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A systematic review and meta-analysis was completed to summarize care delivery models that used care coordination and/or team approach methods in the management of patients requiring long-term enteral tube feeding. Our aim was to evaluate team composition, implementation strategies, and the effectiveness of these methods.We conducted a broad search of 7 databases from inception to May 2012, cross-referenced clinical reviews and medical guidelines, and consulted clinical experts. Independent reviewers screened eligible studies, extracted data, and assessed study quality.Fifteen studies enrolling 2145 patients were included in this review. The studies described multidisciplinary teams composed of primary care physicians, specialists, nurses, dietitians, and language or speech specialists. Patients and their families/caregivers were also an important part of the care team. The interventions were multifaceted and employed multiple simultaneous strategies that particularly included patient and family education, staff education, and continuous auditing and feedback methods. Meta-analysis suggested no significant reductions in complications (incidence rate ratio [IRR], 0.53; 95% confidence interval [CI], 0.27-1.05), infections (IRR, 0.77; 95% CI, 0.48-1.24), and overall hospital admissions (IRR, 0.36; 95% CI, 0.13-1.00) most likely due to lack of statistical power. We found significant reduction of total hospital costs (estimates in US dollars: -623.08; 95% CI, -745.64 to -500.53; P.01) after the interventions.Studies suggested a positive association of care coordination by a multidisciplinary team approach and improved patient outcomes for long-term enteral feeding patients. However, the available evidence does not allow estimating the effectiveness of a particular intervention or team composition.

The concepts of peer review and the venerable morbidity and mortality conference are familiar improvement approaches to health care providers. These 2 entities are typically provider or patient centric and are not typically extended within hospitals and health systems as a tool for organizational learning for care process or system failures. Out of a desire to deepen our understanding and accelerate learning about quality and safety opportunities in our hospitals, Mayo Clinic embarked on journey to analyze the stories of all patient deaths. This paper illuminates the lessons learned through the development and evolution of the Mayo Clinic Mortality Review System (Rochester, MN).

OBJECTIVE To determine, using a sensitive glucose assay, whether monitoring of tracheal aspirate glucose concentration could serve as a marker of aspiration of enteral feedings. DESIGN Prospective, controlled trial. SETTING Intensive care units of a tertiary care hospital. PATIENTS Fifteen enterally fed and 15 nonenterally fed, tracheally intubated patients who had normal lung fields on a routine chest radiograph. INTERVENTIONS Patients with endotracheal tubes undergoing routine tracheal suctioning had tracheal secretions collected three times per day with a minimum of 4 hrs between samples for up to 5 days. Daily chest radiographs were reviewed for evidence of the development of pneumonitis using defined criteria. MEASUREMENTS AND MAIN RESULTS Glucose concentrations in five commonly used commercial feeding formulas, as well as in the medications patients were receiving enterally or as an oral wash, were measured. Tracheal secretion glucose concentrations were 66 +/- 54 (SD) mg/dL (3.7 +/- 3.0 mmol/L) and 105 +/- 70 mg/dL (5.8 +/- 3.9 mmol/L) in the enterally fed and nonenterally fed patients, respectively (p = NS). Of the medications administered, the majority contained negligible glucose, but ten had > 3 mg/dose of glucose. However, there was no correlation between administration of these medications and the tracheal glucose concentrations. Tracheal glucose concentrations were similar in patients who received medications containing glucose and patients who received either no medications or medications with negligible glucose content. A small but significant correlation between blood glucose and tracheal secretion glucose concentrations (r2 = .15, p < .05) was observed. None of the patients developed aspiration pneumonitis. Glucose concentrations in widely used commercial formulas (44 to 202 mg/dL; 2.4 to 11.2 mmol/L) overlapped considerably with glucose concentrations in tracheal secretions in the absence of aspiration and were for the most part within 2 SD of mean values in tracheal secretions. CONCLUSIONS Tracheal secretions contain high glucose concentrations, both in enterally fed patients without evidence of aspiration pneumonitis and in nonenterally fed patients. The concentration of glucose in tracheal secretions appears to be determined, in part, by ambient extracellular glucose concentrations. We conclude that measurement of glucose in tracheal secretions is unlikely to be useful in monitoring for tube feeding aspiration in tracheally intubated, enterally fed patients.

E dwina Paolo, 68, is hospitalized with a nonhealing saphenous vein donor site on her left leg three months after a coronary artery bypass graft. The distal portion of her wound is covered with fibrin, and bone is exposed. After several weeks of traditional wound care and moist dressings, vacuumassisted closure (VAC) therapy is initiated to prepare the wound bed for a skin graft. The nurse caring for Ms. Paolo cuts a piece of sterile polyurethane foam sponge to fit the wound cavity. She places a tube with end and side ports inside the sponge and connects it to a disposable canister loaded into a programmable vacuum pressure pump.1.2 She covers the foam dressing and the embedded evacuation tube with a transparent film to hold the sponge and tubing in place, to ensure an airtight seal and to maintain a moist environment. X Negative suction pressure-pressure lower i than that of the atmosphere at sea level-is applied by the VAC pump at 75 mmHg, increasing in increments of 25 mmHg (to prevent pain during therapy) to a target pressure of 125 mmHg. The device can be programmed to deliver an amount of negative pressure appropriate to a patient's comfort level and the characteristics of the wound. Continuous negative pressure is applied for 48 hours; then the sponge is changed and treatment is continued. For two weeks, Ms. Paolo receives therapy with intermittent negative pressure-suction is turned on for five minutes and off for two minutesto remove excess fluids, promote formation of granulation tissue, and restore capillary flow.