DHMC

Early detection of inpatient deterioration with continuous physiologic monitoring. Postoperative adverse events in a hospital setting are commonly preceded by a significant period of physiologic deterioration. Until recently, most attempts to prevent adverse outcomes have focused on the quality of the response to an adverse event rather than early detection of signals that presage and adverse event. Andreas H. Taenzer, MD, working with quality and safety officers at the Dartmouth Hitchcock Medical Center, has developed a continuous physiologic monitoring system that was recently demonstrated to provide more accurate and timely data on true patient state compared to standard intermittent assessments (Anesth Analg. 2014;118:326-31). Implementation of such a monitoring system, with appropriate parameter adjustments to minimize false alarms, decreased rescue events and intensive care unit transfers of hospital inpatients by more than 50% (Anesthesiology. 2010;112:282-7).

Development of an international clinical registry to identify targets for quality improvement. The recent advent of sophisticated and effective imaging techniques has greatly enhanced the effectiveness and reliability of regional block techniques for major surgery. Despite the widespread popularity of these techniques and some data to suggest that they improve patient outcomes, individual institutions have had no way to examine the quality of care that they provide with regional anesthesia relative to care provided at other institutions. Brian D. Sites, MD has been instrumental in the development and evaluation of an International Registry of Regional Anesthesia (from 19 centers world-wide) that contains prospectively collected data on complications and immediate patient outcomes following regional block anesthesia (Reg Anesth Pain Med. 2014 (39:487-95). This is the first large-scale clinical registry to provide comparative outcome rates regarding quality, effectiveness and complication rates of regional anesthesia.

Prevention of intraoperative bacterial transmission to reduce the incidence of postoperative surgical infections. Despite decades of concerted effort, the incidence of infections in postoperative surgical patients remains alarmingly high. Individual interventions such as hand hygiene or patient decolonization have shown some limited, and often only temporary, effectiveness in selected patient populations. There has never been a systematic and sustained approach to identify the sources and root causes of postsurgical infections. Over the past 8 years, Randy W. Loftus, MD has systematically measured and categorized patterns of bacterial transmission in the modern operating room and identified specific links to postsurgical infections (Anesthesiology. 2008;(109):399-407). In addition to identifying important patterns of transmission of pathogenic bacteria, he has determined the relative effectiveness of novel interventions to prevent transmission and patient infection. New approaches to catheter care and handling, a more effective hand hygiene system, targeted environmental cleaning and control of patient bacterial reservoirs have all been shown to impact the transmission of pathogenic bacteria in the operating room (Anesth Analg. 2012;114:1236-48. Results from this ongoing research is now being used to guide clinical interventions that are expected to reduce intraoperative bacterial transmission and postoperative surgical infections.

Examining how cortisol can increase resistance to infection. Cortisol and similar synthetic glucocorticoid hormones such as dexamethasone are widely known for their anti-inflammatory and immune suppressive properties. Until recently, these potent and clinically important effects of cortisol have obscured a pre-existing understanding that hormones like cortisol can also support and even stimulate immune defense mechanisms. Mark P. Yeager, MD, working with colleagues in Physiology, has been examining the ability of cortisol, at concentrations observed during major stress such as surgery, can increase the responsiveness of the human innate immune system to bacterial challenge (Crit Care Med. 2009;37:2727-32). Using whole genome microarray technology, the investigators have identified key components of the immune response to bacteria (including leukocyte localization and migration) that are enhanced by temporary exposure to stress associated concentrations of cortisol. Results of these studies will help redefine our understanding of the broad range of glucocorticoid regulation of human immune responses.