1283-1297
  5. The NICE-GLUCOSE Study Investigators. N Engl J Med. 2012; 367:1108-1118
  6. Umpierrez, GE et al. Diabetes Care 2011; 34:1-6
  7. Umpierrez, GE et al. GLUCO-CABG Trial. Diabetes June 2014; ADA oral presentation
  8. Smiley D et al. GLUCO-CABG Trial: Cost Analysis. Diabetes June 2014; ADA poster presentation
  9. Davidson, PC et al. Diabetes Care 2005; 28:2418-2423
  10.  Davidson, PC et al. J Diabetes Sci and Technol. 2008; 2:369-375
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Pediatric Orthopedic Services Now Offered at WellStar Windy Hill Hospital

Monday, November 24th, 2014

WellStar Health System continues to expand medical services with a new pediatric orthopedic services program. On November 5, WellStar Windy Hill Hospital launched its pediatric orthopedic services. The new program offers pediatric orthopedic surgery to patients from birth to age 21.

At WellStar Windy Hill Hospital, families will be provided a room in the pre/post-op area for the duration of the patient’s stay, allowing providers to easily and quickly provide procedure and progress updates.

“Pediatric Orthopedics at Windy Hill reflects our commitment to serve children with excellence close to home,” said Avril Beckford, M.D., chief pediatrics officer for WellStar Health System. “Part of this strategy is to collaborate with those who place the needs of the child in the context of the family at the very center of all we do. Our new facility is an extension of the services offered at our new, state-of-the-art WellStar Pediatric Center.”

WellStar has partnered with Pediatric Orthopaedic Associates, whose surgeons will perform the procedures. Anesthesia will be administered by fellowship-trained providers with WellStar Medical Group, Pediatric Anesthesia. Patient care will be provided by the team at WellStar Windy Hill Hospital.

 

 

 

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DeKalb Medical Nurse Awarded the Georgia Hospital Heroes Award

Monday, November 24th, 2014

Rose McKeever, LPNDeKalb Medical Nurse Clinician Rose McKeever, LPN, was awarded the Georgia Hospital Heroes Award at the Georgia Hospital Association’s (GHA) Annual Meeting on Nov. 13. McKeever, who was one of only 10 individuals to receive the award, was recognized for her work with breast cancer patients.  

McKeever has been employed as a nurse at DeKalb Medical since 1978 and currently serves as a breast nurse navigator for the cancer support team on DeKalb Medical’s North Decatur campus. Over the years, she has given countless hours to cancer support groups and is the facilitator of the breast cancer support group that has met every week since 1990.

McKeever’s support also extends to the children and grandchildren of cancer patients. In 1993, she established the Tree House Gang, a support group that helps children comprehend what their loved ones are going through and provides them with an outlet to express their feelings and deal with their grief. McKeever plans activities throughout the year and has built relationships with sponsors to help fund the events. She also oversees an annual card fundraiser for the Tree House Gang. Each member designs a card with a theme of their choosing and the cards are then reproduced and sold throughout the hospital. Some of the cards are made specifically for patients in the hospital.

McKeever is also always willing to dedicate her time wherever she can in the hospital. DeKalb Medical’s cancer center director recently lost a long battle with cancer. During her treatment, McKeever provided her with personal support, even traveling to her home to comfort her.

“Cancer patients and their children would not have the support they do without Rose McKeever,” said GHA President Earl V. Rogers. “She is continually providing help and support where she can and is an inspiration to all of us. She is a most-deserving recipient of this award.”

 

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The DeKalb Medical Foundation Announces New Medical Vice Co-Chairs

Friday, November 14th, 2014
Melissa W. Seely-Morgan

Dr. Melissa W. Seely-Morgan

Raoul Mayer, M.D.

Dr. Raoul Mayer

The DeKalb Medical Foundation announced the appointments of two new Medical Vice Co-Chairs for its Board of Trustees, Raoul Mayer, M.D. and Melissa W. Seely-Morgan, M.D., effective immediately. Both will serve three-year terms in this position.

“I would like to congratulate Dr. Mayer and Dr. Seely-Morgan on their new appointments,” said outgoing Medical Vice Chair, Robin Dretler, M.D, who has served in this role since the Foundation was founded in 1991. “Their medical expertise and commitment to DeKalb Medical will be assets in their new roles.  I am confident they will provide the leadership the Foundation Board of Trustees needs to further the mission of the Foundation.”

Raoul Mayer, M.D. currently holds the position of Vice President of Medical Affairs at DeKalb Medical while also serving as the preeminent colorectal surgeon with Atlanta Colon and Rectal Surgery, PA., which he joined in 1977. He is a graduate of Columbia College and Mount Sinai School of Medicine in New York. He completed his General Surgery training at Mount Sinai Hospital and Colon and Rectal fellowship at the University of Minnesota.  Additionally, Dr. Mayer has served as Chief of Surgery, Chief of Staff and Chairman of the Physician Advisory Committee, at DeKalb Medical, and has been involved with many hospital leadership committees.

Melissa W. Seely-Morgan, M.D. is a specialist in Vascular & Interventional Radiology with Radiology Associates of DeKalb, PC.  She is a graduate of the Medical College of Virginia Commonwealth University and completed her internship at Georgetown University Hospital, both her residency and fellowship at Emory University.  Dr. Seely-Morgan has served on the Foundation Board of Trustees since 2011.

 

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GAFP Annual Scientific Assembly

Friday, November 14th, 2014

November 14-16, 2014, Westin Buckhead Atlanta, Atlanta, Ga. For more information, visit Georgia Association of Family Physicians

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AMGMA November Meeting

Thursday, November 13th, 2014

November 13, 2014, Atlanta. For more information, visit Atlanta Medical Group Management Association

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American Medical Association: How to Fight Ebola in the United States

Tuesday, November 11th, 2014

An archived recording of an official update on Ebola made at the 2014 American Medical Association (AMA) Interim Meeting is now available for viewing.

Watch Arjun Srinivasan, MD, an expert from the Centers for Disease Control and Prevention (CDC) and captain in the U.S. Public Health Service, discuss how physicians can prepare for and manage Ebola patients in hospital and ambulatory care settings.

If you are looking for additional Ebola information, you can visit the AMA’S Ebola Resource Center for convenient access to materials created by the CDC and other public health experts for physicians and the public.

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