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*1st Place Oral competition*
The Outcome of Cardio
Pulmonary Resuscitation in an Inner City Hospital..
M Bautista, S Vasudevan, K Saluja, A Chadha, V Thiru, Cable. Jersey City Medical Center
Background & Aim:
The out come of Cardio Pulmonary Resuscitation in inner city hospitals is largely unknown. Our aim was to analyze the outcome of CPR for in - hospital cardiac arrest among medical patients in an inner city hospital setting. Methodology: Medical records of all patients, aged > 18 years subjected to CPR from 1996 to 1998, were studied retrospectively. Out of hospital CPR, Trauma, DNR, Surgical Unit and Operation suite and cardiac catheterization suite codes were excluded. Pre and intra arrest variables were analyzed. [Pre Arrest Variables: Age, Race, Cardiac Failure, sepsis, diabetes, COPD, pneumonia, HIV Status, GI Bleeding, pre arrest functional status. Intra Arrest Variables: duration of code, biochemical imbalance [K, and hyponatremia] and epinephrine dose. Initial success of CPR, final success of CPR were analysis. The statistical computer package from SAS institute was used to analyze the data. All the continuous variables were described as mean, and p value of < 0.05 was considered significant. Results: There were a total of 240 codes were attempted in 170 patients. Mean age was 67.8[ranged 24 to 93] Immediate success of code was 94/240[39.2%] and the final success was 15/170 [8.8%] Multivariate analyzes, while controlling for all other measured variables revealed, poor outcome correlated with epinephrine use of > 5 mgs. [OR 3.85 & p < 0.001] sepsis [OR 0.32 & p < 0.01] duration of code [OR 0.97 & p < 0.04] COPD [OR 0.31 & p < 0 07]. There was an overall better outcome noted in minority groups [OR 1.92 & p < 0.01]. Conclusion: Controlling for severity of illness we found that for each 5 minutes duration of code there is 15% less likelihood of survival and with epinephrine less than 5 mgs was associated with 4 times greater survival advantage than the higher dose. While our results are comparable to other published data in the clinical parameters, our finding that CPR efforts in minorities are twice as likely to be successful has not been reported.
2nd Place Oral competition
Effect on Internal Medicine Training on Costs and
Reimbursements in a Community Teaching Hospital.
Beg S, Penuche D, Shine D. — Dept. Medicine, Monmouth Medical Center, Long Branch, NJ
It has been assumed by federal funding agencies and others that resident teaching delays the discharge of hospitalized patients and negatively affects payor mix and reimbursement.
We compared length of stay (LOS) and reimbursements between general medical patients cared for by attending-supervised residents and those cared for by attendings without resident help in a community teaching hospital. We adjusted for factors that might have confounded differences between these groups, including the distribution of DRG;s, the admitting habits of the attending physicians, and the severity (within each DRB) of patients assigned to teaching and non-teaching services. Severity was measured as predicted LOS using a U92-based risk adjustment methodology.
There was no significant difference in any DRG between teaching and non-teaching patients with respect to length of stay, length of stay in excess of predicted, or reimbursement. Across all DRG’s and attendings, non-teaching patients stayed 0.8 days longer on average. Patients of physicians who characteristically admitted to non-teaching wards showed a greater effect of assignment to those wards, a 1.6-day longer stay on average.
Across all DRG’s and attendings, non-teaching patients stayed, on average, 2.0 days longer than predicted, while teaching patients stayed 1.0 day longer. Average per-DRG reimbursement was $6,777 among teaching and $7,556 among non-teaching patients. Because of the lower LOS among non-teaching patients, reimbursement was $87 per DRG per day higher among teaching patients.
We conclude that resident care was not associated with longer stays or diminished reimbursement in a large community teaching hospital. Our study suggests, indeed, that the reverse may have been true.
1st Place Poster competition
Do Individuals Prescribed Non-Steroidal
Anti-Inflammatory Drugs (NSAIDs) Need Aspirin for Prophylaxis
G Mihailescu, R VanSolingen, N Kramer, E Rosenstein, M Drejka, A Kahlia, A Cohen. Saint Barnabas Medical Center, Livingston, NJ
Aspirin (ASA) is commonly used as an antithrombotic agent. Its mechanism of action is the irreversible inhibition of platelet cyclooxygenase (COX) with resultant inhibition of thromboxane A2, a potent vasoconstrictor and promoter of platelet aggregation. NSAIDs inhibit platelet COX in a reversible fashion. We sought to establish the degree to which treatment with an NSAID will inhibit platelet function in vivo, and to establish if the addition of a moderate dose of ASA will further suppress platelet function in a clinically significant fashion. Methods: 25 healthy volunteers, 18 to 60 years old, with no acute or chronic disease or contraindication to NSAIDs or ASA, and with normal initial screening investigations were selected. Subjects were administered ketoprofen 200 mg daily for 2 weeks and were randomly assigned to receive ASA 325 mg or placebo during the second week. Platelet aggregation stimulated by agonistic agents was measured at the baseline, days 8 and 15. COX activity was measured by radioimmunoassay of thromboxane B2, the stable metabolite of TxA2 at baseline, days 8 and 15. Results: On day 8 all subjects demonstrated abnormal platelet aggregation (> 50% inhibition) in response to arachidonic acid and epinephrine, which persisted at days 15 in both ASA and placebo groups. One week of ketoprofen treatment resulted in inhibition of TxB2 levels by 83.5% in ASA group and by 84.7% in placebo (p=0.78), without any further inhibition measured on day 15 (+0.4% ASA vs. —13.6% placebo, p=0.56). Conclusion: Ketoprofen, an NSAID, significantly inhibits platelet aggregation and TxA2 production in healthy volunteers. ASA added to NSAID had no additional effect on platelet aggregation or TxA2 synthesis. We suggest that traditional NSAIDs may be used alone as antithrombotic drugs in patients who have musculoskeletal conditions and are at risk for thromboembolic events, thereby avoiding toxicity of NSAID/ASA combination therapy.
2nd Place Poster competition
GUIDELINES DIRECTED CLINICAL MANAGEMENT AND EDUCATION
PROGRAM IMPROVES ASTHMA OUTCOMES FOR HIGH-RISK INNER-CITY
A Roy, B Kominsky, E Morales, EG Jahn, P Lehrer, MI Siddique
UMDNJ- Robert Wood Johnson Medical School, New Brunswick, New Jersey
To improve asthma disease management, the National Heart, Lung and Blood Institute (NHLBI) updated Guidelines for the Diagnosis and Management of Asthma (EPR-2). It remains unknown, however, as to whether implementation of an integrated asthma educational and clinical management program based upon the principles put forth in this document can improve asthma morbidity and self-management knowledge outcomes for high risk, socio-economically distressed urban minority patients. To explore this issue, we reviewed the records of 32 inner city asthmatics (70% female; 47% African American, 38% Hispanic and 15% Caucasian; X age 39 ± 2 years) enrolled in an inner-city, guidelines-directed asthma management and education clinic (X no. of months followed = 3.5 ± 0.6, X no. of encounters = 3.5 ± 0.4). Upon entry, 87% of the patients had moderate to severe persistent asthma symptoms and 67% had moderate to severe persistent lung function impairment; only 6 patients owned a peak expiratory flow rate meter; and none had written medication plans. Over 90% had no effective asthma action plans. Ninety percent utilized short-acting b -agonists ³ 2 canisters per month, and 69% on inhaled steroids. At their latest clinic visit, 100% were on inhaled anti-inflammatories. Metered dose inhaler competency improved from 51 ± 5 to 79 ± 4 % correct steps (N=32, P<.0001). Improvements in lung function, symptom class, subjective and objective measures of asthma control occurred (P<.0001), such that 60% had mild asthma symptoms and pre-bronchodilator FEV1 > 80% predicted. In addition, there was a significant reduction in ED visits (34 ED visits by 17 patients in the six months prior to entry vs 5 by 3 patients, 14 hospitalizations in 12 patients in the 6 months prior to entry vs 1 hospitalization by one patient). These data demonstrate that individually tailored implementation of the NHLBI asthma diagnosis and management guidelines can result in cost-effective decrements in asthma morbidity in high-risk inner-city patients.