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Hickman S.E.,Indiana University | Hickman S.E.,Indiana University - Purdue University Indianapolis | Keevern E.,Indiana University | Hammes B.J.,Gundersen Medical Foundation
Journal of the American Geriatrics Society | Year: 2015

The Physician Orders for Life-Sustaining Treatment (POLST) form is a palliative care tool that contains standardized, actionable medical orders. It is designed to ensure that patient treatment preferences are elicited, communicated, and honored throughout the healthcare system. A systematic review of the literature was conducted to evaluate what is currently known about the POLST program and identify directions for future research. Twenty-three research studies focused on POLST use in the clinical setting were identified. A majority of studies have been conducted all or in part in Oregon, with chart review the most frequently used methodology. Research suggests that POLST is most commonly used in older, white patients who are near the end of life. A nonphysician facilitator usually prepares the POLST form for the physician to review and sign. The orders documented on POLST reflect a wide degree of individualization, with only approximately one-third of patients having orders reflecting the lowest level of treatment in all POLST form sections. Clinicians have generally positive attitudes regarding use of POLST yet report a wide range of challenges. POLST alters treatment in a way that is consistent with orders. However, evidence that POLST reflects patient or surrogate treatment preferences is lacking. Research is needed to evaluate the quality of POLST decisions, explore the experiences of patients and their surrogates, develop decision-support tools, improve clinician education, and assess the effect of POLST on care outcomes through intervention and population-based studies. © 2015, Copyright the Authors Journal compilation © 2015, The American Geriatrics Society. Source

Mankovecky M.R.,Gundersen Medical Foundation | Roukis T.S.,Podiatry and Sports Medicine
Journal of Foot and Ankle Surgery | Year: 2014

Septic arthrosis of the ankle is a rare, often devastating, infection, with a high potential for morbidity and mortality. Delay in treatment can lead to cartilage erosion, painful synovitis, and osteomyelitis. Septic ankle arthrosis deserves prompt recognition and intervention. However, quality, sound, protocol-directed arthroscopic treatment of septic ankle arthrosis of the ankle has not yet been reported. We performed a systematic review of the electronic databases and other relevant peer-reviewed sources to determine the outcomes and treatment protocols associated with septic ankle arthrosis treated with arthroscopic synovectomy, irrigation, and debridement. Nine studies, involving a total of 15 ankles, met our inclusion criteria. In addition, we present the short-term outcomes of a protocol-driven arthroscopic synovial biopsy, deep culture procurement, synovectomy, irrigation, and debridement approach for 8 ankles (8 patients). To our knowledge, this would be the largest individual case series specific to arthroscopic treatment of septic ankle arthrosis. The most common infectious organism reported in the systematic review and in our case series was methicillin-sensitive Staphylococcus aureus. Arthroscopic synovectomy, irrigation, and debridement represents an acceptable treatment method for septic ankle arthrosis and demonstrated outcomes similar to the more traditional open approach, with fewer complications. Additional, appropriately weighted, randomized controlled studies with long-term follow-up are warranted. © 2014 American College of Foot and Ankle Surgeons. Source

Prissel M.A.,Gundersen Medical Foundation | Roukis T.S.,Podiatry and Sports Medicine
Foot and Ankle Specialist | Year: 2014

Lateral ankle instability is a common mechanical problem that often requires surgical management when conservative efforts fail. Historically, myriad open surgical approaches have been proposed. Recently, consideration for arthroscopic management of lateral ankle instability has become popular, with promising results. Unfortunately, recurrent inversion ankle injury following lateral ankle stabilization can occur and require revision surgery. To date, arthroscopic management for revision lateral ankle stabilization has not been described. We present a novel arthroscopic technique combining an arthroscopic lateral ankle stabilization kit with a suture anchor ligament augmentation system for revision as well as complex primary lateral ankle stabilization. © 2014 The Author(s). Source

O'Heron C.T.,Gundersen Medical Foundation | Jarman B.T.,Gundersen Health System
Journal of Surgical Education | Year: 2014

Objective To outline a structured approach for general surgery resident integration into institutional quality improvement and patient safety education and development. Design A strategic plan to address Accreditation Council for Graduate Medical Education (ACGME) Clinical Learning Environment Review assessments for resident integration into Quality Improvement and Patient Safety initiatives is described. Setting Gundersen Lutheran Medical Foundation is an independent academic medical center graduating three categorical residents per year within an integrated multi-specialty health system serving 19 counties over 3 states. Results The quality improvement and patient safety education program includes a formal lecture series, online didactic sessions, mandatory quality improvement or patient safety projects, institutional committee membership, an opportunity to serve as a designated American College of Surgeons National Surgical Quality Improvement Project and Quality in Training representative, mandatory morbidity and mortality conference attendance and clinical electives in rural surgery and international settings. Conclusions Structured education regarding and participation in quality improvement and patient safety programs are able to be accomplished during general surgery residency. The long-term outcomes and benefits of these strategies are unknown at this time and will be difficult to measure with objective data. © 2014 Association of Program Directors in Surgery. Source

Kowalski T.J.,Section of Infectious Disease | Thompson L.A.,Gundersen Medical Foundation | Gundrum J.D.,Gundersen Medical Foundation
Infection | Year: 2014

Purpose: The optimal antimicrobial treatment for patients with hand or wrist septic arthritis is unknown. We report the treatment outcomes in patients with these infections. Methods: The medical records of 40 consecutive adult patients with hand or wrist septic arthritis treated at our institution from 2000 to 2008 were retrospectively reviewed. The primary outcome measure was treatment failure (histopathologic or microbiologic evidence of relapsed infection from the same joint or a contiguous anatomic area). Results: Involved joints were the wrist (n = 10, 25 %), metacarpal-phalangeal (n = 11, 27.5 %), proximal interphalangeal (n = 8, 20 %), distal interphalangeal (n = 10, 25 %), and thumb interphalangeal (n = 1, 2.5 %). Methicillin-sensitive (n = 15, 45 %) and -resistant (n = 7, 17.5 %) Staphylococcus aureus were the most common pathogens. Surgical therapies included open arthrotomy with debridement (n = 33, 82.5 %), arthroscopic debridement (n = 2, 5 %), and aspiration alone (n = 5, 12.5 %). Most patients (23/40, 58 %) received less than 1 week of parenteral antimicrobial therapy. Only two patients developed definite antimicrobial treatment failure, one of whom had an atypical mycobacterium infection. Patients with subacute to chronic infections were at high risk for finger amputation. Conclusions: When combined with surgical debridement, relatively short courses of parenteral antimicrobial treatment (<1 week) supplemented with oral therapy for an additional 2-3 weeks is usually sufficient antimicrobial therapy for hand or wrist septic arthritis. © 2013 Springer-Verlag. Source

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